Registered Nurse The Role of the Oncology

The Role of the OncologyRegistered Nurse

In Outpatient Medical Oncology

The Role of the Oncology Registered NurseIn Outpatient Medical Oncology

AAcckknnoowwlleeddggeemmeennttss “The Role of the Oncology Registered Nurse in Outpatient Medical Oncology” would not have been possible without the input and expertise provided by Eric Berger, Bridget Culhane, Cynthia Fisher, Laura Fennimore, Ilisa Halpern, Kris Hartigan, Gail Mallory, Pearl Moore, Julie Painter, Dianne Richardson, Paula Sherwood, Kathleen Shuey, and Karen Stanley.


Table of Contents

Introduction 1

Section One: Pretreatment 3

Section Two: Treatment 18

Section Three: Additional Clinical Responsibilities 28

Section Four: Oral Chemotherapy 34

Section Five: Case Study 36

Definitions 40

References 44

1


IInnttrroodduuccttiioonn

A diagnosis of cancer is a frightening and life-changing event. The individual and his/ her family fear the worst as they face the unknown, undergo a variety of treatment options and procedures and experience the side effects of therapy that can alter their quality of life. The impact of cancer on an individual’s life correlates with the degree of change and disruption experienced. In today’s world, patients in the midst of treatment continue to care for families, work, and face life with the resources that are available. The registered nurse’s ability to provide patient and family education across the illness and treatment continuum assists patients to adjust to the realities of the illness, cope more effectively, and reduces anxiety. The registered nurse’s skills in thorough assessment and intervention significantly impact patient outcomes. Research verifies that ongoing nursing communication, assessment, and intervention can reduce readmission rates and assist in the early diagnosis of problems so that patients experience fewer complications. The purpose of this document is to provide information on the unique needs of cancer patients and their families and the responsibility and unique contributions of the registered nurses who care for them. This document has been developed through a collaborative partnership between nurses representing the Oncology Nursing Society and US Oncology. The mission of both organizations is to promote quality patient care. The document explains and details services that may be provided during the care of the patient and family in an outpatient oncology setting/facility. Of note are the numerous interventions (such as delivery of chemotherapy/biotherapy, treatment of a disease by means of chemical substances or drugs, and management of side effects of therapy) requiring the unique contribution of the registered nurse with oncology specific training and competencies. Registered nurses enhance quality care by utilizing state-of-the-art knowledge and the skills of assessment, planning, intervention(s), and evaluation and provide the safest environment for the patient and family. Chemotherapeutic agents used for treating cancer are available in various forms. The form (route of administration) may depend on patient capability to receive the medication in that way or the requirements of a specific chemotherapeutic regimen/ treatment plan. Routes of chemotherapy administration include: topical (rubbed onto the skin), oral (by mouth in pill form), intravenous (administered through a catheter inserted into the patient’s vein in the arm, neck or chest), intrathecal (administered via a catheter inserted into the patient’s cerebrospinal fluid), via ommaya reservoir (administered through a device that allows the medication to enter ventricular spaces in the brain), and intraperitoneal (administered into the peritoneal /abdominal cavity). All routes of chemotherapy require safe and consistent delivery. Many patients will require surgical or radiologic placement of central venous access devices (intravenous devices that are placed into large veins in the upper chest) while other devices such as peripherally inserted central catheters may be placed by a specially trained registered nurse into a large vein in the arm. As these devices provide a direct line of infusion to major blood vessels supplying the heart, they

2


require meticulous care to prevent infection, regular dressing changes, and intermittent flushing with solutions that prevent the blood from clotting and keep the line open. This document is divided into key sections or treatment phases. Each phase details specific healthcare provider interventions and essential registered nurse interventions along the continuum of outpatient medical oncology care.

Section One, the Pre-Treatment phase, addresses interventions prior to the actual initiation of chemotherapy.

Section Two, the Treatment Phase, addresses those interventions that occur from the time therapy is initiated until all drug delivery devices (catheters used to deliver therapy into a vein, the cerebrospinal fluid, or ventricular spaces in the brain) are removed from the patient.

Section Three, Additional Clinical Responsibilities, addresses interventions that might occur more frequently and/or intermittently across the treatment continuum − ongoing education, reinforcement of previously given information, symptom/side effect management, management of intravenous devices, and other issues as they arise, as well as those responsibilities focusing on documentation and telephone triage.

Section Four, Oral Chemotherapy, addresses those unique interventions required when patients are self-administering chemotherapy in the home setting.

Section Five includes case scenarios with examples of patient treatment experiences and nursing interventions.

3


The

follo

win

g se

ctio

ns d

escr

ibe

the

resp

onsi

bilit

ies

of t

he r

egis

tere

d nu

rse

in m

edic

al o

ncol

ogy

and

acti

viti

es a

ssoc

iate

d w

ith

cari

ng f

or p

atie

nts

rece

ivin

g ch

emot

hera

py o

r bi

othe

rapy

. S

ome

of t

he a

ctiv

itie

s de

scri

bed

can

be p

erfo

rmed

by

clin

ical

sta

ff

othe

r th

an t

he r

egis

tere

d nu

rse

(e.g

., a

pha

rmac

ist)

or

by t

echn

ical

sta

ff w

ho a

re s

uper

vise

d by

the

reg

iste

red

nurs

e.

Dut

ies

that

ar

e ex

clus

ivel

y th

e re

spon

sibi

lity

of t

he o

ncol

ogy

nurs

e ar

e no

ted.

In

addi

tion

, th

e fr

eque

ncy

of a

ctiv

ity

is li

sted

. A

ctiv

itie

s m

ay

occu

r on

the

fir

st d

ay o

f ch

emot

hera

py (

firs

t vi

sit)

, at

eac

h ch

emot

hera

py v

isit

, ea

ch t

ime

a ch

emot

hera

py a

gent

is g

iven

by

IV

push

or

IV in

fusi

on,

at e

ach

cycl

e (c

hem

othe

rapy

age

nts

are

give

n fo

r a

pred

eter

min

ed t

ime

fram

e [e

.g.,

a g

roup

of

chem

othe

rapy

ag

ents

may

be

give

n fo

r th

ree

days

eve

ry 2

1 da

ys a

nd t

he p

atie

nt’s

res

pons

e to

tre

atm

ent

eval

uate

d at

the

end

of

each

cyc

le])

, or

so

me

othe

r fr

eque

ncy.

SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Pati

ent

asse

ssm

ent:

phy

sica

l and

psy

chos

ocia

l.

Com

preh

ensi

ve p

hysi

cal a

sses

smen

t:

X X

X

His

tory

and

phy

sica

l exa

min

atio

n (d

eter

min

es c

urre

nt c

ondi

tion

).

X X

X

Revi

ew o

f sy

stem

s: h

ead

and

neck

, sk

in,

resp

irat

ory,

car

diov

ascu

lar,

ga

stro

inte

stin

al,

geni

tour

inar

y, m

uscu

losk

elet

al,

lym

ph n

odes

and

re

late

d sw

ellin

g, b

lood

cel

ls,

nerv

ous

syst

em,

and

part

icul

ar b

ody

chem

istr

ies.

X X

X

Co

exis

ting

hea

lth

prob

lem

s (e

.g.,

car

diac

his

tory

, di

abet

es,

emph

ysem

a).

X X

X

Cu

rren

t al

lerg

ies

to m

edic

atio

n, f

ood,

and

env

iron

men

tal f

acto

rs.

X

X

Nut

riti

onal

sta

tus.

X

X X

Revi

ew a

nd u

pdat

e m

edic

atio

n lis

t an

d ch

eck

for

inco

mpa

tibi

litie

s or

dru

g in

tera

ctio

ns.

Dis

cuss

pot

enti

al in

tera

ctio

ns w

ith

phys

icia

n an

d/or

ph

arm

acis

t to

det

erm

ine

if c

hang

es n

eed

to b

e m

ade.

X

X

Cu

rren

tly

pres

crib

ed m

edic

atio

ns.

X

X

Ove

r-th

e-co

unte

r m

edic

atio

ns.

X

X

4


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Co

mpl

emen

tary

and

/or

alte

rnat

ive

med

icat

ions

or

ther

apie

s.

X

X

Obt

ain

and

revi

ew la

bora

tory

res

ults

to

dete

rmin

e if

the

y ar

e w

ithi

n an

ac

cept

able

ran

ge a

s se

t by

the

pra

ctic

e. C

hem

othe

rapy

des

troy

s ra

pidl

y di

vidi

ng c

ells

, bo

th n

orm

al (

hair

fol

licle

s, li

ning

of

the

gast

roin

test

inal

tr

act,

rep

rodu

ctiv

e tr

act,

and

blo

od c

ells

) an

d m

alig

nant

cel

ls.

Ass

ess

labo

rato

ry v

alue

s in

ligh

t of

exp

ecte

d si

de e

ffec

ts (

e.g.

, de

crea

sed

bloo

d co

unts

) an

d un

anti

cipa

ted

com

plic

atio

ns o

f pr

evio

usly

adm

inis

tere

d th

erap

ies.

Al

ert

the

phys

icia

n re

gard

ing

labo

rato

ry r

esul

ts t

hat

may

im

pact

the

che

mot

hera

py r

egim

en.

X X

X

Exam

ples

of

labo

rato

ry v

alue

s m

ay in

clud

e:

Com

plet

e bl

ood

coun

t: w

hite

blo

od c

ells

tha

t fi

ght

bact

eria

l and

vir

al

infe

ctio

n, r

ed c

ells

tha

t ca

rry

oxyg

en t

o th

e bo

dy a

nd h

elp

wit

h fa

tigu

e pr

oble

ms,

and

pla

tele

ts t

hat

assi

st w

ith

clot

ting

.

X X

X

X

Co

mpr

ehen

sive

met

abol

ic p

anel

(bl

ood

chem

istr

y te

sts)

. X

X

X X

Li

ver

func

tion

stu

dies

. X

X

X X

Re

nal f

unct

ion

stud

ies.

X

X

X X

Tu

mor

mar

ker

stud

ies

(som

e ca

ncer

s ha

ve m

arke

rs t

hat

indi

cate

the

re

duct

ion

or p

rogr

essi

on o

f th

e ca

ncer

); a

sses

smen

t fr

eque

ncy

vari

es

base

d on

dis

ease

.

X X

X

X

Dev

elop

or

revi

se t

he p

lan

of c

are

base

d on

ass

essm

ent

data

and

con

sult

w

ith

othe

r m

embe

rs o

f th

e he

alth

care

tea

m a

s ne

cess

ary.

Bas

ed o

n a

com

preh

ensi

ve p

atie

nt a

sses

smen

t, t

he p

hysi

cian

and

/or

regi

ster

ed n

urse

m

ay f

ind

it n

eces

sary

to

alte

r th

e tr

eatm

ent

plan

(e.

g.,

adju

stin

g ch

emot

hera

py d

osag

es o

r de

lay

of t

reat

men

t) o

r pr

ovid

e pr

etre

atm

ent

inte

rven

tion

s (e

.g.,

blo

od t

rans

fusi

on).

X X

X

Com

preh

ensi

ve p

sych

osoc

ial a

sses

smen

t of

pat

ient

and

fam

ily:

X X

X

5


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Ps

ycho

logi

c di

stre

ss t

hat

incl

udes

sad

ness

, de

pres

sion

, an

xiet

y, a

nger

, an

d fe

elin

gs o

f lo

ss o

f co

ntro

l.

X X

X

D

isru

ptio

n of

fam

ily d

ynam

ics

(e.g

., r

ole

chan

ges)

. X

X X

N

eed

for

outs

ide

serv

ices

. X

X X

Valid

ate

pati

ent

and

fam

ily c

once

rns

and

feel

ings

. A

llow

ade

quat

e ti

me

for

liste

ning

. X

X X

Mak

e ap

prop

riat

e re

ferr

als

or c

onsu

ltat

ions

in c

olla

bora

tion

wit

h th

e m

ulti

disc

iplin

ary

heal

thca

re t

eam

for

mor

e co

mpr

ehen

sive

ass

essm

ent

and

inte

rven

tion

as

nece

ssar

y.

X X

X

Prep

roce

dure

edu

cati

on (

may

be

rein

forc

ed p

ostp

roce

dure

).

Conf

irm

pat

ient

iden

tifi

cati

on.

X X

X

Asse

ss le

arni

ng n

eeds

, an

d de

velo

p an

d ga

ther

app

ropr

iate

mat

eria

ls.

X X

X D

iscu

ss w

ith

pati

ent

and

fam

ily a

nd p

rovi

de w

ritt

en m

ater

ials

as

need

ed:

X X

X

Canc

er o

r di

seas

e pr

oces

s an

d im

pact

on

the

indi

vidu

al.

X X

X

Prev

enti

on o

r de

tect

ion

mea

sure

s fo

r co

ncer

ned

fam

ily m

embe

rs.

X X

X

Gen

eral

med

icat

ion

side

eff

ects

(fo

r an

y pr

escr

ipti

ons

curr

entl

y ta

ken)

. X

X

X

D

rug

and/

or d

ieta

ry in

tera

ctio

ns t

hat

may

occ

ur a

nd t

heir

m

anag

emen

t.

X X

X

Impo

rtan

ce o

f m

aint

aini

ng a

ppro

pria

te s

ched

ule

as p

resc

ribe

d an

d no

tifi

cati

on o

f he

alth

care

tea

m if

tha

t is

not

pos

sibl

e (e

spec

ially

whe

n or

al c

hem

othe

rapy

dru

gs a

re p

resc

ribe

d).

