24. 95* Table of Contents. CE for Ohio Nursing Professionals. All 24 Hrs ONLY. Elite. Student Final Examination Answer Sheet Page 133

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1 Table of Contents CE for Ohio Nursing Professionals NURSING IN OHIO: LAWS AND RULES ( UPDATE) (CATEGORY A - EXPIRES APRIL 10, 2019) Page 1 This course qualifies as a Category A nursing continuing education course; Category A courses clarify laws, rules, and guidelines found in Chapter 4723 of the Ohio Revised Code (the Ohio Nurse Practice Act), and rules of the Board of Nursing found in Chapter to of the OAC. Ohio Laws and Rules for Nurses Final Exam Page 8 CANCER NURSING, PREVENTION AND EARLY DETECTION FOR THE ADULT PATIENT Page 9 This course focuses on cancer prevention, early cancer detection, and nursing care of adults with cancer during and after treatment. This course is intended to help nurses provide not only cancer care, but accurate and up-to-date information as well. PATHOPHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM Page 71 Caring for diseases of the cardiovascular system are part of every day nursing care. This course reviews the pathophysiology of the cardiovascular system, and updates current standards and therapies. It is a vital course of contemporary best practices nursing care. PATIENT AND FAMILY ANGER: WHAT TO DO WHEN FRUSTRATION SPILLS INTO THE WORKPLACE Page 94 Workplace violence in healthcare settings can affect anyone who works or volunteers in such areas. Violence can also affect other patients, families, and visitors. It is imperative that persons who work in healthcare know the factors which trigger violent behavior and which actions to take to reduce the potential for that violence. They must also know how to deal with violence, whether it is verbal or physical, if and when it does occur. This education program is designed to help nurses reduce the occurrence of workplace violence and to intervene effectively when it does occur. PATIENT SAFETY: IMPLEMENTATION OF NATIONAL SAFETY STANDARDS FOR NURSES Page 109 Safety comes first in patient care and in health care environments. This course presents the latest National Patient Safety goals as well as strategies for nursing. Student Final Examination Answer Sheet Page 133 All 24 Hrs ONLY $ * with referral code *Get this course package for only $24.95 with referral code NOH2017. Regularly $ Special package pricing expires 8/31/2017. Get everything you need: Includes all required hours. Satisfies all mandatory courses. Features all new updated ANCC-accredited courses. Want your certificate fast? Complete your exam online and get instant access to your course certificate. Want to pick your own courses? Access these courses and more at. Course Evaluation Page 134 Elite Continuing Education 2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Page i

2 Frequently Asked Questions What are the requirements for license renewal? Licenses Expire LPNs will expire on 10/31 of the even year. RNs will expire on 10/31 of the odd year. Contact Hours Required 24 (All hours are allowed through home-study) How do I complete this course and receive my certificate of completion? On-Line Submission: Go to and follow the prompts. You will be able to print your certificate immediately upon completion of the course. Fax Submission: Fax to (386) , be sure to include your credit card informaton. All completions will be processed within 2 business days of receipt and certificates ed to the address provided*. Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL All completions will be processed and certificates issued within 10 business days from the date it is mailed*. *Please note - providing a valid address is the quickest and most efficient way to receive your certificates when submitting via fax, or mail. Submissions without a valid address will be mailed to the address provided at registration. How much will it cost? Cost of Courses Course Title Contact Hours Price Nursing in Ohio: Laws and Rules ( Update) (Category A - Expires April 10, 2019) 1.0 $10.00 Cancer Nursing, Prevention and Early Detection for the Adult Patient 12 $29.00 Pathophysiology of the Cardiovascular System 4 $19.00 Patient and Family Anger: What to do When Frustration Spills Into the Workplace 3 $19.00 Patient Safety: Implementation of National Safety Standards for Nurses 4 $19.00 BEST VALUE SAVE $69.05 RN 24-HOUR OHIO PACKAGE 24 $26.95 Are you a Ohio board approved provider? Elite is an approved provider of continuing education by the Florida Board of Nursing, Provider No Ohio accepts providers approved by another state board of nursing. The Ohio Nursing Law CE activity that we offer has been approved. This CE activity, OLN-I , being offered by Elite Professional Education, LLC, has been approved for 1.0 contact hours, Category A, by the Ohio Board of Nursing through the approver unit at the Ohio League for Nursing (OBN ) and this program may be offered through April 10, All Ohio nursing professionals are required to complete 1 hour of Category A prior to renewal. Are you approved by ANCC? Yes. Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Ohio Board of Nursing Contact Information Ohio Board of Nursing 17 South High Street, Suite 400 Columbus, OH Phone: (614) Fax: (614) Website: Page ii

