Chemotherapy/Biotherapy Administration (Pre, Immediate and Post)

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

2. Objectives • At 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

3. Objectives • At 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

4. Pre-administration Preparation • Components 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

5. Individual Treatment 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

6. Pretreatment Physiological Assessment • 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

7. Pretreatment Physiological Assessment • Assess 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

8. Pretreatment Physiological Assessment • Begin the process of physiologic preparation for chemotherapy/biotherapy. This will include hydration and plans for control of nausea and vomiting • Obtain baseline vital signs • Deliver premedications for supportive care and schedule at appropriate intervals

9. Dosing of Chemotherapy/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

10. Dosing of Chemotherapy/Biotherapy • Milligram/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

11. Preparation of Setting • The following should be obtained before beginning chemotherapy/biotherapy: • Personal protective equipment (PPE) • Disposal equipment • Chemotherapy spill kit • Emergency drugs and equipment available • Infusion pump

12. Preparation of Setting • The following should be obtained before beginning chemotherapy: • IV fluids and tubing • Premedications (e.g., antiemetics) • Emesis basin

13. Family Assessment & Education • 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

14. Family Assessment & Education • 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

15. Principles of Administration • Comprehensive patient assessment • Review/verification of treatment plan • Preparation • Safe handling principles • Patient/family education • Follow institutional guidelines

16. Verification • Patient-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

17. Verification • Chemotherapy 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

18. Preparation • Preparation 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

19. Preparation • Preparation 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

20. Chemotherapy/Biotherapy Administration • To ensure safe administration: • Follow institutional and OSHA guidelines for administration/disposal • Administer medications in accordance with institutional medication and nursing practice policies and guidelines

21. Administration • 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

22. Administration • Oral • 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

23. Administration • Oral • 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

24. Administration • Intramuscular/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

25. Administration • 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

26. Administration • Intravenous (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

27. Administration • 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 antecubitalfossa should be avoided • During IVP vesicant administration, blood return should be verified after each 0.5cc-1cc injected

28. Administration • Implanted 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

29. Administration • CVC 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

30. Administration • IV Administration Methods • IV Push (IVP) • Bolus infusion • Continuous infusion

31. IV Push Administration • IV 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

32. Continuous IV Infusion • 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

33. Vesicants/Irritants • Vesicants: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

34. Monitoring for Potential Side 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

35. Monitoring for Potential Side Effects • Hemodynamic monitoring • Monitor hemodynamic status taking vital signs as indicated throughout administration

36. Monitoring for Potential Side Effects • Fluid 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

37. Monitoring for Potential Side Effects • Specific side effects: • Monitor for the occurrence of side effects • Monitor the effectiveness of the anti-emetic regimen

38. Monitoring for Potential Side Effects – 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

39. IgE Mediated Specific 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 IgE Mediated vs Non IgE Mediated Chung, C 2008

40. Signs and Symptoms Infusion Reaction • Allergic Reaction/Hypersensitivity • Pruitis/itching • Rash/desquamation • Urticaria: hives, welts, wheals • Rigors/chills • Headache • Arthralgia/myalgia • Fatigue (asthenia, lethargy, mailaise) • Dizzyness • Sweating • Nausea/Vomiting • Cough, Dyspnea, bronchospasm • Hypotension/hypertension • Tachycardia Heinz-Josef Lenz, 2007

41. Severe 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

42. Prevention/Prophylaxis Acetominophen Antihistamines Corticosteroids H2 antagonist Management Antihistamines Corticosteroids Epinephrine Oxygen Vasopressors Bronchodilators Infusion Reactions Mild to Moderate Reactions Resume infusion at 50% reduction of infusion rate once symptoms are completely resolved Chung, C 2008

43. Monitoring for Potential Side Effects – 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

44. Documentation • Date and time • Venipuncture site (central or peripheral) • Venipuncture needle type, gauge, length • Verification of blood return, prior to, during and after infusion • Drug name, dose, route and volume in ml • Type and amount of IV flush solution used • Infusion duration • Document per institution guidelines

45. Documentation • 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

46. Patient and Family Education • Prior 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

47. Patient and Family Education • Supportive 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

48. Patient and Family Education • Ensure 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

49. Discharge Planning • CVC teaching • Home care referral • Review expected or potential side effects they may experience at home • Chemotherapy/ biotherapy schedule (calendar) • Follow-up appointment

50. Patient and Family Outcomes • 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