Cisplatin

an antineoplastic medication that can cause renal toxicity. Assessment of renal function includes
laboratory values and urine output.

Warfarin (Coumadin)
Anticoagulant given to clients with a mechanical valve replacement
To determine if the client is receiving an appropriate dose, the INR needs to be checked
regularly. A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. The nurse should not
administer warfarin without checking the INR first. If the INR is >3.5, the nurse should hold the
dose and contact the health care provider for further direction.

Radiation therapy to the head and neck can decrease a client's oral intake due to the development
of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry
mouth).

These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on
the client's nutritional status.
The nurse teaches the client to:
 Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol.
 Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow.
 Use artificial saliva to manage xerostomia and the production of thick saliva due to altered
salivary gland function. Sipping water throughout the day is equally effective and less expensive.
 Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake
 need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using
soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis.

Tumor lysis syndrome (TLS)

A potential complication of chemotherapy
A rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular
ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids
produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing
calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are
deposited into the kidneys, causing renal injury.
Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not
affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the
administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an
adult male is 4.4–7.6 mg/dL and female is 2.3-6.6 mg/dL.

Severe anemia
A normal hemoglobin level for an adult male is 13.2-17.3 g/dL and female is 11.7-15.5 g/dL. Will
have tachycardia, which will maintain cardiac output. Shortness of breath (dyspnea) may occur due to an
insufficient number of red blood cells. The respiratory system must increase the respiratory rate to
maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced
blood flow to the skin.

** Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and
occult gastrointestinal bleeding. Clients age ≥50 should be screened for colorectal cancer. Early signs
include anemia.
Oral mucositis
inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral
hygiene practices that minimize oral mucositis and promote comfort include the following:
 Cleansing the mouth with normal saline after meals and at bedtime to promote oral health
 Use of a soft-bristle toothbrush to decrease gum irritation
 Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain
 Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to
therapy
 Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort
 avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes.
 Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor,
prevents oral mucositis in clients diagnosed with hematologic malignancies. However, it does
not help with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain caused by
mucositis.

Clopidogrel (Plavix)
platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial
infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease.
can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care
provider (HCP) of the low platelet count (normal: 150,000-400,000/mm before administering

Calcium acetate (PhosLo)

control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the
intestines and excreting it in the high (normal adult: 2.4-4.4 mg/dL)

Magnesium sulfate
used to correct hypomagnesemia and treat torsades de pointes and seizures associated with
eclampsia. normal adult: 1.5-2.5 mEq/L

Metformin (Glucophage)
first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated
hemoglobin (A1C) measures the total hemoglobin that has glucose attached to it, expressed as a
percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and
reflects glycemic control over an extended period. The recommended A1C level for a client with diabetes
is <7%.

Warning signs of cancer

A mnemonic to remember the warning signs of cancer is CAUTION and includes the following:
Change in bowel or bladder habits
 Black stool may be a sign of colon cancer. Painless hematuria is a symptom of bladder cancer.
A sore that does not heal
 A sore that bleeds and does not heal may be an indication of skin cancer
Unusual bleeding or discharge
 Unusual bleeding or discharge from the vagina may indicate cancer of the cervix or endometrium
Thickening or lump in the breast or elsewhere
 A lump in the breast or testicles might be a warning sign of breast or testicular cancer
Indigestion or difficulty swallowing
 Indigestion or difficulty swallowing that does not go away could be a sign of gastric or
esophageal cancer
Obvious change in a wart or mole
 A change in color, size, or shape of a wart or mole may indicate skin cancer
Nagging cough or hoarseness
 A cough that lingers may be a symptom of lung cancer. Hoarseness may be a sign of cancer of
the larynx.
Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin
(orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also
indicate malignancy and require further workup.

Enoxaparin (Lovenox)
low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and
knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy
includes:

1. Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin.
2. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-
degree angle.
3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT
rub the site with the hand. Using an ice cube on the injection site can provide relief.
4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal
supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can
increase the risk of bleeding.
5. Monitor complete blood count (CBC) to assess for thrombocytopenia.

requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of

unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR
monitoring. Clients on these medications should avoid aspirin and NSAIDs.

Radiation contamination (and chemotherapy)

affects rapidly proliferating (dividing) cells first, such as those of the oral mucosa, gastrointestinal tract,
and bone marrow.
followed by tissues with slowly proliferating cells (eg, cartilage, bone, kidney). As a result, early
manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood
cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts.

