Chemotherapy/Biotherapy Chemotherapy/Biotherapy Administration Administration (Pre, Immediate and Post)(Pre, Immediate and Post)

ObjectivesObjectivesAt the completion of this session

the participant will be able to◦Identify components of pre-treatment assessment

◦Calculate BSA and confirm chemotherapy/biotherapy dosage

◦Describe required family teaching prior to chemotherapy/biotherapy administration

ObjectivesObjectivesAt the completion of this session

the participant will be able to◦Describe safety measures to verify chemotherapy/biotherapy orders

◦List steps in preparation of chemotherapy/biotherapy

◦Identify nursing measures for different routes of administration

Pre-administration Pre-administration PreparationPreparationComponents to safe preparation

for chemotherapy/biotherapy administration:◦Individual treatment plans◦Pretreatment physiologic evaluations

◦Dosing of chemotherapy/biotherapy in children and adolescents

◦Preparation of the setting◦Family assessment and education

Individual Individual Treatment PlanTreatment Plan

Review the individual treatment plan for any required pretreatment laboratory tests, imaging studies or specialized organ evaluations. Schedule all required studies

Check the general treatment plan for any amendments and updates that may alter therapy. Clarify any discrepancies

Follow institutional policies for verifying chemotherapy/biotherapy orders

Pretreatment Physiological Pretreatment Physiological AssessmentAssessment

The following should be assessed and completed prior to starting chemotherapy/biotherapy:◦ Review the individual's experience

with previous chemotherapy/biotherapy regarding side effects or toxic effects from the medications

◦ Review with the child and family the effectiveness of supportive care with past chemotherapy/biotherapy

◦ Perform a thorough physical assessment

Pretreatment Physiological Pretreatment Physiological AssessmentAssessmentAssess that all pretreatment laboratory

and imaging studies are complete and within acceptable limits. Ascertain that results of all pretreatment studies have been evaluated

Calculate the patient’s absolute neutrophil count (ANC) prior to administering chemotherapy using the following formula:

ANC = (% segs + % bands) x total white blood count

Verify within institutions ANC parameters prior to beginning treatment

Pretreatment Physiological Pretreatment Physiological AssessmentAssessment

Begin the process of physiologic preparation for chemotherapy/biotherapy. This will include hydration and plans for control of nausea and vomiting

Obtain baseline vital signsDeliver premedications for supportive

care and schedule at appropriate intervals

Dosing of Dosing of Chemotherapy/BiotherapyChemotherapy/Biotherapy

When calculating doses in pediatrics, the actual body weight is used

Chemotherapy/biotherapy doses are generally calculated using body surface area. Accuracy of weight and height measurements is essential to correct dosing of chemotherapy/biotherapy ◦ BSA = Ht (cm) X Wt (kg) ÷ 3600, then square

root the result

Dosing of Dosing of Chemotherapy/BiotherapyChemotherapy/BiotherapyMilligram/kilogram formulas are used to

calculate chemotherapy/biotherapy doses in children weighing less than 10 kilograms or who are less than 12 months of age

Maintenance fluids are calculated using the BSA. A formula for calculating fluids is 1500ml/m2/24 hours

Toxicity from prior therapy may necessitate dose reductions. Organ dysfunction may necessitate dose reduction

Preparation of Preparation of SettingSettingThe following should be obtained

before beginning chemotherapy/biotherapy: ◦ Personal protective equipment (PPE)◦ Disposal equipment◦ Chemotherapy spill kit◦ Emergency drugs and equipment

available◦ Infusion pump

Preparation of Preparation of SettingSettingThe following should be obtained before beginning chemotherapy: ◦IV fluids and tubing◦Premedications (e.g., antiemetics)

◦Emesis basin

Family Assessment & Family Assessment & EducationEducation Accomplish the following

prior to each chemotherapy/biotherapy course:◦ Identify barriers to learning,

including primary language, anxiety and illiteracy

◦ Explore with the child and family any personal preferences they have regarding chemotherapy administration, such as the time they prefer treatment to start, any rituals the child finds helpful and supportive care

Family Assessment & Family Assessment & EducationEducation

Accomplish the following prior to each chemotherapy course (cont.):◦ Review the medications to be given.

Include the name of the medication, administration route, length of therapy and administration schedule

◦ Discuss potential side effects, when they might occur and how they may be managed

◦ Review plans for the management at home after the chemotherapy/biotherapy is complete

Principles of Principles of AdministrationAdministrationComprehensive patient assessment

Review/verification of treatment plan

Preparation Safe handling principlesPatient/family educationFollow institutional guidelines

VerificationVerificationPatient-Specific Information

◦Patient identification◦Allergies◦Current height, weight, BSA◦Pre-treatment parameters such as pertinent lab values that influence dosage

◦Pre-treatment diagnostic testing results necessary to begin chemotherapy/biotherapy cycle

VerificationVerificationChemotherapy Orders & select

Biotherapy Orders per institution◦ The chemotherapy/Biotherapy order should

include: (2 RN Check) Patient identification Patient-specific measurements (body

weight, height, and body surface area) The full generic name of the drug The drug dose, dose calculation, dose

modification calculation, route, frequency, administration guidelines such as duration of infusion and rate of administration

