AngCN Chemotherapy Core Education Package Part B Worksheets for Modules 1-7

Transcription

1 AngCN-CCG-C13 AngCN Chemotherapy Core Education Package Part B Worksheets for Modules 1-7 AngCN would like to acknowledge and thank the AngCN Chemotherapy Nurses Group for their efforts in the production and review of this document, with special thanks to Jill Ireland for her considerable support in writing, formatting and reviewing this document. Reference: AngCN-CCG-C13 (part of the AngCN Chemotherapy Education Pack AngCN-CCG-C11) Approval Date: 20 September 2011 Evidence of Approval: See page 43

2 Worksheet for Module 1: Understanding Cancer... 3 Worksheet for Module 2: Treatment Process... 8 Worksheet for Module 3: Safe Handling and Disposal of Cytotoxic Drugs Worksheet for Module 4: Principles of Safe Chemotherapy Checking Worksheet for Module 5: Venous Access and Extravasation Worksheet for Module 6: Administration of Chemotherapy Worksheet for Module 7: Intrathecal Chemotherapy Page 2 of 43 Approved and Published: Sept 2011

3 Worksheet for Module 1: Understanding Cancer Characteristics of a normal functioning cell The cell is the basic structural and functional unit of life (Montague and Knight, 1999). The adult human body comprises of over a 100 trillion individual cells. There are many different types of cells with a variety of functions, dependent on the organisation of the cells, but all have the same common structure. The most abundant component of most cells is protein (Guyton and Hall, 2000). Draw a normal cell, naming & describing the basic structure: The cell cycle (5 marks) The cell cycle is the period from the beginning of one cell division to the beginning of the next (Murray and Hunt, 1993 in Hinchliff and Montague, 1999). There are 3 clearly identified phases within the cell cycle: i. Interphase This is the period of cellular growth detailed by the replication of DNA in the nucleus. There are 3 stages in this phase called G1, S and G2. ii. Mitosis This is the point where the nucleus splits. iii. Cytokinesis The point where the cytoplasm splits. Adapted from Hinchliff and Montague (1999). Using the space below draw a diagram of the cell cycle and describe in more detail the specific stages listed above: (5 marks) Page 3 of 43 Approved and Published: Sept 2011

4 There are different types of blood cells with different functions. From the list below can you identify the cell function and the normal life span of each? Function Erythrocytes: / Life Span Neutrophils: / Platelets: / REGULATION AND DIFFERENTIATION There are certain mechanisms employed by the body to ensure it produces the correct number of specific cells and that those cells behave in a civilised and orderly manner. These mechanisms are governed by regulatory and differentiation processes. Regulation The cellular reproductive activity of a cell is affected by its surrounding environment, that is, the presence or absence of growth hormones, essential nutrients to allow growth and enough space to grow in. Normal cells characteristically like to remain in their own environment, that is, renal cells in the kidney capsules, hepatocytes within the liver wall, breast tissue cells in the breasts. In malignant, or cancerous, cells the rules are broken, the cells do not behave in a conformist manner and do not have the same control mechanisms influencing their activity. Cancer cells proliferate without organisation and often without differentiation. There are many characteristic differences between normal and malignant cells that account for cancers invasive behaviour: i. Cancer cells have the ability to establish new growth at surrounding ectopic sites (metastasis); ii. Cancer have functional difficulties and behave in an uncontrolled way, this is called anaplasia; iii. Cancer cells are greedy, and consume more nutrients than they require, starving surrounding cells from essential nutrients required for survival; some cancers have angiogenic properties, allowing new blood vessels to grow within the cancer bulk; iv. Malignant cells lack the ability to mature and perform specialist functions with decreased cell differentiation; v. Cancer cells undergo uncontrolled proliferation, the rate of cell reproduction and renewal out numbers natural cell death in malignant; vi. Cancer cells lack contact inhibition and cell recognition and exhibit the inappropriate ability to invade surrounding tissue. Differentiation This is the process a cell goes through to develop its specialised characteristics enabling it to perform a specific role, that is, the control that governs the physical and functional properties of a cell. Different malignant tumours develop from different tissue types. This information can be helpful when diagnosing and staging the disease, as it identifies a tumour source. Can you match up the tissue type, with related malignant disease? There may be more than one malignancy related to one tissue type. Page 4 of 43 Approved and Published: Sept 2011

