Okay, let's dive into the major
toxicities of cancer chemotherapy.
I love this picture, I wanna
have that kind of spunk.
So look how she's holding her
new wig right off to the side.
So we know that the first area of
high growth fraction cells is hair.
So the hair follicles get attacked.
Now you develop alopecia which is baldness
and you have significant hair loss.
Now I don't anticipate,
like on an NCLEX type question.
You'll see a lot of questions
coming from this area of content.
But for your patients, this
is extremely traumatic.
I know a patient that have just
went ahead and shaved their head
before they lost the hair just to feel
like they had some kind of control.
But this can be a very traumatic hair loss.
Like it doesn't just fall out a little bit,
some people lose all of it almost at once.
So I love her spunk there in that picture,
she's got a great smile
and she's willing to take a
picture completely bald.
Now, the next area is GI.
Remember? Hair, GI.
Now the most significant or problematic
issue with GI is stomatitis.
Those are horrible mouth sores.
But they're also gonna have
diarrhea and there's a possibility
that they're gonna end up with
severe nausea and vomiting.
So let's talk about that stomatitis.
They have this horrific mouth sores.
So these are folks that we
really need to eat well
because they need their
energy to focus on healing.
But they end up with these
horrific mouth sores
and the thought of eating anything
like a strawberry or tomato
just gives them excruciating pain.
It's just so painful for
them to even drink liquids.
They have a very difficult
time taking anything in.
So they end up with a real risk of becoming
dehydrated and definitely having low protein.
Now the diarrhea obviously
can be problematic.
It can certainly mess with their
GI tract from start to finish.
But the nausea and vomiting is
incredibly intense with chemotherapy.
Beacause you have this nausea center
of your brain and it is triggered.
The areas of the esophagus and the
stomach and the small intestine
they all get involved in trigger
of that nausea area of response.
You have this reflex pathway.
Now don't be fooled.
Nausea is miserable to experience
but it's also very complex.
So, I wanna show you some risk factors with
you for people who are having chemotherapy
who's most likely to really develop
severe nausea with the drugs.
Certain drugs are more
prone to causing nausea
but certain people are more
vulnerable to becoming nauseated.
One, if you're a woman.
Well, that stinks because I
definitely have that risk factor.
You're younger than 50.
You've experienced nausea and
vomiting with previous treatments
or you have a history of motion sickness.
Woah! I'm good there because
I love roller coasters.
You have a high level of anxiety.
We'll I don't know who wouldn't have a
high level of anxiety going through chemo.
You experienced morning
sickness during pregnancy.
You're a prone to vomiting when you're sick.
And you have a history of drinking
little or no alcohol.
Those might seem very unusual to you but
those have been identified as risk factors
and the more of those you have,
the more likely a patient is to endure
nausea and vomiting during chemotherapy.
Now, I'll talk about specific drugs that are
more likely to cause emesis or vomiting.
This group of drugs that you're seeing
appear on your screen right now
have an extremely high 90%
or greater than 90% chance
of causing really nasty
nausea and vomiting.
These drugs that you're seeing
up here on your screen now
have a 30 to 90% chance,
still too high for my liking.
But I wanted you to have a list of drug
names that are known chemotherapy agents
so you'll recognize those
if you see them come up
on your NCLEX exam or on
any of your program exams.
So take a look at those drugs.
Write yourself a note to
just to review these over the next
couple of days on a regular basis
to make sure that you
recognize those drug names.
Okay, remember I talked about how
complex that process is?
It really is.
You have that emesis center,
that CPG, look what's involved.
Your cortex and limbic system,
your vestibular system,
your medulla oblongata - the CTZ
and your GI tract.
So this is a very complex experience,
feels horrible when you're the patient
and it's a major part of the toxicity
associated with the GI tract and chemotherapy.
So let's look at four types of medications
that we use to treat nausea and vomiting
that's induced by
chemotherapy or pre-treated.
and that's a really important
If we know the patient is
gonna be administered chemotherapy
and it's likely that they're
gonna experience nausea,
you should treat them with these medications
before they receive the chemotherapy.
Try to stop this complex
process before it gets started.
So again, how many different groups of
medications did I say we're gonna talk about?
First, serotonin antagonist.
Hey, an extra serotonin
always is better.
So, this is one of the
I've taken it personally and I love
it, and it's called Ondansetron.
