Chemotherapy/Biotherapy
Administration
(Pre, Immediate and Post)
Objectives

At the completion of this session
the participant will be able to
◦ Identify components of pretreatment assessment
◦ Calculate BSA and confirm
chemotherapy/biotherapy
dosage
◦ Describe required family
teaching prior to
chemotherapy/biotherapy
administration
Objectives

At the completion of this session
the participant will be able to
◦ Describe safety measures to
verify chemotherapy/biotherapy
orders
◦ List steps in preparation of
chemotherapy/biotherapy
◦ Identify nursing measures for
different routes of
administration
Pre-administration
Preparation

Components to safe preparation
for chemotherapy/biotherapy
administration:
◦ Individual treatment plans
◦ Pretreatment physiologic
evaluations
◦ Dosing of
chemotherapy/biotherapy in
children and adolescents
◦ Preparation of the setting
◦ Family assessment and
education
Individual
Treatment Plan



Review the individual treatment plan
for any required pretreatment
laboratory tests, imaging studies or
specialized organ evaluations.
Schedule all required studies
Check the general treatment plan for
any amendments and updates that may
alter therapy. Clarify any discrepancies
Follow institutional policies for verifying
chemotherapy/biotherapy orders
Pretreatment Physiological
Assessment

The following should be assessed and
completed prior to starting
chemotherapy/biotherapy:
◦ Review the individual's experience
with previous
chemotherapy/biotherapy regarding
side effects or toxic effects from the
medications
◦ Review with the child and family the
effectiveness of supportive care with
past chemotherapy/biotherapy
◦ Perform a thorough physical
assessment
Pretreatment Physiological
Assessment



Assess that all pretreatment laboratory
and imaging studies are complete and
within acceptable limits. Ascertain that
results of all pretreatment studies have
been evaluated
Calculate the patient’s absolute
neutrophil count (ANC) prior to
administering chemotherapy using the
following formula:
 ANC = (% segs + % bands) x total
white blood count
Verify within institutions ANC parameters
prior to beginning treatment
Pretreatment Physiological
Assessment



Begin the process of physiologic
preparation for
chemotherapy/biotherapy. This will
include hydration and plans for control
of nausea and vomiting
Obtain baseline vital signs
Deliver premedications for supportive
care and schedule at appropriate
intervals
Dosing of
Chemotherapy/Biotherapy
When calculating doses in
pediatrics, the actual body weight
is used
 Chemotherapy/biotherapy doses
are generally calculated using
body surface area. Accuracy of
weight and height measurements
is essential to correct dosing of
chemotherapy/biotherapy

◦ BSA = Ht (cm) X Wt (kg) ÷ 3600, then square
root the result
Dosing of
Chemotherapy/Biotherapy
Milligram/kilogram formulas are used
to calculate chemotherapy/biotherapy
doses in children weighing less than 10
kilograms or who are less than 12
months of age
 Maintenance fluids are calculated using
the BSA. A formula for calculating
fluids is 1500ml/m2/24 hours
 Toxicity from prior therapy may
necessitate dose reductions. Organ
dysfunction may necessitate dose
reduction

Preparation of
Setting

The following should be obtained
before beginning
chemotherapy/biotherapy:
◦
◦
◦
◦
Personal protective equipment (PPE)
Disposal equipment
Chemotherapy spill kit
Emergency drugs and equipment
available
◦ Infusion pump
Preparation of
Setting

The following should be
obtained before beginning
chemotherapy:
◦ IV fluids and tubing
◦ Premedications (e.g.,
antiemetics)
◦ Emesis basin
Family Assessment &
Education

Accomplish the following
prior to each
chemotherapy/biotherapy
course:
◦ Identify barriers to learning,
including primary language,
anxiety and illiteracy
◦ Explore with the child and
family any personal
preferences they have
regarding chemotherapy
administration, such as the
time they prefer treatment to
start, any rituals the child
finds helpful and supportive
care
Family Assessment &
Education

Accomplish the following prior to
each chemotherapy course (cont.):
◦ Review the medications to be given.
Include the name of the medication,
administration route, length of therapy
and administration schedule
◦ Discuss potential side effects, when
they might occur and how they may be
managed
◦ Review plans for the management at
home after the
chemotherapy/biotherapy is complete
Principles of
Administration
Comprehensive patient
assessment
 Review/verification of
treatment plan
 Preparation
 Safe handling principles
 Patient/family education
 Follow institutional guidelines

Verification

Patient-Specific Information
◦
◦
◦
◦
Patient identification
Allergies
Current height, weight, BSA
Pre-treatment parameters such
as pertinent lab values that
influence dosage
◦ Pre-treatment diagnostic testing
results necessary to begin
chemotherapy/biotherapy cycle
Verification

Chemotherapy Orders & select
Biotherapy Orders per institution
◦ The chemotherapy/Biotherapy order should
include: (2 RN Check)
 Patient identification
 Patient-specific measurements (body
weight, height, and body surface area)
 The full generic name of the drug
 The drug dose, dose calculation, dose
modification calculation, route, frequency,
administration guidelines such as duration
of infusion and rate of administration
 Required monitoring
 Admixture fluid type, volume and rate
Preparation

