Oncology Nursing Guide 2026

⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.

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Chemotherapy drug classes and side effects, safe handling guidelines, tumor lysis syndrome, neutropenic fever protocol, oncologic emergencies, and cancer pain management for bedside nurses.

1. Chemotherapy Drug Classes & Key Toxicities

Class	Examples	Mechanism	Key Toxicities
Alkylating agents	Cyclophosphamide, ifosfamide, busulfan, cisplatin, carboplatin	Cross-link DNA strands — prevents replication	Hemorrhagic cystitis (cyclophosphamide/ifosfamide — give Mesna; force fluids; monitor UA), nephrotoxicity (cisplatin — aggressive hydration required), myelosuppression, ototoxicity (cisplatin)
Antimetabolites	Methotrexate, 5-fluorouracil (5-FU), cytarabine, gemcitabine	Interfere with DNA/RNA synthesis by mimicking normal metabolites	Myelosuppression, mucositis, diarrhea. Methotrexate: leucovorin rescue (folinic acid "antidote"); renal toxicity; monitor levels. 5-FU: hand-foot syndrome (palmar-plantar erythrodysesthesia)
Anthracyclines	Doxorubicin (Adriamycin), daunorubicin, epirubicin, idarubicin	Intercalate DNA; generate free radicals	Cardiomyopathy (cumulative dose-dependent — lifetime max doxorubicin dose ~450–550 mg/m²; monitor ECHO/MUGA before each cycle), RED urine (normal — warn patient), severe vesicant (extravasation = tissue necrosis), alopecia
Vinca alkaloids	Vincristine, vinblastine, vinorelbine	Inhibit microtubule formation → prevent mitotic spindle formation	Vincristine: neurotoxicity (peripheral neuropathy, SIADH, jaw pain, constipation — prophylactic laxatives); NEVER intrathecal (fatal). Vinblastine: myelosuppression (more than vincristine)
Taxanes	Paclitaxel (Taxol), docetaxel (Taxotere)	Stabilize microtubules → prevent cell division	Hypersensitivity reactions (paclitaxel — premedicate with dexamethasone + diphenhydramine + H2-blocker; infuse slowly; have epinephrine ready), peripheral neuropathy, myelosuppression, alopecia, fluid retention (docetaxel)
Topoisomerase inhibitors	Etoposide (VP-16), irinotecan, topotecan	Inhibit topoisomerase enzymes → DNA strand breaks	Myelosuppression; irinotecan: severe diarrhea (cholinergic — early onset treated with atropine; late-onset treated with loperamide)
Monoclonal antibodies	Rituximab (anti-CD20), trastuzumab (Herceptin, anti-HER2), bevacizumab (anti-VEGF), cetuximab	Target specific tumor antigens or growth factors	Infusion reactions (rituximab — first infusion highest risk; premedicate; slow infusion; monitor), cardiotoxicity (trastuzumab — monitor ECHO; do not give with doxorubicin concurrently), hypertension/hemorrhage (bevacizumab)

2. Safe Chemotherapy Handling

Chemotherapy is a hazardous drug — exposure risk to nurses during preparation and administration.

PPE: Chemotherapy-rated gloves (double-glove), impermeable chemo gown, eye protection/face shield if splash risk; some agents require respiratory protection
Preparation: Only in certified biosafety cabinet (pharmacy); never on the floor or at bedside
Administration: Closed system transfer devices (CSTD); check for IV patency BEFORE connecting; verify blood return on peripheral IVs for vesicants
Waste: Yellow chemotherapy waste bags and sharps containers; all contaminated materials in chemo waste
Spills: Chemo spill kit; wear full PPE; contain spill; notify pharmacy/safety officer
Body fluids: Patient's urine, stool, vomit contain active chemotherapy for 48–72+ hours after treatment; wear gloves when handling
Pregnancy: Pregnant nurses should not handle or administer chemotherapy

3. Vesicants vs. Irritants

Classification	Meaning	Examples	If Extravasation Occurs
Vesicant	Causes severe tissue necrosis and ulceration on extravasation	Doxorubicin, vincristine, vinblastine, mechlorethamine, paclitaxel	STOP infusion immediately; leave needle in place; aspirate residual drug; apply antidote if available (dexrazoxane for anthracyclines; hyaluronidase for vinca alkaloids); elevate extremity; cold compress (anthracyclines) or warm compress (vinca alkaloids); plastic surgery consult
Irritant	Causes pain and phlebitis at infusion site; less severe than vesicant	Etoposide, carboplatin, irinotecan	Stop infusion; treat symptoms; may continue via new IV access

4. Tumor Lysis Syndrome (TLS)

TLS = massive lysis of tumor cells → release of intracellular contents into bloodstream
Most common with: large tumor burden, hematologic malignancies (Burkitt lymphoma, ALL, AML), highly chemosensitive tumors

