NLE Oncology Nursing — Cancer Treatment Modalities and Nursing CareRevision Notes

Exam Tips

• NLE frequently asks which tissues are most affected by chemotherapy — always answer: bone marrow, GI mucosa, hair follicles.
• Remember the S-phase drugs with the mnemonic 'META-FLUORO S-phase' — Methotrexate and Fluorouracil = S-phase = antimetabolites.
• Vincristine (a vinca alkaloid) = M-phase = Mitosis phase. M for vincristine = M for Mitosis.
• Cyclophosphamide is the classic alkylating agent — watch for hemorrhagic cystitis (cola-colored urine, dysuria). Encourage high fluid intake.

Key Points

• Chemotherapy uses CYTOTOXIC drugs that kill rapidly dividing cells. It is a SYSTEMIC therapy — it travels through the bloodstream and reaches cancer cells throughout the body.
• The three normal tissues most damaged by chemotherapy are: (1) BONE MARROW, (2) GI MUCOSA (mouth to rectum), and (3) HAIR FOLLICLES — because these cells also divide rapidly.
• CELL-CYCLE-SPECIFIC drugs act during a specific phase of the cell cycle. Examples: Antimetabolites (methotrexate, fluorouracil) act in the S phase; Plant alkaloids/vinca alkaloids (vincristine) act in the M phase. Best given as divided or continuous doses.
• CELL-CYCLE-NONSPECIFIC drugs act in ANY phase, including resting cells (G0). Examples: Alkylating agents (cyclophosphamide) and antitumor antibiotics (doxorubicin). Often given as single bolus doses.
• Because they act in any phase, cell-cycle-nonspecific drugs can kill both actively dividing AND resting tumor cells, making them useful for slow-growing tumors.
• COMBINATION chemotherapy regimens are used to hit cancer cells at multiple phases, reduce resistance, and minimize individual drug toxicities.

Definitions

Section Title

Chemotherapy: Mechanisms and Cell-Cycle Activity

Common Mistakes

• Confusing cell-cycle-specific with cell-cycle-nonspecific — remember: SPECIFIC drugs target ONE phase (like a sniper), NON-SPECIFIC drugs attack all phases (like a grenade).
• Thinking that only bone marrow is affected — GI mucosa and hair follicles are equally fast-dividing and equally vulnerable.
• Forgetting that doxorubicin is both a vesicant AND a cell-cycle-nonspecific antitumor antibiotic.

Formulas

Exam Tips

• NADIR = 7 to 14 DAYS — memorize this number. NLE loves asking when the patient is most at risk.
• ANC below 500 = SEVERE neutropenia = EMERGENCY. Below 1,000 = neutropenia = increased precautions.
• Priority nursing diagnosis for neutropenic patients (NANDA): Risk for Infection related to myelosuppression and altered immune response.
• Priority nursing diagnosis for thrombocytopenic patients (NANDA): Risk for Bleeding related to decreased platelet count.
• Maslow prioritization: Physiological safety (infection, bleeding) takes priority over psychosocial concerns (body image from alopecia) in the neutropenic/thrombocytopenic patient.
• Remember filgrastim for neutropenia; epoetin alfa (erythropoietin) for anemia; oprelvekin (Interleukin-11) for thrombocytopenia — each stimulates a different cell line.

Key Points

• MYELOSUPPRESSION (bone marrow suppression) is the most serious and DOSE-LIMITING toxicity of chemotherapy — it determines the maximum safe dose.
• Three blood cell lines are affected: NEUTROPENIA (low WBCs → infection risk), THROMBOCYTOPENIA (low platelets → bleeding risk), ANEMIA (low RBCs → fatigue and dyspnea).
• The NADIR is the point of LOWEST blood counts after a chemotherapy dose, typically occurring 7–14 DAYS after administration. This is the period of greatest vulnerability.
• The next chemotherapy dose is often DELAYED if counts have not recovered from the nadir.
• ANC (Absolute Neutrophil Count) guides infection risk: ANC below 1,000/mm³ = neutropenia; ANC below 500/mm³ = SEVERE neutropenia — mandatory strict neutropenic precautions.
• GRANULOCYTE COLONY-STIMULATING FACTOR (G-CSF / filgrastim) is given to stimulate the bone marrow to produce neutrophils faster, shortening the nadir period.
• NEUTROPENIC PRECAUTIONS: meticulous hand hygiene (most important), private room, restrict visitors (no sick contacts), no fresh flowers or standing water (harbor Pseudomonas), low-bacteria diet (no raw fruits/vegetables/undercooked meats), avoid invasive procedures, monitor temperature every 4 hours.
• THROMBOCYTOPENIC PRECAUTIONS: soft toothbrush, electric razor (no straight razor), no aspirin or NSAIDs, avoid injections if possible, apply pressure to puncture sites for at least 5 minutes, test stool and urine for occult blood.
• ANEMIA management: rest periods, energy conservation, administer erythropoietin-stimulating agents (ESAs) or blood transfusions as ordered, monitor hemoglobin.

