1. PYRAMID POINTS CHAPTER 52: ANTINEOPLASTIC MEDICATIONS

2. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-2 PYRAMID POINTS I. Antineoplastic Medications  Description Kill or inhibit reproduction of neoplastic cells Kill or inhibit reproduction of neoplastic cells  Side effects Low white blood cell (WBC) count (neutropenia) Low white blood cell (WBC) count (neutropenia) Thrombocytopenia Thrombocytopenia Fatigue, nausea, vomiting Fatigue, nausea, vomiting

3. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-3 PYRAMID POINTS I. Antineoplastic Medications (continued)  Interventions Monitor complete blood cell (CBC) count, including WBC, platelets, electrolytes Monitor complete blood cell (CBC) count, including WBC, platelets, electrolytes Initiate bleeding precautions if thrombocytopenia occurs, including use of soft toothbrush, electric razor Initiate bleeding precautions if thrombocytopenia occurs, including use of soft toothbrush, electric razor Initiate neutropenic precautions if neutropenia occurs, including no fresh fruits and vegetables, no uncooked fish, protective isolation Initiate neutropenic precautions if neutropenia occurs, including no fresh fruits and vegetables, no uncooked fish, protective isolation

4. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-4 PYRAMID POINTS I. Antineoplastic Medications (continued)  Interventions (continued) Monitor for petechiae, ecchymosis, bleeding gums, epistaxis Monitor for petechiae, ecchymosis, bleeding gums, epistaxis Avoid intramuscular (IM) injections, venipuncture Avoid intramuscular (IM) injections, venipuncture Administer antiemetics several hours prior to chemotherapy Administer antiemetics several hours prior to chemotherapy Pregnant nurses should avoid chemotherapy preparation, administration Pregnant nurses should avoid chemotherapy preparation, administration Encourage hydration, promoting at least 2000 mL/day Encourage hydration, promoting at least 2000 mL/day Administer allopurinol (Zyloprim) as prescribed Administer allopurinol (Zyloprim) as prescribed Prepare IV chemotherapy in air-vented space per agency protocol Prepare IV chemotherapy in air-vented space per agency protocol

5. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-5 PYRAMID POINTS I. Antineoplastic Medications (continued)  Interventions (continued) Discard intravenous (IV) equipment in designated containers Discard intravenous (IV) equipment in designated containers Monitor for extravasation Monitor for extravasation Instruct client in potential side effects, including hair loss, mucositis, infection, bleeding episodes Instruct client in potential side effects, including hair loss, mucositis, infection, bleeding episodes Instruct client about need for contraception during treatment Instruct client about need for contraception during treatment Live vaccinations should not be administered. Live vaccinations should not be administered.  Anaphylactic reactions Obtain allergy history Obtain allergy history Monitor for signs of anaphylactic reactions Monitor for signs of anaphylactic reactions Airway first priority if anaphylaxis occurs Airway first priority if anaphylaxis occurs

6. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-6 PYRAMID POINTS II. Alkylating and Alkylating-like Medications  Description Affects synthesis of DNA by causing cross-linking of DNA to inhibit cell reproduction Affects synthesis of DNA by causing cross-linking of DNA to inhibit cell reproduction  Side effects Cisplatin (Platinol) may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, nephrotoxicity Cisplatin (Platinol) may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, nephrotoxicity Cyclophosphamide (Cytoxan, Neosar) may cause alopecia, gonadal suppression, hemorrhagic cystitis, hematuria Cyclophosphamide (Cytoxan, Neosar) may cause alopecia, gonadal suppression, hemorrhagic cystitis, hematuria

7. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-7 PYRAMID POINTS II. Alkylating and Alkylating-like Medications (continued)  Interventions Assess vital signs, CBC results Assess vital signs, CBC results Withhold medication if platelet count below Withhold medication if platelet count below 75,000 cells/µL or WBC count below 4,000 cells/µL as prescribed Administer antiemetic 30 minutes before antineoplastic medication as prescribed Administer antiemetic 30 minutes before antineoplastic medication as prescribed Monitor for side effects development Monitor for side effects development Instruct client to eat diet low in purines Instruct client to eat diet low in purines

8. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-8 PYRAMID POINTS III. Antitumor Antibiotic Medications  Description Interfere with DNA, RNA synthesis Interfere with DNA, RNA synthesis  Side effects Vesication Vesication Doxorubicin (Adriamycin, Doxil) and idarubicin (Idamycin) may cause cardiotoxicity Doxorubicin (Adriamycin, Doxil) and idarubicin (Idamycin) may cause cardiotoxicity Pulmonary toxicity can occur with bleomycin (Blenoxane) Pulmonary toxicity can occur with bleomycin (Blenoxane)  Interventions Assess for myocardial toxicity, dyspnea, dysrhythmias, hypotension when administering doxorubicin, idarubicin Assess for myocardial toxicity, dyspnea, dysrhythmias, hypotension when administering doxorubicin, idarubicin Monitor pulmonary status when administering bleomycin Monitor pulmonary status when administering bleomycin

9. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-9 PYRAMID POINTS IV. Antimetabolite Medications  Description Halt synthesis of cell protein Halt synthesis of cell protein Replace normal proteins required for DNA synthesis Replace normal proteins required for DNA synthesis  Side effects Fluorouracil (Adrucil) may cause alopecia, stomatitis, diarrhea, phototoxicity Fluorouracil (Adrucil) may cause alopecia, stomatitis, diarrhea, phototoxicity Methotrexate may cause alopecia, stomatitis, hyperuricemia, photosensitivity, hepatoxicity Methotrexate may cause alopecia, stomatitis, hyperuricemia, photosensitivity, hepatoxicity  Interventions When administering fluorouracil, assess for signs of cerebellar dysfunction, stomatitis, diarrhea When administering fluorouracil, assess for signs of cerebellar dysfunction, stomatitis, diarrhea

10. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-10 PYRAMID POINTS IV. Antimetabolite Medications (continued)  Interventions (continued) When administering methotrexate in large doses, prepare to administer leucovorin as prescribed to prevent toxicity (known as leucovorin rescue) When administering methotrexate in large doses, prepare to administer leucovorin as prescribed to prevent toxicity (known as leucovorin rescue) When administering fluorouracil or methotrexate, instruct client to wear sunscreen or protective clothing When administering fluorouracil or methotrexate, instruct client to wear sunscreen or protective clothing

11. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-11 PYRAMID POINTS V. Antimitotic Medications (Vinca Alkaloids)  Description Prevent mitosis, causing cell death; Prevent mitosis, causing cell death; Prevent cell division Prevent cell division  Side effects Neurotoxicity with vincristine (Oncovin, Vincasar) Neurotoxicity with vincristine (Oncovin, Vincasar)  Interventions Monitor for neurotoxicity with vincristine including numbness, tingling in fingers, toes Monitor for neurotoxicity with vincristine including numbness, tingling in fingers, toes Monitor for constipation, paralytic ileus Monitor for constipation, paralytic ileus

12. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-12 PYRAMID POINTS VI. Hormonal Medications and Enzymes  Description Suppress immune system; block normal hormones in hormone- sensitive tumors Suppress immune system; block normal hormones in hormone- sensitive tumors  Side effects Tamoxifen citrate decreases effects of estrogen Tamoxifen citrate decreases effects of estrogen  Interventions Monitor vital signs Monitor vital signs Monitor serum calcium levels with androgens Monitor serum calcium levels with androgens Monitor pancreatic function with asparaginase (Elspar) Monitor pancreatic function with asparaginase (Elspar) Encourage fluid intake of 2 to 3 L/day as prescribed Encourage fluid intake of 2 to 3 L/day as prescribed Monitor uric acid, cholesterol serum levels Monitor uric acid, cholesterol serum levels Monitor for signs of hemorrhagic cystitis Monitor for signs of hemorrhagic cystitis Instruct client about potential for alterations in sexual characteristics Instruct client about potential for alterations in sexual characteristics

13. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-13 PYRAMID POINTS VII. Immunomodulator Agents: Biological Response Modifiers  Description Stimulate immune system to recognize cancer cells and take action to eliminate or destroy them Stimulate immune system to recognize cancer cells and take action to eliminate or destroy them Colony-stimulating factors induce more rapid bone marrow recovery after suppression by chemotherapy Colony-stimulating factors induce more rapid bone marrow recovery after suppression by chemotherapy

14. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-14 PYRAMID POINTS VII. Immunomodulator Agents: Biological Response Modifiers (continued)  Medications include interferon alfa-2a; recombinant interferon-alfa-2b (Intron A); rituximab (Rituxan); sargramostim (Leukine); filgrastim (Neupogen); epoetin alfa (Epogen)  Side effects include flu-like symptoms; nausea and vomiting; nephrotoxicity (interferon alfa); edema and dyspnea (epoetin alfa)  Interventions Monitor vital signs Monitor vital signs Monitor liver and renal function tests Monitor liver and renal function tests Teach clients to avoid persons who have received live immunizations Teach clients to avoid persons who have received live immunizations Monitor CBC results Monitor CBC results

15. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-15 PYRAMID POINTS VIII. Gene Therapy  Description Allows the client’s immune system to be better able to recognize cancer cells as non-self Allows the client’s immune system to be better able to recognize cancer cells as non-self

16. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-16 PYRAMID POINTS IX. Targeted Therapy  Description Monoclonal antibodies that target a cellular element of the cancer cell or medications that work at the gene level Monoclonal antibodies that target a cellular element of the cancer cell or medications that work at the gene level  Side effects Monoclonal antibodies can cause allergic reactions Monoclonal antibodies can cause allergic reactions

17. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-17 PYRAMID POINTS XI. Other Antineoplastic Medications  Altretamine (Hexalen)  Denileukin diftitox (Ontak)  Gemcitabine (Gemzar)  Irinotecan (Camptosar)  Paclitaxel (Abraxane, Taxol, Onxol)  Pegaspargase (Oncaspar)  Topotecan (Hycamtin)  Trastuzumab (Herceptin)  Bexarotene (Targretin)

18. ADULT HEALTH: Antineoplastic Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.52-18 The client receiving antineoplastic medications by the intravenous (IV) route has ongoing monitoring of serum laboratory results to monitor for adverse medication effects. The nurse should prepare to institute bleeding precautions if which of the following results is telephoned to the nursing unit by the laboratory staff? 1. Clotting time of 12 minutes 2. Ammonia level of 28 mcg/dL 3. White blood cell count (WBC) 4,500 cells/mm³ 4. Platelet count of 50,000 cells/mm³