#438: Chemo Basics

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In this lesson, we’re covering a topic that can seem intimidating at first – caring for patients who are undergoing chemotherapy. So let’s break this down into manageable bits so you can feel confident and prepared when you encounter chemo patients in the clinical setting or on an exam.

What is chemotherapy?

Chemotherapy is a pharmacological cancer treatment that uses cytotoxic drugs (“cyto” means cell and “toxic” means poisonous or harmful). Because cancer cells divide and replicate quickly, cytotoxic drugs target rapidly dividing cells. However, note that other cells in the body also replicate quickly such as those in the bone marrow, hair follicles and the GI tract. This is why the side effects from chemotherapy can be so widespread and cause problems such as low blood counts and hair loss.

The goals of chemotherapy vary depending on the patient’s diagnosis and stage of disease. Sometimes chemotherapy is curative, while other times it is used to control tumor growth and may be utilized prior to surgery to make the tumor more manageable. And other times, chemotherapy is palliative, meaning it is utilized to ease symptoms and improve quality of life.

Chemotherapy classifications

Chemo drugs are classified by their mechanism of action. 

• Alkylating agents such as cisplatin and ifosfamide create an unstable alkyl group to inhibit DNA replication and transcription. These drugs can cause a wide range of adverse effects including myelosuppression, nausea, vomiting, mucositis, alopecia, and neurotoxicity. Long term effects can include pulmonary fibrosis, secondary cancers, and infertility. 
• Antimetabolites such as methotrexate and gemcitabine inhibit DNA replication and can cause myelosuppression, hepatotoxicity, and nephrotoxicity. Some can cause interstitial pneumonitis while others can even lead to cardiac dysfunction and encephalopathy. 
• Antimicrotubular agents such as doxorubicin and vincristine inhibit RNA and DNA synthesis. Adverse effects from this class of drugs include myelosuppression, secondary cancers, peripheral neuropathy, mucositis, and cardiotoxicity.
• Antibiotics can also be used as chemotherapeutic agents. Examples include bleomycin and antinomycin D. These medications inhibit RNA and DNA synthesis. Common side effects include hyperpigmentation and pulmonary toxicity.
• Medications in the miscellaneous category include hydroxyurea, tretinoin, arsenic trioxide, and proteasome inhibitors. Side effects from these drugs range from dermatologic reactions and peripheral neuropathy to myelosuppression and QT prolongation (which can lead to dangerous cardiac arrhythmias).

While most chemotherapeutic agents are administered intravenously, they can also be administered orally, intrathecal, intramuscularly, and subcutaneously.

Chemotherapy Administration

As the nurse, you play an important role before, during and after chemotherapy administration. Note that unless you are “chemo certified” you will not be the one administering chemotherapy. But, you could have a patient who is on chemotherapy and still play an active role in their care. 

Pre-treatment:

Prior to chemo administration, which requires two chemo-certified RNs, you may be responsible for verifying or drawing labs and possibly administering pre-treatment medications that can help reduce side effects. These often include an antiemetic such as ondansetron and/or dexamethasone. Patients may also receive medications to mitigate hypersensitivity reactions such as acetaminophen, dexamethasone, or diphenhydramine. In some cases, IV fluids may be administered prior to the infusion to ensure the patient is well hydrated.

During treatment:

During the infusion, the patient will be monitored closely for signs of adverse effects such as nausea, vomiting, and hypersensitivity reactions. Since chemotherapy medications are considered vesicants, they can cause extensive tissue damage if they leak into surrounding tissues, so watching for extravasation is also important.

After treatment:

After the infusion, the patient is monitored for delayed reactions and adverse effects. It’s also important to instigate “chemo precautions” to keep everyone interacting with the patient safe.