Definitions

Section Title

Myelosuppression: The Most Critical Chemotherapy Toxicity

Common Mistakes

• Confusing the nadir timing — the nadir is NOT immediately after chemotherapy; it is typically 7–14 DAYS later. The patient may feel fine right after treatment but be most vulnerable a week or two later.
• Thinking fresh flowers are just an aesthetic issue — fresh flowers and standing water harbor Pseudomonas aeruginosa and other gram-negative bacteria that can cause fatal infections in neutropenic patients.
• Forgetting to calculate the ANC — the total WBC alone does not tell you the infection risk; you must calculate the ANC.
• Giving aspirin for fever in a thrombocytopenic patient — aspirin inhibits platelet function and is strictly contraindicated. Use acetaminophen as ordered.
• Waiting for a high fever before acting on a neutropenic patient's temperature — a single temperature of 38.3°C OR sustained 38.0°C is already an emergency.

Exam Tips

• Ondansetron = 5-HT3 antagonist = first-line antiemetic for chemotherapy. Memorize the mechanism.
• Doxorubicin = cardiotoxic (cumulative dose limit), vesicant, red-colored drug (warn patients urine may be red/pink — this is expected, not hematuria).
• Cisplatin = nephrotoxic → aggressive hydration is the key nursing intervention.
• Cyclophosphamide = hemorrhagic cystitis → push fluids, give mesna.
• Vincristine = peripheral neuropathy + constipation (not diarrhea — opposite of most chemo drugs).
• NANDA nursing diagnoses for this section: Imbalanced Nutrition: Less Than Body Requirements (nausea, mucositis); Impaired Oral Mucous Membrane (stomatitis); Disturbed Body Image (alopecia); Fatigue.

Key Points

• NAUSEA AND VOMITING: Give antiemetics PROPHYLACTICALLY — BEFORE chemotherapy, not after nausea starts. First-line agents: ondansetron (5-HT3 antagonist), aprepitant (NK-1/substance P antagonist), dexamethasone. Offer small, bland, frequent meals; monitor hydration and electrolytes (especially potassium and sodium).
• ALOPECIA (hair loss): Temporary — hair regrows after treatment, sometimes with different texture or color. Prepare the patient BEFORE hair loss begins. Suggest wigs, scarves, caps. This is a body-image concern (NANDA: Disturbed Body Image), NOT a safety priority.
• STOMATITIS/MUCOSITIS: Painful inflammation and ulceration of the oral mucosa. Assess oral cavity at every shift. Oral care every 4 hours and after meals with a SOFT toothbrush. Use saline or sodium bicarbonate rinses. Topical anesthetics (viscous lidocaine) before meals. AVOID alcohol-based mouthwashes, commercial mouthwash, hot/spicy/acidic foods, and lemon-glycerin swabs.
• FATIGUE: The most commonly reported symptom in cancer patients. Teach energy conservation: prioritize activities, schedule rest periods, do light exercise (if tolerated). Fatigue is not laziness — validate the patient's experience.
• DIARRHEA: Common with antimetabolites (fluorouracil). Maintain hydration, low-residue diet, antidiarrheals as ordered. Monitor for dehydration and electrolyte imbalance.
• CONSTIPATION AND PERIPHERAL NEUROPATHY: Characteristic of VINCA ALKALOIDS (vincristine). Assess bowel function, increase fluids and fiber, use stool softeners as ordered. Also assess for tingling, numbness, and weakness in hands and feet (peripheral neuropathy).
• CARDIOTOXICITY: Associated with DOXORUBICIN (Adriamycin). Monitor for signs of heart failure (dyspnea, edema, decreased ejection fraction). There is a cumulative lifetime maximum dose — track total dose received.
• NEPHROTOXICITY: Associated with CISPLATIN. Ensure aggressive IV hydration before, during, and after administration. Monitor BUN, creatinine, and urine output. Pre-treat with amifostine as ordered.
• HEMORRHAGIC CYSTITIS: Associated with CYCLOPHOSPHAMIDE. Encourage high fluid intake (3–4 L/day). Give mesna (uroprotectant) as ordered. Monitor for blood in urine.

