2.2: Usual Elements of an Asset Management Process
Figure 2.1 illustrates the typical steps in an asset management process. These steps would often be undertaken on an annual basis, although many of the elements might not change from year to year such as goals and policies. In the remainder of this section, we will comment upon the various components in the generic asset management systems in Fig. 2.1. Later chapters will examine these process steps in greater detail.
Goals and policies will differ among enterprises. For example, a water provider (e.g., a water utility) might have goals to provide a certain quantity of water within defined quality standards. Further, the water provider might have goals to preserve its physical infrastructure at a certain quality standard. A major difference in policies concerns corporate taxation. For private corporate-owned assets, the tax implications of depreciation and maintenance expenses may be important in the overall profitability of the corporation. Infrastructure managers must assess the specific goals and policies pertaining to their own enterprise.
Asset inventory identifies the numbers and types of assets available. For example, a roadway agency might keep track of the numbers and types of roads in their system, but also assets such as road signs and lane markings. Inventory is often hampered by the absence or loss of historic records, such as the exact locations of old underground pipes. Inventory changes over time as assets are created (through construction or purchase) or disposed of (through retirement or sale).
Computer aids are available for asset inventory. For fixed in place assets, geographic information systems may be quite helpful, showing the location and types of assets visually on a computer screen (Figure 2.2 provides an example of such a GIS inventory). For these aids, a standardized labeling or numbering system for assets is required. These identifiers are usually stored in an inventory database of asset information, but also installed on pieces of infrastructure themselves. For example, railway cars will have a standardized ‘reporting mark’ to indicate the owner of the car and its number. The identifiers may be written on the assets or stored in readable digital form by technologies such as radio frequency identifier (RFID) tags or bar codes. In many cases, computer aids pertain to individual assets such as bridges or roadway segments, and some form of ‘data gateway’ may be required to provide a holistic view of enterprise assets.
Condition Assessment and Performance Modeling requires an assessment of the current functionality of each asset and often involves a forecast of asset deterioration. Condition assessment can be done mechanistically by assuming a standard deterioration with use and time, but more often involves active survey and/or sensing along with models of performance and deterioration. In many cases, condition assessment is summarized in a numerical rating score based on a survey, sensing or testing. Figure 2.3 shows a pavement segment having less than perfect conditions as an example.
Alternatives Evaluation and Program Optimization is a process step to plan asset maintenance, rehabilitation or replacement for the planning horizon. In this step, managers need to formulate reasonable alternatives for asset improvement. For a roadway segment, alternatives might include various maintenance activities (such as crack sealing or pothole patching), repaving (such as milling off the top layer of asphalt and placing a layer of smooth, recycled asphalt), or reconstruction. Of course, any asset management plan will have to be modified over time in response to changing conditions or priorities.
Computer aids can also be useful in the process of alternatives evaluation and program optimization. Databases of possible alternative actions (and their costs and other characteristics) are helpful. Optimization programs to minimize costs may be employed. Alternatives evaluation can also involve multiple stages, with preliminary investigation followed by a detailed analysis of a final set of possible actions.
Budget and Allocations define the resources available for asset management and will influence selection of management alternatives. In effect, most infrastructure managers are constrained by the allocation of resources and budgets available in any particular period. As shown in Figure 2.1, budget and allocations may also influence the goals and policies defined for the entire process.
Short and Long Range Plans (Project Selection) develops a plan of action for selected alternatives over periods of time. ‘Short-range’ typically is a yearlong planning
horizon, although it might be as short as scheduling activities over the course of a day or week. Long-range plans usually involve major projects and may involve a significant planning process. For discussion of long-range planning, see Hendrickson (2016). Plans usually involve the infrastructure management organization itself, but often include provisions to contract out for specific projects.
A component of most infrastructure management short-range plans is a process for responding to routine maintenance requests. For example, a building manager might have a systematic plan for replacing light bulbs in the building, but would also respond to reports of burnt out or broken lights.
Program Implementation is the process of actually completing the selected projects. For example, a City might plan to repave 200 kilometers of designated roadway segments over the course of a construction season. Program implementation involves actually doing the repaving work.
Performance Monitoring (Feedback) is a means of providing continuous feedback information on asset management performance. While Fig. 2.1 shows this feedback as a flow into goals and policies, the feedback can influence all stages of the asset management process. For example, the performance of particular maintenance or rehabilitation alternatives may inform alternatives evaluation and project selection. Performance monitoring often involves measures of infrastructure usage and quality of services provided in addition to direct information on asset management actions.


4: Multiplicative Number Theoretic Functions
In this chapter, we study functions, called multiplicative functions, that are defined on integers. These functions have the property that their value at the product of two relatively prime integers is equal to the product of the value of the functions at these integers. We start by proving several theorems about multiplicative functions that we will use later. We then study special functions and prove that the Euler \(\phi\)-function that was seen before is actually multiplicative. We also define the sum of divisors and the number of divisors functions. Later define the Mobius function which investigate integers in terms of their prime decomposition. The summatory function of a given function takes the sum of the values of \(f\) at the divisors of a given integer \(n\). We then determine the Mobius inversion of this function which writes the values of \(f\) in terms of the values of its summatory function. We end this chapter by presenting integers with interesting properties and prove some of their properties.
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- 4.2: Multiplicative Number Theoretic Functions
- We now present several multiplicative number theoretic functions which will play a crucial role in many number theoretic results. We start by discussing the Euler phi-function which was defined in an earlier chapter. We then define the sum-of-divisors function and the number-of-divisors function along with their properties.
Contributors and Attributions
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Dr. Wissam Raji, Ph.D., of the American University in Beirut. His work was selected by the Saylor Foundation’s Open Textbook Challenge for public release under a Creative Commons Attribution ( CC BY ) license.


We next went to Steventon, in Berkshire. It was a small town, said to be the poorest in the county. I saw men working in the fields for six shillings, and seven shillings, a week, and women for sixpence, and sevenpence, a day, out of which they boarded themselves. Of course they lived in the most primitive manner; it could not be otherwise, where a woman’s wages for an entire day were not sufficient to buy a pound of meat. They paid very low rents, and their clothes were made of the cheapest fabrics, though much better than could have been procured in the United States for the same money. I had heard much about the oppression of the poor in Europe. The people I saw around me were, many of them, among the poorest poor. But when I visited them in their little thatched cottages, I felt that the condition of even the meanest and most ignorant among them was vastly superior to the condition of the most favored slaves in America. They labored hard; but they were not ordered out to toil while the stars were in the sky, and driven and slashed by an overseer, through heat and cold, till the stars shone out again. Their homes were very humble; but they were protected by law. No insolent patrols could come, in the dead of night, and flog them at their pleasure. The father, when he closed his cottage door, felt safe with his family around him. No master or overseer could come and take from him his wife, or his daughter. They must separate to earn their living; but the parents knew where their children were going, and could communicate with them by letters. The relations of husband and wife, parent and child, were too sacred for the richest noble in the land to violate with impunity. Much was being done to enlighten these poor people. Schools were established among them, and benevolent societies were active in efforts to ameliorate their condition. There was no law forbidding them to learn to read and write; and if they helped each other in spelling out the Bible, they were in no danger of thirty-nine lashes, as was the case with myself and poor, pious, old uncle Fred. I repeat that the most ignorant and the most destitute of these peasants was a thousand fold better off than the most pampered American slave.
I do not deny that the poor are oppressed in Europe. I am not disposed to paint their condition so rose-colored as the Hon. Miss Murray paints the condition of the slaves in the United States. A small portion of my experience would enable her to read her own pages with anointed eyes. If she were to lay aside her title, and, instead of visiting among the fashionable, become domesticated, as a poor governess, on some plantation in Louisiana or Alabama, she would see and hear things that would make her tell quite a different story.
My visit to England is a memorable event in my life, from the fact of my having there received strong religious impressions. The contemptuous manner in which the communion had been administered to colored people, in my native place; the church membership of Dr. Flint, and others like him; and the buying and selling of slaves, by professed ministers of the gospel, had given me a prejudice against the Episcopal church. The whole service seemed to me a mockery and a sham. But my home in Steventon was in the family of a clergyman, who was a true disciple of Jesus. The beauty of his daily life inspired me with faith in the genuineness of Christian professions. Grace entered my heart, and I knelt at the communion table, I trust, in true humility of soul.
I remained abroad ten months, which was much longer than I had anticipated. During all that time, I never saw the slightest symptom of prejudice against color. Indeed, I entirely forgot it, till the time came for us to return to America.
XXXVIII. Renewed Invitations To Go South.
We had a tedious winter passage, and from the distance spectres seemed to rise up on the shores of the United States. It is a sad feeling to be afraid of one’s native country. We arrived in New York safely, and I hastened to Boston to look after my children. I found Ellen well, and improving at her school; but Benny was not there to welcome me. He had been left at a good place to learn a trade, and for several months every thing worked well. He was liked by the master, and was a favorite with his fellow-apprentices; but one day they accidentally discovered a fact they had never before suspected—that he was colored! This at once transformed him into a different being. Some of the apprentices were Americans, others American-born Irish; and it was offensive to their dignity to have a “nigger” among them, after they had been told that he was a “nigger.” They began by treating him with silent scorn, and finding that he returned the same, they resorted to insults and abuse. He was too spirited a boy to stand that, and he went off. Being desirous to do something to support himself, and having no one to advise him, he shipped for a whaling voyage. When I received these tidings I shed many tears, and bitterly reproached myself for having left him so long. But I had done it for the best, and now all I could do was to pray to the heavenly Father to guide and protect him.
