Guide — Oncology
Chemotherapy Nursing Considerations
Chemotherapy targets rapidly dividing cells — which means it affects both cancer cells and normal tissues with high turnover. This guide covers chemotherapy principles, cell cycle phases, major drug classes, systemic toxicities, safe handling requirements, extravasation management, and patient education priorities.
13 min read · Oncology
Educational use only. This content is intended for nursing students and exam preparation. Chemotherapy administration requires specialized oncology nursing training, institutional protocols, and Oncology Nursing Society (ONS) certification. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Chemotherapy Principles
Chemotherapy drugs are cytotoxic agents that disrupt cell division. Because they target any rapidly dividing cell — not only cancer cells — normal tissues with high proliferative rates are susceptible: bone marrow, GI mucosa, hair follicles, and gonads.
Drugs are classified as cell-cycle specific (act on cells in a specific phase of the cycle — most effective when cells are actively dividing and when given as continuous infusions) or cell-cycle non-specific (can kill cells in any phase, including G0 resting cells — dose-dependent).
Cell Cycle Overview
| Phase | Activity | Drug Classes That Act Here |
|---|---|---|
| G0 | Resting phase — cells not actively dividing | Cell-cycle non-specific agents (alkylating, nitrosoureas) |
| G1 | Cell growth; protein and RNA synthesis | Corticosteroids, asparaginase |
| S | DNA synthesis and replication | Antimetabolites (methotrexate, 5-FU, cytarabine) |
| G2 | Final preparation for division; repair check | Bleomycin, topoisomerase II inhibitors |
| M | Mitosis — cell physically divides | Vinca alkaloids (vincristine, vinblastine), taxanes (paclitaxel, docetaxel) |
Major Drug Classes
| Class | Mechanism | Examples | Key Toxicity |
|---|---|---|---|
| Alkylating agents | Cross-link DNA strands — prevent replication | Cyclophosphamide, cisplatin, carmustine | Bone marrow suppression, hemorrhagic cystitis (cyclophosphamide), nephrotoxicity (cisplatin) |
| Antimetabolites | Interfere with DNA/RNA synthesis by mimicking normal metabolites | Methotrexate, 5-fluorouracil, cytarabine, gemcitabine | Mucositis, bone marrow suppression, hepatotoxicity (methotrexate) |
| Anthracyclines | Intercalate DNA; inhibit topoisomerase II; generate free radicals | Doxorubicin, daunorubicin, epirubicin | Cardiotoxicity (cumulative — dilated cardiomyopathy), alopecia, bone marrow suppression |
| Vinca alkaloids | Bind tubulin — prevent spindle formation; arrest mitosis | Vincristine, vinblastine, vinorelbine | Peripheral neuropathy (vincristine), myelosuppression (vinblastine) |
| Taxanes | Stabilize microtubules — prevent depolymerization; arrest mitosis | Paclitaxel, docetaxel | Peripheral neuropathy, hypersensitivity reactions, myelosuppression, alopecia |
| Topoisomerase inhibitors | Inhibit enzymes that manage DNA supercoiling during replication | Etoposide, irinotecan, topotecan | Bone marrow suppression, diarrhea (irinotecan — 'early' and 'late') |
| Platinum compounds | Form DNA adducts — cross-link DNA strands | Cisplatin, carboplatin, oxaliplatin | Nephrotoxicity (cisplatin), peripheral neuropathy (oxaliplatin — cold-sensitive), ototoxicity |
Hematologic Toxicities — Nadir Timing
Nadir = the lowest point of blood counts after chemotherapy administration. Timing varies by drug — most reach nadir 7–14 days post-treatment. The nadir is the highest-risk period for infection, bleeding, and fatigue.