Chemo precautions

Chemo precautions are a group of interventions that are followed for a certain period of time after the chemotherapy infusion. In most cases, chemo precautions are followed for 48 hours after the medication is administered. Chemo precautions include: 

• Post a “chemo precautions” sign where it will be easily visible by staff and visitors.
• Wearing the appropriate PPE, which includes a non-permeable gown, goggles or face shield, and double gloving with chemo-rated gloves when coming into contact with chemotherapy medications, body fluids or waste. When providing extended care, change gloves every 30 minutes.
• Discard all disposable items that have been contaminated by chemotherapy in the chemo waste bin. In most cases, these bins are yellow but double check at your facility to be sure.
• Double flush the toilet and close the lid when one is available.
• Dispose of linen appropriately. If linen is soiled with body fluids or waste, most facilities state it can go into the standard linen bin, though some facilities may have special linen bins for chemotherapy patients. If linen is soiled with chemotherapy medication, then it should be disposed of in the chemo waste bin or in a bin for hazardous waste spills (this may vary by facility).
• If accidentally exposed to chemotherapy medication, remove PPE and immediately wash the affected skin with soap and water (not a germicidal cleanser or cleanser with CHG). For eye exposure, flush the eye(s) with water using the emergency eye flush station for at least 15 minutes. If one is not available, utilize isotonic saline.
• If chemotherapy is spilled, follow your facility’s protocol for a hazardous waste spill. Ideally, your facility has chemo spill kits readily available.
• Dispose of used medication vials, bags, tubing, etc… in the appropriate waste bin (this may vary depending on which medication is used, so double check with the pharmacist if you are unsure).
• Do not crush or split oral chemo pills and be sure to always handle them with the appropriate gloves as you should not touch them with bare hands.

These precautions are important to follow since exposure to chemotherapy poses a significant risk for healthcare workers. Exposure to antineoplastic agents can cause bone marrow damage, damage to vital organs (liver, kidney, heart, lung), infertility, fetal harm, hearing loss, and cancer.

Common side effects of chemotherapy and how to manage them:

Chemotherapy can cause a wide range of side effects; these are the most common: 

Myelosuppression: Myelosuppression is when the bone marrow functions are diminished leading to low white blood cells (leukopenia), low red blood cells (anemia) and/or platelets (thrombocytopenia). When all cell types are affected, this is called pancytopenia. 

• Leukopenia puts the patient at increased risk for infection. When the leukopenia is severe, the patient is considered neutropenic (more on neutropenic precautions further down). In general, patients receiving chemotherapy reach the lowest point of WBC production approximately 6 to 10 days after the medication was administered. This point is called the “nadir” and precautions should be taken to prevent infection. This can include the basics such as hand hygiene, watching for fever, keeping the patient clean, changing linens daily or when soiled, and avoiding urinary catheters when possible. It’s also important to teach the patient how to recognize signs of infection, how to clean their hands properly, the importance of avoiding crowds (or wearing a mask), and how to monitor their temperature.
• Anemia leads to symptoms such as fatigue, shortness of breath, and hypotension. Symptomatic anemia is treated with blood transfusions.
• Thrombocytopenia places the patient at risk for bleeding. When the thrombocytopenia is significant, bleeding precautions should be utilized. These include no IM injections, no rectal temps, no razors, no floss, using a soft toothbrush, and avoiding medications that prevent blood clots such as heparin and aspirin.

Neutropenia: Neutropenia is present when the absolute neutrophil count (ANC) is below 1500/microL and the risk of infection is severe when the count gets below 500. Neutropenic precautions take infection control even further: 

• The patient should be in a positive pressure room to prevent contaminants from entering the environment.
• All visitors and staff must wear PPE including masks when entering the room.
• Everyone entering must wash their hands.
• No fresh flowers are allowed in the room.
• The patient should avoid uncooked foods, including fruits and vegetables (in some cases, fruits with a skin may be allowed as long as the fruit is washed thoroughly and peeled).
• The patient should also avoid undercooked foods such as meat or eggs, unpasteurized dairy products.
• Minimize procedures that puncture the skin.
• Avoid catheters, enemas, rectal suppositories, and rectal thermometers.

