Chapter 46: Antineoplastic Drugs Part 2: Cell Cylce-Nonspecific and Miscellaneous Drugs

Question 1

• There are currently two broad classes of cell cycle–nonspecific cancer drugs:

Answer 1

: alkylating drugs and cytotoxic antibiotics.

Question 2

• The alkylating drugs commonly used in clinical practice in the United States today fall into three categories

Answer 2

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.

Question 3

• Classic alkylators (nitrogen mustards) include

Answer 3

chlorambucil, cyclophosphamide, ifosfamide, mechlorethamine, melphalan, nitrosoureas, carmustine, lomustine, and streptozocin

Question 4

• Miscellaneous alkylators include

Answer 4

include altretamine, busulfan, carboplatin, cisplatin, dacarbazine, oxaliplatin, procarbazine, temozolomide, and thiotepa

Question 5

• The alkylating drugs work by

Answer 5

preventing cancer cells from reproducing, altering the chemical structure of the cells’ deoxyribonucleic acid (DNA).

Question 6

• Other severe toxicities associated with the use of cytotoxic antibiotics

Answer 6

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).

Question 7

• Perform a head-to-toe physical assessment that includes attention to the following:

Answer 7

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.

Question 8

• For patients receiving alkylating drugs…

Answer 8

bone marrow suppression (carboplatin), pulmonary fibrosis (busulfan), nephrotoxicity and/or neurotoxicity (more with cisplatin than carboplatin), and hemorrhagic cystitis (cyclophosphamide) may occur.

Question 9

• One of the major adverse effects associated with the use of cytotoxic antibiotics

Answer 9

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.

Question 10

• With use of bevacizumab, an angiogenesis inhibitor

Answer 10

, 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.

Question 11

• Most nursing interventions are focused on

Answer 11

preventing infection, conserving energy, preventing bleeding and injury, and reducing nausea

Question 12

• Oncologic emergencies occur

Answer 12

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.

Question 13

4. 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

Answer 13

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.

Question 14

Extravasated site….. First, stop the IV infusion immediately and have another nurse notify the prescriber. However, do not remove the IV catheter.

Answer 14

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.

Question 15

How would the nurse define the term nadir to a patient?

Answer 15

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.

Question 16

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:

Answer 16

nitrogen-containing bases (adenine, guanine, thymine, and

cytosine, abbreviated A, G, T, and C, respectively)

Question 17

busulfan… severe adverse effects

Answer 17

busulfan Pulmonary fibrosis

Question 18

carboplatin* … severe adverse effects

Answer 18

carboplatin* Nephrotoxicity, neurotoxicity, bone marrow suppression

Question 19

cisplatin … severe adverse effects

Answer 19

cisplatin Nephrotoxicity, peripheral neuropathy, ototoxicity

Question 20

cyclophosphamide… … severe adverse effects

Answer 20

cyclophosphamide Hemorrhagic cystitis

Question 21

extravasation
may occur with central lines and PICC lines due to dislodging of the access
catheter, venous thrombosis, and catheter breakage

Answer 21

Blood needs to be aspirated

prior to administration to check for patency

Question 22

Extravasation may be suspected if the

following occurs at either a central line site, PICC line site, or peripheral IV site:

Answer 22

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

Question 23

Steps to help manage extravasation of an irritant and/

or a vesicant include the following:

Answer 23

(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

Question 24

The available
cytotoxic antibiotics, categorized according to the specific
subclass to which they belong, are as follows:
Anthracyclines

Answer 24

• daunorubicin
• doxorubicin
• epirubicin
• idarubicin
• valrubicin

Question 25

Other cytotoxic antibiotics

Answer 25

• bleomycin (which is actually a cell cycle–specific drug)
• dactinomycin
• mitomycin
• mitoxantrone
• plicamycin

