Managing Patients On Chemotherapy

Nausea and Vomiting

Nausea occurs when patients feel sick and want to throw up, whereas vomiting is the actual throwing up. Chemotherapy may cause nausea, vomiting, and/or dry heaves (when the body tries to vomit even though stomach is empty). Nausea and vomiting may occur during or after chemotherapy. For relief, anti-emetic or anti-nausea drugs can be given to patients one hour before chemotherapy treatment and for a few days after.

Medication, Suggestion and Advice to Patients

  • Big filling meals should be avoided. Instead, numerous small meals should be consumed throughout the day.

  • Liquids should be drunk an hour before or after mealtimes rather than during mealtimes.

  • Eat and drink slowly.

  • Stay away from sweet, fried, or fatty foods.

  • To avoid aversion to strong smells, foods should be eaten cold or at room temperature.

  • Chew food well for easier digestion.

  • If nausea is a problem in the morning, try eating dry foods like cereal, toast, or crackers before getting up. (Do not try this if there are mouth or throat sores or troubled by a lack of saliva.)

  • Drink cool, clear, unsweetened fruit juices, such as apple or grape juice, or light-coloured sodas, such as ginger ale, that have lost their fizziness.

  • Suck on ice cubes, mints, or candies. (Do not use tart candies if there are mouth or throat sores)

  • Avoid strong odours such as cooking smells, smoke, or perfume.

  • Prepare and freeze meals in advance for days when cooking cannot be done

  • Avoid lying down for at least two hours after finishing a meal. Rest on a chair instead.

  • Wear loose-fitting clothes.

  • Breathe deeply and slowly when feeling nauseated

  • Divert concentration by chatting with friends or family members, listening to music, or watching a movie or TV show.

  • Use relaxation techniques.

  • Avoid eating for at least a few hours before treatment if nausea usually occurs during chemotherapy.

  • Tips to Prevent Vomiting

  • Rinse and gargle frequently with baking soda solution (1 tablespoon baking soda with 1 quart water) to clean oropharynx and temporarily remove thick secretions.

  • Eat fresh pineapple, which helps thin oral and pharyngeal secretions.

  • Limit caffeine, as it causes dehydration.

  • Avoid mouthwashes that contain alcohol which can dry the mouth.

  • Anti-nausea drugs include:

  • Kytril (granisetron)

  • Zofran (ondansetron)

  • Metoclopramide (Octamide, Metoclopramide, Intensol, Reglan)

Hair Loss

Hair loss (alopecia) is a common side effect of chemotherapy. The hair grows back after the treatments are completed.

Care for the patient’s scalp and hair during chemotherapy:

  • Use mild shampoos.

  • Use soft hair brushes.

  • Use low heat when drying hair.

  • Do not use brush rollers to set hair.

  • Do not dye hair.

  • Have hair cut short to make hair look thicker and fuller and any occurring hair loss easier to manage.

  • Use sunscreen, sun block, hat, or scarf to protect scalp from the sun. Some patients wear turbans, scarves, caps, wigs, or hairpieces, while others leave their head uncovered. Some alternate depending on whether they are in public or at home with friends and family members. There are no “right” or “wrong” choices; whatever feels comfortable for the patient will be the best choice.

  • Get a wig or hairpiece that matches with the natural hair colour and current hair style.

Faituge/Anaemia

Red blood cells carry oxygen to all parts of the body, and a reduction in them could lead to body tissue being unable to function well. Chemotherapy can reduce the bone marrow’s ability to make red blood cells. This condition is called anaemia. If red blood cell count falls too low, the patient may need a blood transfusion. Anemia can develop from cancer or chemotherapy and can have significant effects on treatment options, the patient’s quality of life and survival. The doctor must be informed if any of the following symptoms are present:

  • Unusually pale skin or hypersensitivity to cold.

  • Dizziness, headaches or mood changes.

  • Shortness of breath or labored breathing.

  • Rapid heartbeat or heart palpitations.

  • Anorexia or indigestion.

  • Have hair cut short to make hair look thicker and fuller and any occurring hair loss easier to manage.