5 TISSUE SOURCE Epithelium Nerve Lymphoid Muscle Haemopoietic Connective MALIGNANT TUMOUR Lymphoma Sarcoma Myeloma Leukaemia Carcinoma Various (6 marks) Please identify and list 8 symptoms displayed by a patient presenting with the following diseases:- i.... ii.... iii.... iv.... v.... vi.... vii.... viii.... (8 marks) Page 5 of 43 Approved and Published: Sept 2011

6 INFORMATION AND SUPPORT Being diagnosed with a condition that may require treatment with cytotoxic chemotherapy can be an overwhelming and terrifying experience. 1. Consider what concerns a patient may have when receiving cytotoxic chemotherapy. Also consider the needs of their relatives or carers. (5 marks) 2. What patient support services are available to patients in your area? (5 marks) 3. What charitable organisations are available to provide patient information and support to your patients? (4 marks) 4. Peoples informational needs vary. What is the minimum information a patient receiving cytotoxic chemotherapy needs to ensure their safety and informed consent? Also consider the information needs of their relatives or carers. (4 marks) 5. We always advise patients or their carers to contact us for help if they have problems following discharge after cytotoxic chemotherapy. In what circumstances should they contact the hospital rather than their GP? (4 marks) Page 6 of 43 Approved and Published: Sept 2011

7 6. Who, in your clinical area should patients or carers be advised to contact if they have any concerns regarding their cytotoxic chemotherapy treatment following discharge? 7. Give two examples of circumstances in which you would refer a patient receiving cytotoxic chemotherapy to a district nurse. 8. What specific information would you provide a patient undergoing a continuous ambulatory cytotoxic chemotherapy infusion before discharging them home? (5 marks) Page 7 of 43 Approved and Published: Sept 2011

8 Worksheet for Module 2: Treatment Process WHAT IS CYTOTOXIC CHEMOTHERAPY (CC)? Chemotherapy simply means chemical or drug therapy although is generally associated with cytotoxic drug therapy. Define the word CYTOTOXIC Chemotherapy is best known for its effectiveness in treating cancer cells, but it is used as an immunosuppressant therapy for non cancerous conditions. What other diseases may be treated with chemotherapy? HOW CYTOTOXIC CHEMOTHERAPY KILLS CANCER The key to the effectiveness of CC is related to cellular reproduction and the cell cycle. Cytotoxic drugs work by interfering with cell division and reproduction, that is, they effect a cancer cell at some point during it s period of reproduction. Some cytotoxic agents are most active during the cell cycle. Very few agents are active against cells in the resting G0 phase. Cytotoxic chemotherapy doesn t necessarily kill the cell at the time of exposure, but by virtue of the prevention of reproduction, the malignant cell will die at the end of its life span without allowing the reproduction of any further cancer cells. What does cell cycle phase specific mean? What does cell cycle non-specific mean? The rate of cell proliferation varies depending on the individual cell. Some cells cease reproduction once reaching maturity, whilst others produce millions of new cells every day. CC is most effective against frequently dividing cells, thus aggressive and acute malignancies tend to be very sensitive to chemotherapy and respond well, for example, acute leukaemia. Unfortunately, CC cannot discriminate between malignant frequently dividing cells, and healthy frequently dividing cells. This is one of the primary dose limiting factors in chemotherapy administration. Page 8 of 43 Approved and Published: Sept 2011

9 Define the theory of Gompertzian growth. What is the fractional cell kill hypothesis? (4 marks) The normal cells that are most frequently affected by CC include, bone marrow cells, hair follicles, mucosal lining of the GI tract, skin and germinal cells. Consider the clinical impact, describing signs and symptoms, a patient might experience following treatment with chemotherapy. Bone marrow cells (4 marks) GI tract (3marks) Skin Germ cells Page 9 of 43 Approved and Published: Sept 2011

