**Cancer Nursing: Chemotherapy Side Effects, Neutropenia Precautions, & Tumour Lysis Syndrome**

Cancer Nursing: Chemotherapy Side Effects, Neutropenia Precautions, & Tumour Lysis Syndrome

A high-density, practical guide for nurses and healthcare professionals.

What Is This?

This guide covers chemotherapy side effects, neutropenia precautions, and tumour lysis syndrome (TLS)—three critical areas in cancer nursing. You’ll learn how to recognize, prevent, and manage these complications to improve patient outcomes.

Why it matters today:
Chemotherapy remains a cornerstone of cancer treatment, but its toxicity can be life-threatening. Neutropenia increases infection risk, while TLS can cause fatal metabolic imbalances. Nurses must act fast to prevent harm.

Why It Matters

• Chemotherapy side effects (e.g., nausea, fatigue, myelosuppression) reduce quality of life and treatment adherence.
• Neutropenia (low neutrophil count) is the #1 cause of chemotherapy delays and sepsis-related deaths.
• Tumour Lysis Syndrome (TLS) is an oncologic emergency that can lead to renal failure, arrhythmias, and death if untreated.

Real-world impact:
- 1 in 3 cancer patients develop neutropenic fever during chemotherapy.
- TLS occurs in 5–20% of high-risk patients (e.g., acute leukemias, lymphomas).
- Early intervention can reduce mortality by 50% or more.

Core Concepts

1. Chemotherapy Side Effects: Mechanisms & Management

Chemotherapy damages rapidly dividing cells (cancer + healthy cells like bone marrow, GI tract, hair follicles).

Key principle: Prevention > treatment. Always pre-medicate (e.g., antiemetics before chemo) and monitor labs (CBC, electrolytes, renal function).

2. Neutropenia Precautions: Infection Control

Neutropenia = ANC (absolute neutrophil count) < 1,000 cells/µL (severe if < 500).
Neutropenic fever = ANC < 500 + single temp ≥ 38.3°C (101°F) or ≥ 38°C (100.4°F) for 1 hour.

Risk Factors for Neutropenia

• High-dose chemotherapy (e.g., induction for AML, stem cell transplant).
• Bone marrow involvement (e.g., leukemia, lymphoma).
• Prior radiation (especially pelvic/bone marrow).
• Comorbidities (diabetes, renal failure).

Neutropenia Precautions (Nursing Interventions)

Key principle: Assume infection until proven otherwise. Start broad-spectrum antibiotics within 1 hour of neutropenic fever (e.g., piperacillin-tazobactam + vancomycin if central line present).

3. Tumour Lysis Syndrome (TLS): Pathophysiology & Management

TLS = Rapid cell death → release of intracellular contents (K⁺, PO₄³⁻, uric acid) → metabolic chaos.

TLS Risk Factors (Cairo-Bishop Criteria)

TLS Complications

• Hyperkalemia → arrhythmias, cardiac arrest.
• Hyperphosphatemia → hypocalcemia, tetany, seizures.
• Hyperuricemia → acute kidney injury (uric acid crystals in tubules).
• Acute renal failure → metabolic acidosis, fluid overload.

TLS Management (Nursing Interventions)

Key principle: Prevent TLS before it starts. Hydrate aggressively 24–48 hours before chemo in high-risk patients.

How It Works (Step-by-Step Workflow)

1. Chemotherapy Side Effect Management

1. Assess → Review chemo regimen (e.g., cisplatin = high emetogenic risk).
2. Pre-medicate → Administer antiemetics (e.g., ondansetron + dexamethasone) 30 mins before chemo.
3. Monitor → Check CBC, electrolytes, renal function before/after chemo.
4. Educate → Teach patient about hand hygiene, hydration, when to call (fever, bleeding).

2. Neutropenia Precautions

1. Calculate ANC → (Segs + Bands) × WBC / 100.
2. Example: WBC = 1,000, Segs = 20%, Bands = 5% → ANC = (20 + 5) × 1,000 / 100 = 250 (severe neutropenia).
3. Initiate precautions → Private room, no fresh flowers/veggies, strict hand hygiene.
4. Monitor for fever → Q4h temps, inspect IV sites, avoid rectal exams.
5. Act fast if fever → Blood cultures, CXR, start antibiotics within 1 hour.

3. Tumour Lysis Syndrome (TLS) Prevention & Treatment

1. Risk stratify → Use Cairo-Bishop criteria (high/intermediate/low risk).
2. Prevent → Hydrate (2–3 L/m²/day), allopurinol/rasburicase, monitor labs Q6h.
3. Treat →
4. Hyperkalemia → Insulin + glucose, kayexalate, dialysis if severe.
5. Hyperphosphatemia → Phosphate binders (sevelamer), avoid calcium unless symptomatic.
6. Hyperuricemia → Rasburicase (if uric acid > 8 mg/dL).
7. Supportive care → Telemetry, renal consult, possible CRRT (continuous renal replacement therapy).

Hands-On / Getting Started

Prerequisites

• Knowledge: Basic understanding of chemotherapy, CBC interpretation, electrolyte imbalances.
• Skills: IV insertion, blood draws, medication administration.
• Equipment: IV pumps, telemetry, point-of-care testing (e.g., i-STAT for electrolytes).

Step-by-Step Example: Managing Neutropenic Fever

1. Patient presents with fever (38.5°C) + ANC 200 post-chemo.
2. Assess:
3. Vitals (BP, HR, SpO₂).
4. IV site (redness, swelling?).
5. Lungs (crackles? → possible pneumonia).
6. Act:
7. Draw blood cultures (peripheral + central line if present).
8. Start antibiotics (e.g., piperacillin-tazobactam 4.5g IV Q6h + vancomycin 15 mg/kg IV Q12h).
9. Administer fluids (e.g., NS 1L bolus).
10. Monitor:
11. Q1h temps, Q4h labs (CBC, electrolytes, lactate).
12. Telemetry (watch for arrhythmias if hyperkalemic).

Expected outcome: Fever resolves in 48–72 hours, no sepsis, ANC recovers in 7–10 days.

Common Pitfalls & Mistakes

Best Practices

Chemotherapy Side Effects

✅ Pre-medicate (e.g., antiemetics before chemo, not after).
✅ Monitor labs (CBC, electrolytes, renal function) before and after each cycle.
✅ Educate patients on when to call (fever, bleeding, severe nausea).

Neutropenia Precautions

✅ Calculate ANC daily (not just WBC).
✅ Isolate high-risk patients (private room, HEPA filter if ANC < 100).
✅ Start antibiotics within 1 hour of neutropenic fever.

Tumour Lysis Syndrome (TLS)

✅ Hydrate aggressively (2–3 L/m²/day) before chemo.
✅ Monitor labs Q4–6h (K⁺, PO₄³⁻, uric acid, creatinine).
✅ Use rasburicase (not allopurinol) if uric acid > 8 mg/dL.

Tools & Frameworks

Real-World Use Cases

1. Acute Myeloid Leukemia (AML) Induction Chemotherapy

• Scenario: Patient receives 7+3 (cytarabine + daunorubicin).
• Risk: High TLS risk (bulky disease, high WBC), severe neutropenia (ANC 0 for 2–3 weeks).
• Nursing Actions:
• Pre-chemo: Hydrate (3L/day), allopurinol + rasburicase, telemetry.
• Post-chemo: Q6h labs, neutropenic precautions, broad-spectrum antibiotics if fever.

2. Breast Cancer (Adjuvant Chemo: AC-T)

• Scenario: Patient receives doxorubicin + cyclophosphamide (AC) → paclitaxel (T).
• Risk: Cardiotoxicity (doxorubicin), neuropathy (paclitaxel), neutropenia.
• Nursing Actions:
• Pre-chemo: Echocardiogram (EF > 50%), antiemetics (ondansetron + dexamethasone).
• Post-chemo: Monitor for fever (neutropenia), neuropathy (gabapentin if needed).

3. Burkitt Lymphoma (High TLS Risk)

• Scenario: Patient presents with abdominal mass, LDH 5x ULN, uric acid 12 mg/dL.
• Risk: Imminent TLS → renal failure, arrhythmias.
• Nursing Actions:
• Emergency: IV fluids (3L bolus), rasburicase, telemetry.
• Monitor: Q4h labs (K⁺, PO₄³⁻, Ca²⁺, uric acid), urine output (goal > 100 mL/hr).

Check Your Understanding (MCQs)

Question 1

A patient with acute lymphoblastic leukemia (ALL) receives hyper-CVAD chemotherapy. On day 3, their uric acid is 10 mg/dL, potassium 6.2 mEq/L, and creatinine 2.8 mg/dL. What is the priority intervention?

A. Administer allopurinol 300 mg PO.
B. Start rasburicase 0.2 mg/kg IV.
C. Give calcium gluconate 1g IV.
D. Initiate hemodialysis.

✅ Correct Answer: B (Start rasburicase 0.2 mg/kg IV).
Explanation: The patient has TLS with hyperuricemia and hyperkalemia. Rasburicase rapidly lowers uric acid (allopurinol is too slow). Calcium gluconate stabilizes the heart but doesn’t treat the underlying cause. Dialysis is reserved for refractory hyperkalemia or renal failure.

Why the distractors are tempting:
- A (Allopurinol): Commonly used for TLS prevention, but not effective for acute hyperuricemia (takes days to work).
- C (Calcium gluconate):