  • IUse sunscreen, sun block, hat, or scarf to protect scalp from the sun. Some patients wear turbans, scarves, caps, wigs, or hairpieces, while others leave their head uncovered. Some alternate depending on whether they are in public or at home with friends and family members. There are no “right” or “wrong” choices; whatever feels comfortable for the patient will be the best choice.

  • Get a wig or hairpiece that matches with the natural hair colour and current hair style.

infection

Chemotherapy patients are prone to catching infections as treatment drugs affect bone marrow and decrease its ability to produce white blood cells. An infection can begin in almost any part of the body including the mouth, skin, lungs, urinary tract, rectum, and reproductive tract. To prevent infection when white blood cell count is low, the following steps should be taken:

  • Wash hands often especially before eating and before and after using the bathroom.

  • Rectal area must be cleaned gently but thoroughly after each bowel movement. Doctors or nurses can be referred for advice if the area becomes irritated, if patient has hemorrhoids, and before using enemas or suppositories.

  • Avoid crowds as well as people with contagious diseases such as cold, flu, measles, or chickenpox.

  • Stay away from children who have recently received immunizations against diseases such as polio, measles, mumps and rubella (German measles).

  • Carefully avoid cutting or nicking skin when using scissors, needles, or knives.

  • To prevent breaks or cuts in the skin, use an electric shaver.

  • Use a soft toothbrush that protects gums.

  • Do not squeeze or scratch pimples.

  • Take a warm (not hot) bath, shower, or sponge bath every day. Pat skin dry using a light touch. Do not rub.

  • Use lotion or oil to soften and heal skin if it becomes dry and cracked.

  • Clean cuts and scrapes right away with warm water, soap, and an antiseptic.

  • Wear protective gloves when gardening or cleaning up after animals and others, especially small children.

  • Do not get any immunization shots without checking first with the doctor to see if it is all right.

  • Be aware of any signs and symptoms of infection and check the body regularly, paying special attention to the patient’s eyes, nose and mouth, genital and rectal areas. Symptoms of infection include:

  • Fever over 100 degrees F /38 degrees Celsius.

  • Chills

  • Sweating

  • Loose bowels (this can also be a side effect of chemotherapy).

  • Burning feeling when urinating.

  • Severe cough or sore throat.

  • Unusual vaginal discharge or itching.

  • Redness or swelling, especially around a wound, sore, pimple, or intravenous catheter sites.

Bleeding and Blood Clotting Problems

Chemotherapy drugs may affect the bone marrow’s ability to make platelets, the blood cells that help stop bleeding by assisting the blood to clot. The doctor should be informed if there is unexplained bruising, small red spots under the skin, bleeding from gums or nose, reddish or pinkish urine, or black or bloody bowel movements. To avoid problems caused by low platelet count, patients should:

  • Check with the doctor or nurse before taking any medicine including non-prescriptions such as aspirin or aspirin-free pain relievers like acetaminophen and ibuprofen. These drugs may affect platelet function.

  • Get authorization from the doctor before drinking any alcoholic beverage.

  • Use a very soft toothbrush to clean teeth.

  • Clean nose by blowing gently into a soft tissue.

  • Take care not to cut or nick the skin when using scissors, needles, knives, or tools.

  • Be careful not to burn the skin when ironing or cooking. Use a padded glove when reaching into the oven.

  • Avoid contact sports and other activities that might result in injury.

Mouth,Gums and throat Problems

Infections during chemotherapy should be prevented. Chemotherapy drugs can cause mouth and throat sores as well as bleeding in these areas. Patients are encouraged to maintain good oral health care as infections contracted during chemotherapy can cause serious problems.

To keep mouth, gums and throat healthy, patients should:

  • See a dentist before treatment to have teeth cleaned and receive any necessary oral care procedures. These procedures include treating cavities, abscesses, gum disease, or poorly fitted dentures. The patient should seek advice on proper care techniques during treatment and receive any additional medication (such as fluoride rinse or gel for daily use).

  • Gently brush teeth and gums after every meal using a soft toothbrush to avoid damaging the soft tissues in the mouth. Ask a doctor, nurse, or dentist to suggest a special type of toothbrush and/or toothpaste if gums are very sensitive.

