9.1 Oncology Nursing and Oncologic Emergencies
Key Takeaways
- The nadir of chemotherapy-induced myelosuppression usually falls 7 to 14 days after a cycle; an absolute neutrophil count below 500/mm³ with a single temperature of 38.3 °C, or 38.0 °C sustained for an hour, is febrile neutropenia and demands antibiotics within one hour.
- Vesicant extravasation is managed by stopping the infusion, leaving the cannula in place to aspirate residual drug, marking the area, and applying the drug-specific antidote and thermal compress before removal.
- Tumour lysis syndrome produces hyperkalaemia, hyperphosphataemia, hyperuricaemia, and hypocalcaemia; prevention is aggressive hydration plus allopurinol or rasburicase before cytotoxic therapy begins.
- New or worsening back pain in a patient with known malignancy is malignant spinal cord compression until proven otherwise, and requires urgent imaging and corticosteroids before neurological deficit becomes irreversible.
- Handle cytotoxic agents and the excreta of a treated patient using chemotherapy-rated personal protective equipment for at least 48 hours after administration, and dispose of waste in designated cytotoxic containers.
9.1 Oncology Nursing and Oncologic Emergencies
Cancer care generates a recognisable family of exam items: a blood count with a dangerous nadir, an infusion site that has gone wrong, or a patient whose new symptom is an emergency rather than a side effect. The organising principle is that cytotoxic therapy attacks rapidly dividing cells indiscriminately, so the predictable toxicities appear precisely where normal cells divide fastest — bone marrow, gastrointestinal mucosa, hair follicles, and gonads.
Myelosuppression: The Three Cell Lines
| Cell line | Nadir | Threshold of concern | Priority nursing response |
|---|---|---|---|
| Neutrophils | 7–14 days | ANC < 1,000/mm³; severe < 500/mm³ | Neutropenic precautions; fever = emergency |
| Platelets | 7–14 days | < 50,000/mm³ risk; < 20,000/mm³ spontaneous bleeding | Bleeding precautions; no IM injections, no rectal route |
| Red cells | Later, cumulative | Hb < 8 g/dL symptomatic | Energy conservation; transfusion per protocol |
Absolute neutrophil count is calculated as total WBC × (percentage of segmented neutrophils + percentage of bands) ÷ 100. A WBC of 2,000/mm³ with 30% segs and 5% bands gives an ANC of 700/mm³ — severe neutropenia despite a WBC that looks only mildly low.
Febrile neutropenia is the single most time-critical oncology scenario. A neutropenic patient cannot mount inflammation, so fever may be the only sign of overwhelming infection: there may be no purulence, no infiltrate on chest radiograph, and no erythema at a line site. The standard trigger is a single oral temperature of 38.3 °C, or 38.0 °C sustained for one hour, in a patient with an ANC below 500/mm³. Draw blood cultures and administer broad-spectrum intravenous antibiotics within one hour. Do not wait for the source to be identified, and do not give antipyretics that mask the only available sign without first escalating.
Neutropenic precautions: single room with the door closed; scrupulous hand hygiene by staff and visitors; no visitors with any infection; no fresh flowers or standing water (a Pseudomonas and Aspergillus reservoir); thorough cooking of food per local policy; no rectal thermometers, suppositories, or enemas; no intramuscular injections; meticulous oral and perineal hygiene; and daily assessment of every line site.
Thrombocytopenia precautions: soft toothbrush or foam swabs, electric razor, avoid flossing, avoid aspirin and non-steroidal anti-inflammatory drugs, no rectal procedures, apply prolonged pressure after any venepuncture, use stool softeners to avoid straining, and report headache, visual change, or altered consciousness immediately as possible intracranial haemorrhage.
Safe Handling of Cytotoxic Agents
Chemotherapy is hazardous to the people who give it. Prepare in a biological safety cabinet, wear double chemotherapy-rated gloves, an impermeable gown, and eye protection, use a closed-system transfer device, and know where the spill kit is kept. Cytotoxic drugs and metabolites are excreted in urine, faeces, vomit, and sweat: treat all body fluids as hazardous for at least 48 hours after administration, wear gloves and a gown for handling linen or excreta, flush the toilet with the lid closed, and dispose of waste in designated cytotoxic containers. Pregnant and breastfeeding staff should not handle these agents.
Extravasation of a vesicant
Vesicants such as the anthracyclines and vinca alkaloids cause deep tissue necrosis if they leak into the perivascular space. Signs are burning or stinging pain, swelling, absence of blood return, resistance to injection, and a slowing infusion.
The sequence:
- Stop the infusion immediately but leave the cannula in place.
- Aspirate residual drug and blood back through the cannula.
- Disconnect the infusion tubing; do not flush.