Preparation for
Administration
◦ Assure test dose and/or premedications and hydration are
administered
◦ Protect light-sensitive drugs
◦ Inspect medication prior to
administration for discoloration
and particulate matter
◦ Inspect medication label for drug
name, dose and expiration date
Preparation

Preparation for
Administration
◦ Assure that the mode of
administration is consistent with
knowledge of vesicants and
irritants and matches order, label
and protocol
◦ Avoid bringing medications
administered by different routes to
the patient’s room at the same time
◦ Ensure patient/family education
completed
Chemotherapy/Biotherapy
Administration

To ensure safe
administration:
◦ Follow institutional
and OSHA guidelines
for
administration/dispos
al
◦ Administer
medications in
accordance with
institutional
medication
and nursing practice
policies
and guidelines
Administration

To ensure safe
administration:
◦ Utilize the 6 rights
of safe
administration:






Right
Right
Right
Right
Right
Right
patient
medication
dose
route
time
fluid/volume
◦ Use leur lock
connections and
safety needles
Administration

Oral
◦ Do not handle without PPE
◦ Tablets should not be crushed
and dissolved outside of a
biological safety hood
◦ If an oral dose is vomited,
establish guidelines for
repeating the dose with the
ordering clinician
Administration

Oral
◦ Creative measures for helping small
children tolerate oral medications
◦ School-age children and adolescents,
who are responsible for taking their
own oral chemotherapy/biotherapy,
should have their doses verified by an
adult
◦ Liquids should be given in an oral type
syringe to deliver an accurate dose of
the entire drug and minimize
spills/residue
Administration

Intramuscular/Subcutaneous
◦ Site selection
 Injection into larger muscles is
recommended
 Avoid injection into areas of pre-existing
tenderness and/or ecchymosis or nodules
from prior injections
 Volume for single injection is sitedependent
◦ Smallest gauge needle as appropriate
for child’s size
◦ Ensure age-appropriate preparation and
teaching are completed with the patient
and family
Administration

Intramuscular/Subcutaneous
◦ If the patient is mildly thrombocytopenic,
after the injection, apply pressure directly
to injection site for 5 minutes to prevent
formation of a hematoma
◦ Apply topical anesthetic agent or ice to the
injection site prior to the injection to
minimize pain
◦ Dispose of waste in accordance with OSHA
and institutional policies and guidelines
◦ Rotate the site of injection for subsequent
injections
Administration
Intravenous (IV) access must be
established and patency verified
prior to administration
 IV access may be established via:

◦ Peripheral IV catheter
◦ Central venous catheter(CVC)
 External catheters
 Broviac, Hickman, Groshong, PICC
 Implanted ports
 Medi-Port, Port-a-CathTM
Administration

Peripheral IV
◦ Avoid site selection distal to any recent
venipuncture
◦ A new peripheral IV site is
recommended if an already existing
peripheral IV site is older than 24 hours
◦ Areas over joints or bony prominences
and the antecubital fossa should be
avoided
◦ During IVP vesicant administration,
blood return should be verified after
each 0.5cc-1cc injected
Administration

Implanted Central Venous
Catheters
◦ Assure the selected site is stabilized
just prior to injection/infusion to
avoid accidental needle punctures
and/or accidental drug exposure. For
long-term infusions, tape the site
securely, without obstructing your
view of the site, so that signs of
extravasation can be promptly
identified
Administration

CVC and continuous infusion
◦ Blood return should be verified
immediately prior to beginning the
infusion
◦ The CVC site should be evaluated for
signs of inflammation and extravasation
of a vesicant infusion every hour
throughout the infusion
◦ Secure IV tubing with leur lock
connections
◦ Use gauze and/or plastic backed drape
beneath connections during access or
de-access procedures
Administration

IV
Administration
Methods
◦ IV Push (IVP)
◦ Bolus infusion
◦ Continuous
infusion
IV Push
Administration
IV push therapy is infused in
less than 5 minutes
 Methods

◦ Direct push: Directly infusing
chemotherapy agents into the IV
access device using a syringe
◦ Stop cock method: Using a 3way stop-cock to administer
chemo
Continuous IV
Infusion



Infusions should not be
interrupted unless
absolutely necessary
Infusion pump should be
used
Ensuring drug is infused
in prescribed time
◦ Some protocols allow
for increasing dose by
10%
◦ Other protocols do not
allow for change of
rate
◦ Check with the
prescribing clinician if
infusion will not finish
at prescribed time
Vesicants/Irritants

Vesicants: are a class of drugs,
that when extravasated cause
severe tissue damage and may
lead to necrosis (Jenkins, 1998)
 Irritants: are agents that have
the potential to cause phlebitis
and irritate tissue if extravasated,
they do not cause the degree of
tissue damage and necrosis that
vesicants do
Monitoring for Potential
Side Effects