  • Rinse toothbrush well after each use and store it in a dry place.

  • Use a mild mouthwash as recommended by a doctor/nurse. Commercial mouthwashes that contain alcohol and salt should be avoided.

  • The patient should contact a doctor or nurse if he/she develops sores in the mouth. If the sores are painful or keep the patient from eating, they can try the following ideas for treatment:

  • Get advice on treatment including information on any prescribed medication that can directly be applied to the sores to relieve pain

  • Eat food cold or at room temperature as hot and warm foods irritate tender mouth and throat.

  • Consume soft, soothing foods, such as ice cream, milkshakes, baby food, soft fruits (bananas and applesauce), mashed potatoes, cooked cereals, soft-boiled or scrambled eggs, cottage cheese, macaroni and cheese, custard, pudding, and gelatine. Patients can puree cooked foods in the blender to make them smoother and easier to eat.

  • Avoid acidic foods such as tomatoes, citrus fruit and fruit juices (orange, grapefruit, and lemon); spicy or salty foods; and rough, coarse, or dry foods such as raw vegetables, granola, and toast

  • If mouth dryness makes it difficult to eat, try these tips

  • Suck lemon drops, ice cubes or sugarless candy or chew sugarless gum

  • Moisten dry foods with butter, margarine, gravy, sauces, or broth.

  • Soak crisp, dry foods in mild liquids to soften them

  • Eat soft and pureed foods

  • Use lip balm if the lips become dry

  • Sip fruit juice throughout the day.

  • Avoid caffeine-containing drinks such as coffee, tea or colas.

  • Consume soft and/or moist foods with extra sauce, dressings or gravies

  • Eat foods at room temperature or chilled

  • Add lemon, lime, vinegar or salt to foods that taste sweet

  • Add lemon, lime, instant decaffeinated coffee powder, or mint to milk shakes.

  • For dry mouth or xerostomia:

  • Swish and spit a solution of salt or baking soda and water 4-5 times daily.

  • Add lemon, lime, instant decaffeinated coffee powder, or mint to milk shakes.

  • Avoid using oral hygiene products that contain alcohol or peroxide such as "Listerine".

  • Use artificial saliva or make own using 1 teaspoon of baking soda and 1 teaspoon of salt to a quart of water

  • Swish and swallow a bit of olive oil or vegetable oil. This will lubricate the esophagus for about 15 minutes. Caution: Some people cannot tolerate this

    For altered flavors or a metallic taste in the mouth:

  • Brush teeth and gums after meals.

  • Mix 1/2 to 1 teaspoon salt or baking soda with 1 glass of water. Swish and spit 4-5 times per day or more often if needed.

  • Suck mints, lemon or candies to keep the mouth moist

  • Use plastic utensils rather than metal/stainless steel

  • Avoid bland flavorings such as vanilla

  • Add fresh fruit to foods if tolerated.

  • Try adding herbs or marinades (not overly spicy) that enhance flavor

  • For sores or ulcers in the mouth (mucositis):

  • Keep to a pureed, liquid or soft diet (to decrease chewing)

  • Avoid vinegar, all tomato and citrus products.

  • Consume commercial or homemade protein and calorie rich, fortified, nutritional milkshakes.

  • Avoid foods with extreme temperatures which are too hot or too cold.

  • Avoid alcohol or nicotine.

  • Drink at least 8 glasses of water per day.

  • Supplement diet with electrolyte drinks.

  • Maintain good oral hygiene by gently brushing teeth and flossing gums every 4 hours.

  • Avoid spicy foods.

  • Use a straw to direct fluid away from the painful parts of the mouth.

  • Remove dentures except when eating to avoid further irritation

  • Supplement diet with electrolyte drinks.

  • For difficulty in swallowing (dysphagia):

  • Eat mainly soft foods, pureed foods or liquids to minimize swallowing.

  • Control amounts of food going into the mouth by using a straw.

  • Eat slowly and chew all foods thoroughly.

  • A change in position can make swallowing easier.

  • Use commercially prepared food thickeners, tapioca, flour, instant mashed potatoes, infant cereal, and or cornstarch to thicken liquids.

