Chapter 42: Oncological and Hematological Medications

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Welcome to the Deep Dive.

Today, we're tackling a really important topic,

antineoplastic and hematological medications.

That's right.

These are the drugs used against cancer and also for blood disorders.

We're diving into a key nursing review chapter today.

Our mission basically is to pull out the must -know info for you, what's crucial for understanding these complex myths.

And you'll see two concepts pop up again and again, cellular regulation, how cells grow and divide, and critically, safety.

So these drugs, they work by either killing cancer cells or stopping them from growing.

Exactly.

But the tricky part is they don't just affect cancer cells.

They often hit normal, healthy cells too, especially those that divide quickly.

And that's where we get side effects.

Okay.

And the chapter mentions the cell cycle, figure 42 to 1.

How does that fit in?

Right.

Think of the cell cycle as the life stages of a cell.

Some drugs only work during a specific stage.

They're phase specific.

Others are non -specific, meaning they can act pretty much any time during the cycle.

Like targeting a specific point in an assembly line versus just disrupting the whole factory.

That's a great analogy.

And understanding that helps explain why doctors often use combinations of drugs.

Attacking the cancer from multiple angles.

Precisely.

Hitted at different phases, different vulnerabilities,

increases the chances of success.

And it's often part of a bigger plan with surgery or radiation too.

Makes sense.

Now, how are these drugs actually given?

The source mentions IV is common.

IV is definitely most common.

But you also see oral meds intra -arterial directly into an artery.

Yeah.

Isolated limb perfusion, even intracavitary, like into the bladder or chest cavity.

And dosing.

It mentions body surface area, BSA,

not just weight.

Correct.

BSA is crucial.

It uses height and weight for calculation.

It's generally considered a more accurate way to dose these powerful drugs than weight alone.

So you need accurate height and weight before every single dose.

Every single time.

It's that important for getting the dose right effective, but minimizing toxicity as much as possible.

Okay.

So right at the start, the chapter throws out a critical thinking question.

A nurse sees a patient has a low neutrophil count before giving an anti -neoplastic drug.

What's the move?

Stop.

That's the move.

A low neutrophil count neutropenia means a high risk of infection.

So you withhold the medication and immediately notify the RN or the primary health care provider.

Safety first.

Got it.

Withhold and notify.

Okay.

Let's dig into these anti -neoplastic meds more, starting with those side effects you mentioned.

Sounds like they can be pretty widespread.

They can be, unfortunately, because they target rapidly dividing cells, healthy cells that also divide, quickly get caught in the crossfire.

Think about the lining of your mouth, your hair follicles, bone marrow.

Right.

So the list includes mucusitis.

That's the mouth inflammation.

Yes.

Painful sores in the mouth or gut.

Then there's alopecia hair loss.

Which can be really tough emotionally.

Absolutely.

Also anorexia, loss of appetite, nausea, vomiting.

Diarrhea is common too.

And the effects on blood cells.

Big ones.

Anemia, low red cells, low white blood cell count, which includes that neutropenia we discussed, high infection risk,

and thrombocytopenia, low platelets.

Platelets, meaning higher risk of bleeding.

Exactly.

Plus potential infertility, sexual changes, and neuropathy nerve damage, like tingling or numbness.

That's quite a list.

So nursing interventions.

What's the focus for managing the physical side effects?

Monitoring is paramount.

Regular blood work, CBC, white count, platelets.

Also checking uric acid levels, electrolytes.

Catching problems early is key.

And if the platelet count is low, thrombocytopenia.

Bleeding precautions kick in immediately.

The source even gives thresholds.

Below 50 ,000 platelets, minor trauma can cause significant bleeding.

Below 20 ,000, risk of spontaneous bleeding.

Wow.

So you'd hold the med then based on policy and tell the RNPHCP.

Definitely.

And you're constantly watching for signs of patechia, those little red spots, ecumosis, bruising, bleeding gums, nosebleeds.

And avoiding things like intramuscular injections.

Right.

Avoid IM shots, unnecessary venipunctures, anything invasive if possible.