Not long after my return, I received the following letter from Miss Emily
Flint, now Mrs. Dodge:—
In this you will recognize the hand of your friend and mistress. Having heard that you had gone with a family to Europe, I have waited to hear of your return to write to you. I should have answered the letter you wrote to me long since, but as I could not then act independently of my father, I knew there could be nothing done satisfactory to you. There were persons here who were willing to buy you and run the risk of getting you. To this I would not consent. I have always been attached to you, and would not like to see you the slave of another, or have unkind treatment. I am married now, and can protect you. My husband expects to move to Virginia this spring, where we think of settling. I am very anxious that you should come and live with me. If you are not willing to come, you may purchase yourself; but I should prefer having you live with me.  Think this over, and write as soon as possible, and let me know the conclusion.
Of course I did not write to return thanks for this cordial invitation.
“Come up into my parlor,” said the spider to the fly;
“Tis the prettiest little parlor that ever you did spy.”
It was plain that Dr. Flint’s family were apprised of my movements, since they knew of my voyage to Europe. I expected to have further trouble from them; but having eluded them thus far, I hoped to be as successful in future. The money I had earned, I was desirous to devote to the education of my children, and to secure a home for them. It seemed not only hard, but unjust, to pay for myself. I could not possibly regard myself as a piece of property. Moreover, I had worked many years without wages, and during that time had been obliged to depend on my grandmother for many comforts in food and clothing. My children certainly belonged to me; but though Dr. Flint had incurred no expense for their support, he had received a large sum of money for them. I knew the law would decide that I was his property, and would probably still give his daughter a claim to my children; but I regarded such laws as the regulations of robbers, who had no rights that I was bound to respect.
The Fugitive Slave Law had not then passed. The judges of Massachusetts had not then stooped under chains to enter her courts of justice, so called. I knew my old master was rather skittish of Massachusetts. I relied on her love of freedom, and felt safe on her soil. I am now aware that I honored the old Commonwealth beyond her deserts.
XXXIX. The Confession.
For two years my daughter and I supported ourselves comfortably in Boston. At the end of that time, my brother William offered to send Ellen to a boarding school. It required a great effort for me to consent to part with her, for I had few near ties, and it was her presence that made my two little rooms seem home-like. But my judgment prevailed over my selfish feelings. I made preparations for her departure. During the two years we had lived together I had often resolved to tell her something about her father; but I had never been able to muster sufficient courage. I had a shrinking dread of diminishing my child’s love. I knew she must have curiosity on the subject, but she had never asked a question. She was always very careful not to say any thing to remind me of my troubles. Now that she was going from me, I thought if I should die before she returned, she might hear my story from some one who did not understand the palliating circumstances; and that if she were entirely ignorant on the subject, her sensitive nature might receive a rude shock.
When we retired for the night, she said, “Mother, it is very hard to leave you alone. I am almost sorry I am going, though I do want to improve myself.
I did not throw my arms round her. I did not answer her. But in a calm, solemn way, for it cost me great effort, I said, “Listen to me, Ellen; I have something to tell you!” I recounted my early sufferings in slavery, and told her how nearly they had crushed me. I began to tell her how they had driven me into a great sin, when she clasped me in her arms, and exclaimed, “O, don’t, mother! Please don’t tell me any more.”
I said, “But, my child, I want you to know about your father.”
“I know all about it, mother,” she replied; “I am nothing to my father, and he is nothing to me. All my love is for you. I was with him five months in Washington, and he never cared for me. He never spoke to me as he did to his little Fanny. I knew all the time he was my father, for Fanny’s nurse told me so, but she said I must never tell any body, and I never did. I used to wish he would take me in his arms and kiss me, as he did Fanny; or that he would sometimes smile at me, as he did at her. I thought if he was my own father, he ought to love me. I was a little girl then, and didn’t know any better. But now I never think any thing about my father. All my love is for you.” She hugged me closer as she spoke, and I thanked God that the knowledge I had so much dreaded to impart had not diminished the affection of my child. I had not the slightest idea she knew that portion of my history. If I had, I should have spoken to her long before; for my pent-up feelings had often longed to pour themselves out to some one I could trust. But I loved the dear girl better for the delicacy she had manifested towards her unfortunate mother.
The next morning, she and her uncle started on their journey to the village in New York, where she was to be placed at school. It seemed as if all the sunshine had gone away. My little room was dreadfully lonely. I was thankful when a message came from a lady, accustomed to employ me, requesting me to come and sew in her family for several weeks. On my return, I found a letter from brother William. He thought of opening an anti-slavery reading room in Rochester, and combining with it the sale of some books and stationery; and he wanted me to unite with him. We tried it, but it was not successful. We found warm anti-slavery friends there, but the feeling was not general enough to support such an establishment. I passed nearly a year in the family of Isaac and Amy Post, practical believers in the Christian doctrine of human brotherhood. They measure a man’s worth by his character, not by his complexion. The memory of those beloved and honored friends will remain with me to my latest hour.
XL. The Fugitive Slave Law.
My brother, being disappointed in his project, concluded to go to California; and it was agreed that Benjamin should go with him. Ellen liked her school, and was a great favorite there. They did not know her history, and she did not tell it, because she had no desire to make capital out of their sympathy. But when it was accidentally discovered that her mother was a fugitive slave, every method was used to increase her advantages and diminish her expenses.
I was alone again. It was necessary for me to be earning money, and I preferred that it should be among those who knew me. On my return from Rochester, I called at the house of Mr. Bruce, to see Mary, the darling little babe that had thawed my heart, when it was freezing into a cheerless distrust of all my fellow-beings. She was growing a tall girl now, but I loved her always. Mr. Bruce had married again, and it was proposed that I should become nurse to a new infant. I had but one hesitation, and that was feeling of insecurity in New York, now greatly increased by the passage of the Fugitive Slave Law. However, I resolved to try the experiment. I was again fortunate in my employer. The new Mrs. Bruce was an American, brought up under aristocratic influences, and still living in the midst of them; but if she had any prejudice against color, I was never made aware of it; and as for the system of slavery, she had a most hearty dislike of it. No sophistry of Southerners could blind her to its enormity. She was a person of excellent principles and a noble heart. To me, from that hour to the present, she has been a true and sympathizing friend. Blessings be with her and hers!
About the time that I reentered the Bruce family, an event occurred of disastrous import to the colored people. The slave Hamlin, the first fugitive that came under the new law, was given up by the bloodhounds of the north to the bloodhounds of the south. It was the beginning of a reign of terror to the colored population. The great city rushed on in its whirl of excitement, taking no note of the “short and simple annals of the poor.” But while fashionables were listening to the thrilling voice of Jenny Lind in Metropolitan Hall, the thrilling voices of poor hunted colored people went up, in an agony of supplication, to the Lord, from Zion’s church. Many families, who had lived in the city for twenty years, fled from it now. Many a poor washerwoman, who, by hard labor, had made herself a comfortable home, was obliged to sacrifice her furniture, bid a hurried farewell to friends, and seek her fortune among strangers in Canada. Many a wife discovered a secret she had never known before—that her husband was a fugitive, and must leave her to insure his own safety. Worse still, many a husband discovered that his wife had fled from slavery years ago, and as “the child follows the condition of its mother,” the children of his love were liable to be seized and carried into slavery. Every where, in those humble homes, there was consternation and anguish. But what cared the legislators of the “dominant race” for the blood they were crushing out of trampled hearts?
When my brother William spent his last evening with me, before he went to California, we talked nearly all the time of the distress brought on our oppressed people by the passage of this iniquitous law; and never had I seen him manifest such bitterness of spirit, such stern hostility to our oppressors. He was himself free from the operation of the law; for he did not run from any Slaveholding State, being brought into the Free States by his master. But I was subject to it; and so were hundreds of intelligent and industrious people all around us. I seldom ventured into the streets; and when it was necessary to do an errand for Mrs. Bruce, or any of the family, I went as much as possible through back streets and by-ways.  This state of things, of course, gave rise to many impromptu vigilance committees. Every colored person, and every friend of their persecuted race, kept their eyes wide open. Every evening I examined the newspapers carefully, to see what Southerners had put up at the hotels. I did this for my own sake, thinking my young mistress and her husband might be among the list; I wished also to give information to others, if necessary; for if many were “running to and fro,” I resolved that “knowledge should be increased.”
This brings up one of my Southern reminiscences, which I will here briefly relate. I was somewhat acquainted with a slave named Luke, who belonged to a wealthy man in our vicinity.  In the division of the slaves, Luke was included in the son’s portion. This young man became a prey to the vices he went to the north, to complete his education, he carried his vices with him. He was brought home, deprived of the use of his limbs, by excessive dissipation. Luke was appointed to wait upon his bed-ridden master, whose despotic habits were greatly increased by exasperation at his own helplessness. He kept a cowhide beside him, and, for the most trivial occurrence, he would order his attendant to bare his back, and kneel beside the couch, while he whipped him till his strength was exhausted. Some days he was not allowed to wear any thing but his shirt, in order to be in readiness to be flogged. A day seldom passed without his receiving more or less blows. If the slightest resistance was offered, the town constable was sent for to execute the punishment, and Luke learned from experience how much more the constable’s strong arm was to be dreaded than the comparatively feeble one of his master. The arm of his tyrant grew weaker, and was finally palsied; and then the constable’s services were in constant requisition. The fact that he was entirely dependent on Luke’s care, and was obliged to be tended like an infant, instead of inspiring any gratitude or compassion towards his poor slave, seemed only to increase his irritability and cruelty. As he lay there on his bed, a mere degraded wreck of manhood, he took into his head the strangest freaks of despotism; and if Luke hesitated to submit to his orders, the constable was immediately sent for. Some of these freaks were of a nature too filthy to be repeated. When I fled from the house of bondage, I left poor Luke still chained to the bedside of this cruel and disgusting wretch.
