Chart — Oncology
Chemotherapy Side Effects
Chemotherapy toxicities affect multiple organ systems. This chart provides a comprehensive side-by-side reference of each major side effect, its cause, monitoring parameters, and nursing interventions — including NCLEX-relevant alert points.
Educational use only. This content is intended for nursing students and exam preparation. Oncology nursing requires specialized training and institutional protocol adherence. 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.
| Side Effect | Cause / Key Drugs | Monitoring | Nursing Interventions |
|---|---|---|---|
| Neutropenia Most agents: nadir 7–14 days | Bone marrow suppression — chemotherapy destroys rapidly dividing myeloid precursors | CBC with differential; ANC; temperature q4h or per protocol; assess for signs of infection | Neutropenic precautions (private room, hand hygiene, restrict visitors with illness); neutropenic diet; no rectal temps/enemas; febrile neutropenia protocol if T ≥38°C + ANC <500; G-CSF (filgrastim) per order Febrile neutropenia = emergency |
| Anemia Most agents; cumulative over treatment cycles | Bone marrow suppression — reduced RBC production; chronic blood loss; hemolysis (rare with certain agents) | CBC — Hgb, Hct; signs/symptoms: fatigue, pallor, dyspnea, tachycardia, orthostatic hypotension | Activity restrictions and energy conservation; fall risk assessment; administer erythropoietin-stimulating agents (epoetin alfa) per order; blood transfusion if severely symptomatic (Hgb <7–8 g/dL threshold); iron supplementation if iron deficient Transfuse symptomatic patient per protocol |
| Thrombocytopenia Most agents: nadir 8–14 days | Bone marrow suppression — reduced platelet production | Platelet count; assess for bleeding: petechiae, purpura, ecchymosis, gingival bleeding, epistaxis, hematuria, guaiac stools, headache (intracranial bleed) | Bleeding precautions: soft toothbrush, electric razor, no IM injections, avoid NSAIDs; fall precautions; apply pressure to all venipuncture sites ≥5 min; platelet transfusion per protocol (<10,000 prophylactic; <50,000 for procedures) Platelets <10,000 = prophylactic transfusion threshold |
| Nausea & Vomiting (CINV) Acute: within 24 hrs; Delayed: 24–120 hrs; Anticipatory: conditioned response | Chemotherapy activates 5-HT3 receptors in GI tract and CTZ (chemoreceptor trigger zone) in brainstem | Frequency and severity of N/V (CTCAE grade); oral intake; hydration status; weight; electrolytes | Premedicate: 5-HT3 antagonists (ondansetron), NK1 antagonists (aprepitant), dexamethasone, lorazepam; small frequent meals; bland cool foods; avoid strong odors; ginger (evidence-based); adequate IV hydration if unable to tolerate PO; anti-anxiety agents for anticipatory N/V Grade 3–4 CINV: hospitalization, IV antiemetics, IV hydration |
| Mucositis 5-FU, methotrexate, doxorubicin, cytarabine; onset 5–10 days after chemo | Antimetabolites and anthracyclines damage rapidly proliferating oral/GI mucosal cells — disrupts barrier integrity | Oral cavity assessment each encounter; WHO or NCI CTCAE mucositis grading scale; pain rating; ability to eat and swallow; oral culture if infection suspected | Oral care protocol: saline rinse q4h, soft toothbrush; avoid alcohol-based mouthwash; topical anesthetics (viscous lidocaine); magic mouthwash per order; antifungal rinse for prophylaxis; palifermin (keratinocyte growth factor) for high-risk; dietary modification (soft/liquid); NG tube if severe Grade 3: unable to eat; Grade 4: life-threatening — hospitalize |
| Alopecia Anthracyclines, taxanes, alkylating agents; begins 2–4 weeks after chemotherapy start | Cytotoxic effects on hair follicle matrix cells — follicles temporarily stop producing hair | Scalp skin integrity; patient's emotional response; body image disturbance | Inform patient it is expected and temporary (regrowth 3–6 months after treatment ends; hair texture may change); scalp cooling cap (reduces exposure in some regimens); wig fitting, scarves, head coverings; psychosocial support and body image discussion Regrowth expected; temporary |
