A healthcare prescriber orders chemotherapy medications.

A pharmacist, physician, physician assistant, advanced practice registered nurse (APRN) or registered nurse (RN) who has completed competency training in the administration and safe handling of chemotherapy may administer antineoplastic agents. These personnel must also be skilled in venipuncture, assessment and management of various types of central venous access devices (CVADs), and drug administration systems.

The individual administering the chemotherapy is responsible for the prevention, early detection, and management of acute reactions associated with chemotherapy, including hypersensitivity, anaphylaxis, hypotension, extravasation, and nausea and vomiting.

All personnel handling the transport and administration of chemotherapy should have specific instructions related to hazardous waste and spill precautions.

All equipment used in drug preparation and any unused drugs are treated as hazardous waste and disposed of according to the institution’s policies.

The use of personal protective equipment (PPE) is one of the best ways for nurses to prevent occupational exposure to chemotherapy agents. The National Institute for Occupational Safety and Health (NIOSH) recommends reducing exposure by using the following PPE:

Storage and labeling of chemotherapeutic agents follow the institutional pharmacy guidelines.

According to NIOSH, cytotoxic drugs, including oral drugs that must be compounded or crushed, should be prepared in a biologic safety cabinet (BSC). All tubing should be primed in the pharmacy with a solution that is not a chemotherapy solution (e.g., normal saline or the solution the chemotherapy is mixed in, such as D5W). Prior to transport to patient care areas a “Cytotoxic Agent” label should be affixed to the chemotherapy. Chemotherapy should be delivered to the patient care area “ready to administer.”

To prevent accidental ingestion of cytotoxic agents, it is prohibited to eat, drink, chew gum, apply cosmetics, or store food in areas where chemotherapy is prepared or administered.

A multidisciplinary verification process should include the general “rights” of medication administration, treatment plan, and independent dose calculations by the physician, the pharmacist, and the nurse.

Ensure chemotherapy orders include all essential components according to the institution’s policies.

Verbal or telephone orders for chemotherapy administration are not acceptable.

Use aseptic technique in the preparation and administration of chemotherapy.

Two chemotherapy-competent personnel should check the written orders and ensure that the six “rights” of drug administration (drug, dose, time, route, fluid/volume and patient) are correct.

Possible routes are oral, subcutaneous, intramuscular, intravenous (IV), intrathecal, and intra-arterial. The best route is dependent on chemical properties of the medicines and desired effect.

Intrathecal administration is performed in a sterile procedure area and never administered at the same time as IV chemotherapy (Cohen, 2007).

Administration of intravenous chemotherapy agents should be done through a central line if possible, especially if it requires continuous infusion.

If indicated, peripheral IV (PIV) access for chemotherapy administration is established with minimal trauma, and repeated attempts are avoided. If repeated attempts are necessary, they should be done proximally to prevent leakage of the cytotoxic agent from previous needle insertion sites.

An established PIV site for administration of chemotherapy should not be used if the site is more than 24 hours old.

Optimal sites for PIV insertion for administration of chemotherapy include large, healthy veins in the nondominant arm (e.g., upper extremities, especially veins of the forearms). The dorsum of the hand, foot, and antecubital fossa areas should not be used because of the increased risk for serious functional damage if infiltration occurs.

Small-gauge (22- to 24-gauge) catheters are recommended. Catheters made of Teflon are preferred for longer infusions.

If a PIV needs to stay in for more than 1 hour, it is best to place an Angiocath that will be less likely to infiltrate and will be less traumatic to the vein. If the patient is to receive only an injection of chemotherapy and PIV antiemetics without hydration, a butterfly needle is preferred because it is easy to insert into small veins and is less traumatic due to the short duration of therapy.

Insertion sites should be visible, secured, and stable at all times. Occlusive clear dressings are recommended for covering the site.

Venous integrity will be assessed before each administration of chemotherapy to validate blood return and proper flow. For chemotherapy administered IV push, blood return will be assessed every 1 to 2 mL. For longer infusions, blood return should be accessed every hour.

The use of infusion pumps with high-flow pressures is not recommended for peripheral line infusions.