The examination for skin cancer follows the ABCDE rule:

1. Asymmetry (eg, one half unlike the other)
2. Border irregularity (eg, edges are notched or irregular)
3. Color changes and variation (eg, different brown or black pigmentation)
4. Diameter of 6 mm or larger (about the size of a pencil eraser)
5. Evolving (eg, appearance is changing in shape, size, color)
Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication
that there is blood beneath the skin, as in petechiae and/or purpura.
Pus or purulent drainage is usually indicative of an infectious process, not cancer.

Lymphedema
the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or
radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid
can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor
function may be impaired. The presence of lymphedema increases the client's risk for infection or injury
of the affected limb.
Interventions to manage lymphedema include:
 Decongestive therapy (massage technique to mobilize fluid)
  Compression sleeves or intermittent pneumatic compression sleeve
o Compression sleeves are graduated with increased distal pressure and less proximal
pressure.
o Clothing should also be less constrictive at the proximal arm and over the chest.
 Elevation of arm above the heart
 Isometric exercises
 Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure
measurements, and injections (eg, vaccinations) on the affected limb
 Injury prevention (limb less sensitive to temperature changes)
Infection prevention (limb more prone to infection through skin breaks)

Neutropenia an ANC below 1,000/mm3

An ANC below 500/mm3 is defined as severe neutropenia and is a critical emergency.
The normal range for a WBC count is 4,000-11,000/mm3
Client needs reverse or protective isolation from organisms that people or objects may have that the client
lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be
equipped with HEPA (high-efficiency particulate air) filtration (or positive pressure air flow).
Until the room can be readied, the client should be protected with a mask and separated from infectious
clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and
undercooked meat. In addition, no infectious health care providers (eg, with colds) should care for the
client.

Thrombocytopenia (low platelets)

can result from bone marrow suppression caused by chemotherapy.
normal range (150,000-400,000/mm3. Spontaneous or surgical bleeding from thrombocytopenia rarely
occurs with a platelet count of >50,000/mm3 (50 × 109/L).

Epoetin alfa (human recombinant erythropoietin)

a hematopoietic growth factor. The erythropoietin is produced in the kidney and stimulates bone marrow
production of red blood cells (RBCs), a process called erythropoiesis. Epoetin alfa is used to stimulate
RBC production but is not typically prescribed unless the client has symptomatic anemia with
hemoglobin of <10 g/dL.

Teletherapy (external beam radiation therapy)

experience significant effects to the skin of the treatment area. Teaching essential skin care standards to
these clients is focused on preventing infection and promoting healing of the affected skin.
Key measures of skin care that clients receiving teletherapy should take include:
 Protect the skin from infection by not rubbing, scratching, or scrubbing
o Wear soft, loose-fitting clothing
o Use soft, cotton bed sheets and towels
o Pat skin dry after bathing
o Avoid applying bandages or tape to the treatment area
 Cleanse the skin daily by taking a lukewarm shower
o Use mild soap without fragrance or deodorant
o Do not wash off any radiation ink markings
 Use only creams or lotions approved by the health care provider (HCP)
o Avoid over-the-counter creams, oils, ointments, or powders unless specifically
recommended by the HCP as they can worsen any irritation
 Shield the skin from the effects of the sun during and after treatment
o Avoid tanning beds and sunbathing
o Wear a broad-brimmed hat, long sleeves, and long pants when outside
 o Use a sunscreen that is SPF 30 or higher
 Avoid extremes in skin temperature
o Avoid heating pads and ice packs
o Maintain a cool, humid environment for comfort

Filgrastim (Neupogen) and pegfilgrastim (Neulasta)

stimulate neutrophil production and are given prophylactically or if the client has an infection and more
neutrophils are needed to fight it

Colorectal cancer
the third most common cancer and the second leading cause of cancer deaths affecting both genders
equally.
Medical risk factors include a personal or family history of inflammatory bowel disease. Lifestyle risk
factors include a history of obesity, a diet high in red meat, cigarette smoking, and alcohol consumption.

