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Drugs for Neoplasia

Drugs for Neoplasia. Chapter 37 . Cancer in the U.S. 2007 Prevalence: 11.7 Million Males: 5.36 M; Females: 6.37 M 2008: New Cancer Cases 745,000 Males 692,000 Females Estimated Deaths 294,000 Males 272,000 Females American Cancer Society 2011.

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Drugs for Neoplasia

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  1. Drugs for Neoplasia Chapter 37

  2. Cancer in the U.S. 2007 Prevalence: 11.7 Million Males: 5.36 M; Females: 6.37 M 2008: New Cancer Cases 745,000 Males 692,000 Females Estimated Deaths 294,000 Males 272,000 Females American Cancer Society 2011

  3. Cancer in the U.S. • Leukemia: most common childhood cancer, makes up 25% of all cancers for <20 age group • Lung Cancer has highest mortality rate-28% of all cancer deaths. • Pearson Education, Inc., 2011 (Am. Cancer Society 2008)

  4. Description & Pathogenesis • Neoplasm = new tissue mass or Tumor • Carcinoma or Cancer = abnormal, uncontrolled cell division or tissue growth. • Oncogenes: genes that cause cancer(?) (Members of one family develop the same type of cancer.) • Damaged tumor suppressor genes? • Pearson Education, Inc. 2008, 2011

  5. Pathogenesis Viruses are associated with 15% of all cancers: Herpes Simplex Virus Epstein-Barr Cytomegalovirus Human Papillomavirus (HPV) HIV & Transplant Medications : weaken or suppress the immune system • Pearson Education, Inc. 2008

  6. Environmental Risk Factors Alcohol → Liver Cancer Asbestos → Lung Cancer Benzene → Leukemia

  7. More Risk Factors • Tobacco → Lung, Head, Neck Cancer (1/3rd of all Cancer in U.S.) • X Rays/Radiation → Leukemia • Sun → Skin Cancer • Pearson Education, Inc. 2008, 2011

  8. Cancer Treatment • Surgery • Radiation therapy • Drug therapy (chemotherapy) • To cure • To control • For palliation • For prophylaxis • Pearson Education, Inc. 2008, 2011

  9. Cancer Treatment Surgery • Remove localized, solid Tumor • Reduce numbers of cancer cells • When compromising blood flow, breathing, or causing pain (Palliation). Radiation • Localized Tumor, follow up after Surgery, or palliation for inoperable Cancers

  10. Chemotherapy • Transported through blood • Has potential to reach each cancer cell • Some drugs can cross blood-brain barrier • Some drugs instilled directly into body cavities (ex: bladder) • Often combined with or done after surgery and radiation to increase chance of cure (adjuvant therapy). • Pearson Education, Inc. 2008

  11. Chemotherapy • Cancer Cells mutate and also develop resistance, making for a difficult cure • More toxic or effective upon tumors/cells that have a high Growth Fraction (greater ratio of replicating vs.resting cells). • Multi-drug Protocols: smaller dose of each drug, may reduce adverse effects

  12. Case Study • Mr. C. is a 57 y.o. white male with a history of duodenal ulcer, Right Total Hip Replacement, pneumonia, HTN, 20 pack/yrs smoker (10 cigarettes/day X 40 years), and a recent onset of weakness, loss of appetite, constipation and fatigue. He was diagnosed with a partial bowl obstruction due to adenocarcinoma. Mr. C. just completed a course of Radiation and has now been admitted to the Cancer Care Unit status post (s/p) Sigmoid Colectomy.

  13. Admission Orders • IV Dextrose 5% in Water (D5W) at 125 cc/hr • IV Fluorouracil (5-FU) 12mg/kg/day X 4 days • Cyclophosphamide (Cytoxin) 5 mg PO daily X 5, then 3 mg PO weekly • Morphine PCA 2 mg IV/hr basal rate, 1 mg q 6 min PRN, max 12 mg/hr lock out, for pain • Pearson Education, Inc. 2008, 2011. • Nursing Drug Handbook 2008

  14. Admission Orders • Ondansetron (Zofran) 4 mg IV 30 minutes before meals and Q2h PRN N/V • Sips of water then Clear Liquid diet as tolerated after passing flatus • Up with assistance • Intake and Output