  • Magic mouthwash (e.g. clorhexidine mouth wash, difflam gargle) usually contains at least three of these basic ingredients:

  • Antibiotic to kill bacteria around the sore.

  • Antihistamine or local anesthetic to reduce pain and discomfort.

  • Antifungal to reduce fungal growth

  • Corticosteroid to treat inflammation.

  • Antacid to enhance coating of the other ingredient

  • Most formulations of magic mouthwash are intended to be used every 4-6 hours, and to be held in the mouth for one to two minutes before being either spat out or swallowed. It is recommended that the patient does not eat or drink for 30 minutes after using magic mouthwash so that the medicine has time to be effective.

Diarrhoea

When chemotherapy affects the cell linings of the intestine, the result can be diarrhoea (loose stools). If diarrhoea continues for more than 24 hours,or is accompanied with pain and cramps, advise the patient to call the doctor.

The patient may control diarrhoea by:

To keep mouth, gums and throat healthy, patients should:

  • Adding soluble fibre to the diet at regular intervals throughout the day.

  • High-fibre foods including whole-grain breads and cereals, raw vegetables, beans, nuts, seeds, popcorn, and fresh and dried fruit can lead to diarrhoea and should be avoided. Low-fibre foods including white bread, white rice or noodles, creamed cereals, ripe bananas, canned or cooked fruits without skins, cottage cheese, yogurt, eggs, mashed or baked potatoes without the skin, pureed vegetables, chicken or turkey without the skin, and fish should be consumed.

  • Avoid coffee, tea, alcohol, sweets, and fried, greasy, or highly spiced foods.

  • Avoid milk and milk products if they make diarrhoea worse.

  • Diarrhoea can cause loss of potassium. Bananas, oranges, potatoes, and peach and apricot nectars are good sources of potassium and should be consumed when suffering from diarrhoea unless otherwise advised by the doctor.

  • Slowly drink plenty of fluids to replace those lost through diarrhoea. Recommended drinks include mild, clear liquids, such as apple juice, water, weak tea, clear broth, or ginger ale and flat carbonated drinks are best. Drink them at room temperature.

  • If diarrhoea is severe, patient should consume a clear liquid diet for 3 -5 days to allow bowel time to rest. Gradually add low-fibre foods to replace lost nutrients when feeling better.

  • A patient suffering from severe diarrhoea may need intravenous fluids to replace lost water and nutrients.

  • Gas producing foods such as cabbage, onions and sprouts aggravate the bowel and should be avoided. In addition, spices, condiments and very hot or cold foods should also be avoided.

  • Treatment for diarrhea include:

  • Diphenoxylate and atropine (Lomotil)

  • Loperamide (Imodium)

Constipation

Constipation may be caused by chemotherapy drugs, lack of nourishment or inactivity. For relief, the patient may take a laxative, stool softener or use an enema. Any remedy should be checked with the doctor, especially if the patient has a low white blood cell count.

Patients may also try the following remedies:

  • Drink plenty of fluids to help loosen the bowels. Warm and hot fluids work especially well.

  • Eat high-fibre foods including bran, whole-wheat breads and cereals, raw or cooked vegetables, fresh and dried fruit, nuts, and popcorn.

  • Recommend exercise. A simple walk or even a structured exercise program can be effective. Seek doctor’s advice when beginning any exercise regime.

  • Avoid caffeine.

  • Drink hot beverages such as prune juice.

  • The suggested dietary fibre intake for healthy women is 21-25g/day and men should consume 30-38g/day. For mild cases of constipation, increasing fibre in the diet may stimulate regular bowel movements. Any change in diet should be discussed with the doctor especially for patients who have had bowel obstruction or bowel surgery. An increase in consumption of high fibre foods including nuts, bran, vegetables, legumes, whole wheat breads and pastas, and fruits can help relieve constipation.

    Constipation Symptoms

  • Infrequent bowel movements. As there is no “normal” schedule for bowel movements, frequency or infrequency is based on the patient’s own “normal” schedule. For example, if the patient normally moves bowels once per day, “infrequent” may be defined as every 2nd or 3rd day. This should be a consistent change, not a onetime occurrence.