Medications commonly prescribed for a client with an open fracture include:

 Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora
(Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection
 Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain
associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be
prescribed
 Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent
infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or
unknown
 Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and
pain
 Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia
Internal radiation (brachytherapy)
involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually
24–72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of
radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the
following nursing measures is vital as the client receiving brachytherapy emits radiation.
Following the principles of time, distance, and shielding provides staff and visitors protection from
exposure to radiation.
1. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the
room to 30 minutes per shift.
o Cluster nursing care to minimize exposure to the radiation source
o Rotate daily staff responsibilities to limit time spent in the client room
o All staff must wear a dosimeter film badge when assigned to care for a client receiving
internal radiation
o No individuals who are pregnant or under age 18 may be in the room
2. All staff and visitors must keep the maximum distance possible from the radiation
source. Maintaining a distance of at least 6 feet is an established standard.
o Assign the client to a private room with a private bath
o Keep the door to the room closed
o Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door
o Instruct the client to remain on bedrest to prevent dislodgement of the implant
 3. Shielding with lead diminishes exposure to radiation. All staff providing nursing care that
requires physical contact must wear a lead apron.\
The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the
radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never
touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead
container.

Polycythemia vera (PV)

a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of
red blood cells (RBCs).
Treatment of PV usually includes periodic phlebotomy, the removal of 300 to 500 milliliters of blood
through venipuncture, to reduce the RBC count and achieve a hematocrit of less than 45%. Initially,
clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then
monitored monthly, and additional blood draws performed as necessary.
taught preventive measures (elevating the legs when sitting, support stockings, stayig hydrated) and
symptoms to report. They should take measures to prevent dehydration, and avoid iron-rich foods and
hot showers/baths.
at risk for developing thrombus due to the increased volume, viscosity, and stasis of their blood. Client
reports of swelling, redness, or tenderness in the legs should be followed up immediately. Stroke is
another potential complication.

Oropharyngeal candidiasis/thrush (moniliasis)

is a fungal infection of skin or mucous membranes. It resembles curdled milk and can bleed when
removed. The etiology may be due to not rinsing the mouth after steroid inhaler use. It is treated with
antifungal suspensions (nystatin) and is nonurgent.

Shingles (herpes zoster)

is reactivation of dormant varicella virus. The lesions follow the nerve dermatome and can be quite
painful. Incidence increases after age 50. Active chickenpox requires airborne and contact precautions,
but not the shingles with crusted lesions, especially if the lesions are covered with clothes. It can be
contagious to individuals who have not had varicella or who are immunocompromised.

Folliculitis
usually due to the presence of staphylococci in moist areas where there is friction. It is most common in
the scalp, beard, and extremities in men. It can be treated with medicated soap, topical antibiotics, and
warm compresses.

A new-onset finding is more concerning than chronic or expected findings. There is a risk of spinal cord
compression from a metastatic tumor in the epidural space. The classic symptoms are localized,
persistent back pain; motor weakness; and sensory changes (eg, numbness, paresthesia). There can also
be autonomic dysfunction, reflected by bowel or bladder dysfunction.
Neurologic changes are a priority because the symptoms are subtle and time sensitive for permanent
negative outcomes. Bone is a common site for metastasis due to its vascularity.
Pulmonary embolism (PE)
Early identification of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage)
can have a positive effect on client outcome. Death from (PE) is often attributed to a missed diagnosis
This postoperative client is at greatest risk due to the presence of the following 4 risk factors:
 Abdominal cesarean section surgery (endothelial damage)
 Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood)
  Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate
postoperative period and epidural anesthesia (venous stasis)
 Postpartum state (hypercoagulability of blood)

Tamoxifen
Selective estrogen receptor modulators
In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of
estrogen-receptive breast cancer cells.
However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive
endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to
cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in
postmenopausal women can be a sign of endometrial cancer
Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke,
pulmonary embolism, deep vein thrombosis).
Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore,
monitoring for life-threatening side effects is very important.
Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common
not associated with significant immunosuppression although it may rarely cause leukopenia.

Lymph nodes
Ordinarily are not palpable in adults. a lymph node that is palpable, superficial, small (0.5-1 cm), mobile,
firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent
mastectomy (trauma) with resulting inflammation and lymph flow interference.
A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to
inflammation but hard or fixed nodes could indicate malignancy.