See

Sect

ion

Four

.

X X

X

X

Chem

othe

rapy

and

adm

inis

trat

ion

issu

es:

6


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Si

de e

ffec

ts a

nd t

oxic

itie

s.

X X

X

X

IV-r

elat

ed c

ompl

icat

ions

(e.

g.,

swel

ling,

red

ness

, di

scol

orat

ion

of

vein

s).

X

X

X

Ve

sica

nt d

rug

issu

es:

Som

e ch

emot

hera

py a

gent

s ha

ve t

he p

oten

tial

to

cau

se s

ever

e ti

ssue

dam

age

if a

ccid

enta

lly le

aked

into

tis

sue

arou

nd t

he v

ein;

des

crib

e sy

mpt

oms

such

as

burn

ing

or s

ting

ing

at t

he

site

so

that

the

pat

ient

may

not

ify

the

nurs

e if

the

y oc

cur

duri

ng

adm

inis

trat

ion

of t

he c

hem

othe

rapy

age

nt.

X

X

Trea

tmen

t sc

hedu

le (

e.g.

, da

ily f

or f

our

days

, ev

ery

Tues

day

for

four

w

eeks

):

X X

X

X

O

ngoi

ng p

lan

esta

blis

hed

by p

hysi

cian

and

pat

ient

. X

X X

X X

Po

tent

ial f

or c

hang

es in

the

reg

imen

or

sche

dule

bas

ed o

n la

bora

tory

va

lues

or

othe

r di

agno

stic

tes

ts.

X X

X

X

X

Supp

orti

ve c

are

med

icat

ions

use

d to

con

trol

can

cer

and

trea

tmen

t-re

late

d sy

mpt

oms:

X

X

G

row

th f

acto

rs (

drug

s w

hich

sti

mul

ate

the

body

’s b

one

mar

row

to

mak

e w

hite

blo

od c

ells

or

red

bloo

d ce

lls).

X

X

D

rugs

tha

t pr

even

t or

con

trol

nau

sea

and

vom

itin

g du

ring

and

aft

er

chem

othe

rapy

. X

X

An

alge

sics

for

pai

n co

ntro

l.

X

X

Info

rmat

ion

abou

t ce

ntra

l ven

ous

acce

ss d

evic

e (C

VAD

) (i

.e.,

an

IV d

evic

e pl

aced

into

larg

e ve

ins

in t

he u

pper

che

st).

X

X

X

Sym

ptom

iden

tifi

cati

on a

nd m

anag

emen

t.

X

X Si

de e

ffec

ts o

f ch

emot

hera

py a

re t

o be

tak

en s

erio

usly

. If

the

y ar

e no

t w

ell m

anag

ed,

pati

ents

may

be

hosp

ital

ized

, tr

eatm

ent

regi

men

s de

laye

d, a

nd li

ves

risk

ed.

The

reg

iste

red

nurs

e m

ust

inte

rpre

t

X

X

7


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

info

rmat

ion

from

pat

ient

s an

d fa

mili

es w

ho r

epor

t un

man

aged

sym

ptom

s an

d en

sure

tha

t pr

oper

car

e is

pro

vide

d.

Inst

ruct

pat

ient

and

fam

ily m

embe

rs o

r ca

regi

vers

and

pro

vide

wri

tten

m

ater

ials

as

need

ed r

egar

ding

:

Fe

ver:

Mon

itor

the

pat

ient

’s t

empe

ratu

re.

Eve

n a

slig

ht f

ever

in a

pa

tien

t w

ho h

as r

ecei

ved

chem

othe

rapy

may

indi

cate

an

infe

ctio

n th

at is

life

thr

eate

ning

. R

epor

t a

feve

r im

med

iate

ly t

o he

alth

care

te

am.

Fev

er m

ay r

equi

re f

urth

er a

sses

smen

t (e

.g.,

blo

od o

r ot

her

tiss

ue c

ultu

res,

ant

ibio

tics

).

X

X

Ch

ills:

Mon

itor

for

pre

senc

e of

chi

lls a

nd/o

r sh

akin

g, w

hich

may

be

a si

gn o

f in

fect

ion

or n

euro

logi

c re

acti

on.

Not

ify

the

heal

thca

re t

eam

. X

X

N

ause

a: If

nau

sea

is p

rese

nt,

take

ant

inau

sea

med

icat

ions

as

pres

crib

ed,

and

focu

s on

mul

tipl

e sm

all m

eals

and

col

d fo

ods

wit

hout

ar

omas

.

X

X

Vo

mit

ing:

Res

tric

t in

take

of

food

and

flu

id le

adin

g to

mal

nutr

itio

n an

d se

vere

deh

ydra

tion

, as

wel

l as

elec

trol

yte

imba

lanc

e. I

f on

goin

g de

spit

e pr

escr

ibed

dru

g th

erap

y, b

lood

tes

ts m

ay b

e re

quir

ed t

o as

sess

for

deh

ydra

tion

. A

dif

fere

nt f

orm

of

nutr

itio

nal s

uppo

rt m

ay

be n

eces

sary

. Ca

ll th

e he

alth

care

tea

m if

una

ble

to k

eep

flui

ds o

r fo

od d

own.

Re

port

dur

atio

n of

the

pro

blem

and

the

num

ber

of

vom

itin

g ep

isod

es.

X

X

D

iarr

hea:

Can

lead

to

sign

ific

ant

flui

d lo

ss le

adin

g to

sev

ere

dehy

drat

ion.

Tak

e an

tidi

arrh

ea m

edic

atio

ns a

s pr

escr

ibed

and

dri

nk

flui

ds a

s pr

escr

ibed

. M

onit

or f

requ

ency

of

epis

odes

and

rep

ort

prob

lem

to

heal

thca

re t

eam

if n

onre

spon

sive

to

pres

crib

ed

inte

rven

tion

s. M

ay r

equi

re la

bora

tory

ass

essm

ent

and

furt

her

inte

rven

tion

.

X

X

Co

nsti

pati

on:

Can

lead

to

stra

inin

g, t

raum

a to

rec

tal t

issu

e, r

isk

of

X

X

8


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

infe

ctio

n in

the

tra

umat

ized

tis

sues

, an

d fe

cal i

mpa

ctio

n (i

.e.,

in

test

ines

blo

cked

wit

h st

ool)

. T

ake

cons

tipa

tion

med

icat

ions

(e.

g.,

stoo

l sof

tene

rs,

laxa

tive

s) a

s pr

escr

ibed

, dr

ink

plen

ty o

f fl

uids

, ca

refu

lly m

onit

or b

owel

mov

emen

ts,

and

noti

fy t

he h

ealt

hcar

e te

am

if c

onst

ipat

ion

is n

ot r

espo

nsiv

e to

inte

rven

tion

s.

M

outh

ulc

ers:

Wat

ch f

or m

outh

ulc

ers

or in

flam

mat

ion

of t

he o

ral

tiss

ue.

Use

med

icat

ions

to

cont

rol d

isco

mfo

rt a

s pr

escr

ibed

. C

old

food

s an

d ic

y nu

trit

iona

l dri

nks

may

be

easi

er t

o to

lera

te.

Cal

l the

he

alth

care

tea

m if

foo

d an

d fl

uid

inta

ke is

res

tric

ted,

pai

n do

es n

ot

resp

ond

to p

resc

ribe

d m

edic

atio

ns,

or f

ever

dev

elop

s.

X

X

Bl

eedi

ng o

r br

uisi

ng:

May

be

a si

gn o

f lo

w p

late

let

coun

t (i

.e.,

cel

ls

that

hel

p to

clo

t th

e bl

ood)

. A

void

sha

rp in

stru

men

ts a

nd r

igor

ous

phys

ical

act

ivit

y, a

nd c

all t

he h

ealt

hcar

e te

am if

sig

nifi

cant

inju

ry

occu

rs o

r bl

eedi

ng c

anno

t be

sto

pped

. A

spir

in a

nd o

ther

med

icat

ions

th

at in

terf

ere

wit

h bl

ood

clot

ting

sho

uld

not

be t

aken

unl

ess

the

phys

icia

n ha

s in

dica

ted

they

can

be

take

n. N

otif

y th

e he

alth

care

te

am if

ble

edin

g is

fre

quen

t or

can

not

be s

topp

ed.

X

X

Sh

ortn

ess

of b

reat

h: M

ay in

dica

te r

espi

rato

ry d

istr

ess

resu

ltin

g fr

om

resp

irat

ory

infe

ctio

n, b

lood

clo

ts in

the

lung

, ca

rdia

c co

mpl

icat

ions

, bl

eedi

ng,

seve

re f

atig

ue,

or s

ever

e pa

in.

Cal

l the

hea

lthc

are

team

if

shor

tnes

s of

bre

ath

has

a su

dden

or

unex

pect

ed o

nset

.

X

X

An

orex

ia:

A lo

ss o

f de

sire

to

eat

can

resu

lt in

mal

nutr

itio

n.

Not

ify

the

heal

thca

re t

eam

if t

his

occu

rs.

Mon

itor

wei

ght

loss

. Al

tern

ate

sour

ces

of n

utri

tion

may

be

pres

crib

ed.

Sm

all,

fre

quen

t m

eals

may

hel

p.

X

X

N

euro

toxi

city

: Th

is is

a c

hang

e in

sen

sati

on a

nd/o

r fe

elin

g in

the

ex

trem

itie

s. I

f th

e ha

nds

are

num

b or

sen

sati

on is

cha

ngin

g, a

void

ho

ldin

g ho

t or

ver

y co

ld it

ems

and

typi

cal h

ouse

hold

tas

ks s

uch

as

was

hing

dis

hes

or p

utti

ng it

ems

in a

hot

ove

n.

Not

ify

the

heal

thca

re

team

reg

ardi

ng s

ympt

oms.

X

X

9


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Prov

ide

a lis

t of

hea

lthc

are

team

mem

bers

(e.

g.,

phys

icia

ns,

regi

ster

ed

nurs

es,

phar

mac

ists

) an

d th

eir

phon

e nu

mbe

rs t

o co

ntac

t fo

r pr

oble

ms.

Re

info

rce

the

impo

rtan

ce o

f re

port

ing

sym

ptom

s as

pre

viou

sly

desc

ribe

d.

Ther

apy

may

be

inte

rrup

ted

if t

imel

y in

terv

enti

on is

not

pro

vide

d.

X X

X

Rein

forc

e pa

tien

t ed

ucat

ion

from

pre

viou

s vi

sits

and

ens

ure

fam

ily

mem

bers

und

erst

and

the

info

rmat

ion.

Ch

eck

to e

nsur

e th

at w

ritt

en

mat

eria

ls h

ave

been

pro

vide

d to

all

who

will

nee

d th

em.

Em

phas

ize

the

need

to

noti

fy t

he h

ealt

hcar

e te

am if

pro

blem

s ar

ise

betw

een

visi

ts.

X

X

Prep

are

the

room

aft

er c

onfi

rmin

g pa

tien

t id

enti

fica

tion

. G

athe

r an

d pr

epar

e eq

uipm

ent

(e.g

., IV

pol

e, t

able

).

X

X

Prep

are

the

pum

p (i

.e.,

a m

echa

nica

l dev

ice

used

to

regu

late

the

rat

e of

in

fusi

on o

f ch

emot

hera

py d

rugs

) fo

r us

e.

X

X

Eq

uipm

ent

mai

nten

ance

. (

Veri

fy t

hat

equi

pmen

t is

cle

an a

nd

func

tion

al.)

X

X

Pr

ogra

m t

he p

ump.

X

Te

st t

he a

larm

.

X

X

Ev

alua

te t

he e

lect

rica

l saf

ety.

X

X

Gat

her

and

prep

are

IV s

uppl

ies.

Det

erm

ine

the

type

of

IV a

cces

s. (

CVAD

ve

rsus

an

IV li

ne p

lace

d in

to v

eins

of

the

hand

or

low

er a

rm k

now

n as

a

peri

pher

al IV

).

X

X

X

For

a pe

riph

eral

IV s

tart

, as

sem

ble

supp

lies:

X

X

IV

cat

hete

r.

X

X

Appr

opri

ate

occl

usiv

e dr

essi

ng t

hat

cove

rs t

he IV

sit

e.

X

X

Tape

.

X

X

10


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

G

love

s.

X

X

Anti

sept

ic w

ipes

.

X

X

Al

coho

l wip

es.

X

X

Hep

arin

cap

(pl

aced

on

the

end

of a

per

iphe

ral o

r ce

ntra

l lin

e to

m

aint

ain

a cl

osed

, st

erile

sys

tem

).

X

X

H

epar

in f

lush

or

solu

tion

and

tub

ing

to m

aint

ain

IV p

aten

cy (

IV is

ope

n /n

o cl

ots

or s

lugg

ish

flow

and

eas

ily in

fuse

s w

ith

good

blo

od r

etur

n).

X

X

For

CVAD

, as

sem

ble

supp

lies:

Ap

prop

riat

e oc

clus

ive

dres

sing

tha

t co

vers

the

sit

e.

X

X

Tape

.

X

X

G

love

s.

X

X

Mas

k.

X

X

Anti

sept

ic w

ipes

.

X

X

Al

coho

l wip

es.

X

X

Hep

arin

cap

.

X

X

H

epar

in f

lush

or

solu

tion

and

tub

ing

to m

aint

ain

pate

ncy.