  • Hard or difficult to pass bowel movements. Often, a person will pass small marble-like pieces of stool without satisfactory elimination.

  • Drugs prescribed for constipation include

  • Psyllium (Metamucil ®)

  • Senna (Senokot®)

  • Bisacodyl (Dulcolax®)

  • Docusate sodium (Colace®)

  • Glycerin suppository

  • Magnesium citrate

  • Magnesium hydroxide (Milk of Magnesia®)

  • Lactulose (Chronulac®)

  • Sorbitol and sodium phosphate (Fleet’s enema®)

  • The above drugs should not be taken unless consulted with the patient’s doctor first.

Nerve and Muscle Effects

As the nervous system affects the body’s organs and tissues, it is also affected by chemotherapy drugs. A wide range of side effects may occur including peripheral neuropathy, a condition that may cause tingling, burning, weakness, or numbness in the hands and/or feet, loss of balance, clumsiness, difficulty picking up objects and buttoning clothing, walking problems, jaw pain, hearing loss, stomach pain, constipation and weak, tired, or sore muscles.

All nerve or muscle symptoms should be reported to the patient’s doctor in case they indicate serious problems that require medical attention.

Patients may also try the following remedies:

  • Drink plenty of fluids to help loosen the bowels. Warm and hot fluids work especially well.

  • Eat high-fibre foods including bran, whole-wheat breads and cereals, raw or cooked vegetables, fresh and dried fruit, nuts, and popcorn.

  • Recommend exercise. A simple walk or even a structured exercise program can be effective. Seek doctor’s advice when beginning any exercise regime.

  • Avoid caffeine.

  • Drink hot beverages such as prune juice.

  • The suggested dietary fibre intake for healthy women is 21-25g/day and men should consume 30-38g/day. For mild cases of constipation, increasing fibre in the diet may stimulate regular bowel movements. Any change in diet should be discussed with the doctor especially for patients who have had bowel obstruction or bowel surgery. An increase in consumption of high fibre foods including nuts, bran, vegetables, legumes, whole wheat breads and pastas, and fruits can help relieve constipation.

    Constipation Symptoms

  • Infrequent bowel movements. As there is no “normal” schedule for bowel movements, frequency or infrequency is based on the patient’s own “normal” schedule. For example, if the patient normally moves bowels once per day, “infrequent” may be defined as every 2nd or 3rd day. This should be a consistent change, not a onetime occurrence.

  • Hard or difficult to pass bowel movements. Often, a person will pass small marble-like pieces of stool without satisfactory elimination.

  • Drugs prescribed for constipation include

  • Psyllium (Metamucil ®)

  • Senna (Senokot®)

  • Bisacodyl (Dulcolax®)

  • Docusate sodium (Colace®)

  • Glycerin suppository

  • Magnesium citrate

  • Magnesium hydroxide (Milk of Magnesia®)

  • Lactulose (Chronulac®)

  • Sorbitol and sodium phosphate (Fleet’s enema®)

  • The above drugs should not be taken unless consulted with the patient’s doctor first.

NERVE AND MUSCLE EFFECTS

As the nervous system affects the body’s organs and tissues, it is also affected by chemotherapy drugs. A wide range of side effects may occur including peripheral neuropathy, a condition that may cause tingling, burning, weakness, or numbness in the hands and/or feet, loss of balance, clumsiness, difficulty picking up objects and buttoning clothing, walking problems, jaw pain, hearing loss, stomach pain, constipation and weak, tired, or sore muscles.

All nerve or muscle symptoms should be reported to the patient’s doctor in case they indicate serious problems that require medical attention.

Effects on Skin and nails

Chemotherapy may cause minor skin problems including redness, itching, peeling, dryness, and acne. Nails may become brittle, darkened, or cracked and may develop vertical lines or bands. Patients can do most skin and nail care themselves. To treat acne they must keep face clean and dry and over-the-counter medicated creams or soaps can be used with caution. To avoid dryness, quick showers or sponge baths rather than long hot baths will help. Cream and lotion should be applied while the skin is still moist whereas perfume, cologne, or aftershave lotions that contain alcohol should be avoided. Nails should be protected by wearing gloves when washing dishes, gardening, or doing house work. Sun exposure may increase the effects of chemotherapy drugs on skin.

Kidney and bladder effects

Chemotherapy drugs can irritate the bladder and even cause temporary to permanent damage to the kidneys.

Signs to watch for include:

  • Pain or burning when urinating.

  • Frequent urination

  • A feeling that the patient must (urgency) urinate right away.

  • Reddish or bloody urine.

  • Fever

  • Chills.

A patient needs to drink plenty of fluids to ensure good urine flow and help prevent problems especially if treatment drugs affect the kidney and bladder. Water, juice, coffee, tea, soup, soft drinks, broth, ice cream, soup, popsicles, and gelatine are all considered fluids. The doctor will recommend if the patient must increase fluid intake.

Patients should note that some chemotherapy drugs affect the colour (orange, red, or yellow) or odour (to take on strong or medicine-like odour) of urine or semen.

Flu-like Syndrome

Some patients report feeling as though they have flu a few hours to a few days after chemotherapy. Flu-like symptoms - muscle ache, headache, tiredness, nausea, slight fever, chills, and poor appetite may last from 1 to 3 days. These symptoms may also be caused by an infection.

Fluid Retention

Hormonal changes and drugs' side effects may lead to fluid retention during chemotherapy. To prevent aggravating the issue, the patient should avoid table salt and foods with high sodium content. If the problem is severe, the doctor may prescribe diuretics to help the body get rid of excess fluids.

Appetite Changes

There may be days when the patient is unable to eat because of nausea, taste changes, or mouth and throat problems. Depression and exhaustion may cause the patients to lose their appetite as well.

When patients have poor appetite, they should attempt to:

  • Eat small meals or snacks whenever they want. Patients do not have to eat three regular meals each day.

  • Vary the diet and try new foods and recipes.

  • Take a walk before meals whenever they can. This may increase their appetite.

  • Change the mealtime routine. For example, eat by candlelight or at a different place.

  • Eat with friends or family members. When eating alone, listen to the radio or watch TV.

Weight Gain

During chemotherapy, a balanced nutritious diet containing fruits and vegetables, poultry, fish and meat, cereals and breads, and dairy products will help a patient cope with side effects better, fight infection and rebuild healthy tissues faster

Adequate protein builds and repairs skin, hair, muscles, and organs. Extra fluid protects the bladder and kidneys. Good nutrition and adequate amount of calories are important to keep weight up, whether or not this leads to weight gain.

Pain

Many cancer patients believe that pain is a normal part of cancer/cancer treatment and expect to simply “deal with it” when it arrives. Cancer related pain can always be relieved through various avenues

There is an association between high anxiety levels and pain in patients undergoing cancer treatment. Depression and suicide may result from unmanaged pain in cancer patients.

Pain Treatment

To make life more enjoyable for the patient, pain must be treated. Patients may be concerned about addiction to pain medication. However, only a small portion of patients become addicted to even the strongest pain killers (such as opioids/narcotics). Side effects of opioid use include nausea, sleepiness and constipation, and these generally go away a few days after starting treatment.

Patients should keep a diary or record of pain so the health care provider can effectively treat the pain. A successful pain management system decreases discomfort while increasing thinking ability, emotional well being, and interaction with friends and family.

Treatments for pain are not conclusive but include examples of drugs that work in a variety of ways. There are many different brands of these drugs, some are listed as follows:

  • Non-steroidal anti-inflammatory drugs (NSAIDs):

    Aspirin

    Ibuprofen

  • COX2 inhibitor - inhibits the cyclooxygenase-2 enzyme.

    Celecoxib (Celebrex®)

  • Opiates and derivatives

    Opiates are a group of drugs containing derivatives of opium, the dried juice of a poppy seed pods. Opiates are primarily used as strong analgesics (pain relievers). Opiates may reduce anxiety and cause drowsiness, euphoria or feelings of relaxation. They include:

    • Codeine

    • Fentanyl

    • Hydrocodone

    • Morphine

    • Oxycodone

    Other pain medication

  • Acetaminophen