Minimize the risk.

Okay, back to the white cells.

The segmented neutrophil count, if it's below 18%.

Hold the med again, start neutropenic precautions, and notify.

Can you break down segmented neutrophil count?

Sure.

Neutrophils are your main infection fighters.

Segmented just means they're mature, ready to fight.

If that percentage is low, your army of mature fighters is depleted.

Big infection risk.

So neutropenic precautions are things like protecting the patient from infection sources.

Yes.

Meticulous hygiene, maybe limiting visitors, watching closely for fever, sore throat, any sign of infection.

What about the GI stuff?

Nausea, appetite loss.

Well, let patients know taste changes can happen, making food less appealing.

For nausea vomiting, antibiotics are crucial, often given before chemo and for a while after.

High calorie, high protein foods can help.

Small, frequent meals sometimes work better.

And hydration keeps coming up.

So important.

Encourage fluids, at least two liters a day if possible.

4V fluids are often given during treatment too.

It helps flush the kidneys, especially since breaking down cancer cells releases uric acid.

Ah, and that's why they might get allopurinol, to lower the uric acid.

Exactly.

Protect those kidneys.

Let's talk safety for the staff too.

Preparing and giving these drugs sounds hazardous.

It requires specific precautions.

Chemo should ideally be mixed under a special hood, usually in the pharmacy.

Anyone handling it needs proper PPE gloves, gown, eye protection, sometimes a mask.

And pregnant nurses.

Should avoid handling or administering these drugs.

It's standard policy.

And disposal is key too.

Everything goes into specific biohazard containers.

Administering the drug itself needs care too, right?

Precise dose, monitoring the IV site.

You mentioned phlebitis.

Yes, inflammation of the vein.

These drugs can be irritating.

So check that IV site often.

And some are vesicans.

What does that mean again?

Vesicans are drugs that can cause severe tissue damage, like blistering and necrosis, if they leak out of the vein.

That leakage is called extravasation.

Ouch.

So how do you prevent that?

Ideally, give vesicans through a central line a bigger catheter in a large vein.

If using a peripheral IV, you must check for blood return before and during infusion to ensure it's in the vein.

And if extravasation does happen...

Stop the infusion immediately.

Notify the RN.

Then, depending on the drug, you might apply ice or heat and maybe inject an antidote right at the site.

Quick action is critical to minimize damage.

Okay.

Shifting to the psychosocial side.

Hair loss.

Yeah, alopecia.

It's a big deal for many patients.

It helps to talk about it up front, discuss wigs before treatment starts, maybe suggest a shorter haircut, reassure them it usually grows back after treatment ends.

And the fertility aspect.

Crucial conversation.

These drugs can harm a fetus' teratogenic effects, so reliable contraception is a must during treatment.

And unfortunately, infertility can sometimes be permanent.

So discussing things like sperm banking or egg preservation beforehand is important.

Very important.

Especially for younger patients who might want children later.

Pre -treatment counseling is key.

Open, honest communication.

What about self -care instructions for patients once they're undergoing treatment?

Health promotion?

Lots of practical advice.

For diarrhea, maybe avoid spicy or high -fiber foods.

For mouth care, inspect the mouth daily.

Rinse often.

Use a soft toothbrush.

To prevent mucositis or catch it early.

Exactly.

Use prescribed mouth rinses if sores develop.

Watch for fungal infections, too.

And infection prevention is huge.

Like avoiding crowds.

Avoiding crowds.

Sick people.

Reporting any fever or chills immediately.

Visitors with cold should wear masks or maybe wait to visit.

Soft toothbrush we mentioned.

Electric razor, too.

To avoid cuts.

Yes.

Minimize any chance of bleeding.

Avoid aspirin products for the same reason.

And absolutely no vaccinations, especially live ones.

Without clearing it with their doctor first, their immune system is compromised.

Okay.

One more major safety point.

Anaphylactic reactions.

Serious allergic reactions.

Yes.

They can happen with these drugs, too.

Precautions start with a thorough allergy history.

Sometimes a test dose is given.

Stay with the patient, especially when starting the infusion.

Monitor vital signs closely.

And have emergency stuff ready.

Absolutely.

Emergency card medications like epinephrine and defenhydramine, oxygen, suction, all readily available.

And good IV access is essential for giving emergency meds fast.

What are the warning signs of anaphylaxis?

Trouble breathing dyspnea, chest tightness, skin stuff like itching pruritus or hives urticaria, fast heart rate, tachycardia, low blood pressure, hypotension, dizziness, anxiety, feeling flushed, maybe even turning bluish, cyanosis from lack of oxygen,

decreased alertness.

Scary.

So if you see those signs, what are the absolute first steps, priority actions?

Number one.

Assess respiratory status, airway, breathing, instantly.

Number two.

Stop the infusion immediately.

Then get help.

Yes.

The RN contacts the provider, maybe calls the rapid response team if the airway is involved.

Give oxygen.

Keep the 5E line open with plain saline.

That's your lifeline for emergency drugs.

Administer the emergency meds ordered.

Right.

Like epinephrine or defenhydramine.

Monitor vital signs continuously.

Document everything.

What happened, what you did, how the patient responded.

Physicianing.

Does that matter?

It can.

If blood pressure is okay, head of the bed up might help breathing.

If hypotensive, they might need to be flat or have legs elevated.

Follow the RN's lead and stay with the patient.

Okay.

That covers the general principles really well.

Now let's get into the specific drug classes.

First up, alkylating medications.

Right.

Vox 42 to 1.

Alkylating agents damage the cancer cell's DNA.

Their cell cycle non -specific.

Side effects include the usual suspects, plus things like stomatitis, rash, IV site pain, some specifics.

Busulfin can cause high uric acid hyperuricemia.

Okay.

Chlorambucil, meclorethamine can affect fertility gonadal suppression and also cause hyperuricemia.

Cisplatin is a big one, known for ear problems, ototoxicity, tinnitus.

Ringing in the ears.

Yes, and hearing loss.

Also kidney damage, nephrotoxicity, and low electrolytes like potassium, calcium, magnesium.

Wow.

Cyclophosphamide, known for hair loss, gonadal suppression, and hemorrhagic cystitis.

That's bleeding from the bladder.

Hematuria, blood in the urine.

Correct.

Ifosfamide can also cause hemorrhagic cystitis plus neurotoxicity.

So for alkylating agents, lots of specific monitoring needed.

Definitely.

Beyond the usual blood counts, watch lung function, kidney, liver function.

For cisplatin, specifically ask about dizziness, hearing changes, numbness, tingling.

For ifosfamide, they often give a protective drug called Mesna to prevent that bladder bleeding.

And hydration is key for cyclophosphamide and ifosfamide too, to flush the bladder.

Very important.

Encourage lots of fluids, like 2 -3 liters a day if the patient can tolerate it, to help prevent hemorrhagic cystitis.

And maybe a low purine diet for hyperuricemia.

Next class.

Anti -tumor antibiotics.

Box 42 -2.

Not for infections, right?

Correct.

These interfere with dRNA synthesis.

Also non -specific.

Common side effects.

Nausea, vomiting, fever, bone marrow depression, low counts of all blood cells, rash, alopecia, stomatitis, fertility issues, high uric acid, and viscication blistering if it leaks from the IV.

Any specific big concerns here?

Yes.

Cardiac issues are a major watch out for some.

Donorubicin can cause heart failure, arrhythmias.

Doxorubicin and idorubicin are known for cardiotoxicity, cardiomyopathy damage to the heart muscle.

You'll see ECG monitoring.

Sometimes dextroseoxane is given with doxorubicin to try and protect the heart.

And bleomycin.

Lungs.

Bleomycin carries a risk of pulmonary toxicity,

lung damage.

So monitoring for this class means really focusing on heart and lungs.

Absolutely.

Listen to lung sounds for crackles.

Watch for shortness of breath, edema, weight gain signs of heart failure.