X

X

Addi

tion

al s

uppl

ies

and

equi

pmen

t fo

r im

plan

ted

pum

p (i

.e.,

dev

ice

impl

ante

d du

ring

a s

urgi

cal p

roce

dure

to

deliv

er c

onti

nuou

s ch

emot

hera

py t

o a

spec

ific

tum

or s

ite

such

as

the

liver

via

the

hep

atic

ar

tery

).

X

To

pica

l ane

sthe

tic

appl

ied

prio

r to

acc

essi

ng d

evic

e w

ith

port

nee

dle.

X

Ap

prop

riat

e ne

edle

for

impl

ante

d pu

mp.

X

Asse

mbl

e ca

thet

er f

lush

sup

plie

s:

X

11


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Fl

ush

solu

tion

(he

pari

n or

sal

ine)

.

X

X

Sy

ring

e.

X

X

Nee

dlel

ess

conn

ecto

r.

X

X

Gat

her

and

use

pers

onal

pro

tect

ive

equi

pmen

t to

pro

tect

clin

ical

sta

ff

(e.g

., r

egis

tere

d nu

rse,

pha

rmac

ist)

fro

m e

xpos

ure

to c

hem

othe

rapy

.

X X

Sp

ecia

l che

mot

hera

py-p

rote

ctiv

e gl

oves

.

X X

Ch

emot

hera

py g

own.

X X

M

ask

(as

need

ed t

o pr

even

t ex

posu

re).

X X

G

oggl

es (

as n

eede

d to

pre

vent

exp

osur

e).

X

X

Chem

othe

rapy

haz

ardo

us w

aste

con

tain

er.

X

X

Prep

are

chem

othe

rapy

. Ve

rify

insu

ranc

e co

vera

ge (

does

not

req

uire

a r

egis

tere

d nu

rse

or

phar

mac

ist

to v

erif

y di

rect

ly w

ith

the

insu

ranc

e co

mpa

ny).

How

ever

, be

fore

pre

pari

ng e

xpen

sive

che

mot

hera

py,

the

regi

ster

ed n

urse

or

phar

mac

ist

mus

t be

cer

tain

the

ver

ific

atio

n w

as m

ade.

X

Obt

ain,

ver

ify,

and

re-

veri

fy p

atie

nt c

onse

nt a

s ne

eded

. X

X X

Prep

arat

ion

of c

hem

othe

rapy

req

uire

s ex

tens

ive

know

ledg

e on

the

par

t of

th

e re

gist

ered

nur

se o

r on

colo

gy-s

peci

aliz

ed p

harm

acis

t to

saf

ely

inte

rpre

t ch

emot

hera

py o

rder

s an

d co

rrec

tly

perf

orm

the

ver

ific

atio

n of

:

X

X

X

D

rug

dosa

ges

(che

mot

hera

py d

rugs

hav

e va

ryin

g do

ses

base

d on

the

ac

tual

the

rapy

or

prot

ocol

).

X

X

X

Ad

min

istr

atio

n ro

ute

for

each

che

mot

hera

py d

rug.

(Ad

min

iste

ring

ch

emot

hera

py v

ia t

he in

corr

ect

rout

e ca

n be

har

mfu

l and

eve

n re

sult

in

dea

th.)

X

X

X

12


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

D

rug

com

pati

bilit

y an

d/or

inte

ract

ions

. X

X X

D

rugs

ord

ered

(m

ust

be a

ppro

ved

for

the

diag

nosi

s, w

hich

req

uire

s aw

aren

ess

of U

.S.

Food

and

Dru

g Ad

min

istr

atio

n-ap

prov

ed in

dica

tion

s as

wel

l as

appr

oved

“of

f-la

bel”

use

).

X

X

X

In

fusi

on t

ime.

(In

appr

opri

ate

infu

sion

tim

es s

uch

as IV

pus

h in

stea

d of

sev

eral

-hou

r in

fusi

on c

ould

res

ult

in s

erio

us h

arm

and

eve

n de

ath

to t

he p

atie

nt.)

X

X

X

Ph

ysic

ian

orde

rs p

er c

omm

unit

y st

anda

rd o

r re

sear

ch p

roto

col (

i.e.

, a

wri

tten

doc

umen

t th

at in

clud

es s

peci

fic

deta

ils o

f a

rese

arch

pro

ject

, in

clud

ing

drug

info

rmat

ion,

how

to

adm

inis

ter

the

drug

, pa

tien

t el

igib

ility

, et

c.).

X

X

X

Ca

lcul

ated

dos

e.

(Mos

t ch

emot

hera

py d

rugs

are

dos

ed a

ccor

ding

to

pati

ent’

s bo

dy s

urfa

ce a

rea

[BSA

], w

hich

is a

for

mul

a ba

sed

on h

eigh

t an

d w

eigh

t th

at is

use

d in

det

erm

inin

g ap

prop

riat

e ch

emot

hera

py

drug

dos

es.)

X

X

X

M

axim

um d

ose

of d

rug.

(Pa

rtic

ular

che

mot

hera

py d

rugs

hav

e a

max

imum

dos

age

that

can

be

give

n. T

his

shou

ld b

e ca

lcul

ated

and

m

onit

ored

to

ensu

re t

hat

the

dosa

ge is

not

exc

eede

d re

gard

less

of

the

pati

ent’

s BS

A. F

or e

xam

ple,

dox

orub

icin

is u

sed

for

man

y tu

mor

s an

d ha

s a

max

imum

dos

age

set

to r

educ

e th

e po

tent

ial f

or c

ardi

ac

dam

age.

)

X

X

X

Asse

mbl

e su

pplie

s fo

r dr

ug p

repa

rati

on:

X

X

IV f

luid

s.

X

X

Anti

emet

ic a

gent

s (i

n vi

als

from

man

ufac

ture

r).

X

X

Chem

othe

rapy

age

nts

(in

vial

s fr

om m

anuf

actu

rer)

.

X X

Tu

bing

: Ce

rtai

n ch

emot

hera

py a

gent

s re

quir

e sp

ecia

l IV

tubi

ng a

nd/

X

X

13


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

or t

he u

se o

f an

in-l

ine

IV f

ilter

to

elim

inat

e un

dilu

ted

part

icle

s.

Sy

ring

es,

alco

hol p

reps

, an

d ne

edle

s fo

r re

mov

ing

solu

tion

fro

m v

ials

an

d pl

acin

g in

eit

her

a sy

ring

e fo

r in

ject

ion

or IV

flu

id f

or in

fusi

on.

X

X

Asse

ss t

he p

atie

nt a

nd d

rug

for

prop

er s

olut

ion.

In

man

y in

stan

ces,

the

vo

lum

e an

d ty

pe o

f IV

flu

id t

hat

a ch

emot

hera

py a

gent

is d

ilute

d in

may

be

det

erm

ined

by

the

indi

vidu

al p

atie

nt’s

nee

d fo

r IV

flu

ids.

For

ex

ampl

e, p

atie

nts

wit

h di

abet

es n

eed

to r

ecei

ve c

hem

othe

rapy

dru

gs

dilu

ted

in n

orm

al s

alin

e (r

athe

r th

an d

extr

ose)

if t

he s

peci

fic

drug

and

fl

uid

are

com

pati

ble.

X

X

X

Asse

ss d

rug

stab

ility

. T

he r

egis

tere

d nu

rse

or p

harm

acis

t ne

eds

to k

now

ho

w lo

ng d

rugs

are

sta

ble

in s

olut

ion

so t

hat

they

are

pre

pare

d in

the

co

rrec

t ti

me

fram

e, s

tore

d in

the

cor

rect

env

iron

men

t to

mai

ntai

n dr

ug

pote

ncy

and

stab

ility

, an

d de

liver

ed in

a s

afe

and

tim

ely

fash

ion.

X

X

X

Prep

are

the

labe

l for

all

IV f

luid

s (f

or in

ject

ion

or in

fusi

on).

X X

Doc

umen

t th

e lo

t nu

mbe

r of

che

mot

hera

py d

rugs

. T

his

allo

ws

for

trac

king

of

each

dru

g th

at is

adm

inis

tere

d.

X

X

Doc

umen

t ex

pira

tion

dat

es o

f ch

emot

hera

py d

rugs

.

X X

Use

the

Cer

tifi

ed B

iolo

gica

l Saf

ety

Cabi

net

(nee

ded

to s

afel

y pr

epar

e dr

ugs

and

prev

ent

expo

sure

of

phar

mac

y or

nur

sing

sta

ff t

o ae

roso

lizat

ion

of c

hem

othe

rapy

age

nts)

. P

repa

rati

on a

nd m

aint

enan

ce in

clud

e:

X

X X

X

Cl

eani

ng t

he c

abin

et e

ach

day

prio

r to

use

, w

hene

ver

a sp

ill o

ccur

s,

and

at t

he e

nd o

f ea

ch w

orkd

ay.

X

D

econ

tam

inat

ing

the

cabi

net

wee

kly,

whe

neve

r a

spill

occ

urs,

or

whe

n th

e ho

od is

ser

vice

d or

mov

ed.

X

O

pera

ting

the

hoo

d co

ntin

uous

ly (

i.e.

, 24

hou

rs p

er d

ay).

X

In

spec

ting

and

cer

tify

ing

the

cabi

net

ever

y si

x m

onth

s.

X

14


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Prep

are

supp

orti

ve c

are

agen

ts.

X

X

Anti

emet

ic a

gent

s fo

r th

e pr

even

tion

of

naus

ea a

nd/o

r vo

mit

ing.

X

X

G

row

th f

acto

rs f

or lo

w r

ed b

lood

cel

l or

whi

te b

lood

cel

l cou

nts:

Co

nfer

wit

h th

e ph

ysic

ian

if la

bora

tory

dat

a in

dica

te t

he n

eed

for

incr

ease

d re

d or

whi

te b

lood

cel

ls t

hat

can

be m

anag

ed w

ith

grow

th

fact

ors.

X

X

Bi

spho

spho

nate

s to

low

er b

lood

cal

cium

leve

ls:

Som

e tu

mor

s an

d/or

ca

ncer

the

rapi

es c

an d

estr

oy b

one

mas

s, c

ausi

ng e

leva

ted

seru

m

calc

ium

. Th

is c

an le

ad t

o co

nfus

ion,

sei

zure

s, a

nd/o

r de

ath.

X

X

An

tibi

otic

s: O

ncol

ogy

prac

tice

s of

ten

adm

inis

ter

IV a

ntib

ioti

cs t

o pa

tien

ts w

ho h

ave

infe

ctio

ns in

an

effo

rt t

o av

oid

hosp

ital

izat

ion.

X

X

IV

flu

ids:

Pat

ient

s m

ay n

eed

to r

ecei

ve IV

hyd

rati

on b

ecau

se o

f ch

emot

hera

py-i

nduc

ed d

iarr

hea

or s

ever

e na

usea

and

vom

itin

g in

an

effo

rt t

o av

oid

hosp

ital

izat

ion.

Th

is a

lso

redu

ces

the

risk

of

blee

ding

(h

emor

rhag

e) in

the

bla

dder

.

X

X

Mix

che

mot

hera

py a

gent

s in

bio

logi

c sa

fety

cab

inet

. A

reg

iste

red

nurs

e,

phar

mac

ist,

or

phar

mac

y te

chni

cian

und

er t

he s

uper

visi

on o

f a

phar

mac

ist

mus

t m

ix t

he c

hem

othe

rapy

. S

ome

stat

es d

o no

t al

low

ph

arm

acy

tech

nici

ans

to p

repa

re c

hem

othe

rapy

. C

hem

othe

rapy

dru

gs

are

carc

inog

enic

(i.

e.,

can

caus

e ca

ncer

) an

d ne

ed t

o be

pre

pare

d un

der

circ

umst

ance

s th

at m

inim

ize

expo

sure

to

the

pers

on p

repa

ring

the

ch

emot

hera

py a

nd t

o th

e en

viro

nmen

t.

X

X X

X X

D

on c

hem

othe

rapy

gow

n an

d gl

oves

, as

wel

l as

a m

ask

and

gogg

les

if

appr

opri

ate.

X X

X X

X

Pl

ace

a pl

asti

c-ba

cked

pap

er d

rape

on

the

coun

ter

surf

ace

of t

he

biol

ogic

saf

ety

cabi

net.

X X

X X

X

Ve

rify

tha

t th

e gl

ass

shie

ld o

n th

e bi

olog

ic s

afet

y ca

bine

t is

onl

y op

en

X

X X

X X

15


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

8" t

o pr

even

t ex

posu

re t

o ch

emot

hera

py a

gent

s.

If

wit

hdra

win

g fr

om a

via

l, r

emov

e th

e du

st c

over

and

cle

an t

he

rubb

er d

iaph

ragm

.

X X

X X

X

At

tach

the

nee

dle

(or

need

lele

ss s

yste

m)

to t

he s

yrin

ge.

X

X X

X X

Inse

rt t

he n

eedl

e co

rrec

tly

into

the

via

l to

prev

ent

cori

ng.

X

X X

X X

Usi

ng a

sept

ic t

echn

ique

, w

ithd

raw

med

icat

ion

from

the

via

l tak

ing

care

not

to

touc

h an

y in

tern

al p

art

of t

he p

lung

er w

hen

pulli

ng b

ack.

X X

X X

X

Cl

ear

all l

iqui

d fr

om n

eedl

e or

hub

pri

or t

o re

mov

ing

the

need

le f

rom

th

e cl

osed

via

l.

X

X X

X X

W

ithd

raw

the

nee

dle

or s

yrin

ge f

rom

the

via

l wit

hout

spi

lling

con

tent

s in

the

Bio

logi

cal S

afet

y Ca

bine

t.

