Page 23 Complete Your CE Test Online - Click Here ● ● High-dose rate implants stay in for a few minutes at a time and are taken out, although an applicator or catheter is usually left in place until the course of radiation is completed. Staff and family will need to limit the time they spend with the patient while the high-dose and low-dose devices are in place. Chemotherapy and drug treatments for cancer Chemotherapy is what most people think of when they think of cancer treatment, even though drug options have greatly expanded for many types of cancer. Chemotherapy (or chemo) is used to treat many types of cancer but it is usually not the only modality used for cancer treatment. Most often, chemotherapy is given in concert with other cancer treatments. The types of treatment depend on the type of cancer, if the cancer has spread and where, and if there are co-morbidities that call for modification of treatment. Before the patient starts chemotherapy, it is advisable to review previous teaching points, such as treatment plan, the purpose of the chemotherapy, and adjunct treatments. For those who are receiving at least part of their chemo as outpatients, appointments for lab testing and follow-up should be emphasized. Be sure to include family caregivers and other family members who may be called on for help when the patient is incapacitated in some way. Make sure they know when to call, and ways to get help during nights, weekends, and holidays. If the patient is a smoker and has not quit, this is again a good time to discuss possible supports for quitting such as nicotine replacement therapy or other pharmaceuticals. One study showed that patients who were receiving chemotherapy for leukemia who continued to smoke were more likely to have serious pulmonary infections than those who quit [194]. Purpose and goals of chemotherapy Chemotherapy works by stopping or slowing the growth of cancer cells, and is used in the following ways. It is important for the patient to know what their therapy is intended to do [152]: ● ● Treat cancer with curative intent: Chemotherapy can be used with the intent to cure, although the patient must obviously know that there is no guarantee that a cure will result. ● ● Reduce the risk of recurrence: This type of treatment is used to decrease the chance the cancer will come back by eradicating micrometastases and other cancer cells that could resume growing. ● ● Stop or slow cancer growth: Maintenance or chronic treatment in patients with cancer that is too widespread or refractory for the possibility of cure. ● ● Palliative care: Can be used for the purpose of minimizing symptoms and reducing discomfort by shrinking tumors that are causing pain and other problems. How chemo is used with other treatments When used with other treatment modalities, chemotherapy can [152]: ● ● Shrink a tumor before surgery or radiation therapy (neoadjuvant chemotherapy). ● ● Destroy cancer cells that may remain after surgery or radiation therapy (adjuvant chemotherapy). ● ● Boost effects of other treatments. ● ● Kill cancer cells that have returned or metastasized. Chemo routes Chemotherapy drugs may be given one or more of the following routes: ● ● Oral. ● ● Intravenous (IV). ● ● IM or SC injection. ● ● Intrathecal. ● ● Intraperitoneal (IP). ● ● Intra-arterial (IA). ● ● Topical (which the patient usually self-applies at home). Vascular access Despite the availability of other routes for many cancer treatment drugs, reliable venous access is essential for many types of cancer treatment. IV devices designed for short-term medical situations can quickly become impossible to maintain in the face of repeated cycles of chemotherapy. Veins become damaged from frequent entry and cannulation for medications (including irritants and vesicants), fluids, transfusions, and blood draws. It becomes a painful and sometimes futile exercise to try and replace short peripheral IV devices. Over time, the number of failed attempts to start IVs or draw blood for labs rises; and the risk of infiltration and phlebitis also increases as fewer and smaller “good” veins can be found. All of this poses risk to the patient and necessitates a long-term IV access plan, preferably before peripheral access becomes difficult. Long-term IV chemotherapy is most often given through a wide assortment of devices such as central lines, tunneled catheters, and implanted ports or reservoirs. Some of the specialized vascular access devices have two or three lumens, which can be used to give solutions that cannot be mixed. A port is a small, round disc with a penetrable top membrane connected to a catheter in a large vein, most often in the chest, which is placed under the skin during minor surgery. Special needles can be inserted into the port for chemo or drawing blood [152]. These long term access devices can also be used to give fluids, blood products, and other drugs. They can be a very convenient to draw blood, which most patients really appreciate. But all of these devices pose the risk of infection. The patient should be taught to watch for and report redness, tenderness, drainage or cording at the catheter site [152]. Pumps are often used to control how fast IV chemotherapy goes in. These may be used for inpatient or outpatient chemotherapy, and may be internal or external. Internal pumps must be positioned under the skin during surgery and refilled at intervals, so follow-up appointments should be emphasized with the patient [152]. If the patient goes home with an implanted pump, s/he must know how to care for it, and know to observe for and report swelling, drainage, redness, or pain near the injection site when any pump is in use. For external pumps, the patient and at least one family member also need to know how to operate the pump and deal with tubing, disconnections, batteries, etc. Other types of access There are also intra-arterial catheters that may be inserted for localized injection of drugs directly into a tumor area. Only trained professionals should use these devices, and patients must be well educated on safety measures and how to handle leakage or bleeding [79]. Intrathecal and intraperitoneal chemotherapy require specialized access devices that are typically inserted by physicians. Training on device use is essential for the nurse, and the patient and other staff must also understand what can and cannot be used in them. The intrathecal space is especially sensitive, and many IV drugs cannot be used for injections there without risk of death or serious damage. It is important that the pharmacist know when a drug is ordered for intrathecal use, to be sure that the right formula makes it to the patient. A bedside double-checking procedure is extremely important here and should be performed independently by two professionals. Patients who are receiving intraperitoneal chemotherapy will need to lie on one side and switch sides periodically. A number of chemotherapy drugs often given via IV can be used for intraperitoneal treatment, and the same side effects tend to result. There are additional side effects from increased pressure, such as abdominal pain, shortness of breath, and diarrhea. Besides the drugs for nausea, pain medications may be needed. Shortness of breath may be helped by raising the head of the bed to reduce pressure on the diaphragm [79]. Nursing management of access devices Many different devices are used in different settings. The nurse should thoroughly understand: how his or her patients’ devices work; how to use them; device care and maintenance; possible risks and complications of each; and how to determine when they might be failing. Documentation of assessments and maintenance are essential. Patients must be instructed on what to do at home, what to report, and how to deal with unexpected complications as well as provided a 24- hour contact number for emergencies. Chemotherapy regimens There are numerous chemotherapy drugs given in combination. Treatment is based mostly on: ● ● The type of cancer. ● ● The stage of cancer. ● ● Whether the patient has had chemo before.