Monitor ECGs, pulmonary function tests, chest x -rays.

Especially watch cardiac function with doxorubicin and donorubicin and lung status with bleomycin.

Got it.

Moving on to anti -metabolites.

Box 42 -3.

These mess with the building blocks.

Cells need to make proteins in DNA, so they stop cell division.

They are cell cycle specific, mostly the S -phase, when DNA is made.

Side effects, the usual GI stuff, hair loss, stomatitis, bone marrow depression.

Any specific drug warnings here?

Synerabine can cause liver toxicity, hepatotoxicity.

Floresil -5 -FU can cause photosensitivity, sun sensitivity, and cerebellar dysfunction.

That affects balance and coordination.

Cerebellar dysfunction, like dizziness.

Dizziness, weakness, trouble walking smoothly at Axia.

Murhapto purine can cause hyperuricemia and hepatotoxicity.

Methotrexate also has a list.

Photosensitivity, hepatotoxicity, plus toxicity to blood, GI tract, and skin.

So sunscreen is important for floresil and methotrexate.

Definitely.

Sunscreen, protective clothing, and monitor kidney function.

With floresil, watch carefully for those cerebellar signs, and severe mouth sores or diarrhea might mean stopping the drug.

And methotrexate sometimes needs a rescue drug.

Yes.

With high -dose methotrexate, leucovarin is given afterwards.

It helps protect normal cells from the methotrexate's effects.

It's called leucovore and rescue.

Okay.

Next, mitotic inhibitors, specifically the vinka alkaloids.

Box 42 -4.

These stop mitosis, actual cell division.

They work in the M phase, so they're phase -specific.

Key side effect, leukopenia, low white count.

But the big one, especially for vincristine, is neurotoxicity.

Nerve damage again.

Yes.

Numbness and tingling in fingers and toes peripheral neuropathy.

Constipation is common and can lead to a serious blockage called paralytic ileus.

Also possible pitosis -drooping eyelid, hoarseness, balance problems, plus the usual alopecia, stomatitis, etc.

So with vincristine, you're really zeroing in on neurological checks.

Absolutely.

Asking about numbness tingling, checking bowel function regularly, assessing balance, watching for eyelid droop or voice changes.

Safety precautions are important if they have motor instability.

Next, toys morose inhibitors.

Box 42 -5.

These block an enzyme needed for DNA synthesis and cell division.

They're phase -specific, G2 and S phases.

Side effects.

The blood count issues leukopenia, thrombocytopenia, anemia,

GI upset, hair loss.

A key one here is orthostatic hypotension.

That's dizziness when standing up.

Exactly.

A drop in blood pressure on standing.

Also, hypersensitivity reactions can occur.

So warn patients about getting up slowly.

Yes!

That's an important teaching point, along with the general interventions.

Okay.

Hormonal medications and enzymes.

Box 42 -6.

These sound different.

They work differently.

Some suppress the immune system.

Others block hormones that fuel certain cancers, like estrogen and breast cancer.

They can change the body's hormonal balance.

Side effects reflect that.

They can.

Nausea, vomiting, leukopenia, asparaginease, an enzyme can impair the pancreas.

You can see changes in sex characteristics, masculinizing effects in women, feminizing in men, like gynecomastia, breast enlargement, hot flashes, weight gain.

Any specific drug effects?

Mitotain can cause hemorrhagic cystitis, low uric acid, high lipids, hypertension, blood clots, thromboembolic disorders, edema, electrolyte imbalances are possible.

Tamoxifen, used for breast cancer, can cause edema, high calcium hypercalcemia, high cholesterol triglycerides.

It works by blocking estrogen effects.

So monitoring here involves checking hormone -related effects, calcium lipids.

Yes, plus checking pancreatic function with asparaginease, watching for blood clots, fluid retention, and those changes in the sexual characteristics.

And always check for drug interactions.

Then we have immunomodulator agents, or biological response modifiers.

Box 42 -7.

These use the body's own immune system.

Interleukins help immune cells find and kill cancer cells, interfere on slow tumor growth and boost immune response.