10 Cytotoxic chemotherapy agents are generally classified into 5 groups. Complete the table below: Cytotoxic drug classification 1) Alkylating Agent List 3 examples of drugs in each group Describe the mode of action of the drugs in this group 2) Plant Alkaloid 3) Antimetabolite 4) Cytotoxic Antibiotic 5) Miscellaneous (10 marks) Name the drugs found in the following combination regimes and state how frequently they are given REGIME CMF CHOP ABVD FEC Drugs Frequency (5 marks) CC can be administered via a variety of routes: Intravenous (IV) Intramuscular (IM) Subcutaneous (SC) Intrathecal (IT) Orally (PO) Topically (TOP) Intraperitoneal or intrapleural (IP) Intravesical Page 10 of 43 Approved and Published: Sept 2011

11 Can you give an advantage of using each method of administration, and an example of a drug administered by each route? Advantage Example IV / IM / SC / Intrathecal / IC / IA / PO / TOP / IP / Intravesical / CC can be administered in a variety of ways. Please complete the table below, providing the definition of the various methods of treatment listed. (7marks) Method of Treatment *Single agent *Combination *Adjuvant *Neo adjuvant *Consolidation *Salvage *Con-comitant maintenance *Palliative Definition Page 11 of 43 Approved and Published: Sept 2011

12 As discussed in the table on the previous page, CC can be administered in combination. This is common practice in most radical treatment protocols. What benefit can you see in giving chemotherapy in combination? Remember to consider the different modes of action and differing side effects. In addition to the use of chemotherapy drugs in combination, CC effectiveness is enhanced by the use of CC drugs in treatment cycles. Can you describe what benefit cyclical treatment might offer, A) (4 marks) b) All other considerations that make this a logical method of administering treatment. B) Page 12 of 43 Approved and Published: Sept 2011

13 CHEMOTHERAPY INDUCED SIDE EFFECTS & NURSING CARE As mentioned previously, despite the effectiveness of cytotoxic chemotherapy on malignant disease, there are side effects associated with all treatment. These side effects can themselves be treatment limiting and their significance should never be underestimated. Work through the following questions to explore the impact of chemotherapy on an individual and consider the relevant side effects. 1. Name 3 sources of information which will tell you about the side effects of specific chemotherapy drugs. 2. Bone Marrow Suppression Cytotoxic chemotherapy is myelosuppressive, that is, it is toxic to the bone marrow and suppresses its function. Which component of the blood is affected first: a. red blood cells b. white blood cells c. platelets Why is this clinically significant? 3. What are the normal ranges for the following blood components: a. haemoglobin b. white blood cells c. neutrophils d. platelets (4 marks) (4 marks) 4. What is neutropenia, and what nursing precautions would you introduce? (4 marks) 5. What is meant by the nadir? 6. When, generally does it occur? Page 13 of 43 Approved and Published: Sept 2011

14 The Gastrointestinal Tract 1. Name 2 drugs that potentially cause constipation. (i) (ii) 2. Name 2 drugs that potentially cause diarrhoea. (i) (ii) 3. What is mucositis? 4. List 4 things you monitor when assessing the condition of a patient s mouth. (i) (ii) (iii) (iv) (4 marks) 5. What are the symptoms of mucositis? And what treatment can you suggest? Symptoms: Treatment: (6 marks) Page 14 of 43 Approved and Published: Sept 2011

15 Nausea and Vomiting 1. What is meant by emetogenic potential? 2. What does highly emetogenic mean? 3. Can you give an example of 3 highly emetogenic chemotherapy drug agents? i) ii) iii) 4. Give an example of 3 moderately emetogenic chemotherapy drugs i) ii) iii) 5. Name 5 groups of anti-emetics, and give an example of each. (5 marks) 6. List 5 potential causes of nausea and vomiting in patients undergoing cancer treatments. Page 15 of 43 Approved and Published: Sept 2011

16 7. Which of the following change(s) are associated with nausea? (5 marks) a) gastric acid secretions increase b) gut motility increases c) salivation increases d) sympathetic nervous activity increases 8. Metoclopramide is a commonly used anti-emetic. List 2 main side effects associated with its use. 9. How would you manage an acute reaction to IV Metoclopramide? (5 marks) 10. Briefly explain how Ondansetron / Granisetron work? 11. What is the significant side effect of 5HT3 receptor antagonist anti-emetic agents? 12. How can you minimise the risk of anticipatory nausea and vomiting, and how is it treated (consider pharmacological and non pharmacological management options)? Diet and Nutrition 1. What advice regarding eating and drinking would you give a patient who has a problem with nausea? 2. Which of the following cytotoxic drug(s) can cause taste changes? a. Cyclophosphamide b. Methotrexate Page 16 of 43 Approved and Published: Sept 2011