Nadir: 7–14 days Recovery: 21–28 days
Infection risk — ANC <500 = febrile neutropenia emergency
Nadir: 10–14 days Recovery: slower (RBC lifespan ~120 days)
Fatigue, dyspnea, tachycardia — may require transfusion or erythropoietin
Nadir: 8–14 days Recovery: 21 days
Bleeding risk — platelets <10,000 = transfusion threshold; <50,000 = bleeding precautions
Other Major Toxicities
| Toxicity | Key Drugs | Nursing Considerations |
|---|---|---|
| Nausea/Vomiting | Most cytotoxic agents — highly emetogenic: cisplatin, cyclophosphamide, doxorubicin | Premedicate with antiemetics (ondansetron, dexamethasone, NK1 antagonists). Assess oral intake, hydration, weight. Small frequent meals. |
| Mucositis | Antimetabolites (methotrexate, 5-FU), anthracyclines | Oral assessment with each contact. Saline rinses. Avoid harsh mouthwashes. Soft diet. Monitor for oral infections (Candida, HSV). |
| Alopecia | Anthracyclines, taxanes, alkylating agents | Warn patients it is expected and temporary. Hair typically regrows 3–6 months after treatment ends. Scalp cooling may reduce severity with some regimens. |
| Cardiotoxicity | Doxorubicin, trastuzumab | Cumulative lifetime dose limit for doxorubicin (550 mg/m²). Baseline and periodic ECHO or MUGA scan. Monitor for HF symptoms: dyspnea, edema, fatigue. |
| Peripheral neuropathy | Vincristine, taxanes, platinum compounds (oxaliplatin) | Assess for numbness, tingling, weakness in hands/feet. Oxaliplatin: cold-induced — warn against touching cold objects. Fall risk assessment. |
| Nephrotoxicity | Cisplatin, methotrexate | Pre-hydrate aggressively (cisplatin requires 1–2 L NS before/after). Monitor BUN, creatinine, urine output. Avoid NSAIDs. Leucovorin rescue for high-dose methotrexate. |
| Hemorrhagic cystitis | Cyclophosphamide, ifosfamide | Adequate hydration, frequent voiding, mesna (uroprotectant). Monitor urine for hematuria. |
Safe Handling of Chemotherapy (Hazardous Drugs)
Hazardous Drug Exposure Risks
Chemotherapy agents are classified as hazardous drugs — occupational exposure causes mutagenicity, carcinogenicity, teratogenicity, and organ toxicity in healthcare workers. PPE and institutional NIOSH protocols are mandatory.
- !PPE required: chemotherapy gloves (double glove), chemotherapy gown (non-absorbent, closed front), eye protection, mask (in certain settings)
- !Preparation in certified biological safety cabinet (BSC) by pharmacy
- !Use Luer-Lock connections — never open-system tubing for chemo infusions
- !Spill management: chemotherapy spill kit, seal area, double-bag waste, document
- !Disposal: all contaminated supplies in yellow chemotherapy waste containers
- !Pregnant nurses should not handle hazardous drugs — request reassignment per institutional policy
- !Wash hands before gloving and after removing gloves
Extravasation — Vesicant vs. Irritant
Vesicant (most dangerous)
Causes severe tissue necrosis, ulceration, and permanent injury if extravasated. Examples: doxorubicin, vincristine, mechlorethamine, mitomycin.
If extravasation suspected:
- 1.Stop infusion IMMEDIATELY
- 2.Leave needle/catheter in place
- 3.Aspirate residual drug
- 4.Apply warm or cold per drug protocol
- 5.Administer antidote if available (e.g., dexrazoxane for anthracyclines)
- 6.Notify provider and document
Irritant (less severe)
Causes pain, burning, and inflammation at the infusion site without tissue necrosis. Examples: 5-fluorouracil, etoposide, carboplatin, dacarbazine.
Prevention focus:
- ✦Assess IV site before each chemotherapy infusion
- ✦Verify blood return before and during infusion
- ✦Monitor for pain, swelling, redness, or leakage throughout infusion
- ✦Use central venous access for repeated vesicant administration
NCLEX Pearls — Chemotherapy
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with Oncology Nursing Society (ONS) · National Comprehensive Cancer Network (NCCN) · American Society of Clinical Oncology (ASCO). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →