| Anemia |
- Low red blood cell (RBC) production in the bone marrow
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- Encourage patient to:
- Rest between activities.
- Eat foods high in protein and iron.
- Treatment options vary by degree of anemia and etiology and may include:
- Iron supplementation
- Red blood cell transfusion
- Administer erythropoietin-stimulating agents (ESAs) to foster production of RBCs but may increase risk for thromboembolism.
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| Appetite changes |
- Mouth and throat sores
- Change in sense of taste or smell
- Nausea and vomiting
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- Advise patient to:
- Maintain adequate hydration.
- Eat a healthy, high-nutrient diet.
- Exercise regularly.
- Treat oropharyngeal sores.
- Provide adequate mouth care.
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| Bleeding and bruising |
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- Instruct patient to:
- Avoid aspirin or ibuprofen.
- Brush teeth gently with a soft toothbrush.
- Use an electric shaver; avoid razors.
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| Constipation |
- Medications such as opioids
- Changes in diet
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- Encourage patient to:
- Eat high fiber foods.
- Increase fluid intake.
- Increase activity.
- Administer stool softeners and/or laxatives as needed.
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| Dehydration |
- Appetite changes
- Nausea and vomiting
- Diarrhea
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- Instruct patient to increase fluid intake.
- Administer intravenous (IV) fluids as needed.
- Manage nausea, vomiting, and diarrhea (see recommendations below).
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| Diarrhea |
- Chemotherapy effect on the smooth muscles in the GI tract and damage to cells lining the GI tract
- Infection
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- Advise the patient to:
- Try the BRAT diet (bananas, rice, applesauce, toast).
- Avoid milk, alcohol, caffeine, fatty, spicy, and high fiber foods.
- Eat small, frequent meals.
- Increase fluid intake (8-12 cups/day).
- Seek medical attention for refractory dehydration.
- Administer antidiarrheal medication as needed.
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| Edema |
- Fluid build-up in the tissues due to chemotherapy or heart, liver, or kidney failure
- Poor nutrition
- Blockage of veins or the lymph system
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- Educate patient to:
- Avoid tight clothing and shoes.
- Avoid crossing legs when sitting.
- Wear compression stockings and sleeves as needed.
- Exercise regularly.
- Limit salt intake.
- Administer diuretics for severe swelling.
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| Fatigue |
- Chemotherapy-induced anemia
- Vasomotor symptoms that result in sleep difficulties
- Depression
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- Advise patient:
- Fatigue typically resolves when chemotherapy is discontinued.
- To rest between activities.
- To eat foods high in protein and iron.
- Assess for anemia, pain, depression, hypoxia, or fluid/electrolyte imbalances.
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| Flu-like symptoms |
- Some types of chemotherapy can cause flu-like symptoms within a few hours after treatment and may last for 2 to 3 days.
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- Instruct patient to:
- Hydrate to treat diarrhea.
- Increase calories and protein.
- Medicate for chills or body aches; but contact provider before medicating to lower a fever.
- Manage nausea and vomiting (see below).
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| Hair loss (alopecia) |
- Some types of chemotherapy cause hair to fall out.
- May begin after the second or third cycle of treatment
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- Reassure the patient that hair often grows back in 2 to 3 months after treatment has ended.
- Advise patient to:
- Treat hair gently: use a soft brush; avoid hair dryers, irons, gels, clips; use a mild shampoo and wash less frequently.
- Apply sunscreen or a hat when outside.
- Wear head wraps and/or wigs.
- Recommend scalp cooling devices; for some patients, when used before, during and after treatment, they may reduce or prevent hair loss.
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| Hepatotoxicity |
- Elevated bilirubin, alkaline phosphatase (ALK), aspartate transaminase (AST), and alanine transaminase (ALT) levels may result from chemotherapy.
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- Usually mild
- Treatment may not be needed, instead adjust dose.
- If severe, discontinue treatment.
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| Infection |
- Chemotherapy may decrease white blood cell production leading to neutropenia which increases risk of infection.
- Neutropenia may occur 10 to 14 days after each cycle and typically resolves prior to the next chemotherapy treatment.
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- Monitor for signs of infection (fever, cough, sore throat, pain, rash, sores on mouth or tongue, swelling, redness).
- Educate patient to:
- Practice good hand hygiene.
- Avoid crowds, people who are sick, and people who recently received a live vaccine.
- Use a mask when out in public.
- Follow food safety guidelines.
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| Memory or concentration changes |
- Exact cause is unknown.
- Symptoms include forgetfulness, difficulty concentrating, memory issues, trouble multi-tasking or remembering common words.
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- Advise patient to:
- Exercise the brain with puzzles or take a class to learn something new.
- Maintain adequate rest and sleep.
- Participate in regular physical activity.
- Follow a daily routine
- Use planners or smart phone applications to set reminders and stay organized.
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| Mouth and throat problems |
- Chemotherapy may cause a chemical or metallic taste, a change in taste or smell, dry mouth, infections, mouth sores, pain/swelling, sensitivity to hot or cold, dysphagia, cavities, and mucositis.
- Low platelet count may cause bleeding in the mouth/gums.
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- Instruct patient to:
- Schedule a dental check-up and cleaning before treatment begins.
- Maintain good oral hygiene.
- Swish ice chips around mouth for 30 minutes (may alleviate inflammation and soothe sores).
- Apply topical diphenhydramine, oral antacids and lidocaine (may relieve symptoms).
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| Myalgias (muscle pain); arthralgias (joint pain) |
- Muscle and joint pain are associated with chemotherapy drugs such as biologic therapies and growth factors
- Blood infections can cause muscle aches and fever.
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- Reassure patient that these symptoms typically resolve when treatment is stopped.
- Administer medications that alleviate symptoms:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Gabapentin
- Glutamine
- Antihistamines
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| Nausea and vomiting |
- Symptoms vary from mild, moderate, or severe depending on the regimen.
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- Administer antiemetics/anti-nausea medications as prescribed.
- Instruct patient to:
- Use ice, popsicles, or hard candy to alleviate symptoms during chemotherapy.
- Increase fluid intake but avoid drinking with meals, and avoid greasy, fried, sweet, or spicy food.
- Sit up for 2 hours after eating.
- Avoid strong odors, caffeine, and smoking during therapy.
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| Peripheral neuropathy |
- Chemotherapy-induced peripheral neuropathy (CIPN) may cause nerve damage and symptoms such as pain, numbness, weakness, burning, tingling, or unusual sensation in arms and legs.
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- Assure patient that symptoms usually resolve after treatment is discontinued.
- Administer duloxetine or agent specific to neuropathic pain as prescribed to treat chemotherapy-induced neuropathy.
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| Pulmonary toxicity |
- Some medications may cause pneumonitis which leads to dyspnea, cough, malaise, or fever.
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- Assure patient that most symptoms resolve after treatment is discontinued.
- Administer as needed and prescribed:
- Oxygen therapy
- Glucocorticoids (severe cases)
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| Sexual health and fertility issues in men |
- Chemotherapy may lower testosterone levels and libido.
- Traces of chemotherapy may be found in semen after treatment.
- Chemotherapy can damage sperm in men and germ cells in boys.
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- Discuss with patient:
- Medications and procedures available to treat erectile dysfunction
- Fertility preservation options (sperm banking)
- Advise patient to use condoms to prevent partner exposure to chemotherapy in semen.
- Refer patient to support groups or counseling.
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| Sexual health and fertility issues in women |
- Chemotherapy may lower estrogen levels and affect ovarian function causing hot flashes, irregular or no periods, and vaginal dryness that can cause painful intercourse.
- Chemotherapy may affect vaginal tissue and cause sores.
- Chemotherapy can stop ovaries from releasing eggs and estrogen or lower the number of eggs in the ovaries.
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- Discuss with patient:
- Medications to decrease pain during intercourse (e.g., vaginal gels, creams, lubricants)
- Fertility preservation options (egg or embryo cryopreservation)
- Condom use to prevent partner exposure to chemotherapy in vaginal fluids
- Educate patient to perform Kegel pelvic muscle exercises.
- Refer patient to support groups or counseling.
- Administer non-estrogen treatments: gabapentin, selective serotonin reuptake inhibitors (SSRI) and selective serotonin norepinephrine reuptake inhibitors (SSNRIs) as prescribed.
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| Skin and nail changes |
- Very common with chemotherapy
- Cause is unknown but there may be a toxic or allergic etiology.
- Severity and duration of allergic skin reactions may be independent of dose and may persist after the drug has been discontinued.
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- For dry, itchy, red skin, instruct patient to:
- Use mild soap, lotions, and creams.
- Avoid products with alcohol or perfume.
- Apply lotion after bathing.
- Avoid hot water.
- Keep home temperature cool and humid.
- Educate patient to:
- Seek medical attention for rash to rule out an allergic reaction.
- Always use sunscreen when outdoors due to increased susceptibility to sunburn.
- Keep nails clean and trimmed, and wear protective gloves for gardening and house cleaning.
- Administer anti-itch medications as needed.
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| Urinary and bladder problems |
- Chemotherapy may affect or damage the bladder and kidneys.
- Chemotherapy can cause a change in the color or smell of urine.
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- Monitor for signs of urinary tract infection: pain, burning on urination, red or cloudy urine, fever, back or abdominal pain, inability to urinate.
- Advise patient to drink a minimum of 8 cups of fluid each day and avoid caffeine, alcohol, and tobacco.
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| Weight gain |
- Chemotherapy may induce hormonal changes and alter adipose tissue causing insulin resistance.
- Chemotherapy-related edema may increase weight.
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- Instruct patient to:
- Eat a proper diet.
- Maintain regular physical activity.
- Avoid salt intake and high-calorie foods.
- Refer patient to a nutritionist, as indicated.
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Weight loss
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- Poor appetite
- Mouth sores, bleeding
- Dysphagia
- Change in sense of taste, smell
- Diarrhea
- Vomiting
- Dehydration
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- Advise patient to:
- Eat high-calorie and high-protein foods and snacks.
- Use liquid food supplements, as needed.
- Maintain adequate hydration.
- Administer antiemetics and antidiarrheals as needed.
- Refer patient to a nutritionist, as indicated.
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