X

X X

X X

If

rec

onst

itut

ing

a po

wde

r, d

raw

up

corr

ect

amou

nt o

f di

luen

t.

X

X X

X X

Inje

ct d

iluen

t in

to v

ial.

X X

X X

X

M

ix c

onte

nts

of v

ial,

dilu

ent,

and

pow

der

(wit

h ne

edle

rem

aini

ng in

vi

al).

X X

X X

X

Fo

r in

fusi

on,

inje

ct t

he c

hem

othe

rapy

dos

e in

to t

he s

olut

ion.

X X

X

X

Cl

ean

the

addi

tive

por

t on

the

sol

utio

n co

ntai

ner

prio

r to

and

aft

er

inje

ctin

g ch

emot

hera

py.

X

X

X X

Pr

oper

ly m

ix c

onte

nts

and

perf

orm

a f

inal

insp

ecti

on.

X

X

X X

Plac

e a

tam

per-

proo

f se

al o

n ad

diti

ve p

ort.

X X

X

X

Pl

ace

a ca

p on

the

end

of

the

tubi

ng t

o m

aint

ain

ster

ility

, m

aint

ain

stab

ility

of

prod

uct,

and

pre

vent

leak

age.

X X

X

X

W

ipe

the

bag

wit

h an

alc

ohol

pre

p to

rem

ove

any

poss

ible

ch

emot

hera

py c

onta

min

atio

n.

X

X

X X

16


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Fo

r an

IV p

ush,

pla

ce t

he c

ap o

n th

e en

d of

the

syr

inge

to

mai

ntai

n st

erili

ty,

mai

ntai

n st

abili

ty o

f pr

oduc

t, a

nd p

reve

nt le

akag

e.

X

X X

X

Pr

int

and

appl

y th

e dr

ug la

bel t

o th

e m

ixtu

re.

X

X X

X X

Dis

pose

of

cont

amin

ated

equ

ipm

ent

in a

n ap

prop

riat

e ha

zard

ous

drug

-dis

posa

l con

tain

er p

er f

eder

al r

egul

atio

ns.

X

X X

X X

Prep

are

syri

nges

wit

h no

rmal

sal

ine

to f

lush

IV li

ne b

etw

een

adm

inis

trat

ion

of e

ach

agen

t.

X

X X

X X

Dou

ble

chec

k:

Ori

gina

l che

mot

hera

py o

rder

. X

X X

X X

X

D

rug

bein

g pr

epar

ed.

(Lo

ok a

t th

e or

igin

al v

ial

to v

erif

y co

rrec

t dr

ug

is b

eing

adm

ixed

.)

X X

X X

X X

Vi

al s

izes

. (

Use

a c

ombi

nati

on o

f vi

al s

izes

tha

t co

mes

clo

sest

to

the

pres

crib

ed d

ose

to r

educ

e w

aste

and

dec

reas

e co

st.)

X

X X

X X

X

Am

ount

of

drug

to

be in

still

ed in

to s

olut

ion

for

infu

sion

. X

X X

X X

X

D

ose

calc

ulat

ions

. X

X X

X X

X

Prep

are

IV c

hem

othe

rapy

. F

ill IV

tub

ing

wit

h a

nonc

hem

othe

rapy

IV f

luid

(s

uch

as n

orm

al s

alin

e).

X

X X

X X

Inve

ntor

y m

anag

emen

t:

Reor

der

drug

s.

X

X

X

Rest

ock

drug

s. (

Mus

t w

ear

pers

onal

pro

tect

ive

equi

pmen

t).

X

X

X

Obt

ain

vita

l sig

ns.

Obt

ain

vita

l si

gns.

(F

indi

ngs

may

sig

nal b

ody

syst

em a

bnor

mal

itie

s ne

cess

itat

ing

post

pone

men

t of

tre

atm

ent.

)

X X

X

Bl

ood

pres

sure

.

X X

X

17


SS eecc tt

ii oonn OO

nnee ::

PPrr ee

tt rree aa

tt mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Pu

lse

and

resp

irat

ory

rate

.

X X

X

Te

mpe

ratu

re.

X

X

X

Obt

ain

heig

ht.

X

O

btai

n w

eigh

t.

X

X

X

Calc

ulat

e th

e ap

prop

riat

e ch

emot

hera

py d

osag

e. A

n in

accu

rate

ch

emot

hera

py o

r bi

othe

rapy

dos

age

coul

d re

sult

in o

ver-

or

unde

rdos

ing

of a

gent

s.

Veri

fy d

osin

g ba

sed

on:

X X

X

X

BS

A (f

orm

ula

usin

g he

ight

and

wei

ght)

OR

X

X X

Ar

ea u

nder

the

cur

ve (

AUC)

. X

X X

Ve

rify

BSA

or

AUC

wit

h or

ders

and

dos

e re

com

men

dati

ons.

Ina

ccur

ate

calc

ulat

ions

of

BSA

have

res

ulte

d in

18%

of

the

seri

ous

prev

enta

ble

adve

rse

drug

eve

nts

whe

n pr

acti

tion

ers

have

insu

ffic

ient

info

rmat

ion

abou

t th

e pa

tien

t.

X

X

X

18


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Adm

inis

trat

ion

of c

hem

othe

rapy

. D

efin

itio

ns.

Chem

othe

rapy

and

sup

port

ive

care

med

icat

ions

are

adm

inis

tere

d in

a v

arie

ty o

f w

ays.

Met

hods

of

adm

inis

trat

ion

incl

ude

the

follo

win

g.

Pe

riph

eral

IV m

etho

ds:

IV p

iggy

back

: A

prim

ary

(mai

n) b

ag o

f IV

flu

ids,

usu

ally

sal

ine

solu

tion

, is

hun

g an

d th

e ch

emot

hera

py s

olut

ion

is c

onne

cted

(p

iggy

back

ed)

into

a s

ide

port

of

the

tubi

ng o

f th

e pr

imar

y fl

uid.

Th

is t

echn

ique

fur

ther

dilu

tes

the

med

icat

ion

as it

ent

ers

the

pati

ent’

s ve

nous

sys

tem

.

IV p

ush:

A p

rim

ary

bag

of IV

flu

ids

is h

ung

and

slow

ly d

rips

into

the

pat

ient

’s v

ein.

Th

e re

gist

ered

nur

se s

low

ly p

ushe

s th

e ch

emot

hera

py a

gent

into

a s

ide

port

of

the

prim

ary

bag’

s IV

tub

ing.

Ch

emot

hera

py a

gent

s kn

own

as v

esic

ants

mus

t be

ad

min

iste

red

in t

his

man

ner.

Bec

ause

the

ves

ican

t dr

ug h

as t

he p

oten

tial

to

caus

e se

vere

dam

age,

incl

udin

g ti

ssue

dea

th,

if

any

of t

he m

edic

atio

n is

allo

wed

to

leak

into

the

tis

sues

aro

und

the

vein

, th

e re

gist

ered

nur

se m

ust

cons

tant

ly m

onit

or t

he

rate

of

deliv

ery

and

the

cond

itio

n of

the

sit

e w

here

the

IV is

pla

ced.

Ce

ntra

l ven

ous

acce

ss m

etho

ds:

Cent

ral v

enou

s ac

cess

req

uire

s th

at a

n IV

dev

ice

is p

lace

d in

to a

larg

e ve

in in

the

upp

er c

hest

(C

VAD

).

Chem

othe

rapy

can

be

very

cau

stic

to

the

vein

s, a

nd r

epea

ted

expo

sure

to

chem

othe

rapy

can

scl

eros

e (h

arde

n) v

eins

or

cau

se t

hem

to

be v

ery

frag

ile,

thus

mak

ing

a pe

riph

eral

IV d

iffi

cult

to

inse

rt.

Fra

gile

vei

ns c

an e

asily

be

punc

ture

d du

ring

in

sert

ion

of t

he p

erip

hera

l IV,

thu

s ne

cess

itat

ing

mul

tipl

e at

tem

pts

at p

laci

ng t

he IV

. In

the

se in

stan

ces,

an

impl

ante

d de

vice

ca

lled

a po

rt c

an b

e su

rgic

ally

pla

ced

unde

r th

e pa

tien

t’s

skin

. A

sm

all t

ube

that

is c

onne

cted

to

the

port

is t

hrea

ded

into

the

la

rge

vein

in t

he c

hest

cav

ity.

Th

e po

rt h

as a

res

ervo

ir m

ade

of t

itan

ium

wit

h a

self

-sea

ling

acce

ss p

orti

on t

hat

allo

ws

a ne

edle

to

be p

lace

d th

roug

h th

e po

rt t

o re

mov

e bl

ood

for

sam

plin

g or

del

iver

a v

arie

ty o

f m

edic

atio

ns (

incl

udin

g ch

emot

hera

py)

and

flui

ds in

to t

he p

atie

nt’s

blo

odst

ream

. E

xter

nal

cath

eter

s al

so c

an b

e pl

aced

in t

he la

rge

vein

in t

he c

hest

ca

vity

. T

hese

cat

hete

rs a

re p

arti

ally

ext

erna

l and

gen

eral

ly h

eld

in p

lace

wit

h st

itch

es in

the

ski

n.

Im

plan

ted

pum

ps:

Arte

rial

acc

ess

devi

ce:

This

impl

ante

d de

vice

res

embl

es a

por

t bu

t ha

ve a

mec

hani

sm t

hat

deliv

ers

chem

othe

rapy

into

the

he

pati

c (l

iver

) ar

tery

. T

he d

evic

e al

low

s fo

r th

e de

liver

y of

che

mot

hera

py in

to a

spe

cifi

c re

gion

of

the

body

thu

s pr

ovid

ing

a hi

gher

con

cent

rati

on o

f ch

emot

hera

py a

t th

e tu

mor

sit

e.

19


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Intr

aven

tric

ular

(om

may

a) a

cces

s de

vice

: Th

is is

a d

ome-

shap

ed,

self

-sea

ling

silic

one

rese

rvoi

r at

tach

ed t

o a

cath

eter

. T

he

devi

ce is

impl

ante

d un

der

the

scal

p ab

ove

the

fron

tal l

obe

and

allo

ws

for

deliv

ery

of c

hem

othe

rapy

into

the

cer

ebra

l spi

nal

flui

d to

tre

at c

ance

r ce

lls p

rese

nt in

tha

t fl

uid.

Epid

ural

and

intr

athe

cal a

cces

s de

vice

s: T

hese

cat

hete

rs a

re in

sert

ed in

to t

he e

pidu

ral s

pace

(be

twee

n th

e bo

ny p

rom

inen

ces

of t

he s

pina

l col

umn)

and

allo

w f

or t

he d

eliv

ery

of c

hem

othe

rapy

, op

ioid

s, a

nd a

nest

heti

c m

edic

atio

n fo

r ch

roni

c in

trac

tabl

e pa

in.

Man

y pa

tien

ts a

re s

ent

hom

e w

ith

chem

othe

rapy

del

iver

ed b

y a

devi

ce t

hat

pum

ps d

rugs

into

the

ir b

odie

s 24

hou

rs a

day

. T

he

regi

ster

ed n

urse

in t

he o

ffic

e is

on

call

for

thes

e pa

tien

ts in

the

eve

nt o

f pu

mp

prob

lem

s, in

clud

ing

disl

odgi

ng a

nee

dle

from

th

e po

rt,

an a

larm

war

ning

of

occl

usio

n (p

ossi

bly

rela

ted

to b

lood

tha

t ha

s co

ngea

led

and

form

ed a

clo

t in

the

cat

hete

r),

the

acci

dent

al c

utti

ng o

f th

e tu

bing

, or

a d

ead

batt

ery.

Pr

oble

ms

can

lead

to

rapi

d or

inad

equa

te in

fusi

on o

f th

e ch

emot

hera

py,

infe

ctio

n, a

nd/o

r th

e fo

rmat

ion

of a

clo

t in

the

cat

hete

r or

a b

lood

ves

sel b

ecau

se o

f in

adeq

uate

flu

id f

low

.

Chem

othe

rapy

tre

atm

ent

plan

s or

ord

ers

are

clea

rly

and

conc

isel

y w

ritt

en a

nd v

erif

ied

befo

re a

dmin

istr

atio

n.

Dou

ble-

chec

k th

e do

se c

alcu

lati

on f

or e

ach

chem

othe

rapy

age

nt p

rior

to

adm

inis

teri

ng.

X

X

X

Ch

eck

the

phys

icia

n or

der

for

the

curr

ent

date

, da

ys o

f ad

min

istr

atio

n fo

r th

e th

erap

y, p

atie

nt a

llerg

ies,

and

phy

sici

an s

igna

ture

. X

X X

Ve

rify

cal

cula

tion

s pe

rfor

med

by

the

phys

icia

n, s

uch

as t

he d

rug

dosa

ge o

f th

e dr

ug (

e.g.

, m

illig

ram

s or

dere

d m

ulti

plie

d by

the

pa

tien

t’s

BSA)

.

X

X

X

U

sing

app

ropr

iate

ref

eren

ce,

chec

k to

ens

ure

that

the

dos

age

falls

w

ithi

n th

e pr

escr

ibed

saf

e ra

nge.

X

X X

Chec

k fo

r co

ntra

indi

cati

ons

(e.g

., a

bnor

mal

labo

rato

ry r

esul

ts,

seri

ous

side

ef

fect

s fr

om p

revi

ous

trea

tmen

ts)

befo

re a

dmin

istr

atio

n.