Required monitoring Admixture fluid type, volume and rate

PreparationPreparationPreparation for Administration◦Assure test dose and/or pre-

medications and hydration are administered

◦Protect light-sensitive drugs◦ Inspect medication prior to

administration for discoloration and particulate matter

◦ Inspect medication label for drug name, dose and expiration date

PreparationPreparationPreparation for Administration

◦Assure that the mode of administration is consistent with knowledge of vesicants and irritants and matches order, label and protocol

◦Avoid bringing medications administered by different routes to the patient’s room at the same time

◦Ensure patient/family education completed

Chemotherapy/Biotherapy Chemotherapy/Biotherapy AdministrationAdministration To ensure safe

administration:◦ Follow institutional

and OSHA guidelines for administration/disposal

◦ Administer medications in accordance with

institutional medicationand nursing practice policies

and guidelines

AdministrationAdministration To ensure safe

administration:◦ Utilize the 6 rights

of safe administration: Right patient Right medication Right dose Right route Right time Right fluid/volume

◦ Use leur lock connections and safety needles

AdministrationAdministrationOral

◦Do not handle without PPE◦Tablets should not be crushed and dissolved outside of a biological safety hood

◦If an oral dose is vomited, establish guidelines for repeating the dose with the ordering clinician

AdministrationAdministrationOral

◦ Creative measures for helping small children tolerate oral medications

◦ School-age children and adolescents, who are responsible for taking their own oral chemotherapy/biotherapy, should have their doses verified by an adult

◦ Liquids should be given in an oral type syringe to deliver an accurate dose of the entire drug and minimize spills/residue

AdministrationAdministrationIntramuscular/Subcutaneous

◦ Site selection Injection into larger muscles is

recommended Avoid injection into areas of pre-existing

tenderness and/or ecchymosis or nodules from prior injections

Volume for single injection is site-dependent

◦ Smallest gauge needle as appropriate for child’s size

◦ Ensure age-appropriate preparation and teaching are completed with the patient and family

AdministrationAdministration Intramuscular/Subcutaneous

◦ If the patient is mildly thrombocytopenic, after the injection, apply pressure directly to injection site for 5 minutes to prevent formation of a hematoma

◦ Apply topical anesthetic agent or ice to the injection site prior to the injection to minimize pain

◦ Dispose of waste in accordance with OSHA and institutional policies and guidelines

◦ Rotate the site of injection for subsequent injections

AdministrationAdministrationIntravenous (IV) access must be

established and patency verified prior to administration

IV access may be established via: ◦ Peripheral IV catheter ◦ Central venous catheter(CVC)

External catheters Broviac, Hickman, Groshong, PICC

Implanted ports Medi-Port, Port-a-CathTM

AdministrationAdministration

Peripheral IV◦ Avoid site selection distal to any recent

venipuncture ◦ A new peripheral IV site is

recommended if an already existing peripheral IV site is older than 24 hours

◦ Areas over joints or bony prominences and the antecubital fossa should be avoided

◦ During IVP vesicant administration, blood return should be verified after each 0.5cc-1cc injected

AdministrationAdministrationImplanted Central Venous

Catheters◦ Assure the selected site is stabilized

just prior to injection/infusion to avoid accidental needle punctures and/or accidental drug exposure. For long-term infusions, tape the site securely, without obstructing your view of the site, so that signs of extravasation can be promptly identified

AdministrationAdministrationCVC and continuous infusion

◦ Blood return should be verified immediately prior to beginning the infusion

◦ The CVC site should be evaluated for signs of inflammation and extravasation of a vesicant infusion every hour throughout the infusion

◦ Secure IV tubing with leur lock connections

◦ Use gauze and/or plastic backed drape beneath connections during access or de-access procedures

AdministrationAdministrationIV Administration Methods◦IV Push (IVP)◦Bolus infusion◦Continuous infusion

IV Push IV Push AdministrationAdministrationIV push therapy is infused in less than 5 minutes

Methods◦Direct push: Directly infusing chemotherapy agents into the IV access device using a syringe

◦Stop cock method: Using a 3-way stop-cock to administer chemo

Continuous IV Continuous IV InfusionInfusion

Infusions should not be interrupted unless absolutely necessary

Infusion pump should be used

Ensuring drug is infused in prescribed time◦ Some protocols allow

for increasing dose by 10%

◦ Other protocols do not allow for change of rate

◦ Check with the prescribing clinician if infusion will not finish at prescribed time

Vesicants/IrritantsVesicants/IrritantsVesicants: are a class of drugs,

that when extravasated cause severe tissue damage and may lead to necrosis (Jenkins, 1998)

Irritants: are agents that have the potential to cause phlebitis and irritate tissue if extravasated, they do not cause the degree of tissue damage and necrosis that vesicants do