17 c. Cisplatin 3. Taste changes are common with some chemotherapy drugs, give an example of a drug that causes taste changes, and suggest some dietary advice to help manage this problem. 4. In what circumstances would you refer a patient to the dietician? 5. What can you do as a nurse to improve the nutritional intake of your patient? (4 marks) Chemotherapy and the Renal / Urinary System 1. Name three cytotoxic chemotherapy drugs which are considered nephrotoxic. 2. What precautions and observations might be carried out when nephrotoxic chemotherapy is administered? 3. Haemorrhagic cystitis is sometimes the side effect of which drug: a. methotrexate b. cyclophosphamide c. cytarabine d. cisplatinum 4. What medication is sometimes administered to prevent this complication? 5. What effect does doxorubicin have on urine? Page 17 of 43 Approved and Published: Sept 2011

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19 Side Effects: Neurotoxicity 1. Peripheral neuropathy is a dose limiting side effect of which drug: a. etoposide b. bleomycin c. dacarbazine d. vincristine 2. What are the early symptoms of peripheral neuropathy? Chemotherapy, Body Image and Quality of Life 1. Name 3 chemotherapy drugs that cause complete alopecia. i. ii. iii. 2. Name 3 drugs that may cause some alopecia. (3marks) How does scalp cooling work? What criteria prevent this treatment being used for certain patients, and why? Are their facilities for this treatment in your hospital? What information should the patient receive before scalp cooling is applied 4. Certain chemotherapy drugs can affect the skin. Explain how the following drugs affect the skin? Cytarabine Capecitabine 5-Fluorouracil Page 19 of 43 Approved and Published: Sept 2011

20 5. Fatigue is described as the most disturbing symptom experienced by cancer patients. List 3 pieces of advice you would give to a patient who is suffering from fatigue, tiredness or lethargy? Fertility and long term effects 1. What advice / information should be given to a woman of child bearing age regarding contraception, and the possible effects on her fertility prior to her receiving cytotoxic chemotherapy? Consider transplant and non transplant patients if appropriate for your clinical area. (6 marks) 2. What advice / information should be given to a man regarding contraception and the possible effects on his fertility prior to his receiving cytotoxic chemotherapy? Consider transplant and non transplant patients if appropriate for your clinical area. (6 marks) 3. Given that cytotoxic chemotherapy is excreted in bodily fluids, what advice would you give a sexually active couple regarding contraception and safe sex during treatment? 4. Name 3 cytotoxic drugs that significantly affect fertility. Page 20 of 43 Approved and Published: Sept 2011

21 5. Name 2 cytotoxic drugs that should allow preservation of fertility. 6. How can fertility be preserved for: Male patients: Female patients: Page 21 of 43 Approved and Published: Sept 2011

22 Activity Complete the table below and where blank list the cytotoxic agents used in your clinical area and list their possible routes of administration, specific side effects etc., Cytotoxic Drug (generic and proprietary names) Normal dose Ranges* Cellular Action Side Effects Short Term Side Effects Long Term Routes of Administration Other information e.g. incompatibilities Vincristine (Oncovin) Cyclophosphamide 1.4 mg/m 2 weekly up to a maximum dose of 2mg a week Vinca-Alkaloid M phase specific Cold sensation along vein if diluent s used. Jaw pain - high dose Neurotoxicity and peripheral neuritis, constipation, bladder atony. Alopecia (high dose) Rare inappropriate secretion of anti-diuretic hormone By bolus IV injection or into the tubing of a fast running compatible intravenous infusion Not for intrathecal injection. FATAL if injected via the intrathecal route. Doxorubicin Methotrexate Cisplatin * Be aware that normal dose ranges will vary according to the clinical area in which you work Page 22 of 43 Approved and Published: Sept 2011 Education Pack - Part B AngCN-CCG-C13_v1 Worksheets for Modules 1-7.doc

23 Worksheet for Module 2 (Part 2): Oncological Emergencies and Life Threatening Complications of Chemotherapy 1. Allopurinol is given to patients with significant disease load. Is it used because: a. it reduces intercranial pressure b. sensitises cells in the S phase of the cell cycle c. inhibits formation of excess serum uric acid d. prevents increase of cell breakdown with increase of the cytotoxic agent Why is this important when considering clinical well being? 2. Tumour lysis syndrome can occur in high risk patients with large disease load, and causes: a. hyperkalaemia b. hypophosphataemia c. hyperuricaemia d. hypocalcaemia What intravenous fluid regimen would be given as prophylaxis against tumour lysis? 3. Who is at risk of Tumour Lysis Syndrome and why? 4. Which of the following are symptoms of Tumour Lysis Syndrome? a. Hyperkalaemia b. Hypophosphataemia c. Hyperuricaemia d. Hypocalcaemia 5. Which of the following conditions may be caused by Tumour Lysis Syndrome? a. Acute anaemia b. Acute uraemia c. Acute renal failure d. Tetany Page 23 of 43 Approved and Published: Sept 2011 Education Pack - Part B AngCN-CCG-C13_v1 Worksheets for Modules 1-7.doc

24 6. What role does Allopurinol play in the prevention of Tumour Lysis Syndrome? 7. Name an IV drug that can be used to prevent tumour lysis, explain its indications for use, and state how long the patient would receive this drug for. Locate the AngCN Anaphylaxis Policy and use it to answer the following 1. Which of the following cytotoxic drugs are recognised as carrying a significant risk of anaphylaxis? Indicate likelihood of anaphylaxis occurring, and describe the signs and symptoms for each drug listed. (14 marks) Bleomycin Carboplatin Cisplatin Cytarabine Docetaxol Etoposide Asparaginase 2. What action would you take in the event of anaphylaxis? 3. What is neutropenia, and what nursing precautions would you introduce? (4 marks) Page 24 of 43 Approved and Published: Sept 2011

25 4. A drug called G-CSF can help to prevent or shorten the period of neutropenia. What does G-CSF stand for, and how does it work? G-CSF: Mechanism of Action: 5. When would you not want to give G-CSF to affect neutrophil recovery? 6. What are the signs and symptoms which indicate your patient might become septic? 7. What will your patients signs and symptoms be if they become septic? Page 25 of 43 Approved and Published: Sept 2011

26 CARE PLAN. Imagine you are caring for a patient who has been admitted to your ward with a neutrophil count of 0.1 and a pyrexia of 39.3 C. Referring to any policies used on your ward, write a brief care plan for your patient. Consider all aspects of patient care and individualised needs. (10 marks) Page 26 of 43 Approved and Published: Sept 2011

27 Worksheet for Module 3: Safe Handling and Disposal of Cytotoxic Drugs HEALTH AND SAFETY ISSUES Cytotoxic chemotherapy agents are considered to be substances hazardous to health, and as such there are legislative documents to offer guidance for their safe use, to prevent any inappropriate use and abuse of this group of drug therapies. This legislation is designed to protect the person receiving cytotoxic treatment and individuals who come into contact with it, either through its production, reconstitution, transportation, administration or disposal. The relevant documents include: Safe handling of cytotoxic drugs HSE Information Sheet MISC615 Control of Substances Hazardous to Health (COSHH) regulations (1988) Network Guidelines for the Safe Prescribing, Handling and Administration of Cytotoxic Drugs Familiarise yourself with the contents of these documents, and consider their relevance to you as a nurse administering cytotoxic agents. Disposal of cytotoxic waste Cytotoxic waste should be disposed of in a designated receptacle designed for that specific purpose. This container should be labelled correctly with the hospital name, clinical area, date of use and date of closure, with the signature of the clinician taking responsibility for the correct compilation of the receptacle and closure. Locate your local policy for the safe disposal of cytotoxic waste and evaluate your own clinical area to ensure you are following legislative requirements. Safe Handling 6. List the steps you would take when disposing of intravenous equipment contaminated with cytotoxic chemotherapy. 7. Where should cytotoxic drugs be reconstituted? 8. What would you do in the event of a cytotoxic spill? (4 marks) 9. Where is the cytotoxic spillage kit in your area? 5. What are the routes of occupational absorption? Page 27 of 43 Approved and Published: Sept 2011

28 6. How would you safely dispose of the following? a. A partially used bag of cytotoxic chemotherapy b. A complete, unused bag of cytotoxic chemotherapy c. Unused oral chemotherapy tablets or solutions 7. Describe how you would deal with skin and eye contamination of cytotoxic substances. Page 28 of 43 Approved and Published: Sept 2011

29 Worksheet for Module 4: Principles of Safe Chemotherapy Checking Cytotoxic chemotherapy is generally dosed using an individuals body surface area, this can be calculated from the individual s height and weight using a nomogram. The measurement of BSA is m2. Some drugs may be determined by weight alone, so check the measurement required. Can you calculate the body surface areas for the patients detailed below? # Jenny White: Height 163cm and Weight 62Kg => BSA =.. m 2 # Peter Blue: Height 1.8m and Weight 14 stone => BSA =.. m 2 # Carol Pink: Height 5 9 and Weight 65Kg => BSA =.... m 2 # John Black: Height 6 2 and Weight 12½ stone => BSA =... m 2 # Pippa Green: Height 142cm and Weight 45Kg => BSA =.. m 2 # George Lilac: Height 160cm and Weight 51Kg => BSA =.. m 2 (8 marks) To calculate cytotoxic chemotherapy dosages following a treatment protocol, the drug dosage will be given as a unit of measurement, such as grams, milligrams of micrograms per BSA, which is expressed in m 2, or per unit of weight, which is expressed in Kg. Can you calculate the correct prescribed doses of cytotoxic chemotherapy for the patients discussed before? # Jenny White is to receive Cytarabine 100mg/ m 2 BD for 10 days What does should be prescribed? # Peter Blue is to receive Etoposide 50mg/ m 2 What dose should be prescribed? # Carol Pink is to receive Cyclophosphamide 500mg/m2 What dose should be prescribed, and would there be any special requirements for this treatment dose? NB patient can have up to 1g cyclophosphamide without needing mesna rescue unless they have had previous problems. Page 29 of 43 Approved and Published: Sept 2011

30 What rescue would you need to give to prevent life threatening complications associated with methotrexate toxicity? # Pippa Green is to receive Bleomycin 10,000 units / m 2. What prescribed dose should she receive? # George Lilac is to receive Vincristine 1.5mg/ m 2. What dose would be given? Consider protocol guidelines carefully when confirming the prescribed dose. (9 marks) Calculate the drug dosage required with the following dose reduction: Doxorubicin 20mg/m 2 Cyclophosphamide 500mg/ m 2 Etoposide 150mg/ m 2 Etoposide 120mg/ m 2 S.A 1.54 Dose reduction of 40% New drug dose: S.A 1.96 Dose reduction 55% New drug dose: Prior to the commencement of treatment there are some investigations that are necessary to perform and review before proceeding. These may alter the dosing of cytotoxic chemotherapy, or necessitate a delay in treatment. Compile a list of investigations that may be required prior to treatment. Consider the side effects of cytotoxic chemotherapy to help identify potential hazards that might impede treatment. (5 marks) To ensure that a patient has had sufficient bone marrow recovery following a course of cytotoxic chemotherapy, what would be the standard minimum blood count values required prior to commencing the next course? Absolute neutrophil count Platelet count Page 30 of 43 Approved and Published: Sept 2011

31 When patients are receiving the following drugs which investigations are required? (Please tick for each test required) (7 marks) Methotrexate GFR ECHO Audiology Liver function tests Doxorubicin Cisplatin Ifosfamide Cytotoxic Chemotherapy Protocols Cytotoxic chemotherapy prescription guidelines exist in the form of PROTOCOLS. That is, an established agreed proforma of drugs, profiled for particular diseases, and proven to be of maximum benefit. The protocols in use are the result of evidence based work and multi centred trials, often involving the UK, Europe and the World. The protocol provides crucial information about the drug dosages, drug preparation and administration. In addition to this it also provides guidance on clinical trial design, side effects, eligibility criteria, supportive care and management, essential prophylaxis and all elements of the patient s care requirements while they are on the trial. Locate the protocols or treatment guidelines in use in your area, and familiarise yourself with accessing key information from them such as: Trial design Eligibility criteria Treatment schedule Supportive care Dose reductions Page 31 of 43 Approved and Published: Sept 2011