X X

X

Com

plic

atio

ns o

f ve

nous

acc

ess

are

prev

ente

d or

red

uced

wit

h ap

prop

riat

e ca

re.

Che

mot

hera

py a

nd t

hera

peut

ic

agen

ts a

re a

dmin

iste

red

safe

ly.

The

regi

ster

ed n

urse

mus

t be

kno

wle

dgea

ble

rega

rdin

g in

dica

tion

s fo

r th

erap

y, s

ide

effe

cts

and

pote

ntia

l adv

erse

rea

ctio

ns,

and

appr

opri

ate

X

X

X

20


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

inte

rven

tion

s.

Init

iate

per

iphe

ral I

V ac

cess

: X

X X

As

sess

for

app

ropr

iate

vei

n se

lect

ion.

Rev

iew

pri

or s

ites

of

acce

ss a

nd

look

for

dam

age

to p

revi

ousl

y us

ed v

eins

. X

X X

Th

orou

ghly

cle

anse

ski

n at

acc

ess

site

to

redu

ce t

he p

oten

tial

for

in

fect

ion.

X

X X

Ro

utin

ely

begi

n IV

acc

ess

in a

reas

bel

ow t

he e

lbow

. X

X X

Su

bseq

uent

sit

es s

houl

d be

init

iate

d ab

ove

the

prev

ious

IV s

ite.

X

X X

Init

iate

CVA

D a

cces

s:

X X

X

Use

a n

onco

ring

nee

dle

for

port

s to

min

imiz

e da

mag

e to

the

sep

tum

. X

X X

Pr

even

t le

akag

e of

che

mot

hera

py f

rom

the

por

t se

ptum

. X

X X

Han

g pr

imar

y IV

flu

ids.

Th

is k

eeps

the

vei

n op

en,

dilu

tes

chem

othe

rapy

ag

ents

, an

d m

aint

ains

IV a

cces

s fo

r th

erap

euti

c an

d po

tent

ial e

mer

genc

y si

tuat

ions

.

X X

X

Veri

fy t

hat

the

IV is

fun

ctio

ning

cor

rect

ly:

X

X

X

Chec

k th

e si

te f

or a

ny s

igns

of

leak

age

into

the

ski

n.

X

X

X

Chec

k fo

r bl

ood

retu

rn.

Som

e ch

emot

hera

py a

gent

s ca

n da

mag

e th

e ti

ssue

sur

roun

ding

the

vei

n if

leak

s oc

cur.

Blo

od r

etur

n is

ver

ifie

d to

co

nfir

m t

he IV

line

rem

ains

in a

sta

ble

posi

tion

in t

he v

ein.

X

X

X

Ensu

re t

he “

five

rig

hts”

of

med

icat

ion

adm

inis

trat

ion

prio

r to

ad

min

iste

ring

any

med

icat

ion

to p

reve

nt e

rror

s:

X

X

X

Ri

ght

pati

ent.

X

X X

Ri

ght

tim

e.

X

X

X

Righ

t dr

ug.

X

X

X

21


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Ri

ght

dose

. X

X X

Ri

ght

rout

e of

adm

inis

trat

ion.

X

X X

Adm

inis

ter

prem

edic

atio

ns (

e.g.

, an

tiem

etic

s an

d/or

ste

roid

s to

pre

vent

na

usea

and

vom

itin

g).

X

X

X

Dou

ble-

chec

k th

e pa

tien

t’s

iden

tity

. (

Ask

the

pati

ent

to s

tate

his

or

her

nam

e, d

ate

of b

irth

, ad

dres

s, o

r ot

her

iden

tifi

er t

o pr

even

t ac

cide

ntal

de

liver

y of

med

icat

ion

to w

rong

pat

ient

.)

X X

X

Begi

n th

e IV

infu

sion

: X

X X

G

athe

r an

d us

e pr

otec

tive

equ

ipm

ent

(i.e

., a

gow

n m

ade

of lo

w-

perm

eabi

lity

fabr

ic,

chem

othe

rapy

glo

ves,

and

gog

gles

if t

he p

oten

tial

fo

r ey

e co

ntam

inat

ion

exis

ts).

X X

X

Co

mpa

re t

he d

rug

in IV

bag

wit

h th

e ph

ysic

ian

orde

r.

X X

X

X

Secu

re a

noth

er r

egis

tere

d nu

rse

to d

oubl

e-ch

eck

the

dosa

ge t

o be

de

liver

ed a

gain

st p

hysi

cian

ord

er.

X X

X

X

Ch

eck

the

IV s

ite

to e

nsur

e th

at it

is w

orki

ng c

orre

ctly

. X

X X

X

Ex

plai

n th

e en

tire

pro

cedu

re t

o pa

tien

t.

X X

X

X

Revi

ew t

he a

ctio

n of

the

dru

g an

d si

de e

ffec

ts w

ith

the

pati

ent.

X

X X

X

In

fuse

the

bag

of

chem

othe

rapy

and

adj

ust

the

rate

of

deliv

ery

as

appr

opri

ate.

X

X X

X

Adm

inis

ter

IV p

ush

agen

ts:

X X

X X

Gat

her

and

use

prot

ecti

ve e

quip

men

t (i

.e.,

a g

own

mad

e of

low

-pe

rmea

bilit

y fa

bric

, ch

emot

hera

py g

love

s, a

non

poro

us p

ad t

o pl

ace

unde

r IV

, an

d go

ggle

s if

the

pot

enti

al f

or e

ye c

onta

min

atio

n ex

ists

).

X X

X X

Co

mpa

re t

he d

rug

in t

he s

yrin

ge,

bag,

or

bott

le w

ith

the

phys

icia

n or

der.

X

X X

X

22


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Se

cure

ano

ther

reg

iste

red

nurs

e to

dou

ble-

chec

k th

e do

sage

to

be

deliv

ered

wit

h th

e ph

ysic

ian

orde

r.

X X

X X

Ch

eck

the

IV s

ite

to e

nsur

e th

at it

is w

orki

ng c

orre

ctly

. X

X X

X

Ex

plai

n th

e en

tire

pro

cedu

re t

o th

e pa

tien

t.

X X

X X

Revi

ew t

he a

ctio

n of

the

dru

g an

d si

de e

ffec

ts w

ith

the

pati

ent.

X

X X

X

Pl

ace

a no

npor

ous

pad

unde

r th

e IV

sit

e w

here

the

dru

g is

bei

ng p

ushe

d to

pre

vent

exp

osur

e of

che

mot

hera

py t

o th

e pa

tien

t.

X X

X X

Pu

sh t

he m

edic

atio

n th

roug

h a

free

-flo

win

g IV

whi

le c

onti

nuou

sly

mon

itor

ing

the

IV s

ite

for

any

sign

s of

leak

age.

X X

X X

Whe

n ad

min

iste

ring

a v

esic

ant

agen

t, m

aint

ain

spec

ific

pre

caut

ions

. X

X

For

peri

pher

al IV

acc

ess:

Ev

alua

te r

isk

fact

ors

for

a pe

riph

eral

ext

rava

sati

on (

i.e.

, th

in,

frag

ile

vein

s; s

cler

osed

, ha

rden

ed v

eins

sec

onda

ry t

o pr

ior

chem

othe

rapy

ex

posu

re).

X

X

Pl

ace

a ne

w p

erip

hera

l IV

(one

sti

ck)

for

vesi

cant

age

nts.

X

X

Av

oid

use

of a

n IV

pum

p fo

r pe

riph

eral

infu

sion

s.

X

X

Chec

k fr

eque

ntly

for

blo

od r

etur

n or

pat

ency

dur

ing

IV p

ush

or

cont

inuo

us in

fusi

on w

itho

ut c

ausi

ng d

amag

e to

fra

gile

vei

ns.

Che

ck

ever

y fi

ve m

inut

es o

r 2–

3 cc

.

X

X

M

onit

or t

he in

sert

ion

site

for

sig

ns o

f le

akag

e or

sw

ellin

g (i

.e.,

a s

mal

l bu

mp

at t

he s

ite)

. X

X

For

CVAD

acc

ess:

Ch

eck

pate

ncy

of t

he C

VAD

per

inst

itut

ion

prot

ocol

. X

X

Ch

eck

for

bloo

d re

turn

upo

n co

mpl

etio

n of

infu

sion

. X

X

23


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

If

blo

od r

etur

n is

not

evi

dent

pri

or t

o or

dur

ing

the

infu

sion

of

a ve

sica

nt,

X

X

Flus

h th

e ca

thet

er w

ith

salin

e.

X

X Re

posi

tion

the

pat

ient

. X

X

Dec

lot

the

acce

ss d

evic

e w

ith

the

pres

crib

ed m

edic

atio

n pe

r pr

otoc

ol.

X

X Se

nd p

atie

nt f

or x

-ray

or

dye

stud

y to

con

firm

pro

per

plac

emen

t of

de

vice

. X

X

Ask

the

pati

ent

to im

med

iate

ly r

epor

t an

y st

ingi

ng o

r bu

rnin

g at

the

sit

e or

in

tern

al d

isco

mfo

rt (

for

CVAD

infu

sion

s).

X

X

Regu

late

and

mon

itor

the

rat

e of

infu

sion

to

ensu

re p

atie

nt s

afet

y.

The

canc

er a

nd p

reex

isti

ng o

r co

mor

bid

cond

itio

ns c

an b

e af

fect

ed b

y th

e ra

te

of d

eliv

ery

of f

luid

s or

che

mot

hera

py (

e.g.

, pa

tien

ts w

ith

pree

xist

ing

kidn

ey d

isea

se w

ho r

ecei

ve la

rge

flui

d vo

lum

es m

ay r

etai

n ra

ther

tha

n ex

cret

e th

e fl

uid)

.

X

X

Cont

rol t

he r

ate

that

the

IV p

ush

agen

t is

adm

inis

tere

d to

avo

id d

amag

e to

or

gan

syst

ems.

X

X

Flus

h th

e pe

riph

eral

IV c

athe

ter

or C

VAD

bet

wee

n ch

emot

hera

py a

gent

s.

This

pre

vent

s ch

emic

al r

eact

ions

or

prec

ipit

ate

form

atio

n th

at m

ight

oc

clud

e th

e ca

thet

er.

X

X

X

Indi

vidu

aliz

e as

sess

men

ts b

ased

on

pati

ent

hist

ory

and

cond

itio

n an

d m

edic

atio

n be

ing

adm

inis

tere

d.

Peri

odic

ass

essm

ents

incl

ude:

X

X X

Pa

tien

t re

spon

se o

r to

lera

nce

to t

reat

men

t.

X X

X X

X

Cond

itio

n of

IV s

ite

and

pate

ncy

(red

ness

, te

nder

ness

, pa

in,

sign

s of

le

akag

e.

X X

X X

X

X

Fl

ow o

f IV

flu

ids.

X

X X

X X

X

Vi

tal s

igns

(if

indi

cate

d, d

epen

dent

on

drug

adm

inis

tere

d).

X X

X

X

24


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Man

age

impl

ante

d pu

mps

or

acce

ss d

evic

es (

CVAD

, ar

teri

al a

cces

s de

vice

, in

trav

entr

icul

ar a

cces

s de

vice

or

omm

aya

rese

rvoi

r, e

pidu

ral a

nd

intr

athe

cal a

cces

s de

vice

s).

Thi

s re

quir

es a

reg

iste

red

nurs

e w

ith

adva

nced

tra

inin

g in

the

car

e an

d m

anag

emen

t of

the

se s

peci

aliz

ed

trea

tmen

t op

tion

s.

X X

X

X

M

onit

or s

kin

reac

tion

s ar

ound

the

pum

p si

te:

sign

s of

ves

ican

t ex

trav

asat

ion,

dru

g cr

ysta

lliza

tion

, an

d sk

in d

eath

ove

r pu

mp

site

.

X X

X

X

Ch

eck

freq

uent

ly f

or c

athe

ter

bloc

kage

. X

X X

X

Ch

eck

and

rech

eck

the

dosa

ge o

f th

e dr

ug in

the

res

ervo

ir t

o av

oid

over

- or

und

erdo

sing

. X

X X

X

As

sess

the

sta

bilit

y of

the

pum

p’s

plac

emen

t (e

.g.,

tur

ning

ove

r in

the

pu

mp

pock

et u

nder

the

ski

n th

at w

ould

pro

hibi

t de

vice

acc

ess)

. X

X X

X

Man

age

ambu

lato

ry p

umps

, if

use

d.

X

X X

X

Flus

h IV

acc

ess,

bot

h pe

riph

eral

and

cen

tral

, at

the

end

of

the

infu

sion

, us

ing

ster

ile t

echn

ique

: X

X X

W

hen

the

infu

sion

of

chem

othe

rapy

is c

ompl

ete,

flu

sh t

he p

erip

hera

l ca

thet

er n

eedl

e be

fore

rem

oval

to

was

h ou

t an

y ch

emot

hera

py t

hat

mig

ht r

emai

n.

Chem

othe

rapy

age

nts

shou

ld n

ot b

e al

low

ed t

o en

ter

the

tiss

ue o

f th

e ha

nd o

r ar

m w

hen

the

need

le is

rem

oved

.

X X

X

Fl

ush

CVAD

S w

ith

hepa

rin

and

norm

al s

alin

e to

ens

ure

and

mai

ntai

n pa

tenc

y an

d fu

ncti

on b

etw

een

inte

rmit

tent

adm

inis

trat

ion.

