Major Toxicities of Cancer Chemotherapy (Nursing)

by Rhonda Lawes, PhD, RN

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      Slides 08 Basic Principles of Cancer Chemotherapy.pdf
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    00:00 Okay, let's dive into the major toxicities of cancer chemotherapy.

    00:05 I love this picture, I wanna have that kind of spunk.

    00:10 So look how she's holding her new wig right off to the side.

    00:14 So we know that the first area of high growth fraction cells is hair.

    00:19 So the hair follicles get attacked.

    00:21 Now you develop alopecia which is baldness and you have significant hair loss.

    00:26 Now I don't anticipate, like on an NCLEX type question.

    00:29 You'll see a lot of questions coming from this area of content.

    00:33 But for your patients, this is extremely traumatic.

    00:37 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.

    00:44 But this can be a very dramatic hair loss.

    00:47 Like it doesn't just fall out a little bit, some people lose all of it almost at once.

    00:52 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.

    00:59 That's awesome! Now, the next area is GI. Remember? Hair, GI.

    01:07 Now the most significant or problematic issue with GI is stomatitis.

    01:12 Those are horrible mouth sores.

    01:14 But they're also gonna have diarrhea and there's a possibility that they're gonna end up with severe nausea and vomiting.

    01:22 So let's talk about that stomatitis.

    01:24 They have this horrific mouth sores.

    01:28 So these are folks that we really need to eat well because they need their energy to focus on healing.

    01:34 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.

    01:43 It's just so painful for them to even drink liquids.

    01:46 They have a very difficult time taking anything in.

    01:49 So they end up with a real risk of becoming dehydrated and definitely having low protein.

    01:55 Now the diarrhea obviously can be problematic.

    01:57 It can certainly mess with their GI tract from start to finish.

    02:01 But the nausea and vomiting is incredibly intense with chemotherapy.

    02:07 Beacause you have this nausea center of your brain and it is triggered.

    02:11 The areas of the esophagus and the stomach and the small intestine they all get involved in trigger of that nausea area of response.

    02:19 You have this reflex pathway.

    02:21 Now don't be fooled.

    02:22 Nausea is miserable to experience but it's also very complex.

    02:27 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.

    02:36 Certain drugs are more prone to causing nausea but certain people are more vulnerable to becoming nauseated.

    02:43 One, if you're a woman.

    02:45 Well, that stinks because I definitely have that risk factor.

    02:49 You're younger than 50.

    02:51 You've experienced nausea and vomiting with previous treatments or you have a history of motion sickness.

    02:57 Woah! I'm good there because I love roller coasters.

    03:00 You have a high level of anxiety.

    03:03 We'll I don't know who wouldn't have a high level of anxiety going through chemo.

    03:07 You experienced morning sickness during pregnancy.

    03:10 You're a prone to vomiting when you're sick.

    03:13 And you have a history of drinking little or no alcohol.

    03:17 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.

    03:30 Now, I'll talk about specific drugs that are more likely to cause emesis or vomiting.

    03:35 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.

    03:48 These drugs that you're seeing up here on your screen now have a 30 to 90% chance, still too high for my liking.

    03:58 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.

    04:09 So take a look at those drugs.

    04:11 Write yourself a note to follow up, just to review these over the next couple of days on a regular basis to make sure that you recognize those drug names.

    04:28 Okay, remember I talked about how complex that process is? It really is.

    04:34 You have that emesis center, that CPG, look what's involved.

    04:37 Your cortex and limbic system, your vestibular system, your medulla oblongata - the CTZ and your GI tract.

    04:45 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.

    04:56 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.

    05:06 and that's a really important point.

    05:08 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.

    05:20 Try to stop this complex process before it gets started.

    05:23 So again, how many different groups of medications did I say we're gonna talk about? Right! four.

    05:38 First, serotonin antagonist.

    05:40 Hey, an extra serotonin always is better.

    05:43 So, this is one of the greatest medications.

    05:46 I've taken it personally and I love it, and it's called Ondansetron.

    05:51 Glucocorticoids like Dexamethasone.

    05:55 Now you wouldn't necessarily think of that as an anti-emetic, as something with nausea.

    05:59 But when we use it as an adjuvant, we use it together with other medications, it can be fantastic.

    06:05 Cannabinoids, yeah, just like those street ones but they don't have the THC kind of experience, Dronabinol.

    06:13 And finally, benzodiazepines like lorazepam.

    06:18 So we've got four categories of medications that can really be helpful in treating nausea and vomiting.

    06:24 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.

    06:37 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.

    06:50 Additional classes now available include dopamine agonists, such as metoclopromide, Neurokinin-1 antagonists, such as aprepitant, and atypical antipsychotics, such as olanzapine.

    07:05 So we've done hair, we've done GI which is stomatitis, nausea/vomiting, diarrhea.

    07:12 Now we're gonna talk about the impact on skin.

    07:15 They can become very sensitive to the sun.

    07:19 They can also end up with these rashes, redness, peeling and itching that looks really bizarre like you see in that picture.

    07:26 They can develop some severe acne.

    07:29 They can also develop some darkening along the veins like almost as if their veins have been tatooed underneath their skin.

    07:36 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.

    07:46 I wish it wouldn't have been painful but even that was really difficult for her, but it looked really strange.

    07:53 So the skin can do all kinds of things.

    07:55 It can become dark, it can become sensitive to light.

    07:57 You'll look like your veins are tatooed, you have this weird acne.

    08:01 So it's not easy on your skin either.

    08:04 Hair, GI, Skin, next stop? Yeah, this one isn't any laughing matter.

    08:12 I used that weird voice to help you remember but this is really significant.

    08:16 Especially if your patient that still wants to have children.

    08:19 Now the changes in the reproductive system affect both males and females.

    08:25 And the changes may either be temporary or permanent for the rest of their life.

    08:30 So underline the word 'temporary' and underline the word 'permanent'.

    08:35 Because we just don't know what the end result is gonna be.

    08:39 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.

    08:46 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.

    08:59 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.

    09:06 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.

    09:15 It can also mess with the chromosomes, so it could lead to some siginificant birth defects.

    09:20 So, let's wrap that one up.

    09:23 These changes can either be temporary or permanent.

    09:27 The sperms are gonna be, cells are gonna be less of them and ones that they do have might not swim as well.

    09:33 They might have some mechanical type problems, in not being able to either get erection or keep an erection.

    09:39 And it might mess with the chromosomes which could lead to birth defects.

    09:44 Now for women, same thing.

    09:47 Please underline the words 'temporary' or 'permanent'.

    09:51 Now I can say this because I am a woman.

    09:53 We are very complex hormonal creatures.

    09:57 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.

    10:05 Now it can also cause infertility in women.

    10:08 Remember, it could either be temporary or permanent.

    10:11 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.

    10:20 And it might even throw them into menopause.

    10:23 It will definitely mess with their menstrual cycles.

    10:26 So, temporary or permanent changes, it could significantly increase our chance of being infertile.

    10:33 It will mess with our ovaries, it could throw them into early menopause which they may be in for the rest of their life.

    10:39 You just don't know how the body's gonna respond.

    10:42 Hair, GI, Skin, Reproductive and last one was bone marrow.

    10:51 Now when we said bone marrow, I meant bone marrow suppression.

    10:55 It causes a decrease in the number of cells that are made in the bone marrow.

    10:59 Now those types of cells that they'll go after first are neutrophils or your white blood cells.

    11:04 When your white blood cell is really low, we call that leukopenia.

    11:09 Next they'll go after your platelets or your thrombocytes.

    11:13 When your platelets are low, we call that thrombocytopenia.

    11:18 So that means, I'm really at risk to be a bleeder.

    11:21 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.

    11:31 The thrombocytes take a hit next.

    11:33 And so I'm thrown in to being a bleeder, because I'm thrombocytopenic.

    11:37 And then you'll see possibly an anemia, going after the red cells.

    11:41 So, bone marrow suppression means I'll have fewer white cells, fewer platelets and fewer red cells.

    11:49 Now there's some very specific things that I'm gonna do for my patients in each one of those areas.

    11:54 For neutropenic or leukopenic - low white cells, I'm gonna have to protect them from anything fresh.

    12:02 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.

    12:12 They should eat things that have been canned, and in my opinion, yucky compared to the fresh stuff.

    12:17 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.

    12:24 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.

    12:34 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.

    12:42 I want them to be careful about wearing shoes at home so they don't step on anything and cut their foot.

    12:47 I don't want them to bump into anything because they're gonna bruise and bleed internally.

    12:51 Now for low red cells, we're gonna have to help them energy conserve.

    12:55 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.

    13:26 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.

    13:39 Now leukopenia, when they give you lab values, you underline that.

    13:42 If you have a lab value below 500, kind of high like that, we won't give the patient the next round of chemo.

    13:50 Remember we talked about intermittent chemo where they got a dose then we check their lab values? This is one of the lab values we will check.

    13:57 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.

    14:07 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.

    14:15 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.

    14:24 Neutropenic precautions, now I shared some of them with you on the previous slide.

    14:29 Take a minute and see if you can write down some of the neutropenic precautions.

    14:33 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.

    14:40 Write them in the margin of your notes.

    14:49 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.

    15:10 We can give them some drugs that stimulate bone marrow to increase their neutrophil production.

    15:16 So these are pretty expensive but they are available.

    15:19 Colony stimulating factor or granulocyte-macrophage colony stimulating factor.

    15:26 Now that is a mouthful.

    15:28 But underline colony-stimulating factor and then macrophage colony-stimulating factor.

    15:34 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.

    15:47 We talked about red cells, that's anemic, that low red blood cells.

    15:51 Remember that using that last group of blood cells that takes a hit.

    15:54 Monitor the lab values, watch their red blood cell count and the med that we can give them is erythropoietin.

    16:01 So write 'medication' right above the word erythropoietin.

    16:07 We can give that to them but we want to be really careful.

    16:11 Now make sure the patient doesn't have a leukemia.

    16:15 Okay, so erythropoietin is given to patients that have low red blood cell count.

    16:20 We also give it to our patients who have chronic kidney disease or on dialysis.

    16:24 But we wanna be careful just in case the patient has leukemia.

    16:29 Here's your chance! There's our favorite slide again.

    16:32 Supercharge your memory, study as you go.

    16:35 So see if you can recall the following without looking at your notes.

    16:42 Think of the toxicities and one more time I'm gonna ask you to list them, head to toe, system by system.

    16:50 Get as specific as you can.

    16:51 So, pause the video, take your time and write on as many specifics as you can remember from our recent discussion.

    About the Lecture

    The lecture Major Toxicities of Cancer Chemotherapy (Nursing) by Rhonda Lawes, PhD, RN is from the course Cancer Medications (Nursing). It contains the following chapters:

    • Hair
    • Gastrointestinal
    • Skin
    • Reproductive
    • Bone Marrow

    Included Quiz Questions

    1. It causes alopecia
    2. It increases hair growth
    3. It increases the volume of hair
    4. It causes a curly texture
    1. Stomatitis
    2. Stomach ulcers
    3. Rectal ulcers
    4. Duodenitis
    1. Cyclophosphamide, cisplatin, dacarbazine, mechlorethamine, streptozocin
    2. Cyclophosphamide, cisplatin, dacarbazine, ifosfamide, doxorubicin
    3. Dacarbazine, mechlorethamine, streptozocin, epirubicin, idarubicin
    4. Mechlorethamine, streptozocin, epirubicin, cyclophosphamide, cisplatin
    1. Ondansetron
    2. Nabilone
    3. Dexamethasone
    4. Lorazepam
    1. Photosensitivity, rashes, redness, and itching
    2. Photosensitivity, rashes, pallor, and indurations
    3. Darkened veins, cyanosis, welts, and acne
    4. Ulcerations, acne, redness, and indurations
    1. Thrombocytes
    2. Neutrophils
    3. Erythrocytes
    4. Lymphocytes
    1. It reduces the chance of acquiring an infection.
    2. It reduces the chance of bleeding.
    3. It reduces the chance of nausea and vomiting.
    4. It reduces the chance of stomatitis.
    1. Reduction of sperm count
    2. Erectile dysfunction
    3. Chromosome changes
    4. Increase in sperm motility
    5. Enlarged prostate

    Author of lecture Major Toxicities of Cancer Chemotherapy (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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