One day, when I had been requested to do an errand for Mrs. Bruce, I was hurrying through back streets, as usual, when I saw a young man approaching, whose face was familiar to me. As he came nearer, I recognized Luke. I always rejoiced to see or hear of any one who had escaped from the black pit; I was peculiarly glad to see him on Northern soil, though I no longer called it free soil. I well remembered what a desolate feeling it was to be alone among strangers, and I went up to him and greeted him cordially. At first, he did not know me; but when I mentioned my name, he remembered all about me. I told him of the Fugitive Slave Law, and asked him if he did not know that New York was a city of kidnappers.
He replied, “De risk ain’t so bad for me, as ’tis fur you. ‘Cause I runned away from de speculator, and you runned away from de massa. Dem speculators vont spen dar money to come here fur a runaway, if dey ain’t sartin sure to put dar hans right on him. An I tell you I’s tuk good car ’bout dat. I had too hard times down dar, to let ’em ketch dis nigger.”
He then told me of the advice he had received, and the plans he had laid. I asked if he had money enough to take him to Canada. “‘Pend upon it, I hab,” he replied. “I tuk car fur dat. I’d bin workin all my days fur dem cussed whites, an got no pay but kicks and cuffs. So I tought dis nigger had a right to money nuff to bring him to de Free States. Massa Henry he lib till ebery body vish him dead; an ven he did die, I knowed de debbil would hab him, an vouldn’t vant him to bring his money ‘long too. So I tuk some of his bills, and put ’em in de pocket of his ole trousers. An ven he was buried, dis nigger ask fur dem ole trousers, an dey gub ’em to me.” With a low, chuckling laugh, he added, “You see I didn’t steal it; dey gub it to me. I tell you, I had mighty hard time to keep de speculator from findin it; but he didn’t git it.”
This is a fair specimen of how the moral sense is educated by slavery. When a man has his wages stolen from him, year after year, and the laws sanction and enforce the theft, how can he be expected to have more regard to honesty than has the man who robs him? I have become somewhat enlightened, but I confess that I agree with poor, ignorant, much-abused Luke, in thinking he had a right to that money, as a portion of his unpaid wages. He went to Canada forthwith, and I have not since heard from him.
All that winter I lived in a state of anxiety. When I took the children out to breathe the air, I closely observed the countenances of all I met. I dreaded the approach of summer, when snakes and slaveholders make their appearance. I was, in fact, a slave in New York, as subject to slave laws as I had been in a Slave State. Strange incongruity in a State called free!
Spring returned, and I received warning from the south that Dr. Flint knew of my return to my old place, and was making preparations to have me caught. I learned afterwards that my dress, and that of Mrs. Bruce’s children, had been described to him by some of the Northern tools, which slaveholders employ for their base purposes, and then indulge in sneers at their cupidity and mean servility.
I immediately informed Mrs. Bruce of my danger, and she took prompt measures for my safety. My place as nurse could not be supplied immediately, and this generous, sympathizing lady proposed that I should carry her baby away. It was a comfort to me to have the child with me; for the heart is reluctant to be torn away from every object it loves. But how few mothers would have consented to have one of their own babes become a fugitive, for the sake of a poor, hunted nurse, on whom the legislators of the country had let loose the bloodhounds! When I spoke of the sacrifice she was making, in depriving herself of her dear baby, she replied, “It is better for you to have baby with you, Linda; for if they get on your track, they will be obliged to bring the child to me; and then, if there is a possibility of saving you, you shall be saved.”
This lady had a very wealthy relative, a benevolent gentleman in many respects, but aristocratic and pro-slavery. He remonstrated with her for harboring a fugitive slave; told her she was violating the laws of her country; and asked her if she was aware of the penalty. She replied, “I am very well aware of it. It is imprisonment and one thousand dollars fine.  I am ready to incur the penalty. I will go to the state’s prison, rather than have any poor victim torn from my house, to be carried back to slavery.”
The noble heart! The brave heart! The tears are in my eyes while I write of her. May the God of the helpless reward her for her sympathy with my persecuted people!
I was sent into New England, where I was sheltered by the wife of a senator, whom I shall always hold in grateful remembrance. This honorable gentleman would not have voted for the Fugitive Slave Law, as did the senator in “Uncle Tom’s Cabin;” on the contrary, he was strongly opposed to it; but he was enough under its influence to be afraid of having me remain in his house many hours. So I was sent into the country, where I remained a month with the baby. When it was supposed that Dr. Flint’s emissaries had lost track of me, and given up the pursuit for the present, I returned to New York.
XLI. Free At Last.
Mrs. Bruce, and every member of her family, were exceedingly kind to me. I was thankful for the blessings of my lot, yet I could not always wear a cheerful countenance. I was doing harm to no one; on the contrary, I was doing all the good I could in my small way; yet I could never go out to breathe God’s free air without trepidation at my heart. This seemed hard; and I could not think it was a right state of things in any civilized country.
From time to time I received news from my good old grandmother. She could not write; but she employed others to write for her. The following is an extract from one of her last letters:—
Dear Daughter: I cannot hope to see you again on earth; but I pray to God to unite us above, where pain will no more rack this feeble body of mine; where sorrow and parting from my children will be no more. God has promised these things if we are faithful unto the end. My age and feeble health deprive me of going to church now; but God is with me here at home. Thank your brother for his kindness. Give much love to him, and tell him to remember the Creator in the days of his youth, and strive to meet me in the Father’s kingdom. Love to Ellen and Benjamin. Don’t neglect him. Tell him for me, to be a good boy. Strive, my child, to train them for God’s children. May he protect and provide for you, is the prayer of your loving old mother.
These letters both cheered and saddened me. I was always glad to have tidings from the kind, faithful old friend of my unhappy youth; but her messages of love made my heart yearn to see her before she died, and I mourned over the fact that it was impossible. Some months after I returned from my flight to New England, I received a letter from her, in which she wrote, “Dr. Flint is dead. He has left a distressed family. Poor old man! I hope he made his peace with God.”
I remembered how he had defrauded my grandmother of the hard earnings she had loaned; how he had tried to cheat her out of the freedom her mistress had promised her, and how he had persecuted her children; and I thought to myself that she was a better Christian than I was, if she could entirely forgive him. I cannot say, with truth, that the news of my old master’s death softened my feelings towards him. There are wrongs which even the grave does not bury. The man was odious to me while he lived, and his memory is odious now.
His departure from this world did not diminish my danger. He had threatened my grandmother that his heirs should hold me in slavery after he was gone; that I never should be free so long as a child of his survived. As for Mrs. Flint, I had seen her in deeper afflictions than I supposed the loss of her husband would be, for she had buried several children; yet I never saw any signs of softening in her heart. The doctor had died in embarrassed circumstances, and had little to will to his heirs, except such property as he was unable to grasp. I was well aware what I had to expect from the family of Flints; and my fears were confirmed by a letter from the south, warning me to be on my guard, because Mrs. Flint openly declared that her daughter could not afford to lose so valuable a slave as I was.
I kept close watch of the newspapers for arrivals; but one Saturday night, being much occupied, I forgot to examine the Evening Express as usual. I went down into the parlor for it, early in the morning, and found the boy about to kindle a fire with it. I took it from him and examined the list of arrivals. Reader, if you have never been a slave, you cannot imagine the acute sensation of suffering at my heart, when I read the names of Mr. and Mrs. Dodge, at a hotel in Courtland Street. It was a third-rate hotel, and that circumstance convinced me of the truth of what I had heard, that they were short of funds and had need of my value, as they valued me; and that was by dollars and cents. I hastened with the paper to Mrs. Bruce. Her heart and hand were always open to every one in distress, and she always warmly sympathized with mine. It was impossible to tell how near the enemy was. He might have passed and repassed the house while we were sleeping. He might at that moment be waiting to pounce upon me if I ventured out of doors. I had never seen the husband of my young mistress, and therefore I could not distinguish him from any other stranger. A carriage was hastily ordered; and, closely veiled, I followed Mrs. Bruce, taking the baby again with me into exile. After various turnings and crossings, and returnings, the carriage stopped at the house of one of Mrs. Bruce’s friends, where I was kindly received. Mrs. Bruce returned immediately, to instruct the domestics what to say if any one came to inquire for me.
It was lucky for me that the evening paper was not burned up before I had a chance to examine the list of arrivals. It was not long after Mrs. Bruce’s return to her house, before several people came to inquire for me. One inquired for me, another asked for my daughter Ellen, and another said he had a letter from my grandmother, which he was requested to deliver in person.
They were told, “She has lived here, but she has left.”
“How long ago?”
“I don’t know, sir.”
“Do you know where she went?”
“I do not, sir.” And the door was closed.
This Mr. Dodge, who claimed me as his property, was originally a Yankee pedler in the south; then he became a merchant, and finally a slaveholder. He managed to get introduced into what was called the first society, and married Miss Emily Flint. A quarrel arose between him and her brother, and the brother cowhided him. This led to a family feud, and he proposed to remove to Virginia. Dr. Flint left him no property, and his own means had become circumscribed, while a wife and children depended upon him for support. Under these circumstances, it was very natural that he should make an effort to put me into his pocket.