Now you wouldn't necessarily think of that
as an anti-emetic, as something with nausea.
But when we use it as an adjuvant, we use it together
with other medications, it can be fantastic.
Cannabinoids, yeah, just like those street ones
but they don't have the THC kind of experience,
And finally, benzodiazepines
So we've got four categories of
medications that can really be helpful
in treating nausea and vomiting.
Serotonin antagonist, glucocorticoids,
cannabinoids and benzodiazepines
So make sure that you remember at least
one drug name I listed there for you
so you have an example that
it falls in that category.
It's really important as you're going
along in pharmacology to make sure
that you know the side effects,
and adverse effects by family
but you do recognize an example
drug name from each family.
So we've done hair, we've done GI which
is stomatitis, nausea/vomiting, diarrhea.
Now we're gonna talk
about the impact on skin.
They can become very sensitive
to the sun.
They can also end up with
these rashes, redness, peeling
and itching that looks really bizarre
like you see in that picture.
They can develop some severe acne.
They can also develop some
darkening along the veins
like almost as if their veins have
been tatooed underneath their skin.
I have a very good friend who is of Asian decent
and when she went through her chemotherapy,
her palms got this horrible,
burgandy, deep, deep, deep color.
I wish it wouldn't have been painful but
even that was really difficult for her,
but it looked really strange.
So the skin can do all kinds of things.
It can become dark,
it can become sensitive to light.
You'll look like your veins are
tatooed, you have this weird acne.
So it's not easy on your skin either.
Hair, GI, Skin, next stop?
Yeah, this one isn't any
I used that weird voice to help you
remember but this is really significant.
Especially if your patient that
still wants to have children.
Now the changes in the reproductive
system affect both males and females.
And the changes may either be temporary
or permanent for the rest of their life.
So underline the word 'temporary'
and underline the word 'permanent'.
Because we just don't know what
the end result is gonna be.
So you got a male patient who's gonna
have to go through chemotherapy,
it's a good idea for them to think about
whether they want to bank their sperm.
That way if they do wanna have
children after the treatment,
they have that option
and they can decide,
because what happens is, it
reduces the number of sperm cells
that are available and their
ability to move.
so they're not as agile and
there's not as many of them
which will obvioulsy decrease the likelihood
of being able to become pregnant.
It can cause difficulty in... it can be right from less
sperm cells to also having impotency problems
with problems in erection or
keeping an erection.
It can also mess with the
so it could lead to some
siginificant birth defects.
So, let's wrap that one up.
These changes can either
be temporary or permanent.
The sperms are gonna be,
cells are gonna be less of them
and ones that they do have
might not swim as well.
They might have some
mechanical type problems,
in not being able to either get
erection or keep an erection.
And it might mess with the chromosomes
which could lead to birth defects.
Now for women, same thing.
Please underline the words
'temporary' or 'permanent'.
Now I can say this
because I am a woman.
We are very complex
And if you think we're complex
hormonal creatures on a regular day,
Wow! you should see what women have
to go with that are on chemotherapy.
Now it can also cause
infertility in women.
Remember, it could either
be temporary or permanent.
It'll reduce their ovary's ability to produce
hormones and you start messing with those levels
and it could wreak all kinds
of havoc in a woman's body.
And it might even throw
them into menopause.
It will definitely mess with
their menstrual cycles.
So, temporary or permanent changes,
it could significantly increase
our chance of being infertile.
It will mess with our ovaries,
it could throw them into early menopause
which they may be in for
the rest of their life.
You just don't know how
the body's gonna respond.
Hair, GI, Skin, Reproductive
and last one was bone marrow.
Now when we said bone marrow,
I meant bone marrow suppression.
It causes a decrease in the number of
cells that are made in the bone marrow.
Now those types of cells
that they'll go after first
are neutrophils or your
white blood cells.
When your white blood cell is really
low, we call that leukopenia.
Next they'll go after your
platelets or your thrombocytes.
When your platelets are low,
we call that thrombocytopenia.
So that means, I'm really
at risk to be a bleeder.
And finally, last, the red cells
are the ones to take the hit,
so the biggest impact you'll see
will be on the white cells first
that means I dont fight off
infection very well.
The thrombocytes take a hit next.
And so I'm thrown in to being a
bleeder, because I'm thrombocytopenic.