** A bitter almond smell on the client's breath is a classic sign of cyanide poisoning.
** Fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to
person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised
pustules.
**Drug-induced thrombocytopenia may result in bleeding; however, heparin-induced thrombocytopenia
has an added risk of thrombosis. The nurse should monitor platelet levels of clients on heparin and report
a decrease of ≥50% from baseline or a drop below 150,000/mm3 to the health care provider.
**Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab,
adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major
concern. Therefore, all clients must receive a TST to rule out latent TB.
**Petechiae (small circles) and purpura (blotches) are reddish/purple rashes that do not blanch. They
indicate systemic blood dyscrasias and are a priority for treatment.
**The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate,
the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is
called polycythemia.

With a heparin drip infusion, the goal is to reach the therapeutic range of the drug's effect and not the
"normal" or "control value." Once the therapeutic effect range has been reached (usually 1.5-2.0 times
the control value), it usually remains within this range without titrating the heparin infusion rate.
Heparin has a short duration (approximately 2-6 hours IV). Therefore, if it is not being infused, the aPTT
level will go back to the control value (aPTT level without administration of anticoagulants). In addition,
the volume of heparin being infused is small (because the standard concentration is 100 units/mL) so it is
possible to miss an infiltration.
Clients do not develop tolerance to heparin
Cyclophosphamide
Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication. The client is instructed to
drink plenty of fluids. This client may need IV hydration and other preventive measures
 Herbal
Uses Side effects
supplement
 Memory enhancement  Increased bleeding risk
Ginkgo biloba

 Improved mental
 Increased bleeding risk
Ginseng performance

 Benign prostatic  Mild stomach discomfort

Saw palmetto hyperplasia  Increased bleeding risk

 Postmenopausal
symptoms (hot flashes &  Hepatic injury
Black cohosh vaginal dryness)

 Drug interactions: Antidepressants

(serotonin syndrome), OCs,
 Depression
anticoagulants (↓ INR), digoxin
St John's wort  Insomnia
 Hypertensive crisis

 Anxiety
 Severe liver damage
Kava  Insomnia

 Stomach ulcers
 Hypertension
Licorice  Hypokalemia
 Bronchitis/viral infections

 Treatment & prevention  Anaphylaxis (more likely in

Echinacea of cold & flu asthmatics)

 Treatment of cold & flu  Hypertension

 Arrhythmia/MI/sudden death
 Weight loss & improved  Stroke
Ephedra
athletic performance
 Seizure
Atorvastatin (Lipitor) is a statin drug, or HMG-CoA reductase inhibitor, prescribed to lower
cholesterol and reduce the risk of atherosclerosis and coronary artery disease. A serious adverse
effect of statins, including atorvastatin and rosuvastatin (Crestor), is myopathy with ongoing
generalized muscle aches and weakness.
A client who develops muscle aches while on a statin drug should call the HCP who will then
obtain a blood sample to assess the creatine kinase (CK) level. If myopathy is present, CK will
be significantly elevated (≥10x normal), and the drug will then be discontinued.

A chronic subdural hematoma involves bleeding into the subdural space that can occur
several weeks to months following a mild head trauma. Elderly clients and those
taking anticoagulants are at high risk. Older individuals are vulnerable due to age-related
changes in the brain and increased risks for falls. Manifestations indicating a chronic subdural
hematoma (eg, headache, gait disturbance, memory loss, decreased level of consciousness)
should be investigated immediately as the condition can lead to increased intracranial pressure
and death

The Z-track technique

The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally
recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then
releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for
administering an IM injection using the Z-track technique includes these steps:

1. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site
2. Hold the skin taut with the nondominant hand,and insert the needle at a 90-degree angle –
taut skin facilitates entry of the needle and this angle ensures that the needle will reach
the muscle
3. Inject the medication slowly into the muscle while maintaining traction – slow injection
promotes comfort and allows time for tissue expansion to facilitate absorption of the
medication
4. Wait 10 seconds after injecting the medication and withdraw the needle while
maintaining traction on the skin; this allows the medication to diffuse before needle
removal and helps to prevent tracking
5. Release the hold on the skin – this allows the tissue layers to slide back to their original
position, sealing off the needle track
6. Apply gentle pressure at the injection site, but do not massage as this can cause the
medication to seep back up to the skin surface and cause local tissue irritation
7. There is no clear evidence to support the need for aspiration prior to IM injection.
Aspiration may be indicated if the dorsogluteal site (last resort) is used for IM injection
due to its proximity to the gluteal artery. The preferred areas for IM injection are the
ventrogluteal site in adults and the vastus lateralis site in children.