Monitoring for Potential Monitoring for Potential Side EffectsSide Effects

Flare Reaction◦ A localized venous inflammatory

reaction in response to an IV agent ◦ Signs and symptoms include pain,

redness at the site and along the vein length

◦ Treatment/management: Once extravasation is ruled out, the vein should be flushed with a compatible IV fluid and resolution of the redness should follow

Monitoring for Potential Monitoring for Potential Side EffectsSide EffectsHemodynamic monitoring

◦Monitor hemodynamic status taking vital signs as indicated throughout administration

Monitoring for Potential Monitoring for Potential Side EffectsSide EffectsFluid status

◦Monitor fluid status: measure urine output and urine specific gravity as needed throughout administration

◦Monitor hydration status: oral intake, skin turgur, mucous membranes, and tears, assess the impact of nausea and vomiting on oral intake

Monitoring for Potential Monitoring for Potential Side EffectsSide Effects

Specific side effects:◦ Monitor for the

occurrence of side effects

◦ Monitor the effectiveness of the anti-emetic regimen

Monitoring for Potential Side Monitoring for Potential Side Effects – Allergic ReactionsEffects – Allergic Reactions

Allergic reactions and anaphylaxis are hypersensitivity reactions to a foreign protein that can occur immediately or within minutes to hours after exposure to the offending protein

The reaction can be localized or systemic

IgE Mediated vs Non IgE IgE Mediated vs Non IgE MediatedMediated

IgE MediatedSpecific IgE is

produced at initial exposure

Reaction occurs at subsequent exposures

Anaphylaxis◦ Allergic Reaction

Non IgE Mediated No prior

sensitization required

Reaction can occur at initial exposure

Anaphylactoid◦ Non-Allergic reaction

Chung, C 2008

Signs and Symptoms Signs and Symptoms Infusion ReactionInfusion ReactionAllergic Reaction/HypersensitivityPruitis/itchingRash/desquamation Urticaria: hives, welts, whealsRigors/chillsHeadacheArthralgia/myalgiaFatigue (asthenia, lethargy, mailaise) DizzynessSweatingNausea/VomitingCough, Dyspnea, bronchospasmHypotension/hypertensionTachycardia

Heinz-Josef Lenz, 2007

Severe Infusion ReactionSevere Infusion Reaction

Life threatening and may appear within minutes of exposure

Severe bronchospasm, laryngeal edema, respiratory distress, and/or cutaneous and gastrointestinal, leading to hypotensive crisis

Chung, C 2008

Infusion ReactionsInfusion ReactionsPrevention/ProphylaxisAcetominophenAntihistaminesCorticosteroidsH2 antagonist

ManagementAntihistaminesCorticosteroidsEpinephrineOxygenVasopressorsBronchodilators

Mild to Moderate ReactionsResume infusion at 50% reduction of infusion rate oncesymptoms are completely resolved

Chung, C 2008

Monitoring for Potential Side Monitoring for Potential Side Effects – Allergic ReactionsEffects – Allergic Reactions

Nursing interventions◦ Stop Infusion◦ Maintain airway, IV access, vital signs◦ Administer medications promptly in

the event of a reaction: acetaminophen (Tylenol) diphenhydramine (Benadryl) Steroids epinephrine (Adrenaline, Sus-phrine)

Know the actual doses of medications that would be needed specifically for an individual patient receiving a potentially anaphylactic medication

DocumentationDocumentation

Date and timeVenipuncture site (central or peripheral)Venipuncture needle type, gauge, lengthVerification of blood return, prior to,

during and after infusionDrug name, dose, route and volume in mlType and amount of IV flush solution

used Infusion duration Document per institution guidelines

DocumentationDocumentation Antiemetic, dose, time Pre-med, dose, time Hydration type and

amount Method of

administration Adverse reactions/side

effects Patient tolerance of

chemotherapy/biotherapy

Ability to tolerate fluid and food

Patient and family education

Patient and Family Patient and Family EducationEducationPrior to administration and during

administration of chemotherapy/biotherapy◦ Name of medications to be given◦ Administration route and any route-

specific step-by-step administration guidelines

◦ Expected or potential side effects and when they may occur

◦ Safe handling considerations

Patient and Family Patient and Family EducationEducationSupportive care measures should be a part of the education plan

If a patient is prescribed growth factors, side effects and detailed administration techniques should be reviewed

Patient and Family Patient and Family EducationEducationEnsure discharge teaching is

completed with the patient and family, and they have all necessary medications, equipment, supplies and disposal instructions, if the patient is to receive medications at home

Patients and family members should be aware of reportable symptoms and side effects, as well as who to contact and the telephone/pager numbers

Discharge PlanningDischarge Planning

CVC teachingHome care referralReview expected or

potential side effects they may experience at home

Chemotherapy/ biotherapy schedule (calendar)

Follow-up appointment

Patient and Family Patient and Family OutcomesOutcomes

Accurate and safe administration of chemotherapy/ biotherapy

Effective management of nausea and vomiting

Effective pain and symptom management

Effective anticipatory guidance

Demonstrate the technical skills necessary to provide care at home◦ Medication

administration, central line catheter care, etc.

Effective documentation of chemotherapy/ biotherapy administration at home