And then you'll see possibly an
anemia, going after the red cells.
So, bone marrow suppression
means I'll have
fewer white cells, fewer platelets
and fewer red cells.
Now there's some very specific
things that I'm gonna do
for my patients in each
one of those areas.
For neutropenic or leukopenic -
low white cells,
I'm gonna have to protect
them from anything fresh.
So their meat has to be super well done,
they can't have fresh flowers in the room,
they can't garden, they shouldn't eat
fresh fruits and fresh vegetables.
They should eat things that have been canned,
and in my opinion, yucky compared to the fresh stuff.
But I wanna keep them away from anything
that could risk them getting infection
because with the low white cell count,
they can't fight it off.
Now people there are thrombocytopenic,
I'm gonna make sure that they don't
use any like straight razor blades
when they're shaving their legs or their neck,
depending which patient need this.
I want them to use an electric razor,
I want them to use a soft toothbrush,
I don't want them to do anything that
could put them at the risk for bleeding.
I want them to be careful
about wearing shoes at home
so they don't step on
anything and cut their foot.
I don't want them to bump into anything because
they're gonna bruise and bleed internally.
Now for low red cells, we're gonna
have to help them energy conserve.
We keep these things in
mind with chemotherapy:
they're loosing their hair,
they have horrible GI side effects
and they might have some painful or
really weird looking skin deals,
they might have temporary or
permanent hormonal changes
that address their fertility and their
ability to participate in sexual activities,
and now I've got bone marrow suppression
that may make it difficult for them
to fight off infection, they're gonna be
bleeders and they're really, really tired
because they don't have as much oxygen
being delivered to their tissues.
So, none of that seems
like good news, does it?
So you should have a lot of empathy for
people when they're going through this
because I cannot imagine how difficult
this would be to walk through it.
Now leukopenia, when they give you
lab values, you underline that.
If you have a lab value below 500,
kind of high like that,
we won't give the patient
the next round of chemo.
Remember we talked about
where they got a dose then
we check their lab values?
This is one of the lab values we will check.
If it's below 500, we're not gonna
give them another round of chemo
because we know that is really gonna drop them
even lower and the risks far outweigh the benefit.
So when we do a CBC, we look at their
white blood cell count and it is what?
Right, below 500,
that's just our rough estimate.
A physician might order a specific
number for each individual patient,
that's just a guide for you to keep in
mind when you're looking at your studies.
Neutropenic precautions, now I shared some
of them with you on the previous slide.
Take a minute and see if you can write
down some of the neutropenic precautions.
Some of the things that you would do because
they don't have a strong immune system
because they have a low white cell count.
Write them in the margin of your notes.
So, is there anything we can do for these patients
besides give them neutropenic precautions
and keep them safe and make sure their meat is
clean and they aren't around fresh flowers,
and they aren't gardening and they aren't
eating fresh fruits and fresh vegetables,
What can we do for them?
Is there anything we can do with drugs?
Yeah, we can.
We can give them some drugs
that stimulate bone marrow
to increase their neutrophil production.
So these are pretty expensive
but they are available.
Colony stimulating factor or
granulocyte-macrophage colony stimulating factor.
Now that is a mouthful.
But underline colony-stimulating factor and
then macrophage colony-stimulating factor.
That'll remind you that yes, we have
some medications that we can give,
they're pretty fancy,
they're pretty expensive
but they can be life saving if
someone has a low white cell count.
We talked about red cells,
that's anemic, that low red blood cells.
Remember that using that last group
of blood cells that takes a hit.
Monitor the lab values, watch
their red blood cell count
and the med that we can give
them is erythropoietin.
So write 'medication' right above
the word erythropoietin.
We can give that to them but
we want to be really careful.
Now make sure the patient
doesn't have a leukemia.
Okay, so erythropoietin is given to patients
that have low red blood cell count.
We also give it to our patients who have
chronic kidney disease or on dialysis.
But we wanna be careful just in
case the patient has leukemia.
Here's your chance!
There's our favorite slide again.
Supercharge your memory,
study as you go.
So see if you can recall the following
without looking at your notes.
Think of the toxicities and
one more time
I'm gonna ask you to list them,
head to toe, system by system.
Get as specific as you can.
So, pause the video, take your time
and write on as many
specifics as you can remember
from our recent discussion.