- Administer the drug-specific antidote through the cannula if one is indicated, then remove the cannula.
- Apply the correct thermal compress: cold for anthracyclines, warm for vinca alkaloids.
- Elevate the limb, mark and photograph the area, document time, drug, volume, and actions, and refer for plastic surgical review.
Never apply pressure to the site — it drives the vesicant deeper into tissue.
Radiation Therapy Nursing
External beam radiation makes the patient radioactive at no point; there is no contact risk. Skin care within the treatment field is the nursing focus: wash gently with lukewarm water and mild pH-neutral soap, pat dry, do not scrub, do not remove skin markings, avoid powders, deodorants, and metallic-containing products, use only creams approved by the radiation team and not immediately before a session, protect from sun and chlorinated water, avoid heat and ice packs to the field, and wear loose soft cotton clothing. Fatigue is near-universal, cumulative, and does not respond to sleep alone; teach energy conservation and paced activity.
Internal radiation (brachytherapy) does create a radiation hazard while the source is in place. Apply the three principles — time, distance, shielding: assign care efficiently, limit the time in the room, maintain distance whenever possible, use portable shields, wear a dosimeter badge, restrict visitors and exclude children and pregnant women, keep a long-handled forceps and a lead container in the room for a dislodged source, and never touch a dislodged implant with bare hands. Pregnant staff must not be assigned to these patients.
The Four Oncologic Emergencies
1. Febrile neutropenia — covered above; antibiotics within one hour.
2. Tumour lysis syndrome. Massive cell death — usually within 24 to 72 hours of starting treatment for a bulky, rapidly proliferating tumour such as acute leukaemia or high-grade lymphoma — releases intracellular contents into the blood. The biochemical signature is hyperkalaemia, hyperphosphataemia, hyperuricaemia, and hypocalcaemia (calcium falls because it precipitates with phosphate), leading to acute kidney injury and fatal arrhythmia. Prevention is the nursing priority: aggressive intravenous hydration started before therapy, allopurinol or rasburicase, strict intake-output measurement, and frequent electrolyte and renal monitoring with cardiac rhythm surveillance.
3. Superior vena cava syndrome. Tumour compression of the superior vena cava produces facial and periorbital oedema worse on waking, neck and upper chest vein distension, upper limb swelling, dyspnoea, hoarseness, and a feeling of head fullness. Nursing actions: sit the patient upright, give oxygen, avoid upper-extremity venepuncture, intravenous lines, and blood pressure cuffs on the arms, avoid anything constricting around the neck, and escalate for urgent imaging, radiotherapy, or stenting.
4. Malignant spinal cord compression. New or escalating back pain — often worse lying flat and on coughing — in a patient with known malignancy is the presenting feature, typically preceding motor weakness, sensory level, and bladder or bowel dysfunction by days to weeks. Once paraplegia is established it is usually irreversible, so the entire nursing value lies in early escalation. Keep the patient flat with spinal precautions until instructed otherwise, perform and document a baseline neurological assessment, expect urgent MRI and high-dose corticosteroids, and assess bladder function actively rather than waiting for the patient to report retention.
Hypercalcaemia of malignancy is a fifth emergency worth knowing: confusion, constipation, polyuria, nausea, and profound weakness, treated with aggressive saline hydration and bisphosphonates.
Supportive Care Essentials
- Nausea and vomiting: give antiemetics prophylactically before the cycle, not reactively. Distinguish acute, delayed, and anticipatory nausea; the last responds to behavioural measures and anxiolytics rather than more antiemetic.
- Mucositis: bland saline or sodium bicarbonate rinses four or more times daily, soft toothbrush, no alcohol-containing mouthwash, no hot, spicy, acidic, or rough foods; assess with a validated oral assessment tool.
- Alopecia: prepare the patient before the first cycle; hair usually regrows, sometimes with a changed texture or colour.
- Fertility: raise fertility preservation before treatment starts, as it cannot be retrofitted afterwards.
- Peripheral neuropathy from taxanes and platinum agents: teach home-safety measures for reduced sensation, and report progressive deficit promptly because dose modification may be required.
A patient who received chemotherapy 10 days ago telephones the oncology day unit reporting a single oral temperature of 38.4 °C and mild fatigue. The most recent full blood count shows a white cell count of 1,400/mm³ with 25% segmented neutrophils and 3% bands. What is the correct nursing response?
During an infusion of doxorubicin through a peripheral cannula, a patient reports burning at the site. The nurse notes swelling, no blood return, and a slowed infusion. In what sequence should the nurse act?
A patient with metastatic prostate cancer reports mid-thoracic back pain that has worsened over two weeks, is worse when lying flat, and now radiates around the chest. On assessment the nurse notes mild bilateral leg weakness and that the patient has not passed urine for 10 hours. What is the nurse's priority action?