I had a colored friend, a man from my native place, in whom I had the most implicit confidence. I sent for him, and told him that Mr. and Mrs. Dodge had arrived in New York. I proposed that he should call upon them to make inquiries about his friends at the south, with whom Dr. Flint’s family were well acquainted. He thought there was no impropriety in his doing so, and he consented. He went to the hotel, and knocked at the door of Mr. Dodge’s room, which was opened by the gentleman himself, who gruffly inquired, “What brought you here? How came you to know I was in the city?”
“Your arrival was published in the evening papers, sir; and I called to ask Mrs. Dodge about my friends at home. I didn’t suppose it would give any offence.”
“Where’s that negro girl, that belongs to my wife?”
“What girl, sir?”
“You know well enough. I mean Linda, that ran away from Dr. Flint’s plantation, some years ago. I dare say you’ve seen her, and know where she is.”
“Yes, sir, I’ve seen her, and know where she is. She is out of your reach, sir.”
“Tell me where she is, or bring her to me, and I will give her a chance to buy her freedom.”
“I don’t think it would be of any use, sir. I have heard her say she would go to the ends of the earth, rather than pay any man or woman for her freedom, because she thinks she has a right to it. Besides, she couldn’t do it, if she would, for she has spent her earnings to educate her children.”
This made Mr. Dodge very angry, and some high words passed between them. My friend was afraid to come where I was; but in the course of the day I received a note from him. I supposed they had not come from the south, in the winter, for a pleasure excursion; and now the nature of their business was very plain.
Mrs. Bruce came to me and entreated me to leave the city the next morning. She said her house was watched, and it was possible that some clew to me might be obtained. I refused to take her advice. She pleaded with an earnest tenderness, that ought to have moved me; but I was in a bitter, disheartened mood. I was weary of flying from pillar to post. I had been chased during half my life, and it seemed as if the chase was never to end. There I sat, in that great city, guiltless of crime, yet not daring to worship God in any of the churches. I heard the bells ringing for afternoon service, and, with contemptuous sarcasm, I said, “Will the preachers take for their text, ‘Proclaim liberty to the captive, and the opening of prison doors to them that are bound’? or will they preach from the text, ‘Do unto others as ye would they should do unto you’?” Oppressed Poles and Hungarians could find a safe refuge in that city; John Mitchell was free to proclaim in the City Hall his desire for “a plantation well stocked with slaves;” but there I sat, an oppressed American, not daring to show my face. God forgive the black and bitter thoughts I indulged on that Sabbath day! The Scripture says, “Oppression makes even a wise man mad;” and I was not wise.
I had been told that Mr. Dodge said his wife had never signed away her right to my children, and if he could not get me, he would take them. This it was, more than any thing else, that roused such a tempest in my soul. Benjamin was with his uncle William in California, but my innocent young daughter had come to spend a vacation with me. I thought of what I had suffered in slavery at her age, and my heart was like a tiger’s when a hunter tries to seize her young.
Dear Mrs. Bruce! I seem to see the expression of her face, as she turned away discouraged by my obstinate mood. Finding her expostulations unavailing, she sent Ellen to entreat me. When ten o’clock in the evening arrived and Ellen had not returned, this watchful and unwearied friend became anxious. She came to us in a carriage, bringing a well-filled trunk for my journey—trusting that by this time I would listen to reason. I yielded to her, as I ought to have done before.
The next day, baby and I set out in a heavy snow storm, bound for New England again. I received letters from the City of Iniquity, addressed to me under an assumed name. In a few days one came from Mrs. Bruce, informing me that my new master was still searching for me, and that she intended to put an end to this persecution by buying my freedom. I felt grateful for the kindness that prompted this offer, but the idea was not so pleasant to me as might have been expected. The more my mind had become enlightened, the more difficult it was for me to consider myself an article of property; and to pay money to those who had so grievously oppressed me seemed like taking from my sufferings the glory of triumph. I wrote to Mrs. Bruce, thanking her, but saying that being sold from one owner to another seemed too much like slavery; that such a great obligation could not be easily cancelled; and that I preferred to go to my brother in California.
Without my knowledge, Mrs. Bruce employed a gentleman in New York to enter into negotiations with Mr. Dodge. He proposed to pay three hundred dollars down, if Mr. Dodge would sell me, and enter into obligations to relinquish all claim to me or my children forever after.  The gentleman replied, “You can do as you choose, sir. If you reject this offer you will never get any thing; for the woman has friends who will convey her and her children out of the country.”
Mr. Dodge concluded that “half a loaf was better than no bread,” and he agreed to the proffered terms. By the next mail I received this brief letter from Mrs. Bruce: “I am rejoiced to tell you that the money for your freedom has been paid to Mr. Dodge. Come home to-morrow. I long to see you and my sweet babe.”
My brain reeled as I read these lines. A gentleman near me said, “It’s true; I have seen the bill of sale.” “The bill of sale!” Those words struck me like a blow. So I was sold at last! A human being sold in the free city of New York! The bill of sale is on record, and future generations will learn from it that women were articles of traffic in New York, late in the nineteenth century of the Christian religion. It may hereafter prove a useful document to antiquaries, who are seeking to measure the progress of civilization in the United States. I well know the value of that bit of paper; but much as I love freedom, I do not like to look upon it. I am deeply grateful to the generous friend who procured it, but I despise the miscreant who demanded payment for what never rightfully belonged to him or his.
I had objected to having my freedom bought, yet I must confess that when it was done I felt as if a heavy load had been lifted from my weary shoulders. When I rode home in the cars I was no longer afraid to unveil my face and look at people as they passed. I should have been glad to have met Daniel Dodge himself; to have had him seen me and known me, that he might have mourned over the untoward circumstances which compelled him to sell me for three hundred dollars.
When I reached home, the arms of my benefactress were thrown round me, and our tears mingled. As soon as she could speak, she said, “O Linda, I’m so glad it’s all over! You wrote to me as if you thought you were going to be transferred from one owner to another. But I did not buy you for your services. I should have done just the same, if you had been going to sail for California to-morrow. I should, at least, have the satisfaction of knowing that you left me a free woman.”
My heart was exceedingly full. I remembered how my poor father had tried to buy me, when I was a small child, and how he had been disappointed. I hoped his spirit was rejoicing over me now. I remembered how my good old grandmother had laid up her earnings to purchase me in later years, and how often her plans had been frustrated. How that faithful, loving old heart would leap for joy, if she could look on me and my children now that we were free! My relatives had been foiled in all their efforts, but God had raised me up a friend among strangers, who had bestowed on me the precious, long-desired boon. Friend! It is a common word, often lightly used. Like other good and beautiful things, it may be tarnished by careless handling; but when I speak of Mrs. Bruce as my friend, the word is sacred.
My grandmother lived to rejoice in my freedom; but not long after, a letter came with a black seal. She had gone “where the wicked cease from troubling, and the weary are at rest.”
Time passed on, and a paper came to me from the south, containing an obituary notice of my uncle Phillip. It was the only case I ever knew of such an honor conferred upon a colored person. It was written by one of his friends, and contained these words: “Now that death has laid him low, they call him a good man and a useful citizen; but what are eulogies to the black man, when the world has faded from his vision? It does not require man’s praise to obtain rest in God’s kingdom.”  Strange words to be uttered in that region!
Reader, my story ends with freedom; not in the usual way, with marriage. I and my children are now free! We are as free from the power of slaveholders as are the white people of the north; and though that, according to my ideas, is not saying a great deal, it is a vast improvement in my condition. The dream of my life is not yet realized. I do not sit with my children in a home of my own, I still long for a hearthstone of my own, however humble. I wish it for my children’s sake far more than for my own. But God so orders circumstances as to keep me with my friend Mrs. Bruce. Love, duty, gratitude, also bind me to her side. It is a privilege to serve her who pities my oppressed people, and who has bestowed the inestimable boon of freedom on me and my children.
It has been painful to me, in many ways, to recall the dreary years I passed in bondage. I would gladly forget them if I could. Yet the retrospection is not altogether without solace; for with those gloomy recollections come tender memories of my good old grandmother, like light, fleecy clouds floating over a dark and troubled sea.
APPENDIX.
The following statement is from Amy Post, a member of the Society of Friends in the State of New York, well known and highly respected by friends of the poor and the oppressed. As has been already stated, in the preceding pages, the author of this volume spent some time under her hospitable roof.
L.M.C.
The author of this book is my highly-esteemed friend. If its readers knew her as I know her, they could not fail to be deeply interested in her story. She was a beloved inmate of our family nearly the whole of the year 1849. She was introduced to us by her affectionate and conscientious brother, who had previously related to us some of the almost incredible events in his sister’s life. I immediately became much interested in Linda; for her appearance was prepossessing, and her deportment indicated remarkable delicacy of feeling and purity of thought.
As we became acquainted, she related to me, from time to time some of the incidents in her bitter experiences as a slave-woman. Though impelled by a natural craving for human sympathy, she passed through a baptism of suffering, even in recounting her trials to me, in private confidential conversations. The burden of these memories lay heavily upon her spirit—naturally virtuous and refined. I repeatedly urged her to consent to the publication of her narrative; for I felt that it would arouse people to a more earnest work for the disinthralment of millions still remaining in that soul-crushing condition, which was so unendurable to her. But her sensitive spirit shrank from publicity. She said, “You know a woman can whisper her cruel wrongs in the ear of a dear friend much easier than she can record them for the world to read.” Even in talking with me, she wept so much, and seemed to suffer such mental agony, that I felt her story was too sacred to be drawn from her by inquisitive questions, and I left her free to tell as much, or as little, as she chose. Still, I urged upon her the duty of publishing her experience, for the sake of the good it might do; and, at last, she undertook the task.