X

X X

X

U

sing

ste

rile

tec

hniq

ue,

disc

onne

ct t

he t

ubin

g an

d pl

ace

a st

erile

cap

on

end

of

CVAD

. X

X X

X

Re

mov

e th

e pe

riph

eral

IV c

athe

ter,

app

ly p

ress

ure

unti

l ble

edin

g is

st

oppe

d, a

nd a

pply

ste

rile

pre

ssur

e dr

essi

ng a

t th

e si

te.

Ass

ess

for

com

plic

atio

ns (

e.g.

, co

ntin

ued

blee

ding

aft

er c

athe

ter

rem

oval

).

X X

X

X

25


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Man

age

any

reac

tion

s th

at o

ccur

dur

ing

ther

apy.

Fl

are

reac

tion

(re

dnes

s an

d it

chin

g at

IV s

ite)

: X

X

As

sess

for

fla

re r

eact

ion.

X

X

Im

plem

ent

appr

opri

ate

man

agem

ent

mea

sure

s, in

clud

ing

stop

ping

tr

eatm

ent.

X

X

If

rea

ctio

n re

solv

es,

asse

ss p

atie

nt s

tatu

s an

d re

sum

e tr

eatm

ent

per

phys

icia

n or

pro

toco

l ord

ers.

X

X

O

nce

flar

e re

acti

on h

as r

esol

ved,

slo

wly

res

ume

infu

sion

of

the

drug

. X

X

An

tici

pati

on a

nd/o

r pr

even

tion

of

futu

re r

eact

ions

: If

the

dru

g is

to

be

adm

inis

tere

d at

a la

ter

date

, co

nsid

er p

rem

edic

atio

n.

X

X

Pote

ntia

l or

susp

ecte

d ex

trav

asat

ion:

X

X

As

sess

con

tinu

ousl

y fo

r ve

sica

nt o

r ir

rita

nt e

xtra

vasa

tion

. X

X

If

app

ropr

iate

, ha

ve a

ntid

ote

ther

apy

(i.e

., d

rugs

giv

en t

o co

unte

ract

po

tent

ial t

issu

e da

mag

e) r

eadi

ly a

vaila

ble.

X

X

As

sess

the

sit

e to

det

erm

ine

man

agem

ent

of f

ollo

w-u

p ca

re (

e.g.

, ch

oice

of

futu

re s

ites

for

IV in

fusi

on o

r pl

acem

ent

of C

VAD

).

X

X

Ev

alua

te a

nd m

anag

e po

tent

ial l

ong-

term

com

plic

atio

ns,

incl

udin

g lo

ss

of li

mb

or lo

ss o

f fu

ncti

on.

X

X

If

ext

rava

sati

on is

sus

pect

ed,

stop

the

infu

sion

, ad

min

iste

r th

e an

tido

te if

one

is a

vaila

ble

and

appr

opri

ate,

and

app

ly ic

e or

hea

t as

ap

prop

riat

e (b

ased

on

chem

othe

rapy

dru

g in

volv

ed).

X

X

If e

xtra

vasa

tion

occ

urs:

X

X

St

op t

he in

fusi

on.

X

X

Dis

conn

ect

the

IV s

ite.

X

X

26


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

If

usi

ng im

plan

ted

port

, ve

rify

nee

dle

plac

emen

t.

X

X

Atte

mpt

to

aspi

rate

any

res

idua

l che

mot

hera

py a

gent

. X

X

Ap

ply

hot

or c

old

pack

s de

pend

ing

on t

he d

rug.

X

X

Ap

ply

the

anti

dote

if a

vaila

ble

(not

all

drug

s ha

ve a

ntid

otes

).

X

X

Init

iate

app

ropr

iate

nur

sing

inte

rven

tion

s.

X

X

Mon

itor

the

sit

e at

24

hour

s, o

ne w

eek,

tw

o w

eeks

, an

d as

nec

essa

ry.

X

X

Educ

ate

the

pati

ent

and

fam

ily o

n m

anag

emen

t of

the

ext

rava

sati

on

site

. X

X

In

itia

te a

tra

ckin

g fo

rm t

o do

cum

ent

the

cond

itio

n of

the

IV s

ite,

pa

tien

t in

stru

ctio

ns,

and

any

follo

w-u

p.

X

X

Hyp

erse

nsit

ivit

y re

acti

on (

i.e.

, a

reac

tion

to

a dr

ug t

hat

can

rang

e fr

om

rash

and

itch

ing

to a

naph

ylax

is,

whi

ch is

life

-thr

eate

ning

sho

ck).

X

X

Pote

ntia

l rea

ctio

ns:

Iden

tify

dru

gs a

t ri

sk f

or c

ausi

ng h

yper

sens

itiv

ity

reac

tion

. X

X

O

btai

n ba

selin

e vi

tal s

igns

. X

X

En

sure

ava

ilabi

lity

of e

mer

genc

y eq

uipm

ent

and

med

icat

ions

. X

X

In

stru

ct t

he p

atie

nt o

n sy

mpt

oms

to r

epor

t.

X

X

Perf

orm

a s

crat

ch t

est,

intr

ader

mal

ski

n te

st,

or t

est

dose

bef

ore

adm

inis

teri

ng in

itia

l dos

e of

dru

g.

X

X

Co

nsid

er m

edic

atio

n de

sens

itiz

atio

n.

X

X

Prov

ide

supp

ort

to f

amily

. X

X

Actu

al r

eact

ions

: X

X

St

op t

he in

fusi

on a

nd in

itia

te a

ppro

pria

te m

easu

res

base

d on

the

X

X

27


SS eecc tt

ii oonn TT

wwoo ::

TT

rr eeaa tt

mmee nn

tt

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

phys

icia

n or

der

or p

roto

col.

Anap

hyla

xis

(lif

e-th

reat

enin

g sh

ock)

: X

X

Id

enti

fy d

rugs

at

risk

for

cau

sing

an

anap

hyla

ctic

rea

ctio

n.

X

X

Obt

ain

base

line

vita

l sig

ns.

X

X

Adm

inis

ter

prem

edic

atio

ns.

X

X

Asse

ss f

or a

naph

ylac

tic

reac

tion

. X

X

If

ana

phyl

axis

occ

urs,

sto

p th

e in

fusi

on o

r ad

min

istr

atio

n of

dru

g.

X

X

Init

iate

app

ropr

iate

em

erge

ncy

mea

sure

s an

d m

anag

emen

t of

an

aphy

laxi

s.

X

X

Ca

ll 91

1 fo

r em

erge

ncy

assi

stan

ce.

X

X

Star

t CP

R.

X

X

Adm

inis

ter

oxyg

en.

X

X

Adm

inis

ter

appr

opri

ate

med

icat

ions

bas

ed o

n ph

ysic

ian

orde

r or

pr

otoc

ol.

X

X

Mon

itor

the

pat

ient

aft

er c

ompl

etio

n of

che

mot

hera

py.

Mon

itor

for

adv

erse

rea

ctio

ns a

nd d

elay

ed a

nd /

or

life-

thre

aten

ing

anap

hyla

ctic

sho

ck.

X

X

Reas

sess

the

infu

sion

sit

e fo

r si

gns

of e

xtra

vasa

tion

. X

X

Mon

itor

for

ble

edin

g po

st-i

nfus

ion.

X

X

28


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Clea

n tr

eatm

ent

area

and

/or

equi

pmen

t.

Occ

upat

iona

l Saf

ety

and

Hea

lth

Adm

inis

trat

ion

com

plia

nce:

X X

D

ispo

se o

f al

l sup

plie

s us

ed f

or t

he a

dmin

istr

atio

n of

che

mot

hera

py

agen

ts (

e.g.

, sh

arps

, bi

ohaz

ard

was

te b

ins)

.

X X

Ch

ange

line

n.

X

X

Rem

ove

reus

able

equ

ipm

ent

afte

r cl

eani

ng.

X

X

Wip

e do

wn

(cle

an)

chai

rs,

tabl

e, a

nd o

ther

roo

m s

uppl

ies.

X X

Com

plet

e do

cum

enta

tion

on

med

ical

for

ms.

O

n la

bora

tory

flo

w s

heet

s, d

ocum

ent

all u

pdat

ed la

bora

tory

res

ults

. Cu

rren

t la

bora

tory

res

ults

may

det

erm

ine

a pa

tien

t’s

resp

onse

to

trea

tmen

t.

Vari

atio

ns in

labo

rato

ry r

esul

ts c

ould

res

ult

in t

he d

elay

of

trea

tmen

t, a

djus

tmen

ts in

dru

g do

sage

s, o

r ad

diti

onal

sup

port

ive

care

dr

ugs

to c

orre

ct c

hang

es in

labo

rato

ry v

alue

s.

X

X

X

X

All l

abor

ator

y va

lues

mus

t be

ver

ifie

d, e

valu

ated

, an

d tr

ende

d so

tha

t ch

ange

s ca

n be

mon

itor

ed o

ver

the

trea

tmen

t co

ntin

uum

. X

X X

Co

mpl

ete

bloo

d co

unt.

X X

Li

ver

func

tion

tes

t.

X

X

Kidn

ey (

rena

l) f

unct

ion

test

.

X X

Tu

mor

mar

kers

.

X X

Reco

rd o

n in

fusi

on f

low

she

ets

all u

pdat

ed in

form

atio

n in

dica

ted

belo

w.

Th

is d

ocum

ents

the

act

ual t

reat

men

t, m

etho

d of

adm

inis

trat

ion,

and

dat

e an

d ti

me

of a

dmin

istr

atio

n. I

t se

rves

as

a hi

stor

ic a

nd le

gal d

ocum

ent

of

the

pati

ent’

s tr

eatm

ent

regi

men

.

X X

X X

X X

D

rug.

X

X X

X X

X

29


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

D

ose.

X

X X

X X

X

So

luti

on o

r vo

lum

es.

X X

X X

X X

Cum

ulat

ive

dose

(ca

nnot

be

exce

eded

wit

h ri

sk o

f se

vere

and

ir

reve

rsib

le s

ide

effe

cts)

. X

X

St

art

and

stop

tim

es f

or e

ach

drug

. X

X X

X X

X

Ro

ute

of a

dmin

istr

atio

n.

X X

X X

X X

Pate

ncy

of IV

. X

X X

X X

X

Ve

sica

nt p

reca

utio

ns (

if a

ppro

pria

te).

X

X

Asse

ss a

nd d

ocum

ent

vita

l sig

ns t

o de

term

ine

base

line

read

ings

and

to

mon

itor

cha

nges

in v

ital

sig

ns d

urin

g an

d af

ter

trea

tmen

t. A

ccur

ate

heig

ht

and

wei

ght

mea

sure

men

ts a

re e

ssen

tial

for

det

erm

inin

g th

e pa

tien

t’s

BSA

and

mus

t be

doc

umen

ted.

The

dos

ages

of

the

med

icat

ions

giv

en t

o th

e pa

tien

t ar

e de

term

ined

by

the

pati

ent’

s BS

A, w

hich

the

reg

iste

red

nurs

e m

ust

calc

ulat

e an

d do

cum

ent

base

d on

hei

ght

and

wei

ght.

X X

X

Bl

ood

pres

sure

.

X X

X

Te

mpe

ratu

re.

X

X

X

Puls

e an

d re

spir

ator

y ra

te.

X

X

X

Hei

ght.

X

W

eigh

t.

X

X

X

BSA

and/

or A

UC.

X

X X

X

Doc

umen

t al

l ora

l and

wri

tten

inst

ruct

ions

giv

en t

o pa

tien

ts a

nd f

amily

m

embe

rs;

incl

udin

g ho

w t

o m

anag

e si

de e

ffec

ts a

t ho

me

follo

win

g tr

eatm

ent,

how

to

mon

itor

for

del

ayed

hyp

erse

nsit

ivit

y re

acti

ons,

and

how

to

man

age

pain

. T

he r

egis

tere

d nu

rse

mus

t as

sess

and

doc

umen

t th

e pa

tien

t’s

and

fam

ily m

embe

rs’

leve

l of

unde

rsta

ndin

g of

the

inst

ruct

ions

.

X X

X

X

30


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

This

doc

umen

tati

on p

rovi

des

a ru

nnin

g re

cord

of

wha

t th

e pa

tien

t an

d fa

mily

mem

bers

hav

e be

en t

augh

t.

D

elay

ed h

yper

sens

itiv

ity.

X

X

M

anag

emen

t of

sid

e ef

fect

s of

tre

atm

ent.

X

X

Pa

in m

anag

emen

t.

X

X

Leve

l of

unde

rsta

ndin

g.

X

X

Asse

ss a

nd d

ocum

ent

the

pati

ent’

s re

spon

se t

o tr

eatm

ent,

incl

udin

g to

lera

nce

of t

he t

reat

men

t an

d an

y re

acti

on o

r si

de e

ffec

ts e

xper

ienc

ed.

This

doc

umen

tati

on is

impo

rtan

t hi

stor

ic in

form

atio

n to

hav

e fo

r su

bseq

uent

tre

atm

ents

wit

h th

e sa

me

ther

apy.

X X

X

To

lera

nce

to c

hem

othe

rapy

. X

X X

Re

acti

ons.

X

X X

Si

de e

ffec

ts (

e.g.

, na

usea

dur

ing

trea

tmen

t).