| Cardiotoxicity Doxorubicin: cumulative — risk increases beyond 400–550 mg/m² lifetime dose | Anthracyclines (doxorubicin): free radical damage to cardiac myocytes — dilated cardiomyopathy; trastuzumab: HER2 pathway disruption in cardiomyocytes | Baseline and periodic LVEF via ECHO or MUGA scan; signs/symptoms of HF: dyspnea, edema, orthopnea, fatigue, tachycardia; 12-lead ECG if symptoms | Track cumulative doxorubicin dose — never exceed lifetime limit; cardioprotectant dexrazoxane for high-dose anthracycline regimens; hold trastuzumab if LVEF drops significantly; refer cardiology if HF develops; manage with standard HF regimen (ACE inhibitor, beta-blocker, diuretics) Irreversible cardiomyopathy if cumulative dose limit exceeded |
| Peripheral Neuropathy Vincristine, paclitaxel, docetaxel, cisplatin, oxaliplatin — often cumulative | Microtubule disruption (vincristine, taxanes) or platinum-DNA adduct formation in dorsal root ganglia neurons (cisplatin, oxaliplatin) | Assess sensation: numbness, tingling, burning in hands and feet (stocking-glove distribution); proprioception; gait; reflexes; fine motor function | Fall risk assessment and precautions; occupational/physical therapy referral; gabapentin, duloxetine for neuropathic pain per order; oxaliplatin: avoid cold exposure (cold-induced neuropathy exacerbation) — warm gloves, avoid cold foods/liquids; dose reduction or discontinuation if severe Oxaliplatin: cold triggers acute neuropathy — educate patient before first dose |
| Nephrotoxicity Cisplatin, carboplatin, high-dose methotrexate | Platinum compounds (cisplatin) accumulate in proximal renal tubular cells → tubular necrosis; methotrexate precipitates in renal tubules at acidic pH | BUN, creatinine, eGFR before each cycle; urine output (goal >0.5 mL/kg/hr during cisplatin); electrolytes: Mg, Ca, K (cisplatin causes magnesium wasting); urinalysis | Pre-hydration and post-hydration with NS (cisplatin: 1–2 L before and after); magnesium replacement for cisplatin-induced hypomagnesemia; leucovorin rescue for high-dose methotrexate; avoid concomitant nephrotoxins (NSAIDs, aminoglycosides, contrast); dose reduction if AKI develops Cisplatin: aggressive pre-hydration is mandatory before each dose |
| Hemorrhagic Cystitis Cyclophosphamide, ifosfamide | Cyclophosphamide and ifosfamide metabolite (acrolein) accumulates in bladder wall — direct mucosal damage | Urinalysis for hematuria before each cycle; urine output; bladder discomfort, dysuria, urgency | Pre-administration and post-administration hydration (2–3 L/day); mesna (uroprotectant — binds acrolein in urine) administered with ifosfamide; encourage frequent voiding — do not allow urine to pool in bladder; monitor for gross hematuria (notify provider immediately) Gross hematuria: notify provider — hold next dose pending evaluation |
| Diarrhea 5-FU, irinotecan, capecitabine | GI mucosal damage (5-FU, irinotecan, capecitabine); prostaglandin-mediated (early irinotecan); late cholinergic/secretory (irinotecan) | Stool frequency, consistency, blood; hydration and electrolyte status; body weight; abdominal assessment | Irinotecan early diarrhea (cholinergic — during/immediately after infusion): atropine. Late diarrhea (>24 hrs): loperamide (high-dose protocol). BRAT diet (bananas, rice, applesauce, toast). Aggressive fluid/electrolyte replacement. Hold chemotherapy if Grade 3–4 (>7 stools above baseline). Irinotecan: two distinct diarrhea types — early (atropine) vs late (loperamide) |
| Fatigue Universal — all cytotoxic agents; also immunotherapy, radiation | Multifactorial: anemia, cytokine release, sleep disruption, depression, malnutrition, pain, hypothyroidism (some agents) | Fatigue severity scale (0–10); contributing factors: Hgb level, thyroid function, pain, mood, sleep; impact on ADLs | Treat underlying contributors (anemia, hypothyroidism, depression, pain); energy conservation strategies; structured low-intensity exercise (walking — evidence-based benefit); sleep hygiene education; psychosocial support; methylphenidate or dexamethasone short-term for refractory cases per order Screen for anemia as reversible contributor |
NCLEX Quick Reference — Chemo Toxicity Matching
Related Resources
Source: ONS (Oncology Nursing Society) Clinical Practice Guidelines; NCI Common Terminology Criteria for Adverse Events (CTCAE v6.0); NCCN Antiemesis Guidelines.
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with ONS Clinical Practice Guidelines; NCI CTCAE v5.0; NCCN Antiemesis Guidelines. 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 →