Having been a slave so large a portion of her life, she is unlearned; she is obliged to earn her living by her own labor, and she has worked untiringly to procure education for her children; several times she has been obliged to leave her employments, in order to fly from the man-hunters and woman-hunters of our land; but she pressed through all these obstacles and overcame them. After the labors of the day were over, she traced secretly and wearily, by the midnight lamp, a truthful record of her eventful life.
This Empire State is a shabby place of refuge for the oppressed; but here, through anxiety, turmoil, and despair, the freedom of Linda and her children was finally secured, by the exertions of a generous friend. She was grateful for the boon; but the idea of having been bought was always galling to a spirit that could never acknowledge itself to be a chattel. She wrote to us thus, soon after the event: “I thank you for your kind expressions in regard to my freedom; but the freedom I had before the money was paid was dearer to me. God gave me that freedom; but man put God’s image in the scales with the paltry sum of three hundred dollars. I served for my liberty as faithfully as Jacob served for Rachel. At the end, he had large possessions; but I was robbed of my victory; I was obliged to resign my crown, to rid myself of a tyrant.”
Her story, as written by herself, cannot fail to interest the reader. It is a sad illustration of the condition of this country, which boasts of its civilization, while it sanctions laws and customs which make the experiences of the present more strange than any fictions of the past.
Amy Post. Rochester, N.Y., Oct. 30th, 1859.
The following testimonial is from a man who is now a highly respectable colored citizen of Boston.
L.M.C.
This narrative contains some incidents so extraordinary, that, doubtless, many persons, under whose eyes it may chance to fall, will be ready to believe that it is colored highly, to serve a special purpose. But, however it may be regarded by the incredulous, I know that it is full of living truths. I have been well acquainted with the author from my boyhood. The circumstances recounted in her history are perfectly familiar to me. I knew of her treatment from her master; of the imprisonment of her children; of their sale and redemption; of her seven years’ concealment; and of her subsequent escape to the North. I am now a resident of Boston, and am a living witness to the truth of this interesting narrative.
George W. Lowther.


8.2: Chemotherapeutic Drugs
By the end of this section, you should be able to:
- 8.2.1 Identify principles of proper handling of chemotherapeutic agents.
- 8.2.2 Discuss different administration methods, phases, routes of administration, and types of chemotherapy.
- 8.2.3 Describe major side effects of chemotherapeutic agents.
- 8.2.4 Identify characteristics of different classes of chemotherapeutic agents used in cancer treatment.
- 8.2.5 Explain the indications, actions, adverse reactions, and interactions of chemotherapeutic agents used in cancer treatment.
- 8.2.6 Describe the nursing implications of chemotherapeutic agents.
- 8.2.7 Explain the client education related to chemotherapeutic agents.
Handling of Chemotherapeutic Agents
The complexity of administering chemotherapy and caring for clients that have been treated with cancer therapies requires advanced knowledge. Special training and certifications to administer chemotherapy are required. Chemotherapy agents may cause cytotoxic exposure to those who compound and administer these drugs as well as to clients, families, and other caretakers who might be exposed through spills, improper handling and disposal, and other means. Proper training in compounding, administering, and managing exposure emergencies is a requirement of all personnel who work with chemotherapy. Principles of appropriate handling include, but are not limited to, storage of cytotoxic substances in impervious containers, double gloving (chemotherapy-rated gloves), compounding in a negative-pressure hood, and disposing of cytotoxic substances based on national standards and institutional policies.
Trending Today
Chemotherapy Administration Safety Standards
The Oncology Nursing Society , a leader in developing oncology standards, developed chemotherapy administration guidelines and safety standards to assist nurses in safely administering chemotherapy and other cancer treatments. Advances in technology, cancer treatment, and nursing training prompted the need for a periodic review and revision of the standards for general oncology practices. The latest standards include pediatric oncology practices and new standards affecting chemotherapy prescription, preparation, and administration (Oncology Nursing Society, 2023).
Cancer Treatments
Chemotherapy may be given for many different reasons. Often, it is given as a curative measure to eradicate all malignant cells. However, cure is not always realistic. When cure is not attainable, chemotherapy can be used to decrease tumor size and prevent metastasis, and sometimes it may be used for palliation and symptom control. Differing regimens of chemotherapy are used for varying client needs (see Table 8.1).
| Type of Therapy | Description |
|---|---|
| Adjuvant therapy | Given after initial treatment with surgery to destroy leftover cells |
| Neoadjuvant therapy | Initial treatment given to shrink the cancer before surgery |
| Salvage therapy | Second-line therapy given when first-line therapy is unsuccessful |
| Targeted therapy | Given to selectively kill cancer cells without harming normal cells |
| Biologic therapy | Used to enable the immune system to better kill cancer cells |
Link to Learning
This video describes the typical day and process of the treatment of a client receiving chemotherapy.
Phases of Chemotherapy
There are three phases of chemotherapy, beginning with induction. This phase is also known as first-line, front-line, or primary therapy. During this phase, the goal is to induce a remission. For most tumors, this may be the only phase required. For hematological cancers, clients may undergo a second phase, called consolidation, intensification, or post-remission therapy. This phase is used after a remission has been achieved, with a goal of eradicating any remaining cancer cells. The third phase, the maintenance phase, may be used either after induction or after consolidation. In this phase, a maintenance dose of chemotherapy is given to prevent reoccurrence of cancer. This phase is the longest phase and may last for several years.
Routes of Chemotherapy Administration
Chemotherapy may be administered by different routes depending on the purpose and toxicities of each individual drug. These different routes include oral, intravenous, subcutaneous, intramuscular, intracavitary, topically, and intrathecally. Intracavitary administration involves the infusion of a chemotherapeutic agent into a body cavity such as the bladder or abdomen. Intrathecal administration involves instilling chemotherapy into the spinal column or intracranially to treat cancers in the central nervous system. For drugs that are vesicant s , which have the ability to cause necrosis if they extravasate , the intravenous route must be used. When a vesicant drug is being administered, slow administration in a rate/minute modality and vigilant assessment of the intravenous infusion site must be performed. Maintaining patency of the administration site is paramount to preventing tissue injury (see Figure 8.3).
Types of Chemotherapy
There are many different classifications of chemotherapy drugs, many of which fall into one of two broad categories—cell-cycle specific and cell-cycle nonspecific therapies. Each cell goes through five phases of mitosis before producing daughter cells (see Figure 8.4). Chemotherapy agents that cause cancer cell death in all phases of mitosis are referred to as cell-cycle nonspecific (CCNS) , whereas those that are effective only in one phase of mitosis are called cell-cycle specific agents (CCS) . In combination chemotherapy, both CCS and NCCS agents are used to eliminate cancer cells more completely.
Adverse Effects and Contraindications
Alkylating agents are some of the most toxic chemotherapies used in cancer treatment. One benefit of these toxicities is that drugs like busulfan can be used to eradicate bone-marrow production prior to stem-cell and bone-marrow transplants. This reduces recurrence of the primary disease after transplant. However, alkylating agents are known for the negative effects associated with administration of these drugs. Short-term side effects include myelosuppression, which usually occurs 6–10 days after administration, with recovery after 14–21 days. Myelosuppression resulting in neutropenia can result in severe infections and sepsis. Mucositis , nausea, and vomiting are side effects that affect the client’s overall nutritional status. Neurotoxicity and alopecia are also short-term side effects. Long-term (delayed) effects of alkylating agents include pulmonary fibrosis, infertility, and secondary malignancies (Amjad & Kasi, 2020). These long-term effects may occur months after treatment or may develop many years later.
Table 8.4 is a drug prototype table for alkylating agents featuring cyclophosphamide. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Alkylating agent–nitrogen mustard Cell cycle nonspecific Mechanism of Action Causes crosslinking of DNA during mitosis to cause nucleic acid chain breakage resulting in cell destruction |
Drug Dosage
Oral: 1–5 mg/kg once daily. Intravenous (IV) (monotherapy): 40–50 mg/kg given in divided doses over 2–3 days, or 10–15 mg/kg given every 7–10 days. IV (combination therapy): 3–5 mg/kg given twice weekly. Note: Doses may be reported in grams versus milligrams. |
|
Indications
Lymphomas Multiple myeloma Leukemia Ovarian and breast cancers Therapeutic Effects Reduction of cancer cells |
Drug Interactions
Protease inhibitors Angiotensin-converting enzyme (ACE) inhibitors Thiazide diuretics Zidovudine Amiodarone |
|
Adverse Effects
Myelosuppression Sepsis Nephrotoxicity Pulmonary toxicity Cardiotoxicity Infertility Hyponatremia |
Contraindications
Myelosuppression Urinary outflow obstruction Caution: Monitor for hemorrhagic cystitis Mesna may be used in high-dose therapy to prevent bladder irritation |
Nursing Implications
The nurse should do the following for clients who are taking alkylating agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Become familiar with the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an alkylating drug should:
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria (cyclophosphamide), changes in hearing (cisplatin).
- Remain well hydrated. Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous access at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Monitor for and report any long-term effects of the chemotherapy.
- Follow up with all recommended health screenings.
- Report any concerning signs and symptoms to their health care provider.