  15. Antineoplastic Drugs • Several different categories of Chemotherapeutic Drugs are derived from plants, bacteria and/or laboratory synthesis. The drugs have diverse actions against Cancer cells, disrupting DNA or RNA production, or having toxic action against metabolic pathways. The result is a slowing or stopping of growth, and/or killing of the cancer cell. Antineoplastic Drugs are more effective against rapidly replicating cells. • Pearson Education, Inc. 2008, 2011

  16. Antimetabolites Structurally similar to folic acid, purines and pyrimidines, which are essential for DNA & RNA synthesis, Antimetabolite Drugs are analogs to Vitamin B9 and nucleic acids. These drugs do not function in the same way, rather they disrupt or slow cancer cell growth or cause their death. Antimetabolites are usually prescribed for leukemia's and solid tumors. wikipedia.org Pearson Education, Inc. 2008, 2011

  17. Fluorouracil (5-FU) • AntimetaboliteCategory (Pyrimadine Analog) • Action: disrupts and slows cancer cell growth in the ‘S’ Phase (DNA synthesis) of the Cell Cycle, causing cell death. • Adverse Effects • Common: N/V, stomatitis, anorexia, rash, H/A, alopecia • Serious: Bone Marrow suppression, severe N/V/D, hepato/pulmonary/neurotoxicity, mucositis, hypersensitivity reactions • Pearson Education, Inc. 2008, 2011

  18. Cyclophosphamide (Cytoxan) • AlkylatingAgent (nitrogen mustard) • Action: Cytoxanchanges or disrupts the shape of the DNA Double Helix which slows or interrupts normal cellular division and causes cellular death. • Pearson Education, Inc. 2008, 2011

  19. Cytoxan • Adverse Effects: • Common: N/V, anorexia, stomatitis, rash, H/A, alopecia, fluid retention • Serious: Bone Marrow suppression, severe N/V/D, Stevens-Johnson syndrome, hemorrhagic cystitis, pulmonary toxicity, hypersensitivity reactions , nephrotoxicity, sterility. (5% develop acute nonlymphocytic leukemia 4 or more years later.) • Pearson Education, Inc. 2008, 2011

  20. Cytoxan Contraindications: • Hypersensitivity reactions • Active infections • Severely suppressed bone marrow Drug-Drug Interactions: Cytoxan used along with Immunosuppressant agents increases risk for infection and neoplasm, bone marrow toxicity if used with allopurinol.

  21. Nursing Process: Assessment • Review Health Hx. : physical exam (current infection?), labs, current medications, neurological (mood, sensory impairment). • Caution: immunosuppressive drugs cause risk of exacerbation of Herpes Zoster in patients with Hx of herpes/chicken pox. • Pearson Education, Inc. 2008

  22. Nursing Diagnosis Which potential or actual Nursing Diagnosis do you think would apply to Mr. C.?

  23. Potential/Actual Nursing Diagnosis • Infection, Risk for, related to compromised immune system • Pain, Acute, related to Surgical Incision • Nutrition, Imbalance, Less than body requirements 2nd to n/v/d, anorexia from drug side effects, limited oral intake Pearson Education, Inc. 2008

  24. Potential/Actual Nursing Diagnosis • Skin Integrity, Impaired, related to extravasation • Body Image, Disturbed, due to physical changes as a result of drug side effects • Activity Intolerance/Fatigue/Risk for Injury/Falls, related to decreased RBC production due to drug side effect and/or poor nutritional intake, and/or muscle wasting. • Pearson Education, Inc. 2008, 2011

  25. Planning: Client Goals & Expected Outcomes • The Client will: • Experience a reduction in tumor mass or progression of abnormal cell growth • Maintain WBC’s >4,000, Platelet’s >50,000, CBC WNL, Absolute Neutrophil Count (ANC) > 500/mm3 • Demonstrate understanding of drug action by describing use, side effects & precautions • Pearson Education, Inc. 2008, 2011

  26. Planning: Client Goals & Expected Outcomes • Good pain management, tolerate gradual progression of increasing activity and maintain ADL’s, quality rest/sleep • Experience minimal or no adverse drug effects • Pearson Education, Inc. 2008, 2011

  27. ImplementationInterventions/Rationales Patient & Family Education Monitor for Hypersensitivity / Adverse Reactions -Observe for/Client immediately reports chest/throat tightness, problem swallowing, facial swelling, abd pain, H/A, dizziness

  28. Implementation/Education Protect from Infection: Monitor Labs and VSS (watch for blood dyscrasias and compromised immune system) • Client reports increasing fatigue or cough, sore throat, fever > 100.4, chills/sweats, freq./painful urination, rash/blisters • Avoid crowds/people with infections/cut flowers or change H2O daily using 1 tsp bleach • Frequent hand washing, oral hygiene, ongoing assessment of opportunistic infections • Pearson Education, Inc. 2008 • Black, J., & Hawks, J., 2009

  29. Implementation Protect from Infection Cont’ed: • Adequate nutrition/fluid intake, avoid raw fruits/vegetables (family prep/clean up, must cook thoroughly) or • Take periods of rest between activities, avoid demanding tasks/avoid activities requiring mental alertness till drug effects are known • Institute Protective Isolation if Neutrophil Count <500/ml

  30. Implementation • Assess for Pain • Provide adequate pain relief from surgery or drug adverse effects • Instruct patient/family in pain management (pain scale, when to medicate, reassessment, call for assistance, etc.). • IV Monitoring: Chemotherapy - Vesicant - risk of extravasation, causing severe tissue injury, nerve damage, infection and even loss of limb. • Pearson Education, Inc. 2010

  31. Implementation • Monitor VSS & Cardiopulmonary status including EKG changes • Client reports any respiratory distress or chest, arm, neck or back pain, edema or activity intolerance • Keeps all scheduled medical/lab appointments. Adverse effects may not appear until 6 months after treatment (tx). • Pearson Education, Inc. 2008

  32. Implementation • Monitor Renal status (I&O, lab values, daily weights). • Client reports changes in thirst, character and/or quantity of urine, low back/flank pain, trouble voiding, weight gain • Observe for blood in urine months after treatments • Drink 2-3 liters of water, in small portions, 1 day before tx, and daily for 72 hrs after tx (if no fluid restrictions & pt. can tolerate) • Encourage pt. to urinate Q1-2 hrs while awake to help avoid hemorrhagic cystitis • Pearson Education, Inc. 2008 • Nursing Drug Handbook 2008

  33. What do you see?

  34. Implementation • Monitor Gastrointestinal (GI) status & Nutrition, administer antiemetic 30 minutes before meals • Client reports anorexia, n/v/d, mouth discomfort (mucositis). • Eat small frequent meals, avoid hot, spicy, difficult to chew and strong odor foods • Drink plenty of cool liquids • Examine mouth for irritations/sores, good hygiene, use soft toothbrush, no toothpicks • Pearson Education, Inc. 2008, 2011

  35. Implementation Monitor GI and Genitourinary (GU) status • Monitor for constipation and report change in bowl habits, increase fiber, fluids and activity as ordered &/or tolerated • Report changes in menstruation, sexual function, vaginal discharge Pearson Education, Inc. 2008

  36. Implementation • Collect Fecal Occult Blood Specimens (FOB) (Drugs may cause GI bleeding) Client to report epigastric pain, coffee-ground emesis, tarry stools or frank bleeding, bruising. Avoid ASA (aspirin), NSAIDS (non-steroidal anti-inflammatory drugs). Each antineoplastic drug has a documented Nadir, the lowest point at which RBC’s, WBC’s and Platelet counts are depressed. Monitor absolute neutrophil counts. Administer growth factors as ordered (granulocyte colony-stimulating factor, etc.) which help shorten periods of neutropenia. Pearson Education, Inc. 2008, 2011

  37. Implementation • Monitor Neurological & Sensory Status • Client to report change in skin color, vision (pain, halo), hearing (ringing, buzz), gait, mood, sensations (numbness or tingling) or any dizziness, vertigo. (Cytoxin can cause ototoxicity.) Encourage periodic ear and eye exams. Assess transportation needs and ability to drive, make social service referral prn. • Limit exposure to sun, use sunscreen, sun glasses, long sleeve shirts • Pearson Education, Inc. 2008, 2011.