Box 42 -8 mentions colony stimulating factors.

Like filgrastem or apoetin alpha.

Exactly.

So gramastem, filgrastem, pegfilgrastem help boost white blood cells after chemo.

Epudin alpha, darbaproidin alpha boosts red blood cells.

Opravacin boosts platelets.

They help the bone marrow recover faster.

And targeted therapy.

This is a newer approach.

Things like monoclonal antibodies, rituximab, trastuzumab, or small molecule inhibitors that target specific parts of cancer cells, even gene -level stuff.

Big potential downside with monoclonal antibodies is allergic reactions.

This chapter also briefly lists a few others.

Oltretamine, Denilukin, Diftitox.

Yeah, drugs for specific cancers like ovarian or certain lymphomas, or special circumstances like Pegaspargus for leukemia patients who react to asparaginease, and bexeratine for cutaneous T -cell lymphoma.

Wow, that's a huge amount of information on the different drug types.

Let's quickly hit those practice questions to reinforce the main points.

Question 431.

For E.

simo patient reports pain at the site.

You see redness, swelling.

What do you do?

Notify the RN immediately.

Classic signs of extravasation.

You need to stop the infusion and manage it properly right away to prevent tissue damage.

Question 432.

Patient getting bluomycin for laryngeal cancer.

What tests would you anticipate to monitor for side effects?

Chest x -ray and pulmonary function studies.

Remember, bluomycin, potential lung toxicity.

Question 433.

Patient with AML getting Bucilfan.

Which lab value needs close watching?

Uric acid level.

Bucilfan can cause tumor lysis syndrome, releasing lots of uric acid, risking kidney damage.

Question 434.

Common adverse effects of cisplatin.

Tinnitus, ototoxicity, hearing, nephrotoxicity, kidneys, and hypomagnesemia.

Low magnesium.

Those are key ones for cisplatin.

Question 435.

What teaching points for a patient starting chemo?

Key things include.

Rinse mouth often.

Use soft toothbrush.

Report fever over 101 degrees F or preple policy immediately.

Check mouth daily for sores.

Always consult provider before any vaccinations, especially live ones.

Question 436.

Patient with ovarian cancer getting vincristine.

What specific adverse effect is a high priority to monitor?

Extremity numbness.

That peripheral neuropathy is a hallmark toxicity of vincristine.

Question 437.

Patient scheduled for asperagenase.

What history finding means you need to consult the RN before giving it?

History of pancreatitis.

Asperagenase can hurt the pancreas, so it's contraindicated if there's a history of pancreatitis.

Question 438.

How does tamoxifen work for metastatic breast cancer?

It competes with estrogen for receptors on the cancer cells, basically blocking estrogen from fueling the cancer's growth.

Anti -estrogen effect.

Question 439.

What lab value to monitor specifically with tamoxifen?

Calcium level.

Tamoxifen can sometimes cause hypercalcemia.

High calcium levels.

And question 440.

Patient on italbicide feels dizzy and weak when standing up.

Likely cause?

Orthostatic hypotension.

That's a known potential side effect specifically linked to atoposide.

Okay, that wraps up our deep dive into this packed chapter on oncological and hematological medications.

Yeah, we've covered a lot from how these drugs work down at the cell level, to all the potential side effects, the crucial assessments nurses need to make,

safety protocols, and specific interventions for many different drug classes.

Safety and understanding the impact on cells were definitely key themes.

Absolutely.

And running through those questions really hammered home the critical nursing role, monitoring, preventing problems, educating the patient.

It's complex work.

It is.

And those review questions are great for you, the listener, to check your own understanding.

So as we finish up, here's something to think about.

Cancer treatment is evolving so fast, especially with targeted therapies and immunotherapy.

How do you see these approaches changing the game even more in the future?

Might we see even more personalized treatments, with potentially fewer side effects down the road?

It's a fascinating area to watch.

And yes, we have thoroughly worked our way through all the essential content presented in this specific chapter of the Saunders Review Text.