Definitions

Section Title

Other Major Chemotherapy Side Effects and Nursing Interventions

Common Mistakes

• Using alcohol-based mouthwash for stomatitis — this is WRONG and worsens mucosal drying and pain.
• Using a hard toothbrush for oral care — must use a SOFT toothbrush to prevent mucosal trauma and bleeding in thrombocytopenic patients.
• Telling patients alopecia is permanent — it is TEMPORARY. Reassure and prepare them before hair loss begins.
• Administering antiemetics only after the patient vomits — antiemetics must be given PROPHYLACTICALLY before chemotherapy.
• Forgetting that vincristine causes CONSTIPATION (not diarrhea) and neuropathy — a common NLE trap question.

Exam Tips

• NLE PRIORITY QUESTION — If extravasation occurs, the FIRST action is: STOP the infusion. The SECOND action: Do NOT remove the needle — aspirate the drug.
• Doxorubicin extravasation = COLD compress + dexrazoxane antidote.
• Vincristine extravasation = WARM compress.
• Pregnant nurses: CANNOT handle chemotherapy drugs and CANNOT care for patients with internal radioactive implants — both rules fall under safe practice standards.
• Document everything about an extravasation incident — this protects the patient and the nurse under RA 9173's standards of professional accountability.

Key Points

• EXTRAVASATION is the accidental leakage of a chemotherapy drug (particularly a VESICANT) out of the vein into surrounding tissue.
• VESICANTS are drugs that cause severe tissue damage, blistering, and necrosis if they leak into tissue. Common vesicants: DOXORUBICIN and VINCRISTINE.
• Extravasation is a NURSING EMERGENCY at the bedside — prompt action prevents permanent tissue damage.
• PREVENTION: Verify blood return and patency of the IV site BEFORE starting infusion and periodically during infusion. Use a CENTRAL VENOUS ACCESS DEVICE (CVAD) for known vesicants whenever possible.
• SIGNS of extravasation: pain, burning, or stinging at the IV site; swelling, redness, or blistering around the site; no blood return.
• EXTRAVASATION PROTOCOL — Step by Step: (1) STOP the infusion IMMEDIATELY. (2) Do NOT remove the needle/cannula — leave it in place to aspirate residual drug from the tissue. (3) Aspirate as much of the drug as possible through the existing needle. (4) Remove the needle after aspiration. (5) Apply warm or cold compresses as indicated by the specific drug (doxorubicin = cold; vincristine = warm). (6) Administer the specific antidote if available (dexrazoxane for doxorubicin extravasation). (7) Elevate the affected extremity. (8) Notify the physician immediately. (9) Document the incident: time, site, drug, amount, appearance, and actions taken.
• SAFE HANDLING of chemotherapy: Wear PPE (double chemotherapy-rated gloves, gown, eye protection, mask). Prepare drugs in a BIOLOGICAL SAFETY CABINET (BSC). Use CYTOTOXIC WASTE containers for disposal. Treat patient body fluids as hazardous for approximately 48 HOURS after administration. PREGNANT nurses must NOT handle chemotherapy or care for internal-radiation patients. Follow facility spill-kit procedure for spills.

Definitions

Section Title

Extravasation: Vesicant Emergency Management

Common Mistakes

• Removing the needle FIRST before aspirating — this is the most critical error. Leave the needle in place to aspirate residual drug from the tissue first.
• Thinking all chemotherapy drugs get cold compresses for extravasation — the choice of warm vs. cold depends on the specific drug. When in doubt, follow the institution's protocol.
• Forgetting to document the extravasation incident — documentation is a professional and legal responsibility under RA 9173.
• Handling chemotherapy without PPE — even brief or incidental exposure to chemotherapy can be mutagenic, teratogenic, or carcinogenic to the nurse.
• Thinking the patient's body fluids are immediately safe after chemotherapy — fluids remain hazardous for approximately 48 hours.

Exam Tips

• KEY DISTINCTION: External beam = patient NOT radioactive. Brachytherapy = patient IS radioactive while source is in place.
• Skin care rule: NO lotions, NO powders, NO deodorants on the radiation field. YES to gentle washing with lukewarm water and mild soap.
• Radiation safety triad: TIME (less), DISTANCE (more), SHIELDING (lead). This is almost always on the NLE.
• Always have FORCEPS and a LEAD-LINED CONTAINER at the bedside of a brachytherapy patient — this is a safety standard.
• Pregnant nurses must NOT handle chemotherapy AND must NOT care for brachytherapy patients — two restrictions, same person.

Key Points

• Radiation therapy uses HIGH-ENERGY IONIZING RADIATION to damage the DNA of cancer cells, preventing them from dividing. It is a LOCAL treatment — side effects are LIMITED to the area being irradiated.
• EXTERNAL BEAM RADIATION (Teletherapy): Radiation comes from a machine outside the body. The patient is NOT radioactive and poses NO RISK to others. Skin markings are placed to precisely target the beam.
• BRACHYTHERAPY (Internal Radiation): A radioactive source is placed INSIDE or NEXT TO the tumor (e.g., sealed implants for cervical cancer, prostate cancer). While the source is in place, the PATIENT EMITS RADIATION and is a source of exposure — safety precautions for staff and visitors are required.
• UNSEALED INTERNAL RADIATION (e.g., radioactive iodine I-131 for thyroid cancer): Body fluids (urine, saliva, sweat) may be radioactive — handle with PPE and dispose of as radioactive waste.
• RADIATION SKIN CARE (External Beam): Do NOT wash off skin markings. Wash the area gently with LUKEWARM WATER and MILD SOAP; PAT DRY — do not rub. Do NOT apply lotions, powders, creams, perfumes, or deodorants to the treatment field unless prescribed. Avoid direct sunlight, extreme heat or cold (no heating pads or ice packs), and tight or abrasive clothing over the site. Wear loose, soft cotton clothing.
• RADIATION SAFETY PRINCIPLES (for internal/brachytherapy patients): TIME (minimize time near the patient), DISTANCE (maximize distance from the radiation source), SHIELDING (use lead shielding).
• BRACHYTHERAPY SAFETY MEASURES: Assign a PRIVATE ROOM. Wear a RADIATION DOSIMETER (film badge) when entering the room. PREGNANT nurses and CHILDREN must NOT enter the room or care for the patient. Keep a LEAD-LINED CONTAINER and LONG-HANDLED FORCEPS at the bedside at ALL TIMES in case the implant becomes dislodged. NEVER TOUCH A DISLODGED SOURCE WITH BARE HANDS — use forceps to pick it up and place it in the lead container, then notify radiation safety personnel. ROTATE staff assignments to limit cumulative exposure.
• COMMON RADIATION SIDE EFFECTS (site-dependent): Fatigue (universal), radiodermatitis (skin in treatment field), mucositis (head and neck radiation), esophagitis (chest radiation), pneumonitis (lung radiation), diarrhea and proctitis (pelvic radiation), cystitis (pelvic/bladder radiation).

Definitions

Section Title

Radiation Therapy: External Beam and Brachytherapy

Common Mistakes

• Thinking external beam radiation patients are radioactive — they are NOT. Only internal radiation (brachytherapy) patients are radioactive.
• Washing off the skin markings — these marks are critical for targeting the radiation beam. They must be preserved. Instruct patients not to wash the area with soap that might remove the markings, or to rub the area.
• Applying lotion or deodorant to the radiation field — this can alter the radiation dose delivery and worsen skin reactions.
• Thinking any nurse can care for a brachytherapy patient without precautions — radiation safety rules are mandatory, and pregnant nurses and children are excluded entirely.
• Picking up a dislodged implant with bare hands — this is strictly prohibited. Always use forceps and place in the lead container.

Exam Tips

• Trastuzumab (Herceptin) = HER2-positive breast cancer = monitor CARDIAC function (cardiomyopathy risk).
• Rituximab = B-cell lymphoma/leukemia = risk of INFUSION REACTIONS — premedicate with acetaminophen and diphenhydramine, slow infusion rate for first dose.
• Imatinib = CML = Philadelphia chromosome-positive — tyrosine kinase inhibitor. Oral drug. Monitor for edema, GI side effects.
• Immune checkpoint inhibitors = pembrolizumab, nivolumab — any organ can be inflamed → assess every body system at every visit.
• Surgery uses: BIOPSY (diagnosis), CURE, DEBULKING, PALLIATION, PREVENTION, RECONSTRUCTION — know all six.

Key Points

• SURGERY is the oldest cancer treatment modality. It is used for: DIAGNOSIS (biopsy — most common reason for first surgery), CURE (removing localized tumors), DEBULKING (reducing tumor mass to help other therapies work), PALLIATION (relieving obstruction, pain, or bleeding), PROPHYLAXIS/PREVENTION (removing high-risk tissue), and RECONSTRUCTION (restoring form and function).
• Perioperative nursing care for cancer surgery follows general principles PLUS: assess nutritional status (cancer causes malnutrition), manage immunosuppression (from prior chemo), monitor for bleeding (prior chemo may cause thrombocytopenia), and provide psychological support (fear, grief, altered body image).
• TARGETED THERAPY attacks SPECIFIC MOLECULES on cancer cells, causing less harm to normal cells than traditional chemotherapy. Examples: TRASTUZUMAB (Herceptin) for HER2-positive breast cancer — monitor CARDIAC FUNCTION (echocardiogram); RITUXIMAB for B-cell lymphoma — watch for INFUSION REACTIONS (fever, chills, hypotension); IMATINIB (Gleevec) for CML/GIST — tyrosine kinase inhibitor.
• MONOCLONAL ANTIBODIES (MABs): large molecules ending in -mab (trastuzumab, rituximab, bevacizumab). Given IV. High risk of HYPERSENSITIVITY and INFUSION REACTIONS — always have emergency equipment ready. Give the first dose slowly.
• IMMUNOTHERAPY stimulates the patient's OWN IMMUNE SYSTEM to recognize and destroy cancer cells. Examples: INTERFERONS and INTERLEUKINS — cause FLU-LIKE SYMPTOMS (fever, chills, myalgia, fatigue). IMMUNE CHECKPOINT INHIBITORS (pembrolizumab, nivolumab) — block PD-1/PD-L1 or CTLA-4, unleashing T cells against cancer; however, they can trigger IMMUNE-RELATED ADVERSE EVENTS (irAEs) — autoimmune inflammation in any organ (colitis, pneumonitis, hepatitis, endocrinopathies, dermatitis).
• NURSING CARE for immunotherapy: monitor for infusion reactions (first doses are highest risk), assess for any organ-specific inflammatory symptoms (SOB, diarrhea, jaundice, rash, fatigue), manage with corticosteroids as ordered for irAEs.

Definitions

Section Title

Surgery and Newer Therapies: Targeted Therapy and Immunotherapy

Common Mistakes

• Thinking targeted therapy has no side effects — while more specific, MABs like trastuzumab still have significant toxicities (cardiotoxicity) and all can cause infusion reactions.
• Forgetting cardiac monitoring for trastuzumab — this is a high-yield NLE point: trastuzumab → HER2+ breast cancer → monitor ejection fraction.
• Thinking immunotherapy side effects are the same as chemotherapy — immunotherapy causes IMMUNE-RELATED adverse events (any organ, autoimmune), not the typical myelosuppression/alopecia of chemo.
• Mixing up interferon and interleukin side effects — both cause flu-like symptoms (fever, chills, myalgia), which are expected and managed with acetaminophen.

Exam Tips

• FEBRILE NEUTROPENIA: CULTURES FIRST → ANTIBIOTICS WITHIN 1 HOUR. This is the standard that will always be tested.
• TLS electrolyte pattern: HIGH K, HIGH Phosphate, HIGH Uric Acid, LOW Calcium. Remember: 3 ups, 1 down.
• SVC Syndrome first nursing action: ELEVATE THE HEAD OF THE BED. Then oxygen, then notify physician.
• Spinal Cord Compression: EARLIEST sign = BACK PAIN. FIRST medication = DEXAMETHASONE. Report immediately.
• Hypercalcemia: First treatment = IV NORMAL SALINE (aggressive hydration). Then bisphosphonates.
• Maslow prioritization for oncologic emergencies: All are physiological (survival) threats — prioritize the one with the most immediate threat to life. Febrile neutropenia and severe arrhythmias (from TLS/hypercalcemia) are most immediately fatal.
• These five emergencies will appear on the NLE — study them as a GROUP and remember the DISTINGUISHING FEATURE and FIRST ACTION for each.