X X

X

Doc

umen

t al

l pre

scri

ptio

ns g

iven

to

the

pati

ent

and

the

reas

on f

or

pres

crip

tion

s. T

his

prov

ides

a r

ecor

d of

all

med

icat

ions

pro

vide

d to

the

pa

tien

t an

d is

an

impo

rtan

t re

fere

nce

whe

n fo

llow

ing

up w

ith

the

pati

ent

by p

hone

or

on s

ubse

quen

t of

fice

vis

its.

X

X

N

ause

a.

X

X

Pain

med

icat

ion.

X

X

Re

fills

.

X

Doc

umen

t no

tes

of p

hone

cal

ls w

ith

the

pati

ent

or f

amily

mem

bers

, in

dica

ting

wha

t w

as d

iscu

ssed

and

whi

ch in

stru

ctio

ns o

r pr

escr

ipti

ons

wer

e gi

ven.

Thi

s pr

ovid

es a

run

ning

rec

ord

of a

ll in

tera

ctio

ns w

ith

the

pati

ent

and

fam

ily m

embe

rs b

etw

een

offi

ce v

isit

s.

X

X

Pa

tien

t co

ncer

n.

X

X

31


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Ph

ysic

ian

inst

ruct

ions

. X

X

Pr

escr

ipti

ons.

X

X

Phon

e tr

iage

(pa

tien

t- a

nd f

amily

-ini

tiat

ed p

hone

cal

ls).

Pr

ovid

e or

rei

nfor

ce in

form

atio

n ab

out:

X

X

Ca

ncer

tre

atm

ent

opti

ons.

X

X

Sy

mpt

om m

anag

emen

t.

X

X

Repo

rtin

g of

labo

rato

ry a

nd t

est

resu

lts.

X

X

Re

ferr

als

and

cons

ulta

tion

s as

app

ropr

iate

. X

X

Pa

lliat

ive

and

end-

of-l

ife

care

. X

X

Phon

e ca

lls:

X

X

Asse

ss p

atie

nt c

ondi

tion

. X

X

Ed

ucat

e th

e pa

tien

t an

d fa

mily

. X

X

Re

cogn

ize

earl

y co

mpl

icat

ions

of

trea

tmen

t.

X

X

Impl

emen

t nu

rsin

g in

terv

enti

ons.

Fo

r ex

ampl

e, w

hen

a pa

tien

t ha

s co

nsti

pati

on f

rom

pai

n m

edic

atio

n, t

he r

egis

tere

d nu

rse

offe

rs

sugg

esti

ons

to r

elie

ve s

ympt

oms

such

as

drin

k a

war

m li

quid

, in

crea

se

flui

d in

take

, av

oid

cons

tipa

ting

foo

ds,

etc.

X

X

Pote

ntia

l pro

blem

s th

at m

ay b

e m

anag

ed b

y ph

one:

X

X

In

terp

reta

tion

of

pati

ent

data

. X

X

O

rder

ver

ific

atio

n.

X

X

Chan

ge in

pat

ient

hea

lth.

X

X

M

edic

atio

n ch

ange

s.

X

X

Fam

ily q

uest

ions

and

con

cern

s.

X

X

32


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

In

sura

nce

ques

tion

s an

d co

ncer

ns.

X

Labo

rato

ry r

esul

ts t

o ot

her

phys

icia

ns.

X

Labo

rato

ry r

esul

ts t

o pa

tien

ts.

X

Sche

dulin

g of

che

mot

hera

py a

ppoi

ntm

ents

, ph

ysic

ian

visi

ts,

or t

ests

(e

.g.,

labo

rato

ry,

x-ra

y).

X

Pr

escr

ipti

on r

efill

.

X

N

ew p

resc

ript

ions

. X

X

Sy

mpt

om m

anag

emen

t (a

sses

s, e

duca

te,

and

inte

rven

e as

nec

essa

ry):

X

X

Feve

r.

X

X Ch

ills.

X

X

Nau

sea.

X

X

Mou

th u

lcer

s.

X

X Vo

mit

ing.

X

X

Fati

gue.

X

X

Blee

ding

and

/or

brui

sing

. X

X

Dia

rrhe

a.

X

X Co

nsti

pati

on.

X

X Sh

ortn

ess

of b

reat

h.

X

X

Cont

act

the

phar

mac

y.

X

Set

up h

ome

care

or

hosp

ice.

X

X

An

swer

gen

eral

que

stio

ns f

rom

the

pat

ient

and

/ o

r fa

mily

. X

X

Oth

er c

linic

al r

espo

nsib

iliti

es.

33


SS eecc tt

ii oonn TT

hhrr ee

ee :: AA

dd ddii tt

ii oonnaa ll

CCll iinnii cc

aa ll RR

ee sspp oo

nnss ii

bb iill iitt ii

ee ss

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Adm

inis

ter

grow

th f

acto

rs a

s pr

escr

ibed

. X

X

Colla

bora

te w

ith

the

phys

icia

n in

scr

eeni

ng p

atie

nts

for

incl

usio

n in

av

aila

ble

clin

ical

tri

als

or r

esea

rch

prot

ocol

s.

X

X

Faci

litat

e th

e su

bmis

sion

pro

cess

for

clin

ical

tri

als

or r

esea

rch

prot

ocol

s.

X

X

Educ

ate

pati

ents

and

fam

ilies

reg

ardi

ng c

linic

al t

rial

s.

X

X As

sist

wit

h pr

oced

ures

(e.

g.,

bone

mar

row

asp

irat

ion;

par

acen

tesi

s, w

hich

is

the

rem

oval

of

abno

rmal

acc

umul

atio

n of

flu

id in

the

abd

omen

for

ev

alua

tion

of

pres

ence

of

canc

er c

ells

; th

orac

ente

sis,

whi

ch is

the

rem

oval

of

abn

orm

al a

ccum

ulat

ion

of f

luid

in t

he lu

ng f

or e

valu

atio

n of

pre

senc

e of

ca

ncer

cel

ls;

lum

bar

punc

ture

, w

hich

is t

he in

sert

ion

of a

nee

dle

into

the

sp

inal

flu

id f

or t

he p

urpo

se o

f re

mov

ing

flui

d fo

r te

stin

g or

adm

inis

trat

ion

of c

hem

othe

rapy

).

X

X

Mon

itor

pat

ient

s re

ceiv

ing

cons

ciou

s se

dati

on (

adm

inis

tere

d du

ring

sel

ect

proc

edur

es).

X

X

Prov

ide

CVAD

dre

ssin

g ch

ange

. X

X

Flus

h IV

line

s an

d ve

nous

acc

ess

devi

ces

betw

een

ther

apy

sess

ions

(i.

e.

mon

thly

por

t fl

ush)

. X

X

Mon

itor

and

ass

ess

pati

ent

stat

us b

etw

een

clin

ic v

isit

s fo

r si

gns

and

sym

ptom

s of

infe

ctio

n.

X

X

Man

age

indi

gent

dru

g in

vent

ory

in c

ompl

ianc

e w

ith

stat

e/fe

dera

l re

gula

tion

s, a

s ap

prop

riat

e. (

Pati

ents

wit

h fi

nanc

ial p

robl

ems

may

be

elig

ible

for

pha

rmac

euti

cal c

ompa

ny-a

dmin

iste

red

free

dru

g pr

ogra

ms.

)

X

Man

age

sam

ple

drug

inve

ntor

y in

com

plia

nce

wit

h st

ate

and

fede

ral

regu

lati

ons.

X

34


SS eecc tt

ii oonn FF

oo uurr ::

OOrr aa

ll CC

hhee mm

oo tthhee rr

aa ppyy

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

Pati

ent

and

fam

ily e

duca

tion

. Pr

ovid

e ve

rbal

and

wri

tten

inst

ruct

ions

tha

t in

clud

e:

X

X

Nam

e of

the

med

icat

ion

(bot

h ge

neri

c an

d br

and)

. X

X

D

ose

(may

be

taki

ng d

iffe

rent

dos

e-si

zed

tabl

ets)

. X

X

Sc

hedu

le o

f sp

ecif

ic d

ays

the

drug

is t

o be

tak

en a

s w

ell a

s fo

llow

-up

labo

rato

ry t

ests

and

med

ical

vis

its.

X

X

Sp

ecia

l ins

truc

tion

s, s

uch

as “

take

wit

h fo

od,”

do

not

doub

le u

p on

m

edic

atio

n to

mak

e up

for

a m

isse

d do

se,

and

the

abso

lute

impo

rtan

ce

of t

ruth

-tel

ling

whe

n re

port

ing

the

degr

ee o

f ac

cura

cy in

tak

ing

the

chem

othe

rapy

as

pres

crib

ed (

Phys

icia

ns m

ake

clin

ical

jud

gmen

ts b

ased

on

res

pons

e to

tre

atm

ent.

Dos

e ad

just

men

ts m

ay b

e m

ade

base

d on

pa

tien

ts a

ccur

atel

y re

port

ing

taki

ng o

ral c

hem

othe

rapy

as

pres

crib

ed.)

X

X

Si

de e

ffec

ts a

nd s

elf-

help

mea

sure

s to

man

age

side

eff

ects

. X

X

H

ow a

nd w

hen

to c

onta

ct t

he c

linic

or

onco

logy

off

ice

(Pat

ient

s ne

ed

to u

nder

stan

d th

e im

port

ance

of

earl

y re

cogn

itio

n of

and

pro

mpt

in

terv

enti

on f

or p

oten

tial

ly s

erio

us s

ide

effe

cts.

)

X X

X

Safe

ty is

sues

: X

X

In

stru

ct p

atie

nts

in t

he p

rope

r st

orag

e of

che

mot

hera

py (

refr

iger

ator

, ro

om t

empe

ratu

re,

away

fro

m e

xces

s he

at a

nd m

oist

ure)

to

mai

ntai

n th

e m

edic

atio

n’s

effi

cacy

and

pre

vent

acc

iden

tal i

nges

tion

(ch

ildre

n or

pe

ts in

the

hom

e).

Als

o pr

ovid

e in

stru

ctio

ns r

egar

ding

wha

t to

do

or

who

to

call

if s

omeo

ne e

lse

acci

dent

ally

tak

es t

he c

hem

othe

rapy

.

X

X

Ke

ep m

edic

atio

n in

ori

gina

l con

tain

ers.

D

o no

t cr

ush

tabl

ets

or o

pen

caps

ules

. X

X

En

tire

hou

seho

ld n

eeds

to

be in

stru

cted

on

how

to

hand

le b

odily

flu

ids

X

X

X

35


SS eecc tt

ii oonn FF

oo uurr ::

OOrr aa

ll CC

hhee mm

oo tthhee rr

aa ppyy

Requires Registered

Nurse

First Visit

Each Visit

Each IV Push

Each Infusion

Each Cycle

As Needed

of p

erso

n ta

king

che

mot

hera

py.

Pr

oper

dis

posa

l of

unus

ed o

ral c

hem

othe

rapy

. X

X X

Adhe

renc

e an

d co

mpl

ianc

e:

Asse

ss t

he p

atie

nt f

or t

he a

bilit

y to

com

ply

wit

h th

is t

ype

of

trea

tmen

t.

Old

er p

atie

nts

are

mor

e vu

lner

able

to

com

plia

nce

prob

lem

s be

caus

e of

vis

ual a

nd c

ogni

tive

impa

irm

ents

, m

emor

y de

fici

ts,

phys

ical

lim

itat

ions

, un

plea

sant

sid

e ef

fect

s, a

nd la

ck o

f so

cial

or

fam

ily s

uppo

rt.

X X

X

As

sess

the

pat

ient

for

a p

rior

his

tory

of

mis

sed

clin

ic v

isit

s fo

r un

expl

aine

d re

ason

s or

a h

isto

ry o

f se

lf-a

djus

ting

dos

es o

f ot

her

med

icat

ions

. Im

plem

ent

nece

ssar

y st

eps

to a

ssis

t th

e pa

tien

t in

ac

hiev

ing

com

plia

nce.

X X

X

36


SSeeccttiioonn FFiivvee:: CCaassee SSttuuddyy

The following case studies are presented to illustrate the actions of a competent registered nurse (RN) in addressing common situations that may arise. Extravasation of Adriamycin The RN is knowledgeable about the dangers associated with an extravasation. Extravasation of a vesicant can cause sloughing of skin, damage to tendons and/or ligaments requiring plastic surgery and possible extended therapy and reduced quality of life. Prompt intervention for actual or suspected extravasation can reduce or prevent skin damage. Even with all safety guidelines carefully in place and followed, chemotherapy emergencies can occur and it is imperative that a RN be present to provide appropriate oncology care. A 35-year-old Caucasian female received her third of four cycles of chemotherapy for a diagnosis of breast cancer. An IV was started in her hand and IV fluid initiated. The RN administered anti-nausea medications and prepared a bag of IV fluids to be used for the infusion. The RN assessed the IV site for patency by observing for swelling, pain, and blood return. The RN carefully and slowly administered Doxorubicin, a vesicant chemotherapy drug, using IV push technique. The vesicant was pushed by the RN 2-3ml at a time while a main IV line of normal saline solution ran continuously to dilute the drug and facilitate infusion. During the course of administering the drug, the RN continuously assessed the IV site for patency, checked for blood return, monitored for pain, burning, stinging, redness, or swelling. The patient reported no discomfort at IV site, no swelling was observed, and a blood return was noted while pushing the vesicant as described above. After 20 ml were delivered, the patient began to complain of some discomfort. Slight swelling at the IV site and no blood return were observed. The RN immediately stopped the infusion and attempted to aspirate drug from the IV catheter. The IV was removed. The physician was notified for further orders. The hand was elevated and an ice pack applied. The patient was given strict directions to follow while at home to reduce adverse side effects. In addition, the patient was instructed to call the physician or go to the emergency room if pain, swelling, redness increased or drainage occurred at the site. Due to the serious nature of the event, the RN would initiate a tracking tool which would allow her to track the site and mobility of the involved extremity/area. She would initiate a patient education form, which clearly defines when to call the physician and/or nurse. Finally, a medication variance report would be initiated to accurately reflect the event. This is an internal document which allows staff to review the chemotherapy process to prevent a possible re-occurrence.