The client taking an alkylating drug should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect their hands from the risk of bacterial contamination.
- Clean feline litter boxes to decrease the risk of exposure to bacteria or parasites.
- Take vaccines without their health care provider’s approval.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Various Alkylating Agents
Busulfan injection causes severe and prolonged myelosuppression at the recommended dosage.
Carboplatin causes severe bone marrow suppression, resulting in bleeding, infection, and anemia. Anaphylactic-like reactions to carboplatin may occur within minutes of administration.
Carmustine causes bone marrow suppression, which may contribute to bleeding and overwhelming infection. In cumulative doses above 1400 mg/m 2 , pulmonary toxicity is a significant risk.
Chlorambucil causes severe bone marrow suppression and infertility and is carcinogenic, mutagenic, and teratogenic.
Cisplatin causes severe renal toxicity that is dose related and cumulative. Peripheral neuropathy occurs and is cumulative with repeat courses. Cisplatin causes severe nausea and vomiting. Bone marrow suppression may be severe, requiring interruption of therapy.
Lomustine causes severe, dose-related, delayed, and cumulative myelosuppression, occurring 4–6 weeks after administration. Overdose is fatal. Only 1 dose should be dispensed with each prescription.
Oxaliplatin may cause anaphylactic-like reactions that may occur within minutes of administration.
Antimetabolites
Antimetabolite chemotherapies are a group of drugs that prevent cancer cell growth by imitating metabolites, which are substances necessary for tumor cell growth. Cancer cells use these substances, which, once inside the cell, prevent DNA replication. This results in cell death. Within this class, there are three types of metabolites that are inhibited: purines, pyrimidines, and folic acid. Each drug in this class specifically targets replacement of one of these substances. The most common drugs within this class are fluorouracil, fludarabine, gemcitabine, and methotrexate. Common side effects include nausea and vomiting, diarrhea, anorexia, stomatitis, alopecia, and myelosuppression. Antimetabolites are useful in treating leukemias, lymphomas, and cancers of the gastrointestinal and biliary tracts.
Table 8.5 lists common antimetabolite agents and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Folate Antimetabolites | |
|
Methotrexate
( Trexall ) |
Intrathecal:
6–15 mg/m
2
age-based dose; frequency depends on regimen.
IV: 10 mg/m 2 up to 12,000 mg/m 2 at varying frequencies depending on the diagnosis and treatment regimen. |
|
Pemetrexed
( Alimta ) |
500 mg/m 2 IV every 21 days. |
| Pyrimidine Antimetabolites | |
|
5-Fluorouracil
(5-FU) |
Colon/rectal adenocarcinoma:
400 mg/m
2
IV bolus followed by 2400–3000 mg/m
2
continuous infusion over 46 hours every 2 weeks.
Pancreatic adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400 mg/m 2 continuous infusion over 46 hours every 2 weeks. Breast adenocarcinoma: 500–600 mg/m 2 IV days 1 and 8 every 28 days for 6 cycles. Gastric adenocarcinoma: 200–1000 mg/m 2 IV over 24 hours at varying frequencies depending on regimen. |
|
Capecitabine
( Xeloda ) |
1250 mg/m 2 orally twice daily for 2 weeks followed by a 1-week rest period. |
|
Cytarabine
( Ara-C ) |
IV:
100 mg/m
2
daily as a single treatment over 7 days.
Intrathecal: 5–75 mg/m 2 once every 4 days. |
| Purine Antimetabolites | |
|
Mercaptopurine
( Purixan ) |
1.5–2.5 mg/kg orally once daily. |
|
Thioguanine
( Tabloid ) |
2–3 mg/kg orally daily. |
|
Gemcitabine
( Gemzar ) |
1000 mg/m 2 IV on days 1 and 8 of a 21-day cycle. |
|
Fludarabine
( Fludara ) |
25 mg/m 2 IV daily for 5 days, every 28 days. |
Adverse Effects and Contraindications
Antimetabolites are associated with many adverse effects. Folate antimetabolites are associated with myelosuppression, mucositis, hepatotoxicity, nephrotoxicity, and cutaneous reactions. Pyrimidine antimetabolites cause mucositis and myelosuppression as well but are also associated with dose-limiting hand-foot syndrome and diarrhea. Contraindications for fluorouracil include clients with dihydropyridine dehydrogenase (DPD) deficiency, which may result in toxic levels of fluorouracil. This can lead to cardiac dysfunction, colitis, neutropenia, and encephalopathy. Uridine triacetate is used to treat toxicity in these clients. Cytarabine is associated with inflammation of the conjunctiva. Corticosteroid eye drops are used prophylactically to prevent this. Purine antimetabolites, in addition to causing myelosuppression, also decrease the CD4 lymphocyte count, resulting in immunosuppression and risk of opportunistic infections (Amjad & Kasi, 2020).
Table 8.6 is a drug prototype table for antimetabolites featuring fluorouracil. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Antimetabolite (pyrimidine antagonist) Mechanism of Action Antagonizes metabolites necessary for cell growth, results in apoptosis (cell death) of cancerous cells |
Drug Dosage
Colon/rectal adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400–3000 mg/m 2 continuous infusion over 46 hours every 2 weeks. Pancreatic adenocarcinoma: 400 mg/m 2 IV bolus followed by 2400 mg/m 2 continuous infusion over 46 hours every 2 weeks. Breast adenocarcinoma: 500–600 mg/m 2 IV days 1 and 8 every 28 days for 6 cycles. Gastric adenocarcinoma: 200–1000 mg/m 2 IV over 24 hours at varying frequencies depending on regimen. |
|
Indications
Breast, colon, pancreatic, and gastric cancers Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Warfarin |
|
Adverse Effects
Mucositis Diarrhea Hand-foot syndrome Myelosuppression Neurotoxicity Gastrointestinal ulcers |
Contraindications
Hypersensitivity Decreased dipyridine dehydrogenase Caution: Increases international normalized ratio (INR) when administered to clients receiving warfarin |
Nursing Implications
The nurse should do the following for clients who are taking antimetabolite agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, oral mucosa, skin, eyes (cytarabine), and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes. Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and spill protocols.
- Be aware of drugs’ boxed warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an antimetabolite agent should:
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, eye irritation (cytarabine), and mouth ulcers (fluorouracil).
- Remain well hydrated.
- Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Monitor and report any long-term effects.
- Follow up with recommended screenings for early identification of any secondary malignancies.
The client taking an antimetabolite should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to decrease the risk of exposure to mold and bacteria.
- Clean feline litter boxes to minimize bacteria or parasite exposure.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Antimetabolites
Methotrexate causes embryo-fetal toxicity, hypersensitivity reactions, benzyl alcohol toxicity, and other serious adverse reactions.
Capecitabine causes increased risk for bleeding when administered with coumarins such as warfarin.
Fludarabine causes severe central nervous system toxicity, including blindness, coma, seizures, and death. Autoimmune syndromes including hemolytic anemia, thrombocytopenia, and hemophilia may occur with fludarabine administration. Concomitant use of deoxycoformycin (pentostatin) may cause fatal pulmonary toxicity.
Anthracyclines/Antitumor Antibiotics
Anthracyclines are some of the most potent chemotherapies on the market today. These drugs are very strong vesicants that cause severe necrosis when extravasated. Three major drugs in this class are daunorubicin, doxorubicin, and epirubicin. These drugs cause cell death by preventing DNA replication. They do this by inhibiting topoisomerase, leaving DNA strands unable to unwind and replicate. The major side effects of anthracyclines are myelosuppression, nausea and vomiting, alopecia, skin and nail hyperpigmentation, and, most notably, cardiotoxicity. Many drugs in this class are red in color and can resultingly cause urine and other body fluids to turn red/orange. This is a benign side effect but is usually discussed with clients to avoid any panic. These drugs are assigned maximum lifetime dose limits to aid in preventing debilitating chemotherapy-induced heart failure. Additionally, clients must have a left ventricular ejection fraction of at least 55% to receive these drugs. Table 8.7 lists common anthracyclines/antitumor antibiotics and typical routes and dosing for adult clients.
| Drug | Drug Routes and Dosages |
|---|---|
| Anthracyclines/Antitumor Antibiotics | |
|
Daunorubicin
( Cerubidine ) |
25–45 mg/m 2 IV; frequency depends on cancer type and other agents administered in combination (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Doxorubicin
( Adriamycin , Doxil ) |
60–75 mg/m 2 IV every 21 days (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Epirubicin
( Ellence ) |
IV: 100–120 mg/m 2 frequency depends on prescribed regimen (720 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
| Other Anthracyclines | |
|
Bleomycin
( Blenoxane ) |
0.25–0.5 units/kg (10–20 units/m 2 ) given IV, intamuscularly, or subcutaneously weekly or twice weekly. (Drug may be discontinued if pulmonary toxicity occurs.) |
|
Dactinomycin
( Cosmegen ) |
12–1250 mcg/m 2 IV; frequency depends on cancer type. |
|
Mitomycin
( Mutamycin ) |
20 mg/m 2 IV at 6–8 week intervals. |
Adverse Effects and Contraindications
Anthracyclines and antitumor antibiotics are associated with very serious adverse effects. In general, the drugs cause significant myelosuppression, alopecia, and nausea and vomiting. Doxorubicin and daunorubicin are associated with both short- and long-term cardiotoxicity. These drugs are contraindicated in clients with preexisting cardiac disease when the left ventricular ejection fraction is less than 55%. Clients receiving doxorubicin are also limited to a lifetime cumulative dose of 550 mg/m 2 . Bleomycin administration requires vigilant monitoring for cumulative pulmonary toxicity and fibrosis . Doxorubicin and daunorubicin are vesicant drugs that cause severe necrosis if extravasation into tissues occurs.
Table 8.8 is a drug prototype table for anthracycline agents featuring doxorubicin. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Anthracycline/antitumor antibiotic Mechanism of Action Inhibits topoisomerase to prevent DNA replication |
Drug Dosage
60–75 mg/m 2 IV every 21 days (550 mg/m 2 maximum lifetime limit due to cardiac toxicity). |
|
Indications
Breast, bronchogenic, and thyroid cancers Leukemia Lymphoma Sarcoma Wilms tumor Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Paclitaxel Trastuzumab 6-mercaptopurine Dexrazoxane (may be used as a cardioprotective agent in certain populations or upon extravasation) |
|
Adverse Effects
Cardiotoxicity Myelosuppression Alopecia Hyperpigmentation of skin and nails Stomatitis |
Contraindications
Hypersensitivity Myelosuppression Decreased cardiac function Caution: 550 mg/m 2 maximum lifetime limit Client must have ejection fraction of at least 55% to receive doxorubicin Severe necrosis with extravasation |
Nursing Implications
The nurse should do the following for clients who are taking anthracyclines/antitumor antibiotic agents:
- Assess client overall well-being prior to chemotherapy administration including vital signs, hydration status, oral mucosa, skin, and weight.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, liver enzymes, and left ventricular ejection fraction and pulmonary function tests (bleomycin).
- Carefully record cumulative doses when lifetime limits are necessary.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking an anthracycline/antitumor antibiotic agent should:
- Know signs and symptoms to report to the health care provider, including fever, chills, productive cough, urinary symptoms, hematuria, palpitations, chest pain, shortness of breath (doxorubicin, daunorubicin, epirubicin), pulmonary pain, and breathing difficulties (bleomycin).
- Remain well-hydrated.
- Report side effects including nausea and vomiting and mucositis.
- Know how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Follow up with screenings for long-term effects and secondary malignancies.
The client taking an anthracycline and antitumor antibiotic agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect hands from direct contact with bacteria and mold present in the soil.
- Clean feline litter boxes to reduce risk of contact with bacteria and parasites.
- Take vaccines without prior approval of their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
FDA Black Box Warning
Doxorubicin and Epirubicin
Potentially fatal congestive heart failure can occur during or years after therapy. The probability is based on the total cumulative doses received.
Secondary acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS) has been reported in clients taking these medications.
Plant Alkaloids
Several chemotherapies are derived from plants and are considered plant alkaloids . Vinca alkaloids are the most common plant alkaloids. Vincristine, vinblastine, and etoposide (VP-16) are all plant alkaloids that cause misalignment of chromosomes in cancer cells, resulting in apoptosis, or cell death.  Side effects include myelosuppression, mouth sores, nausea, vomiting, and fatigue. The most significant adverse effects involve the nervous system. Because plant alkaloids decrease nerve function, these substances can cause hearing loss, neuropathies, and severe constipation that may develop into a paralytic ileus. Neurologic symptoms may necessitate discontinuance of therapy. Vinca alkaloids are often part of regimens that also require intrathecal administration. However, close attention and safety measures (i.e., drug is always compounded in an IV bag for infusion) must be in place to ensure these are never administered via the intrathecal route. The drugs are fatal if administered intrathecally.
Table 8.9 lists common plant alkaloids and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Vincristine
( Oncovin ) |
1.4 mg/m 2 IV weekly. |
|
Vinblastine
( Velban ) |
3.7 mg/m 2 IV initial dose; subsequent doses up to 18.5 mg/m 2 administered weekly. |
|
Etoposide
( Vepesid , VP-16 ) |
35–100 mg/m 2 IV; frequency depends on cancer type and other agents administered. |
Adverse Effects and Contraindications
Peripheral neuropathy is a common but serious adverse effect of plant alkaloids. Both motor and sensory functions are affected, and neuropathy can be severe enough to result in paralytic ileus. Myelosuppression is another adverse effect caused by plant alkaloids. These drugs are classified as irritants, which may cause significant irritation to the skin should extravasation occur.
Table 8.10 is a drug prototype table for plant alkaloids featuring vincristine. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Plant alkaloid Mechanism of Action Causes chromosomal link errors, results in apoptosis of cancerous cells |
Drug Dosage
1.4 mg/m 2 IV weekly. |
|
Indications
Lymphoma Leukemia Kaposi sarcoma Squamous cell carcinoma Lung cancer Bladder cancer Therapeutic Effects Prevents DNA synthesis to cause tumor cell death |
Drug Interactions
Anticonvulsants Amiodarone Carvedilol Erythromycin Fluconazole Rifampin Warfarin Food Interactions Grapefruit |
|
Adverse Effects
Neuropathy Severe constipation Paralytic ileus Urinary retention Hearing loss Alopecia |
Contraindications
Hypersensitivity Charcot-Marie-Tooth disease Caution: For intravenous administration only Fatal if administered intrathecally Causes severe irritation with extravasation |
Nursing Implications
The nurse should do the following for clients who are taking plant alkaloid agents:
- Assess client overall well-being prior to chemotherapy administration including vital signs, hydration status, oral mucosa, skin, weight, bowel function, and signs of neuropathy.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Inspect drug preparation to ensure that these drugs are properly mixed and prepared as intravenous infusions. Do not administer these medications directly to the client using a syringe. This will decrease the risk of having the medication erroneously administered intrathecally, which can be fatal. Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a plant alkaloid agent should :
- Report the following signs and symptoms to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, decreased bowel elimination or constipation, hearing loss, and peripheral neuropathy.
- Remain well hydrated and use stool softeners and laxatives when needed.
- Report side effects including nausea and vomiting, mucositis, and constipation.
- Learn how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Understand the need for surveillance for long-term effects and secondary malignancies.
The client taking a plant alkaloid agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to avoid direct contact with potentially contaminated soil.
- Clean feline litter boxes to protect hands from contamination by bacteria or parasites.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting their health care provider.
- Become pregnant.
Taxanes
Taxanes are a group of chemotherapeutic agents that were developed from the bark of a yew tree. These are effective in the treatment of breast, ovarian, prostate, gastric, esophageal, pancreatic, and non-small cell lung cancers as well as Kaposi sarcoma. These agents are typically used in combination with other agents rather than as a monotherapy. Adverse reactions include, most notably, hypersensitivity reactions. For this reason, clients will be premedicated, usually with corticosteroids, but may also receive diphenhydramine and a histamine-2 receptor antagonist to prevent these reactions from occurring. Other adverse effects include hepatotoxicity, fluid retention, myelosuppression, alopecia, skin and nail changes, and nausea, vomiting, and diarrhea.
Table 8.11 lists common taxanes and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Docetaxel
( Taxotere ) |
60–100 mg/m 2 IV every 3 weeks. |
|
Paclitaxel
( Taxol ) |
100–175 mg/m 2 IV every 3 weeks. |
Adverse Effects and Contraindications
Taxanes are most known for the adverse effect of hypersensitivity reactions. A test dose and premedication with antihistamines and acetaminophen may be used prior administration. Myelosuppression may result in lowered levels of platelets and white blood cells. Taxanes are contraindicated in solid tumors with myelosuppression with neutrophil counts under 1500 cells/mm 3 . Peripheral neuropathy is also commonly associated with taxanes, resulting in pain and limited movement. Fatigue and arthralgias are also seen with these drugs. Cardiovascular changes including hypotension, bradycardia, hypertension, and electrocardiogram (ECG, EKG) changes may be noted (DailyMed, Paclitaxel , 2023).
Table 8.12 is a drug prototype table for taxanes featuring paclitaxel. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Taxane Mechanism of Action Binds to microtubules to block spindle formation during mitosis, blocking cell division during the M phase of mitosis |
Drug Dosage
100–175 mg/m 2 IV every 3 weeks. |
|
Indications
Breast, ovarian, and non-small cell lung cancers Kaposi sarcoma Therapeutic Effects Prevents tumor cell growth |
Drug Interactions
Midazolam Buspirone Statins Felodipine Protease inhibitors Repaglinide Rifampin |
|
Adverse Effects
Hypersensitivity reactions Myelosuppression ECG changes Peripheral neuropathy Arthralgia Nausea Vomiting Diarrhea Mucositis Alopecia Infusion site reactions |
Contraindications
Hypersensitivity Myelosuppression with neutrophil counts under 1500 µL Caution: May cause anaphylaxis due to the medication vehicle, not the drug itself Must premedicate |
Nursing Implications
The nurse should do the following for clients who are taking taxane agents:
- Assess client overall well-being prior to chemotherapy administration, including vital signs, hydration status, oral mucosa, skin, weight, cardiac function, and signs of neuropathy.
- Review laboratory values thoroughly, including complete blood counts, electrolyte profiles, serum creatinine, and liver enzymes.
- Observe clients for adverse effects before, during, and after treatment.
- Ensure patency of intravenous access sites and monitor these frequently during drug administration.
- Adhere to proper handling and administration procedures when administering chemotherapies.
- Be prepared to manage extravasation and follow spill protocols.
- Be aware of the drug’s black box warnings.
- Recognize and manage emergent situations such as hypersensitivity reactions, bleeding, and sepsis.
- Assess for and provide supportive therapies as needed.
- Provide for educational, spiritual, and psychosocial needs of the client and caregivers.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a taxane agent should:
- Recognize signs and symptoms to report to the health care provider: fever, chills, productive cough, urinary symptoms, hematuria, decreased bowel elimination or constipation, hearing loss, and peripheral neuropathy.
- Understand the importance of remaining well hydrated and use stool softeners and laxatives when needed.
- Learn how to manage side effects including nausea and vomiting, mucositis, and constipation.
- Understand how to care for long-term intravenous accesses at home.
- Understand the need for frequent follow-up and laboratory tests.
- Know which drug/food interactions to avoid.
- Understand the need for surveillance and follow-up for management of long-term effects and early identification of secondary malignancies.
The client taking a taxane agent should not:
- Be around others who are ill or who have received live vaccines within 3 months.
- Garden without the use of gloves to protect hands from exposure to bacteria and mold.
- Clean feline litter boxes to protect hands from direct contact with bacteria.
- Take vaccines without consulting with their health care provider.
- Consume uncooked meats and wild game such as deer, rabbits, and pheasants.
- Begin taking new supplements or medications without consulting with their health care provider.
- Become pregnant.
FDA Black Box Warning
Docetaxel
Docetaxel has been associated with fatalities among clients with abnormal liver function, who are receiving higher doses, with non-small cell carcinoma, or with a history of receiving platinum-based chemotherapy including cisplatin, carboplatin, and oxaliplatin.
Common Drugs Used as Supportive Therapies for Clients Receiving Chemotherapy
Because chemotherapy regimens are so complex, supportive care with other pharmacologic agents is usually required. Management of adverse effects is critical to safe and successful chemotherapy treatment. Myelosuppression and nausea and vomiting are most commonly managed with supportive therapies. Corticosteroids and biologic colony stimulating factors are frontline supportive therapies. Table 8.13 encompasses the most common supportive therapies that may be necessary when administering chemotherapy.
| Classification/Drug | Routes and Dosages | Use |
|---|---|---|
| Corticosteroids | ||
|
Dexamethasone
( Decadron ) |
Oral:
0.75–9 mg/day.
IV/intramuscular: 0.5–9 mg/day. |
Decreases nausea and vomiting.
Used as premedication to reduce hypersensitivity reactions. |
| Antihistamines | ||
|
Diphenhydramine
( Benadryl ) |
Oral:
25–50 mg every 4–6 hours as needed.
IV/intramuscular : 10–50 mg up to 100 mg if required; 400 mg maximum daily dose. |
Treats/prevents hypersensitivity reactions. |
|
Loratadine
( Allegra ) |
Oral: 10 mg 1 hour prior to chemotherapy initiation. | Prevents hypersensitivity reactions. |
| Colony Stimulating Factors | ||
|
Filgrastim
( Neupogen ) |
5–10 mcg/kg/day administered as a single daily subcutaneous or IV injection or by continuous subcutaneous or IV infusion. |
Stimulates bone marrow stem cells to produce increased neutrophil production.
Prevents infection. |
|
Pegfilgrastim
( Neulasta ) |
6 mg/dose subcutaneously. |
Stimulates bone marrow stem cells to produce increased neutrophil production.
Prevents infection. |
|
Epoetin alfa
( Epogen ) |
150 units/kg subcutaneously 3 times weekly or 40,000 units/dose weekly; titrated based on hemoglobin response. |
Stimulates bone marrow stem cells to produce increased erythocyte production.
Prevents/treats anemia. |
These supportive therapies can increase the client’s quality of life as well as decrease risks associated with pancytopenia, such as sepsis and decreased oxygen-carrying capacity of the blood. The advent of biologic colony stimulating factors marked a significant decrease in sepsis-related deaths for clients receiving chemotherapy. Ondansetron, specifically, has greatly changed the way chemotherapy-related nausea and vomiting are treated. Traditional phenothiazines cause vein and tissue irritation as well as central nervous system depression, placing a client at risk for injury. Ondansetron does not affect central nervous system function, reducing the risk of falls and other injuries.
FDA Black Box Warning
Erythropoiesis-Stimulating Agents (ESAs)
Erythropoiesis-stimulating agents (ESAs) increase the risk of death, myocardial infarction, stroke, venous thromboembolism, and tumor progression or recurrence.
Unfolding Case Study
Part A
Read the following clinical scenario to answer the questions that follow. This case will evolve throughout the chapter.
Guadalupe Himenez is a 32-year-old female client who presents to the oncology clinic for her first visit after recently being diagnosed with breast cancer. She initially saw her gynecologist after detecting a lump in her left breast. Her provider ordered a mammogram and biopsy, which determined the mass was malignant, and a surgeon performed a lumpectomy to remove it. The surgeon has referred her to the oncologist to start chemotherapy. Prior to this, she has been in good health without any chronic medical conditions.
Social History
Tobacco use: None
Alcohol use: Occasionally drinks socially
Married with two children
Current Medications
None
| Vital Signs | Physical Examination | |
|---|---|---|
| Temperature: | 98.2°F |
|
| Blood pressure: | 122/76 mm Hg | |
| Heart rate: | 73 beats/min | |
| Height: | 5'7" | |
| Weight: | 174 lb |
While completing the initial assessment, which of the following is a priority to assess?
- Answer
-
Date of last menstrual period
After discussing all the treatment options, Guadalupe consents to starting chemotherapy. What type of treatment is this?
- Answer
-
Adjuvant therapy


47: Conservation Biology and Biodiversity Last updated Save as PDF Page ID 12641 Boundless Boundless 47.1: The Biodiversity Crisis 47.1A: Loss of Biodiversity 47.1B: Types of Biodiversity 47.1C: Biodiversity Change through Geological Time 47.1D: The Pleistocene Extinction 47.1E: Present-Time Extinctions 47.2: The Importance of Biodiversity to Human Life 47.2A: Human Health and Biodiversity 47.2B: Agricultural Diversity 47.2C: Managing Fisheries 47.3: Threats to Biodiversity 47.3A: Habitat Loss and Sustainability 47.3B: Overharvesting 47.3C: Exotic Species 47.3D: Climate Change and Biodiversity 47.4: Preserving Biodiversity 47.4A: Measuring Biodiversity 47.4B: Changing Human Behavior in Response to Biodiversity Loss 47.4C: Ecological Restoration


8.8.2: Discrimination
Discrimination is any difference in the way a person is treated that is unfair, unjust, and causes harm. Discrimination can be structural or systemic (see Systemic Racism, above) or individual and interpersonal. Laws, regulations, policies, practices, and even unspoken rules in how individuals are treated can create structural and systemic discrimination. Interpersonal discrimination refers to poor treatment of one individual by another based on personal characteristics, whether or not there was an intent to cause harm. It might be a difference in the way a doctor talks to a specific patient, or the way a group of people is served at a restaurant. It could mean getting repeatedly passed up for promotions at work, or a difference in the appraised value of a house depending on who is living there. Discrimination is based on personal, inherent characteristics like race, ethnicity, sex, gender, sexuality, age, religion, or disability. The term intersectionality recognizes that a person may face discrimination based on multiple facets of their identity. For example, a Black woman may experience discrimination differently than a Black man, and a transgender person who has a disability may experience discrimination differently than a cisgender person with a disability.
Structural discrimination influences health outcomes through other social determinants of health. For example, when a location for a landfill is chosen near a town with a majority Black and Hispanic population, or when sidewalks are not maintained and people using wheelchairs are forced into the street, or when fewer trees are planted in lower-income neighborhoods, depriving them of shade and natural air purification - all of these structures and policies create unjust environments and contribute to health inequities. Systemic discrimination can also include attitudes and beliefs that have been so ingrained in a practice or culture that it might not be obvious that they are there. For instance, some algorithms used in medicine make assumptions about racial differences in biology and genetics, or ascribe higher risk factors for specific surgeries and treatments to patients of color. These algorithms may put Black and Hispanic people at risk for getting denied treatment for no valid medical reason (Vyas et al., 2020). Alternatively, some medical devices have been found to be inaccurate for people of color because they have only been validated on white patients. As a case in point: pulse oximeters were found to be overestimating blood oxygen in Non-Hispanic Black COVID-19 patients, which delayed their care (Sudat et al., 2022).
Interpersonal discrimination can also become a systemic problem when people are repeatedly treated differently due to inherent characteristics, especially by those working in positions of power or authority. Prime examples of systemic, interpersonal discrimination can also be found in healthcare. Healthcare providers may have explicit bias (when they are aware of their biases), or implicit biases (unconscious beliefs and attitudes). Particularly when healthcare providers are rushed or stressed, these biases come out in interactions with patients, resulting in poorer communication and even differing treatment recommendations (Hall et al., 2015). For example, Black patients are less likely to be referred for cardiovascular treatments, receive less pain medication, and have poorer maternal health outcomes. LGBTQ+ individuals may defer or avoid seeking treatment due to fears of discrimination. Negative interactions with healthcare providers decrease trust in medical care and increase the stress response in patients, which in turn affects overall mental and physical health (Apodaca et al., 2022).
All types of discrimination cause higher stress and worse health for those affected by it. And the stress experienced from discrimination, unfair treatment, and unjust systems can have a cumulative effect over time. This long term effect of discriminatory stress to health is part of the “weathering hypothesis” first proposed by Dr. Arlene T. Geronimous to describe disparities in fertility and maternal health of African American women. Subsequent research has linked the cumulative “allostatic load” of stress over the lifetime - including social stressors like discrimination - to brain aging and mental health (Contributors to Wikimedia projects, 2024).