Page 46 nursing.elitecme.com Complete Your CE Test Online - Click Here After a few days of rest, the patient gets an IV infusion of the blood- forming stem cells [196]. After receiving the stem cells, there is the wait for engraftment, when the new stem cells start making new blood cells. Rarely, a graft will not take, i.e. the donor cells can be destroyed. During this procedure, when the patient has little to no immune function (either because the graft has not started working or because of immunosuppressant drugs), latent infections the recipient had can recrudesce and cause complications, some severe. After blood counts return to normal, it takes much longer for the immune system to fully recover: several months for autologous transplants and one to two years for allogeneic or syngeneic transplants [196]. Who receives stem cell transplants? Stem cell transplants are most often used to help people with leukemia, neuroblastoma, multiple myeloma, and some lymphomas. Stem cell transplants for other types of cancer are being studied in clinical trials [196]. Side effects of stem cell transplants The high doses of cytotoxic chemotherapy for conditioning before stem cell transplant can cause severe pancytopenia with anemia and high risk of bleeding and infection. The progress of the transplant is monitored by frequent blood counts. As the newly transplanted stem cells produce blood cells, blood counts go up. Many of the side effects are similar to those seen with chemotherapy and high-dose radiation, although there is one side effect that is specific to the allogeneic transplant process, graft-versus-host disease (GVHD). Allogeneic transplant recipients often develop graft-versus-host disease, in which white blood cells from the donor (the graft) recognize cells in the recipient’s body (the host) as foreign and attack them. This problem can damage skin, liver, gut, and many other organs. It can occur early or later, and may be short-term or become chronic. Graft-versus-host disease can be treated with steroids or other drugs that suppress the recipient’s immune system. The closer the match between the donor and recipient, the less likely graft-versus- host disease is to occur [196]. GVHD is related to the graft-versus- cancer effect, but the graft-versus-cancer can occur even in well- matched donor-recipient pairs. Special diet needs, GI disturbances, and chemoradiation side effects The conditioning regimen given before a stem cell transplant can cause side effects that make it hard to eat, e.g. mouth sores and nausea. People who are having trouble eating might find it helpful to speak with a dietitian (see “Diarrhea” and other problems listed in the “Symptom Management” section) [196]. The toxicities of chemotherapy are typically magnified due to the extreme doses used in HSCT. Treatment assessments and interventions At each visit with the outpatient, the nurse should assess adherence to appointment, laboratory monitoring, at-home medications, symptom control, and other parts of the treatment plan. The nurse should also inquire about side effects, new problems and concerns, reassess previously identified problems, and assess for any unmet physical or psychosocial needs, educational and informational needs, and any referral needs. The patient and family may need additional information on drug-food interactions, what to do when doses of medication are missed, oral chemotherapy drugs, and more. Inpatients are easier to observe, but big-picture assessment may be lost in all of the treatment and side effects that are likely to be going on. If the patient has a family caregiver visiting, that is usually a good time to go over the concerns the patient and family have about the treatment effects and coping at home. Involving home caregivers In assessing symptoms during treatment, it is often helpful to talk with family members or others who are caring for the patient at home. An open-ended question about how the patient seems to be functioning at home is a good way to start. Family members who help care for the patient will often share information that gives the cancer team a clearer picture of how fatigue, nausea, pain, and other symptoms are affecting the patient’s and family’s life. Sometimes the oncology nurse may get a more forthright answer if the patient is not in the room. The caregiver may be taking over more and more of the patient’s care on days that the patient is having trouble taking care of himself or herself, which the patient is sometimes reluctant to share. Caregivers often are the first observers to report mental status changes such as confusion and delirium, of which the patient may be unaware or embarrassed to bring up. In-home and family caregiving will not be covered in this course, but there is a list of resources at the end of this module that can help prepare the caregiver for the sometimes-stressful job of caring for a loved one at home during a serious illness. It is important to include caregivers in care planning, teaching, and assessment. Side effects of cancer treatment Chemotherapy and radiation not only kill fast-growing cancer cells, but also can kill or slow the growth of healthy cells that grow and divide quickly, such as those that line the mouth and gut, or hair follicles. Damage to these healthy cells often causes side effects, such as mouth sores, nausea, and hair loss. These kinds of side effects can sometimes be controlled with medications and other measures, and they usually disappear after chemotherapy is finished [152]. There are innumerable side effects of chemotherapy, from the bothersome (such as alopecia or dry skin) to the life-threatening (such as tumor lysis syndrome or Stevens-Johnson syndrome, a blistering, desquamating rash). Some of these are rare and unexpected, some are predictable and preventable, but nearly all respond best to early recognition and intervention. Chemotherapy can be life-threatening for some people. Side effects profiles are different for every cancer drug, and oncology nurses must spend time reviewing them. Of course, some patients pose the challenge of having side effects that are not on the drug’s adverse effects list. Most of the common symptoms oncology nurses deal with are drug side effects, although some, such as pain, are sometimes in part due to the cancer. Frequent new drug approvals complicate recognition of side effects: Adding to the difficulty of assessment is the fact that there are many new drugs introduced for cancer treatment every year. For example, 24 drugs were on the newly-FDA-approved list for cancer indications in 2014 and 2015 (total for both years). Out of the 24 drugs that were approved for actual cancer treatment over those two years: ● ● Seven were for primary cancer treatment as well as second-line treatments. ● ● Seven were for specific genetic alterations of a cancer. ● ● Eleven were for relapsed, locally advanced, previously treated, refractory, or metastatic cancers (one of these also had a gene- specific type so it counts in two categories). Two additional drugs for symptom management were oral antiemetics, one as a combination and one meant to be given in combination with a previously-approved drug. Some of the newer drugs were approved on a fast track, which means that less information is available on their side effects and adverse outcomes than the older ones with which professionals have had more observation time and experience. This means more responsibility on cancer care teams to identify potentially serious new problems with these drugs (i.e. those that are not currently listed in the Adverse