32 Preparation for administration pre treatment checks 1. How is the dose of cytotoxic chemotherapy calculated? 2. Explain the significance of the following physiological parameters which may need to be checked prior to administering cytotoxic chemotherapy. (10 marks) Liver Function Cardiac Function Renal Function Lung Function Haematopoietic Function Bearing in mind the NMC standards for the administration of medicines, what would you check on the prescription chart to ensure the prescription was valid and safe? (4 marks) According to your Network cytotoxic policy, who needs to check oral or intravenous cytotoxic drugs against the prescription chart? Page 32 of 43 Approved and Published: Sept 2011

33 Informed Consent All patients receiving cytotoxic chemotherapy should be fully informed of their treatment and must have given consent. 1. How should consent be documented? Your answer should consider trial and non-trial patients. 2. What is the consent procedure for an adult patient that is unable to give their own consent? 3. Who within your practice area is responsible for obtaining consent and ensuring it is documented? 4. When is it necessary to re consent a patient for treatment? Page 33 of 43 Approved and Published: Sept 2011

34 Worksheet for Module 5: Venous Access and Extravasation 1. Name four aspects of venous access which must be checked before and during the administration of cytotoxic chemotherapy. This applies to both peripheral and central access. (4 marks) 2. Imagine you are about to administer cytotoxic chemotherapy via a tunnelled central venous catheter but you find that one of the lumens is completely blocked, and the other can be flushed but will not flash-back blood. Where can you find written guidance on action to take in this situation? 3. Explain the following terms which are used in relation to cytotoxic drug administration: Vesicant: Irritant: Extravasation: Page 34 of 43 Approved and Published: Sept 2011

35 4. Complete the following table (9 marks) Complication Definition Cause Action Venous flushing or flare reaction Urticaria Venospasm 5. Name 4 cytotoxic drugs which are vesicants (4 marks) 6. Name 4 cytotoxic drugs which are irritants (4 marks) 7. List four ways you can reduce the risks of extravasation occurring: (4 marks) 8. What signs and symptoms would make you suspect that cytotoxic chemotherapy had extravasated? Consider peripheral and central access. (6 marks) Page 35 of 43 Approved and Published: Sept 2011

36 9. Where is the extravasation pack in your clinical area and how would you replace the pack once it had been used? 10. Where is the extravasation policy in your clinical area? 11. List the steps you would take if you suspected any cytotoxic chemotherapy had extravasated. Consider both peripheral and central access. (10 marks) Page 36 of 43 Approved and Published: Sept 2011

37 Worksheet for Module 6: Administration of Chemotherapy SAFE ADMINISTRATION OF CYTOTOXIC CHEMOTHERAPY Locate and read your local, network guidelines for the safe prescribing, handling and administration of cytotoxic drugs. These documents should outline safe practice guidelines for nursing staff when checking and administering cytotoxic chemotherapy. *Take note of the correct patient checking procedure. Administration of cytotoxic chemotherapy As the nurse responsible for administering cytotoxic chemotherapy, what checks are necessary to make to ensure venous access is adequate prior to commencement of treatment? (Consider both peripheral and central access) (4 marks) Decision to Treat 1. What is the usual method of administration for vesicant drugs via the peripheral route? Indicate method for both a and b. a. Bolus b. Infusion 2. Dacarbazine is a vesicant drug that is given as an infusion. Why is this? 3. Why is it suggested that vesicants should be given first when administered via a peripheral cannula? Page 37 of 43 Approved and Published: Sept 2011

38 4. Of the combinations of drugs listed below, indicate in which order you would administer them (some may be jointly ranked / placed). 1 CHOP Doxorubicin (bolus) Vincristine (bolus) Cyclophosphamide (bolus) 2 MVP Mitoxantrone (bolus) Vincristine (bolus) Prednisolone (tablets) 3 CAV Cyclophosphamide (bolus) Adriamycin (bolus) Vincristine (bolus) 5. Give three reasons why bolus cytotoxic chemotherapy should be given through a fast running drip. 6. Name four cytotoxic drugs that can be given orally. (4 marks) 7. What are the risks involved in handling oral cytotoxic chemotherapy? Page 38 of 43 Approved and Published: Sept 2011