Laboratory TLS (Cairo-Bishop criteria) — 3 of 4 within 3 days before to 7 days after chemo:

Uric acid ≥8 mg/dL (or 25% increase)
Potassium ≥6.0 mEq/L (or 25% increase)
Phosphorus ≥4.5 mg/dL (or 25% increase)
Calcium ≤7 mg/dL (or 25% decrease) — phosphate binds calcium → hypocalcemia

Clinical TLS: Lab TLS + creatinine ≥1.5× ULN, cardiac arrhythmia, seizures

Management:

Aggressive IV hydration: 2–3 L/m²/day NS to promote renal excretion
Allopurinol: prophylaxis; reduces uric acid production (xanthine oxidase inhibitor)
Rasburicase: enzymatic uric acid breakdown; faster than allopurinol; used for high-risk or established TLS; contraindicated in G6PD deficiency (hemolysis)
Treat hyperkalemia: EKG monitoring; kayexalate; insulin/dextrose; dialysis if refractory
Treat hyperphosphatemia: phosphate binders (calcium carbonate, sevelamer)
Avoid supplemental calcium unless symptomatic hypocalcemia (giving calcium when phosphate high → calcium phosphate precipitation in tissues)

5. Neutropenic Fever (Febrile Neutropenia)

Definition: Single oral temperature ≥38.3°C (101°F) OR sustained temperature ≥38°C (100.4°F) over 1 hour PLUS ANC <500 cells/mm³ (or <1000 and expected to drop to <500)

This is a medical emergency — mortality can be >10% if not treated promptly.

Immediate actions:

Blood cultures × 2 sets (from two separate sites or one peripheral + one central line lumen) BEFORE antibiotics
Start broad-spectrum antibiotics within 60 minutes of presentation (door-to-antibiotic time goal)
First-line: anti-pseudomonal beta-lactam (piperacillin-tazobactam, cefepime, or carbapenem)
Add vancomycin if: hemodynamic instability, suspected line infection, mucositis, skin/soft tissue infection, MRSA colonization
Complete history and physical; CXR; UA/urine culture; wound cultures if applicable

Neutropenic precautions: Private room; strict hand hygiene; no fresh fruits/vegetables or flowers; limit procedures; HEPA filtration (for prolonged neutropenia); mask for patient when transported

G-CSF (filgrastim/neulasta): Stimulates neutrophil production; given 24–72h after chemo completion; do NOT give within 24h of chemo; shortens duration of neutropenia

6. Oncologic Emergencies

Emergency	Presentation	Immediate Action
Superior Vena Cava (SVC) Syndrome	Facial/arm/neck swelling, facial plethora (redness), JVD, dyspnea, headache worse when bending forward; Pemberton's sign (arm raise → face turns red)	HOB elevated; oxygen; avoid all upper extremity IVs; emergent oncology/radiation/IR consult; corticosteroids; radiation or stenting
Spinal Cord Compression	Back pain (NEW, severe — precedes neurologic deficits by days/weeks), weakness, paresthesias, bowel/bladder dysfunction; back pain worse with recumbency	URGENT MRI spine; dexamethasone (reduces edema) immediately; radiation/surgery; log-roll precautions; assess neuro q4h; bowel/bladder assessment
Hypercalcemia of Malignancy	"Bones, Groans, Stones, Moans" — bone pain, N/V/constipation, nephrolithiasis, confusion/altered MS; muscle weakness; EKG changes	Aggressive IV NS hydration; zoledronic acid (bisphosphonate) IV; calcitonin for rapid effect; furosemide after adequate hydration (not first)
Increased ICP from Brain Mets	Headache (worse in morning, with Valsalva), N/V, focal neuro deficits, seizures, altered MS	Dexamethasone (reduces peritumoral edema); mannitol for acute herniation; head of bed 30°; neurosurgery/radiation oncology consult; seizure precautions

NCLEX High-Yield: Oncology

Anthracyclines (doxorubicin): cardiotoxicity — monitor ECHO; red/orange urine is normal (not hematuria)
Vincristine: severe neurotoxicity; NEVER intrathecal; prophylactic laxatives for constipation
Cisplatin: nephrotoxicity — aggressive IV hydration before and after; ototoxicity
Paclitaxel: severe hypersensitivity — premedicate with steroids + diphenhydramine + H2-blocker
Vesicant extravasation: STOP infusion; LEAVE needle in place; aspirate; notify provider
TLS: hyperK, hyperP, hypoCa, hyperuricemia; aggressive hydration; rasburicase
Febrile neutropenia: ANC <500 + temp ≥38.3°C; blood cultures THEN antibiotics within 60 min
SVC syndrome: upper extremity swelling + facial plethora; NO upper extremity IVs
Spinal cord compression: back pain → emergent MRI; dexamethasone immediately; time-sensitive
Rasburicase: contraindicated in G6PD deficiency (causes hemolysis)

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