Question 26

bleomycin… adverse effects

Answer 26

bleomycin Pulmonary fibrosis, pneumonitis

Question 27

dactinomycin,

daunorubicin adverse effects

Answer 27

Liver toxicity, tissue damage in the event of

extravasation, heart failure

Question 28

doxorubicin, idarubicin… adverse effects

Answer 28

doxorubicin, idarubicin Liver and cardiovascular toxicities

Question 29

mitomycin… adverse effects

Answer 29

mitomycin Liver, kidney, and lung toxicities

Question 30

mitoxantrone… adverse effects

Answer 30

mitoxantrone Cardiovascular toxicity

Question 31

plicamycin… adverse efrfects

Answer 31

plicamycin Tissue damage in the event of extravasation

Question 32

TREATMENT OF DOXORUBICIN

EXTRAVASATION

Answer 32

1. Cool the site to patient tolerance for 24 hours.
2. Elevate and rest the extremity for 24 to 48 hours, and then have the patient
   resume normal activity as tolerated.
3. If pain, erythema, or swelling persists beyond 48 hours, discuss with the
   prescriber the need for surgical intervention or other treatment options

Question 33

Severe cases of cardiomyopathy are associated with large cumulative
doses of

Answer 33

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

Question 34

The cytotoxic antibiotics that are used in chemotherapy interact
with many drugs

Answer 34

They all tend to produce increased toxicities
when used in combination with other chemotherapeutic drugs
or with radiation therapy.

Question 35

Angiogenesis

Answer 35

is the creation of
new blood vessels that supply oxygen and other blood nutrients
to growing tissues

Question 36

Bevacizumab (Avastin) was the first antineoplastic drug in a new
category—angiogenesis inhibitors

Answer 36

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

Question 37

Humanization

Answer 37

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.

Question 38

The various drugs in the miscellaneous category of antineoplastics
are used to treat a wide range of neoplasms

adverse reactions…

Answer 38

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)

Question 39

Hydroxyurea (Hydrea, Droxia) is an antimetabolite that interferes
with the synthesis of DNA by inhibiting the incorporation of
thymidine into DNA

Answer 39

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

Question 40

Hydroxyurea

interacts with

Answer 40

the anti-HIV drugs zidovudine, zalcitabine, and didanosine

Concurrent use with fluorouracil
increases the risk of neurotoxic symptoms

Question 41

NURSING DIAGNOSES pg 757

Answer 41

1. Decreased cardiac output related to the adverse effect of cardiotoxicity
   associated with cytotoxic antibiotics
2. Diarrhea related to the adverse effects of antineoplastic drugs
3. Imbalanced nutrition, less than body requirements, related
   to loss of appetite, nausea, and vomiting, as a result of antineoplastic
   therapy

Question 42

Most nursing interventions are

focused on

Answer 42

preventing infection, conserving energy, preventing

bleeding and injury, and reducing nausea.

Question 43

nursing

considerations for these drugs include

Answer 43

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

Question 44

If platelet count falls below

pg 758

Answer 44

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

Question 45

in case of an allergic or anaphylactic

reaction.

Answer 45

keep epinephrine, antihistamines, and
antiinflammatory drugs available in case of an allergic or anaphylactic
reaction

Question 46

Some of the complications

that are potential emergencies include

Answer 46

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

Question 47

INDICATIONS OF AN
ONCOLOGIC EMERGENCY

pg 759

Answer 47

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

Question 48

Advise the patient to avoid

Answer 48

aspirin, ibuprofen, and products

containing these drugs to help prevent excessive bleeding

Question 49

Encourage forcing of fluids up to 3000 mL/day, if not contraindicated,

Answer 49

to prevent dehydration and further weakening
and, in the case of cyclophosphamide therapy, to prevent or
help manage hemorrhagic cystitis

Question 50

What is considered a major dose-limiting side effect of doxorubicin (Adriamycin)?

Answer 50

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.

Question 51

Which laboratory test result would cause the nurse to question administration of hydroxyurea (Hydrea)?

Answer 51

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.

Question 52

The nurse will suspect which type of cancer in a patient receiving tamoxifen (Soltamox)?

Answer 52

Tamoxifen is an antiestrogen drug useful in treating malignancies that require estrogen for growth, such as breast cancer.

Question 53

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?

Answer 53

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.

Question 54

When assessing a patient for adverse effects related to cisplatin (Platinol), the nurse will monitor for which adverse effects?

Answer 54

Cisplatin is known to be ototoxic, nephrotoxic, neurotoxic, and emetogenic

Question 55

Which are known adverse effects of alkylating agents?

Answer 55

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.

Question 56

What are the major adverse effects specific to the cytotoxic antibiotics?

Answer 56

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