Flare Reaction
◦ A localized venous inflammatory
reaction in response to an IV agent
◦ Signs and symptoms include pain,
redness at the site and along the vein
length
◦ Treatment/management: Once
extravasation is ruled out, the vein
should be flushed with a compatible
IV fluid and resolution of the redness
should follow
Monitoring for Potential
Side Effects

Hemodynamic monitoring
◦ Monitor hemodynamic status
taking vital signs as indicated
throughout administration
Monitoring for Potential
Side Effects

Fluid status
◦ Monitor fluid status: measure
urine output and urine specific
gravity as needed throughout
administration
◦ Monitor hydration status: oral
intake, skin turgur, mucous
membranes, and tears, assess the
impact of nausea and vomiting on
oral intake
Monitoring for Potential
Side Effects

Specific side
effects:
◦ Monitor for the
occurrence of
side effects
◦ Monitor the
effectiveness of
the anti-emetic
regimen
Monitoring for Potential Side
Effects – Allergic Reactions
Allergic reactions and anaphylaxis
are hypersensitivity reactions to a
foreign protein that can occur
immediately or within minutes to
hours after exposure to the
offending protein
 The reaction can be localized or
systemic

IgE Mediated vs Non IgE
Mediated
IgE Mediated
 Specific IgE is
produced at
initial exposure
 Reaction occurs
at subsequent
exposures
 Anaphylaxis
Non IgE Mediated
 No prior
sensitization
required
 Reaction can occur
at initial exposure
 Anaphylactoid
◦ Non-Allergic reaction
◦ Allergic Reaction
Chung, C 2008
Signs and Symptoms
Infusion Reaction
Allergic Reaction/Hypersensitivity
 Pruitis/itching
 Rash/desquamation
 Urticaria: hives, welts, wheals
 Rigors/chills
 Headache
 Arthralgia/myalgia
 Fatigue (asthenia, lethargy, mailaise)
 Dizzyness
 Sweating
 Nausea/Vomiting
 Cough, Dyspnea, bronchospasm
 Hypotension/hypertension
Heinz-Josef Lenz, 2007
 Tachycardia

Severe Infusion Reaction
Life threatening and may appear
within minutes of exposure
 Severe bronchospasm, laryngeal
edema, respiratory distress, and/or
cutaneous and gastrointestinal,
leading to hypotensive crisis

Chung, C 2008
Infusion Reactions
Prevention/Prophylaxis
 Acetominophen
 Antihistamines
 Corticosteroids
 H2 antagonist
Management
 Antihistamines
 Corticosteroids
 Epinephrine
 Oxygen
 Vasopressors
 Bronchodilators
Mild to Moderate Reactions
Resume infusion at 50% reduction of
infusion rate once
symptoms are completely resolved
Chung, C 2008
Monitoring for Potential Side
Effects – Allergic Reactions

Nursing interventions
◦ Stop Infusion
◦ Maintain airway, IV access, vital signs
◦ Administer medications promptly in
the event of a reaction:




acetaminophen (Tylenol)
diphenhydramine (Benadryl)
Steroids
epinephrine (Adrenaline, Sus-phrine)
 Know the actual doses of medications that
would be needed specifically for an individual
patient receiving a potentially anaphylactic
medication
Documentation








Date and time
Venipuncture site (central or peripheral)
Venipuncture needle type, gauge, length
Verification of blood return, prior to,
during and after infusion
Drug name, dose, route and volume in ml
Type and amount of IV flush solution
used
Infusion duration
Document per institution guidelines
Documentation








Antiemetic, dose, time
Pre-med, dose, time
Hydration type and
amount
Method of
administration
Adverse reactions/side
effects
Patient tolerance of
chemotherapy/biothera
py
Ability to tolerate fluid
and food
Patient and family
education
Patient and Family
Education

Prior to administration and during
administration of
chemotherapy/biotherapy
◦ Name of medications to be given
◦ Administration route and any routespecific step-by-step administration
guidelines
◦ Expected or potential side effects and
when they may occur
◦ Safe handling considerations
Patient and Family
Education
Supportive care measures
should be a part of the
education plan
 If a patient is prescribed
growth factors, side effects
and detailed administration
techniques should be
reviewed

Patient and Family
Education
Ensure discharge teaching is
completed with the patient and
family, and they have all
necessary medications,
equipment, supplies and disposal
instructions, if the patient is to
receive medications at home
 Patients and family members
should be aware of reportable
symptoms and side effects, as
well as who to contact and the
telephone/pager numbers

Discharge Planning
CVC teaching
 Home care referral
 Review expected or
potential side
effects they may
experience at home
 Chemotherapy/
biotherapy schedule
(calendar)
 Follow-up
appointment

Patient and Family
Outcomes
Accurate and safe
administration of
chemotherapy/
biotherapy
 Effective
management of
nausea and
vomiting
 Effective pain and
symptom
management
 Effective
anticipatory
guidance

Demonstrate the
technical skills
necessary to
provide care at
home
◦ Medication
administration,
central line
catheter care, etc.
 Effective
documentation of
chemotherapy/
biotherapy
administration at
home