Key Points

• ONCOLOGIC EMERGENCIES are life-threatening complications of cancer or its treatment that require IMMEDIATE recognition and action. Every nurse must know the hallmark signs and first-line management.
• FEBRILE NEUTROPENIA: A FEVER in a neutropenic patient (ANC < 500/mm³) is a MEDICAL EMERGENCY. Fever criteria: single temperature ≥ 38.3°C OR sustained temperature ≥ 38.0°C for ≥ 1 hour. The patient cannot mount a normal inflammatory response (no pus, no localizing signs). PRIORITY ACTION: Draw blood cultures (from all lumens of central line and peripheral site) and START BROAD-SPECTRUM IV ANTIBIOTICS WITHIN ONE HOUR — do NOT wait for culture results. Do not give aspirin for fever.
• TUMOR LYSIS SYNDROME (TLS): Occurs when large numbers of tumor cells are rapidly destroyed (usually 12–72 hours after starting chemo for bulky, rapidly dividing tumors — leukemia, Burkitt's lymphoma). Intracellular contents flood the bloodstream → HYPERKALEMIA, HYPERPHOSPHATEMIA, HYPERURICEMIA, and HYPOCALCEMIA (the '4 H's' of TLS). Complications: ACUTE KIDNEY INJURY (uric acid crystals obstruct tubules) and FATAL CARDIAC ARRHYTHMIAS (from hyperkalemia). MANAGEMENT: AGGRESSIVE IV HYDRATION to flush kidneys, ALLOPURINOL or RASBURICASE to prevent/reduce uric acid, correct electrolytes, monitor renal function and cardiac rhythm (continuous telemetry).
• SUPERIOR VENA CAVA (SVC) SYNDROME: Compression or obstruction of the superior vena cava by a tumor (most commonly lung cancer or lymphoma), blocking venous return from the head and upper body. SIGNS: facial swelling (especially in the morning), neck edema, edema of arms and hands, distended neck and chest veins, dyspnea, feeling of fullness or pressure in the head, headache, visual changes. MANAGEMENT: Elevate head of bed (HOB) immediately, provide supplemental oxygen, give urgent RADIATION THERAPY or CHEMOTHERAPY to shrink the obstructing tumor.
• SPINAL CORD COMPRESSION (SCC): A tumor (usually from vertebral metastasis) pressing on the spinal cord — a TRUE EMERGENCY because delayed treatment leads to PERMANENT PARALYSIS. EARLIEST SYMPTOM: BACK PAIN (often the first and only symptom before neurological deficits appear). Progression: back pain → motor weakness → sensory loss → bowel/bladder dysfunction → paralysis. PRIORITY ACTION: Report NEW or WORSENING BACK PAIN in a cancer patient IMMEDIATELY. MANAGEMENT: HIGH-DOSE DEXAMETHASONE (corticosteroid to reduce cord edema) FIRST, followed by radiation therapy or surgical decompression.
• HYPERCALCEMIA: Elevated serum calcium level due to bone metastasis releasing calcium or parathyroid-hormone-related protein (PTHrP) secreted by the tumor. Common in multiple myeloma, breast cancer, lung cancer, and renal cancer. SIGNS (remember: BONES, GROANS, MOANS, PSYCHIC OVERTONES): fatigue, muscle weakness, bone pain, CONFUSION and LETHARGY, nausea and vomiting, CONSTIPATION, POLYURIA and polydipsia, and in severe cases, CARDIAC ARRHYTHMIAS and COMA. MANAGEMENT: AGGRESSIVE IV HYDRATION with NORMAL SALINE (the most immediate treatment — dilutes calcium and promotes renal excretion), BISPHOSPHONATES (zoledronic acid, pamidronate — inhibit osteoclast activity to reduce bone calcium release), loop diuretics (furosemide) AFTER rehydration to promote calciuresis, treat the underlying cancer.

Definitions

Section Title

Oncologic Emergencies: Recognition and Immediate Nursing Action

Common Mistakes

• Waiting for culture results before starting antibiotics in febrile neutropenia — cultures must be DRAWN FIRST, but antibiotics must start WITHIN ONE HOUR regardless of culture results.
• Thinking TLS occurs before chemotherapy — it occurs AFTER chemotherapy starts, as tumor cells are destroyed.
• Confusing TLS electrolytes — phosphate and potassium go UP (released from destroyed cells); calcium goes DOWN (binds to excess phosphate). Uric acid goes UP.
• Thinking back pain in a cancer patient is just musculoskeletal — in a cancer patient, new or worsening back pain is spinal cord compression UNTIL PROVEN OTHERWISE. Report immediately.
• Giving loop diuretics BEFORE hydration in hypercalcemia — this can worsen dehydration and increase calcium concentration. HYDRATE FIRST, then diuretics.
• Positioning the SVC syndrome patient flat — always ELEVATE the head of the bed to reduce venous pressure in the head and face.