Neutropenic fever: Neutropenic fever is a medical emergency and it occurs when a neutropenic patient has a single temperature of greater than 100.4-degrees Fahrenheit (38-degrees Celsius). Patients with neutropenic fever have cultures drawn and given broad-spectrum IV antibiotics. In most cases, two sets of blood cultures are obtained along with a urine culture. Depending on symptoms and suspected infection, the patient may also have the sputum, stool, wound, central line, skin or nares cultured. 

Nausea and vomiting: Nausea and vomiting are very common adverse effects of chemotherapy. Treatment includes an antiemetic such as ondansetron. Other ways to manage nausea include sipping liquids slowly throughout the day, eating small meals of bland foods that are easy on the stomach (crackers, toast, plain yogurt or clear broth), and eating foods such as pickles or ginger chews. Other treatments that have been used to address nausea include aromatherapy (peppermint oil), acupuncture, guided imagery and music therapy.

Mucositis: Mucositis is a painful inflammation of the throat and mouth that can make eating difficult. A patient with mucositis should be encouraged to eat soft, bland foods that are not acidic or spicy. Medications include topical anesthetics, “Magic Mouthwash” (a blend of Maalox, diphenhydramine and lidocaine), Nystatin, and prednisone.

Diarrhea and constipation: Bowel irregularity can vary depending on the medication utilized. Interventions for diarrhea include antidiarrheal medications and fluid replacement as needed. Constipation is treated with dietary adjustments (increased fiber, staying hydrated), increased activity (such as walking) and medications such as stool softeners or laxatives.

Alopecia: Hair loss is another common and undesirable side effect of chemotherapy. One promising treatment is scalp cooling, which involves wearing a cold cap during the infusion. Hair loss can also be extremely emotional for patients, so empathetic understanding is vital.

Fatigue: Fatigue is very common amongst patients undergoing chemotherapy. Interventions include balancing rest with activity, and encouraging light activity such as walking when the patient is able.

Weight loss and appetite changes: The weight loss with chemotherapy can be significant, and getting patients to take in sufficient calories can be challenging. Stress, depression, pain, mucositis, diminished appetite, altered sense of taste or smell, and nausea can all contribute to lower caloric intake. The key intervention is to determine the underlying cause and address that whenever possible. In addition, medications such as dexamethasone, metoclopramide, and megastrol can increase appetite. General tips for patients with appetite changes and weight loss include: 

• Eat smaller meals or snacks throughout the day
• Avoid filling up on liquids when eating; drink water and other liquids between meals
• Eat cold or room temperature foods if strong food odors trigger nausea
• Prioritize favorite foods by eating them at any time of day (such as breakfast foods for dinner)
• Make sure meals and snacks include protein
• Eat when hungry instead of waiting for typical mealtimes

Chemo brain: Chemo brain refers to changes in focus, thinking and memory due to chemotherapy. Another term commonly used is “brain fog.” Encourage the patient to exercise as able as this can help improve brain function. Other interventions include using a planner, making lists, following a set routine, and focusing on one task at a time. Some individuals find it helpful to exercise their brain by solving puzzles, playing an instrument or learning something new.

Anxiety and depression: Understandably, anxiety and depression can be common while undergoing treatment for cancer. Some patients benefit by getting more restful sleep and increasing physical activity. Others may benefit from therapy or joining a support group. In some cases, medication may be utilized such as an SSRI (fluoxetine, sertraline, paroxetine) or a benzodiazepine (lorazepam, diazepam, alprazolam). Complementary therapies for anxiety and depression include yoga, reflexology, music therapy, acupuncture and light therapy.

Neuropathy: Some chemotherapy drugs cause peripheral neuropathy which is numbness, tingling, pain, and even weakness in the affected extremity. Peripheral neuropathy can be so severe it puts your patient at high risk for falls and can drastically limit mobility. Medications used to treat neuropathy include gabapentin, duloxetine, lidocaine patches, and narcotics. 

For more lessons related to oncology nursing, explore here!

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Last Updated on September 28, 2025 by Maureen Osuna, MSN, RN