Chapter 46: Antineoplastic Drugs Part 2: Cell Cylce-Nonspecific and Miscellaneous Drugs Flashcards
• There are currently two broad classes of cell cycle–nonspecific cancer drugs:
: alkylating drugs and cytotoxic antibiotics.
• The alkylating drugs commonly used in clinical practice in the United States today fall into three categories
classic alkylators (the nitrogen mustards); nitrosoureas, which have a different chemical structure than the nitrogen mustards but also work by alkylation; and miscellaneous alkylators, which also have a different chemical structure than the nitrogen mustards but are known to work at least partially by alkylation.
• Classic alkylators (nitrogen mustards) include
chlorambucil, cyclophosphamide, ifosfamide, mechlorethamine, melphalan, nitrosoureas, carmustine, lomustine, and streptozocin
• Miscellaneous alkylators include
include altretamine, busulfan, carboplatin, cisplatin, dacarbazine, oxaliplatin, procarbazine, temozolomide, and thiotepa
• The alkylating drugs work by
preventing cancer cells from reproducing, altering the chemical structure of the cells’ deoxyribonucleic acid (DNA).
• Other severe toxicities associated with the use of cytotoxic antibiotics
have bone marrow suppression as a common toxicity. The one exception is bleomycin, which instead causes pulmonary toxicity (pulmonary fibrosis and pneumonitis).
heart failure (daunorubicin) and, in rare cases, acute left ventricular failure (doxorubicin).
• Perform a head-to-toe physical assessment that includes attention to the following:
skin turgor and level of moisture, and integrity of the skin and oral mucosa; baseline level of neurologic functioning, including level of consciousness, alertness, motor and sensory intactness, reflexes, and presence of any abnormal sensations; bowel sounds, bowel patterns, and inquiry into any problems such as diarrhea, constipation, nausea, vomiting, or reflux; color, amount, and odor of urine; breath sounds as well as respiratory rate, rhythm, and depth; and heart sounds.
• For patients receiving alkylating drugs…
bone marrow suppression (carboplatin), pulmonary fibrosis (busulfan), nephrotoxicity and/or neurotoxicity (more with cisplatin than carboplatin), and hemorrhagic cystitis (cyclophosphamide) may occur.
• One of the major adverse effects associated with the use of cytotoxic antibiotics
is pulmonary fibrosis; therefore medical testing (e.g., radiographs, computed tomographic [CT] scans, magnetic resonance imaging [MRI] scans, arterial blood gas levels, and partial pressures of CO2 and O2) may be ordered.
• With use of bevacizumab, an angiogenesis inhibitor
, assess cardiovascular, central nervous system (CNS), GI tract, and renal functioning; and assess metabolism level due to adverse effects of hypotension or hypertension, headache, pain, dizziness, nausea, vomiting, diarrhea, and nephrotoxicity.
• Most nursing interventions are focused on
preventing infection, conserving energy, preventing bleeding and injury, and reducing nausea
• Oncologic emergencies occur
as a consequence of damage occurring to rapidly dividing normal cells as well as rapidly dividing cancerous cells and may be life-threatening.
• Some of the complications that are potential emergencies include infections, infusion reactions and allergy, stomatitis with severe ulceration, bleeding, metabolic aberrations, severe diarrhea, renal failure, liver failure, and cardiotoxicity, including dysrhythmia or heart failure.
- An OSHA-approved spill kit needs to be used to clean up the spilled chemotherapy solution, and the items used for cleaning should be disposed in a special hamper/container designated for chemotherapy waste
The nurse will need to wash the skin with soap and copious amounts of water, according to facility policy, and complete the appropriate paperwork for reporting this incident. Follow-up education may be needed to review the proper handling of chemotherapy fluids and the use of personal protective equipment.
Extravasated site….. First, stop the IV infusion immediately and have another nurse notify the prescriber. However, do not remove the IV catheter.
typical antidote, use a premixed 1:1 solution of sodium bicarbonate and sterile normal saline in a 0.5 mEq/mL solution. Inject 2 to 6 mL of this solution through the existing IV line, and give multiple subcutaneous injections into the extravasated site. The total dose must not exceed 10 mL of 0.5-mEq/mL solution. In addition, apply cold compresses to the area and elevate the limb if possible.
How would the nurse define the term nadir to a patient?
Nadir refers to the average number of days it takes for a chemotherapeutic drug to have its peak effect on the bone marrow, which would coincide with the patient’s lowest blood count and highest risk for infection and/or bleeding.
These components make up what is
called the “backbone” of the DNA strands. These two strands are
chemically linked to each other by the third DNA structural element:
nitrogen-containing bases (adenine, guanine, thymine, and
cytosine, abbreviated A, G, T, and C, respectively)
busulfan… severe adverse effects
busulfan Pulmonary fibrosis
carboplatin* … severe adverse effects
carboplatin* Nephrotoxicity, neurotoxicity, bone marrow suppression
cisplatin … severe adverse effects
cisplatin Nephrotoxicity, peripheral neuropathy, ototoxicity
cyclophosphamide… … severe adverse effects
cyclophosphamide Hemorrhagic cystitis
extravasation
may occur with central lines and PICC lines due to dislodging of the access
catheter, venous thrombosis, and catheter breakage
Blood needs to be aspirated
prior to administration to check for patency
Extravasation may be suspected if the
following occurs at either a central line site, PICC line site, or peripheral IV site:
complaints of burning, stinging pain, or any other acute change of sensation at the
site or along the chest wall, neck, or shoulder (central line); or leakage, swelling,
or induration at the site
Steps to help manage extravasation of an irritant and/
or a vesicant include the following:
(1) Stop the infusion immediately and contact
the prescriber, leaving the intravenous catheter in place. (2) Next, it is usually
recommended to aspirate any residual drug and/or blood from the catheter.
(3) Consult institutional policy or guidelines or the pharmacist regarding the use of
antidotes, application of hot or cold packs and/or sterile occlusive dressings, and
elevation and rest of the affected limb. Document the extravasation incident with
attention to all phases of the nursing process related to the problem
The available
cytotoxic antibiotics, categorized according to the specific
subclass to which they belong, are as follows:
Anthracyclines
- daunorubicin
- doxorubicin
- epirubicin
- idarubicin
- valrubicin
Other cytotoxic antibiotics
- bleomycin (which is actually a cell cycle–specific drug)
- dactinomycin
- mitomycin
- mitoxantrone
- plicamycin
bleomycin… adverse effects
bleomycin Pulmonary fibrosis, pneumonitis
dactinomycin,
daunorubicin adverse effects
Liver toxicity, tissue damage in the event of
extravasation, heart failure
doxorubicin, idarubicin… adverse effects
doxorubicin, idarubicin Liver and cardiovascular toxicities
mitomycin… adverse effects
mitomycin Liver, kidney, and lung toxicities
mitoxantrone… adverse effects
mitoxantrone Cardiovascular toxicity
plicamycin… adverse efrfects
plicamycin Tissue damage in the event of extravasation
TREATMENT OF DOXORUBICIN
EXTRAVASATION
- Cool the site to patient tolerance for 24 hours.
- Elevate and rest the extremity for 24 to 48 hours, and then have the patient
resume normal activity as tolerated. - If pain, erythema, or swelling persists beyond 48 hours, discuss with the
prescriber the need for surgical intervention or other treatment options
Severe cases of cardiomyopathy are associated with large cumulative
doses of
doxorubicin. Routine monitoring of cardiac ejection
fraction with multiple-gated acquisition (MUGA) scans,
cumulative dose limitations, and the use of cytoprotective drugs
such as dexrazoxane can decrease the incidence of this devastating
toxicity
The cytotoxic antibiotics that are used in chemotherapy interact
with many drugs
They all tend to produce increased toxicities
when used in combination with other chemotherapeutic drugs
or with radiation therapy.
Angiogenesis
is the creation of
new blood vessels that supply oxygen and other blood nutrients
to growing tissues
Bevacizumab (Avastin) was the first antineoplastic drug in a new
category—angiogenesis inhibitors
In the case of malignant tumors, angiogenesis
that occurs within the tumor mass promotes continued
tumor growth. As a tumor enlarges, its central tissues gradually
die off (necrosis)Thus, inhibiting this process offers a
promising new mechanism for antineoplastic drug action. Bevacizumab
is a recombinant “humanized” monoclonal immunoglobulin
G1 antibody derived from mouse antibodies… MURINE
Humanization
The
scientific name for any compound derived from mouse tissue
is murine. Humanization refers to the use of recombinant DNA
techniques to make animal-derived antibody proteins more
genetically similar to those of humans.
The various drugs in the miscellaneous category of antineoplastics
are used to treat a wide range of neoplasms
adverse reactions…
the cardiovascular
system (hypertension or hypotension, deep vein thrombosis),
central nervous system (pain, headache, dizziness, asthenia),
skin (alopecia, dry skin), metabolism (weight loss, hypokalemia),
gastrointestinal (GI) tract (nausea, vomiting, diarrhea,
epistaxis, abdominal pain, constipation, GI hemorrhage), kidneys
(nephrotoxicity with proteinuria), hematopoeitic system
(leukopenia), and respiratory tract (infection)
Hydroxyurea (Hydrea, Droxia) is an antimetabolite that interferes
with the synthesis of DNA by inhibiting the incorporation of
thymidine into DNA
More specifically, it inhibits ribonucleotide
reductase, which is involved in conversion of ribonucleotides to
deoxyribonucleotides. It works primarily in the S and G1 phases
of the cell cycle, which makes it a cell cycle–specific drug
Hydroxyurea
interacts with
the anti-HIV drugs zidovudine, zalcitabine, and didanosine
Concurrent use with fluorouracil
increases the risk of neurotoxic symptoms
NURSING DIAGNOSES pg 757
- Decreased cardiac output related to the adverse effect of cardiotoxicity
associated with cytotoxic antibiotics - Diarrhea related to the adverse effects of antineoplastic drugs
- Imbalanced nutrition, less than body requirements, related
to loss of appetite, nausea, and vomiting, as a result of antineoplastic
therapy
Most nursing interventions are
focused on
preventing infection, conserving energy, preventing
bleeding and injury, and reducing nausea.
nursing
considerations for these drugs include
taking vital signs every 1
to 2 hours, or as needed during infusion forcing fluids; monitoring
intake and output; following orders for intravenous
therapy for hydration; and monitoring any vomiting. Contact
the prescriber if vomiting is uncontrolled
If platelet count falls below
pg 758
100,000 platelets/mm3 or leukocyte
count falls below 2000 cells/mm3, therapy may need to be temporarily
halted until counts rise toward the normal values
in case of an allergic or anaphylactic
reaction.
keep epinephrine, antihistamines, and
antiinflammatory drugs available in case of an allergic or anaphylactic
reaction
Some of the complications
that are potential emergencies include
infections, infusion
reactions and allergy, stomatitis with severe ulceration, bleeding,
metabolic aberrations, severe diarrhea, renal failure, liver
failure, and cardiotoxicity, including dysrhythmia or heart failure
INDICATIONS OF AN
ONCOLOGIC EMERGENCY
pg 759
Fever and/or chills with a temperature higher than 100.5° F (38.1° C)
New sores or white patches in the mouth or throat
Swollen tongue with or without cracks and bleeding
Bleeding gums
Dry, burning, “scratchy,” or “swollen” throat
A cough that is new and persistent
Changes in bladder function or patterns
Blood in the urine
Changes in GI or bowel patterns, including “heartburn” or nausea, vomiting,
constipation, or diarrhea lasting longer than 2 or 3 days
Blood in the stools
Advise the patient to avoid
aspirin, ibuprofen, and products
containing these drugs to help prevent excessive bleeding
Encourage forcing of fluids up to 3000 mL/day, if not contraindicated,
to prevent dehydration and further weakening
and, in the case of cyclophosphamide therapy, to prevent or
help manage hemorrhagic cystitis
What is considered a major dose-limiting side effect of doxorubicin (Adriamycin)?
Patients receiving doxorubicin need to be monitored for cardiac toxicity. There is a lifetime limited dose that patients are allowed to receive to minimize the occurrence of cardiomyopathy.
Which laboratory test result would cause the nurse to question administration of hydroxyurea (Hydrea)?
Hydroxyurea causes bone marrow suppression, which is evidenced by a decrease in red blood cells, white blood cells, and platelets. A thrombocyte count of 8000/mm3 is significantly lower than normal. All the other options are within normal limits.
The nurse will suspect which type of cancer in a patient receiving tamoxifen (Soltamox)?
Tamoxifen is an antiestrogen drug useful in treating malignancies that require estrogen for growth, such as breast cancer.
The nurse is discussing the use of alkylating drugs with the patient. What is the best way to describe the mechanism of action of alkylating drugs on cancer cells?
The alkylating drugs work by preventing cancer cells from reproducing. Specifically, they alter the chemical structure of the cells’ DNA, which is essential to the reproduction of any cell. This stops the cancer from reproducing or spreading. Cytotoxic antibiotics interact with DNA through a process called intercalation, in which the drug molecule is inserted between the two strands of a DNA molecule, ultimately blocking DNA synthesis.
When assessing a patient for adverse effects related to cisplatin (Platinol), the nurse will monitor for which adverse effects?
Cisplatin is known to be ototoxic, nephrotoxic, neurotoxic, and emetogenic
Which are known adverse effects of alkylating agents?
Alkylating drugs are capable of causing pulmonary fibrosis, nephrotoxicity, neurotoxicity, bone marrow suppression, peripheral neuropathy, ototoxicity, and hemorrhagic cystitis. The adverse effects of these drugs are important because of their severity, but they can often be prevented or minimized by prophylactic measures. Cardiotoxicity is not listed as an adverse effect for this class of drugs.
What are the major adverse effects specific to the cytotoxic antibiotics?
As with all of the antineoplastic drugs, cytotoxic antibiotics have the undesirable effects of hair loss, nausea and vomiting, and myelosuppression. Major adverse effects specific to the cytotoxic antibiotics include pulmonary fibrosis, pneumonitis, liver toxicity, heart failure, cardiovascular toxicity, tissue damage in the event of extravasation, kidney toxicity, and lung toxicity. This class of drugs is not known for neurotoxicity