  38. Implementation • Monitor hair and skin status • Report any loss of or sloughing of skin or hair, rash, purple-red blisters, pruritis, acne or boils • Wear cold gel cap during chemotherapy to help minimize hair loss Pearson Education, Inc. 2008

  39. Implementation • Monitor Liver Function Tests (LFT’s) • Report jaundice, abd pain, tenderness, bloating, change in stool color or consistency • Keep all lab appointments. Caution in treating pt.’s with Diabetes Mellitus: monitor daily blood sugar levels, notify provider of hypoglycemia (<80 mg/dl) Pearson Education, Inc. 2008

  40. Implementation • Antineoplastic Administration: Nursing Policy and Procedures • Safety • Chemotherapy Certification • IV pump • Equipment & drug disposal • Spill management

  41. Evaluation of Outcomes • Client exhibits reduction of progression of Tumor mass • WBC’s >4,000, Platelet’s >50,000, • CBC & ANC WNL • Client demonstrates an understanding of drug actions by accurately describing side effects and precautions • Pearson Education, Inc. 2008

  42. Mr. C. • It is now 2 days post op and Mr. C. has had two rounds of 5FU and 4 rounds of Cytoxin. His lymph node pathology report states 12 of 17 nodes were positive for cancer cells. His pain is well controlled with the Morphine, however he has had significant N/V and has not tolerated a clear liquid diet. The MD has ordered Phenergan Suppositories 25 mg PR Q6H ATC which has provided good relief, and has changed the IV to D5 & 1/2 NS with 20meq/KCl at 125cc/hr.

  43. Mr. C. • Mr. C.’s lab results show a drop in his WBC’s to 2.2 (pre-op 4.5), Platelets 73,000 (pre-op 138,000) & ANC of 400mm3. What nursing behaviors would be appropriate?

  44. Mr. C. • The nurse assesses for infection and bleeding. After conferring with the MD, the nurse places Mr. C. on protective isolation. She educates Mr. C. that he is at greater risk of infection due to his low white blood cell count and instructs him to avoid exposure to others who are ill or infectious. She also advised Mr. C. that he may bleed or bruise more easily and to be careful to avoid any injury.

  45. Other Antineoplastic Agents • Antitumor Antibiotics: isolated from microorganisms or bacteria, are more toxic than standard antibiotics. • Action: bind to DNA, disrupting replication and or causing cell death (similar to Alkylating Agents) with similar side effects.

  46. Antitumor Antibiotic: Doxorubicin • Action: a prototype drug, Doxorubicin (Adriamycin) attaches to DNA and distorts the helix, preventing normal DNA and RNA synthesis. It is a broad spectrum antibiotic, given IV only. Doxorubicin liposomal (Doxil), has a unique method of delivery via lipid vesicles, or liposomes, which open in close proximity of cancer cells, sparing normal tissue. Very effective against solid tumors. • Pearson Education, Inc 2008, 2011.

  47. Doxorubicin60-75mg/meter squared (m2) IV q 3 weeks • Adverse Effects: • Common: acute n/v, alopecia, anorexia, stomatitis, rash, H/A • Serious: Cardiotoxicity: dysrhythmias and irreversible heart failure. Bone marrow suppression, extravasation can cause severe pain and extensive tissue damage. Severe n/v/d, mucositis, pulmonary toxicity, hypersensitivity reactions (including anaphylaxis). Acute myelogenous leukemia may occur 1-3 years later.

  48. Natural Products Category: Plant Extracts & Alkaloids • Prototype Drug: Vincristine (Oncovin) • Actions and Uses: Vincristine, a Vinca Alkaloid from the periwinkle plant, is a cell-cycle-specific agent that prevents cells from completing mitosis by interrupting the M-phase of replication, has a broad spectrum of activity and causes minimal immuno-suppression. Treats pediatric leukemia's, lymphomas, and solid tumors.

  49. Vincristine (Oncovin)1.4mg/m2 IV weekly • Adverse Effects: • Common: N/V, alopecia, anorexia, stomatitis, rash, asthenia • Serious: Bone marrow suppression, Severe n/v/d, mucositis; cardio, pulmonary, neuro and nephrotoxicity; hypersensitivity reactions (including anaphylaxis). • Pearson Education, Inc. 2008 • Nurse’s Drug Guide 2009

  50. Hormones & Hormone Antagonists • Actions and Uses: Very large doses of glucocorticoids, progestins, estrogens or androgens that block essential substances for the growth of hormone-dependant tumors of the brest or prostate. As a group, they are the least toxic of the antineoplastic drugs. • Pearson Education, Inc 2008, 2011

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