39 8. What advice would you give to a patient and their family when discharging them from hospital, regarding handling and storing oral cytotoxic chemotherapy at home? 9. Describe the measures taken when giving oral cytotoxic chemotherapy to a patient unable to swallow tablets. Page 39 of 43 Approved and Published: Sept 2011

40 Worksheet for Module 7: Intrathecal Chemotherapy 1. What is the function of the Blood Brain Barrier? 2. Name 2 cytotoxic drugs can safely be administered into the CSF? 3. What non-cytotoxic drugs or modes of treatment are used in combination with cytotoxic chemotherapy to treat CNS disease? 4. What cytotoxic drugs should NEVER be administered intrathecally? 5. What catastrophic consequences are there if unsuitable cytotoxic therapy is given via the intrathecal route? 6. List three side effects of intrathecal Methotrexate: Page 40 of 43 Approved and Published: Sept 2011

41 Activity How would you prepare the patient for the administration of intrathecal (IT) chemotherapy? Where are the policies that refer to Intrathecal chemotherapy located? List the areas where IT chemotherapy must NOT be administered in your hospital? What are the risks associated with the administration of IT chemotherapy? (4 marks) USING THE NATIONAL GUIDANCE & LOCAL POLICY ANSWER THE FOLLOWING QUESTIONS RELATING TO THE MANAGEMENT OF INTRATHECAL CYTOTOXIC CHEMOTHERAPY 7. Describe the responsibilities, as well as the procedure, for a nurse checking intrathecal cytotoxic chemotherapy? (8 marks) 8. The patient, and if appropriate a relative or guardian, should be involved in checking the intrathecal cytotoxic chemotherapy. True / False 9. How should intrathecal cytotoxic chemotherapy be stored on the ward? Page 41 of 43 Approved and Published: Sept 2011

42 10. Can intrathecal cytotoxic chemotherapy prescriptions be amended? If so, how and by whom? 11. What is meant by the term designated personnel? 12. Who can prescribe intrathecal cytotoxic chemotherapy? 13. Who can issue, transport and receive intrathecal cytotoxic chemotherapy? 14. Who can check and witness the administration of intrathecal cytotoxic chemotherapy? 15. Who can administer intrathecal cytotoxic chemotherapy? 16. How often do personnel involved with intrathecal cytotoxic chemotherapy need to be re-assessed as competent? Page 42 of 43 Approved and Published: Sept 2011

43 Evidence of Agreement This document (the Worksheet element of the AngCN Chemotherapy Training Pack) has been approved by: The AngCN Chemotherapy Nurses Group Chair Name: Ruth Giles Organisation: Peterborough City Hospital Date agreed: 15 September 2011 Chair of the AngCN Chemotherapy Board Name: Dr Karen McAdam Organisation: Peterborough City Hospital Date agreed: 20 September 2011 The AngCN Chemotherapy Nurses Group This document was discussed at the AngCN Chemotherapy Nurses Group on 15 September 2011 and was agreed to by all members. The AngCN Chemotherapy Board This document was discussed at the AngCN Chemotherapy Board meeting on 20 September 2011 and was agreed to by all members. Document Management Document history Review period: Authors: 2 year Version number as approved and published: The AngCN Chemotherapy Nurses Group Monitoring the effectiveness of the Process V1 Date placed on electronic library: Document Owner: Unique identifier no.: Sept 2011 Anglia Cancer Network Tel: AngCN-CCG-C13 part of the AngCN Chemotherapy Training pack AngCN-CCG-C11 Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by PQ Manager to the AngCN Business Meeting on an annual basis the minutes of this meeting are retained for a minimum of five years. Standards/Key Performance Indicators This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM. Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EqIA assessment is available on request to Anglia Cancer Network QA Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed-out copy is the most recent issue of this document. Please notify any changes required to the Anglia Cancer Network Programme Quality Manager. Page 43 of 43 Approved and Published: Sept 2011