37


Oral Chemotherapy Mr. B. is a 72-year-old widower with a brain tumor. His treating physician has prescribed Temozolomide, an oral chemotherapy drug − a new therapy for his treatment. Mr. B. came to the office alone today, not expecting that a new treatment would be prescribed for him by his physician. Due to Mr. B.’s somewhat compromised thinking and memory ability as a result of his brain tumor, the RN set up an appointment for Mr. B. to return with his adult daughter for a chemotherapy teaching session before the Temozolomide was actually administered. Mr. B. and his daughter returned to the office two days later for the chemotherapy teaching session. The RN first assessed Mr. B. regarding his ability to comply with the very complicated schedule Temozolomide requires. The RN explained that multiple size tablets would be prescribed and that patients can become confused and harmed by taking the medication incorrectly. The RN requested that the daughter purchase a pillbox organizer. The daughter was taught the administration schedule (take the drug with water, on an empty stomach, at bedtime) and the specific scheduled days for taking the oral chemotherapy. The RN offered to assist the daughter in setting up the first round to assure accuracy. The RN provided written instructions regarding Mr. B.’s schedule, a written calendar that showed the specific days the medication was to be taken as well as the follow-up blood tests and physician visit. The RN provided education and written information on the drug Temozolomide that explained how to take the drug, how to store the drug, what food and other medications cannot be taken at the same time, what to do if a dose is missed, the possible side effects, self-help measures to cope with side effects and which side effects required an immediate call to the oncology physician’s office. The RN explained to the patient and daughter the absolute importance of reporting back to the physician/RN any missed doses or missed days, explaining that this is important information for the physician in order to make accurate judgments of how effective the drug is against the cancer and/or deciding on dose adjustments because of side effects. Lastly, the RN confirmed with the patient and daughter their understanding of the information provided, of who and when to call if there were problems or questions and explained that only one cycle of the Temozolomide will be prescribed at a time to lessen the chance of over dosage and to avoid missed follow-up appointments. The initial chemotherapy teaching session took approximately 60 minutes.

38


Chemotherapy Administration Mrs. S is a 66-year-old white female diagnosed with lung cancer in December of 2004. A CT scan revealed that the tumor had invaded her pulmonary artery. Because of the tumor’s location on this critical vessel, surgery was not a viable treatment option. The surgeon explained that she could bleed to death on the operating room table if the artery could not be repaired following the removal of the tumor. Her physician has told her he would try to shrink the tumor with Cis-Platinum and VP16, two chemotherapy agents used frequently in the treatment of lung cancer. He also explained that he hoped to improve her ability to breathe if the burden (size) of the tumor was decreased. Today is the first day of her treatment cycle − chemotherapy agents are given for a predetermined time frame (i.e. a group of chemotherapy agents may be given for three days every 21 days). The patient’s response to treatment will be evaluated at the end of each cycle. Mrs. S and her daughter attended a chemotherapy teaching session yesterday that reviewed basic information related to chemotherapy drug administration. Upon arrival in the clinic, a peripheral IV is started. The RN explains to Mrs. S specific side effects related to the chemotherapy agents she is to receive. Cis-Platinum has the potential to damage the kidneys. To prevent damage to the kidneys, a liter of IV fluid is administered prior to the Cis-Platinum. Additionally, a diuretic (medication that will decrease fluid retention by increasing urinary output) is administered. The IV fluids and a diuretic are administered to prevent severe effects of the drug on the kidneys. After flushing the peripheral IV line with normal saline, an antiemetic agent and steroid are administered by IV push to prevent the severe nausea and vomiting associated with Cis-Platinum. The RN then puts on personal protective equipment to protect her/himself from contact with the chemotherapy agent. Personal protective equipment is worn during mixing of the chemotherapy agents in the pharmacy area, for starting and stopping the chemotherapy agent, and to manage any chemotherapy exposure. The Cis-Platinum is connected to the peripheral IV and administered. During the Cis-Platinum administration, Mrs. B becomes nauseated and starts vomiting. The RN nurse contacts the physician and obtains orders for an additional antiemetic agent and administers the treatment (this requires stopping the Cis-Platinum infusion, flushing the IV with saline, administering the antiemetic, flushing again with saline, and restarting the Cis-Platinum). Upon completion of the Cis-Platinum, a second liter of hydration fluid is given. This fluid is also given to prevent damage to the kidneys. Next, VP16 is administered. Mrs. S. is instructed that her blood pressure and pulse will be taken frequently during administration of the VP16 as this agent has the potential to cause hypotension (low blood pressure – which can result in cardiac complications). Mrs. S did not experience any changes in her blood pressure during the VP16 infusion. Upon completion of therapy, the peripheral IV is discontinued.

39


Prior to leaving the clinic, the RN provides additional instructions to Mrs. S and her daughter. The information includes what to expect in the next few hours, side effects to report and who to call, and next treatment visit/appointment. This information is verbally reviewed and written instructions are provided.

The Role of the Oncology Registered Nurse In Outpatient Medical Oncology

40


Definitions

Antiemetics: medications usually given with steroids and used to prevent the severe nausea and vomiting associated with many chemotherapy agents.

Area under the curve (AUC): a formula used to calculate the dosage of a drug called Carboplatin. It is based on a complex formula utilizing a patient’s age, sex, weight, and the ability of the kidney to excrete waste product.

Arterial access devices: implanted devices, resembling a port, but with a mechanism that delivers chemotherapy into the hepatic (liver) artery. Allows for the delivery of chemotherapy into a specific region of the body thus having a higher concentration of chemotherapy at the tumor site.

Bisphosphonates: some tumors and / or cancer therapy can destroy bone mass causing serum calcium to be elevated. Elevated serum calcium can lead to confusion, seizures, and / or death. This group of drugs lowers blood calcium levels.

Body surface area (BSA): a formula based on height and weight that is used in determining appropriate chemotherapy drug doses.

Carcinogenic: the ability to cause cancer.

Central venous access device (CVAD): intravenous device that is placed into large veins in the upper chest. Chemotherapy is very caustic to the veins. Repeated exposure to chemotherapy can sclerose (harden) veins making a peripheral IV difficult to insert. Veins also can become fragile from repeated exposure to chemotherapy. Fragile veins can easily be punctured in multiple places during insertion of the peripheral IV necessitating multiple attempts at placing a peripheral IV. A surgeon will place an implanted device (port) under the patient’s skin. A small tube that is threaded into the large vein in the chest cavity is then inserted. This device allows for the removal of blood for sampling or for the delivery of chemotherapy and other medications. Also, there are external catheters that are placed in the large vein in the chest cavity. These catheters are not fully implanted and are taped/held in place with a couple of stitches to the skin on the chest.

Certified Biological Safety Cabinet: used to aseptically prepare drugs and prevent exposure of pharmacy/nursing staff to aerosolization of chemotherapy agents.

Chemotherapy: treatment of a disease by means of chemical/biological substances or drugs. These agents work in a variety of ways including destroying rapidly dividing cells and affecting the biologic response of cells. In addition to cancer cells, chemotherapy may destroy many of the body’s other rapidly dividing cells. These include hair follicles, mucous membranes that line the gastrointestinal tract, sperm and female eggs, and blood components such as white blood cells, platelets and red blood cells.

Co-morbidity: co-existing health problems such as cardiac history, history of heart attack, diabetes, emphysema, etc.


41


Cycle: chemotherapy agents are given for a predetermined time frame, for example, a group of chemotherapy agents may be given for three days every 21 days. The patient’s response to treatment is evaluated at the end of each cycle.

Diuretic: medications that decrease fluid retention by increasing urinary output.

Drug delivery device: catheter used to deliver therapy into a vein, an artery, the cerebrospinal fluid, or ventricular spaces in the brain.

Epidural access devices: catheters that are inserted into the epidural space (spaces between the bony prominences of the spinal column), which allow for the delivery of opioids, anesthetic medication for chronic intractable pain, and chemotherapeutic agents.

Extravasation: leakage of vesicant IV fluid into the skin.

Fecal impaction: intestines blocked with stool.

Flare reaction: redness and itching at IV site.

Growth factors: drugs which stimulate the body’s bone marrow to make white blood cells that fight infection, red blood cells that prevent anemia, or platelets that assist in clotting.

Hematologic: related to the blood.

Implanted port: central venous access device that is totally implanted under the skin. A surgeon will place an implanted device (port – reservoir made of titanium with a self sealing material septum/top part of port) under the patient’s skin. A small tube that is threaded into the large vein in the chest cavity is then inserted. The port is accessed with a special needle which is attached to IV fluids that are then administered through the port/catheter into the vein

Implanted pump: device implanted during a surgical procedure to deliver chemotherapy to a specific area, such as the liver via the hepatic artery. Chemotherapy is delivered over a period of weeks directly to the location of the cancer.

Intraperitoneal administration: administration of chemotherapy or fluids into the peritoneal (abdominal) cavity.

Intrathecal administration: administered via a catheter inserted into the patient’s cerebrospinal fluid.

Intrathecal access devices: catheters that are inserted into the epidural space of the spinal column, which allow for the delivery of opioids, anesthetic medication for chronic intractable pain, and chemotherapy.

Intravenous administration: administered through a catheter inserted into the patient’s vein.

Intravenous piggy-back (IVPB): this technique involves hanging a bag of IV fluid, usually saline solution, and attaching (piggy-backing) the medication to be delivered into a side port of the tubing of the primary bag of fluid. This technique allows the


42


medication being administered to be further diluted as it is allowed to drip into the patient’s vein.

Intravenous push (IV push, IVP): this technique is accomplished as the RN sits at the patient bedside and slowing pushes the medication into a side port of the primary bag’s IV tubing. The primary bag of fluid is allowed to drip while the nurse slowly pushes the syringe’s contents into the patient. Many drugs known as vesicants are required to be administered by this technique. Because the vesicant drug has the potential to cause severe damage, including tissue death, if any of the medication is allowed to leak into the tissues around the vein, the RN must constantly monitor the rate over which the drug is delivered and the site around the catheter placed in the patient’s vein to deliver the drugs.

Intraventricular access device: device that is a dome shaped, self-sealing, silicone reservoir attached to a catheter that allows medication to enter ventricular spaces in the brain. It is implanted under the scalp above the frontal lobe. Allows for delivery of chemotherapy into the cerebral spinal fluid to treat cancer cells present in the fluid. See ommaya reservoir.

Irritant: any agent that causes a local inflammatory reaction but does not cause tissue necrosis.

Lumbar puncture: lumbar puncture, which is the insertion of a needle into the spinal fluid for the purpose of removing fluid for testing or administration of chemotherapy.

Necrosis: tissue or muscle death that can lead to loss of use of an extremity or amputation of the extremity.

Neurologic: issues related to the nervous system.

Ommaya reservoir: device that is dome shaped, self-sealing, silicone reservoir attached to a catheter that allows medication to enter ventricular spaces in the brain. It is implanted under the scalp above the frontal lobe. Allows for delivery of chemotherapy into the cerebral spinal fluid to treat cancer cells present in the fluid. See intraventricular access device.

Oral administration: by mouth in pill form.

Paracentesis: removal of abnormal accumulation of fluid in the abdomen for evaluation of presence of cancer cells.

Patency: IV is open, no clots or sluggish blood flow, easily infuses with good blood return.

Peripheral venous access device (peripheral IV): intravenous device that is usually placed into veins of the hand or lower arm.

Personal protective equipment: equipment (gloves, gowns, goggles – if indicated, mask – if indicated) worn by clinical staff to protect from exposure to chemotherapy.

Platelet: type of blood cell that assists with clotting.


43


Premedicate: administering medications for control of symptoms/side effects prior to administration of chemotherapy agents.

Pump: mechanical device used to regulate the rate of infusion of chemotherapy drugs.

Red blood cells: carry hemoglobin, which in turn carries oxygen throughout the body. A lack of red blood cells results in a condition known as anemia.

Research protocol: written document that includes specific details of a research project, including drug information, how to administer the drug, patient eligibility, etc.

Steroids: given with antiemetics and used to prevent the severe nausea and vomiting associated with many chemotherapy agents.

Supportive care medications: include antiemetics and steroids, growth factors, bisphosphonates, and pain medicines. See specific medication group for more information.

Thoracentesis: removal of abnormal accumulation of fluid in the lung for evaluation of presence of cancer cells and reduce shortness of breath associated with presence of fluid.

Topical administration: rubbed onto the skin.

Tumor markers: some cancers have markers that indicate the reduction or progression of the cancer.

Venous access device: see central venous access device and peripheral venous access device.

Vesicant: some chemotherapy drugs have the potential to cause severe damage to tissue, tendons, or ligaments if it leaks into the area surrounding a vein. Damage may be so severe that it may require plastic surgery or amputation.

White blood cells (neutrophils): these cells fight bacteria that can cause serious infections. A lack of sufficient neutrophils can result in impaired ability to fight off a serious infection which could lead to patient death.

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Registered Nurse The Role of the Oncology

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