3 Nursing in Ohio: Laws and Rules ( Update) Release Date: 8/3/2016 Expiration Date: 8/3/2018 Faculty Valerie Wohl, MA, PhD Valerie Wohl is an author and research professional specializing in continuing education course development. She works with institutions of higher learning to create materials that are timely and useful, as well as accurate and clearly written, ensuring high academic standards for content in a wide range of disciplines. She graduated (MA, PhD) from Audience This course is designed for all Registered Nurses, Licensed Practical/ Vocational Nurses, and Nurse Practitioners in the State of Ohio. Purpose statement To familiarize all nurses, practicing in the State of Ohio with the current Nursing Laws and Rules and Scope of Practice, as specified by the Ohio Board of Nursing. 1.0 Contact Hour, Category A the Human Development and Social Policy Program at Northwestern University s School of Education and Social Policy (Evanston, IL), and received her BA from the School of Literature, Science, and the Arts, at the University of Michigan (Ann Arbor). Content Reviewer June D. Thompson, DrPH, MSN, RN, FAEN Learning objectives Identify the two primary sources of laws and rules for Ohio nurses, and where to find these sources. Differentiate between the Ohio Administrative Code (OAC) and the Ohio Revised Code (ORC). Locate the current text of Chapter 4723, the Ohio Administrative Code (OAC). How to receive credit Read the entire course online or in print which requires a 1-hour commitment of time. Depending on your state requirements you will asked to complete either: An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider # CEP15022; District of Columbia Board of Nursing, Provider Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Explain the role of the Ohio Automated Rx Reporting System (OARRS) in nursing practice. Describe two recent changes in Ohio s prescriptive authority for nursing professionals. Explain the purpose of Ohio s New Opioid Prescribing Guidelines for Acute Pain. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print your Certificate of Completion. # ; Florida Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). Page 1

4 Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/Commercial Support and Non-Endorsment It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing. The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction The State of Ohio requires registered nurses (RN) and licensed practical nurses (LPN) to practice in accordance with the standards of nursing care specified within the Ohio Nurse Practice Act, Chapter 4723 of the Ohio Revised Code (ORC or Revised Code), and Sections to of the Ohio Administrative Code (OAC) as well as fulfill continuing education requirements for licensing established by the Ohio Board of Nursing (OBN or Board). This continuing education course qualifies as a Category A nursing continuing education course. Category A courses clarify laws, rules, and guidelines found in Chapter 4723 of the Ohio Revised Code (the Ohio Nurse Practice Act), and rules of the Ohio Board of Nursing found in Chapter to of the OAC. The chapter is presented in two parts: Part I, which discusses scope of practice and Ohio Nursing Law and summarizes some of the most significant changes to nursing scope of practice in recent years; and Part II, which reviews Chapter 4723 of the ORC and highlights new provisions effective in 2015 and As this course can only review a small portion of the recent changes to nursing law, nurses are advised to carefully review Chapter 4723 of the Revised Code to ensure familiarity and compliance with all current nursing laws. Part I: Scope of Practice and Ohio Nursing Laws and Rules Scope of practice refers to an area of competence usually obtained via formal study, training, and/or professional experience. In nursing, scope of practice is closely tied to certification or other proof of qualification conferred by an educational institution. Because nursing practice constantly evolves in response to changing healthcare needs and technology, it is not feasible to provide an exhaustive list of all the specific duties or tasks in the law and rules that licensed nurses may or may not perform. Instead, Chapter 4723 of the Ohio Revised Code communicates the absolute necessities of the scope of practice, specifying that licensed nursing professionals may only provide nursing care in circumstances that are consistent with their specialized preparation, education, experience, knowledge, and demonstrated competency. In many instances, nurses must make critical decisions regarding whether a specific activity or task falls within their scope of practice. Nurses must know the current laws and rules in order to make prudent, legally compliant decisions. The first section of the chapter introduces terms and concepts used in discussing scopes of practice. A solid understanding of these terms and concepts, as defined by the Ohio Board of Nursing, enables nurses to make sound decisions regarding scope of practice questions. Ohio Nursing Laws and Rules It is critical that nursing professionals familiarize themselves with the laws and rules governing their state(s). This information can be obtained from two primary sources for the state of Ohio: the Ohio Administrative Code (OAC), and the Ohio Revised Code (ORC). The Ohio Revised Code contains all LAWS that have been passed by the legislature, while the Ohio Administrative Code contains all RULES passed by various state agencies, e.g. the Ohio Board of Nursing (OBN). State executive agencies, like the OBN, execute state laws through the development and enforcement of regulations. The Nurse Practice Act (i.e. the law governing nursing practice), is found in Chapter 4723 of the Ohio Revised Code. This defines the scope of practice for registered and licensed practical nurses in Ohio. Licensed nurses are professionally accountable and legally responsible for knowing and practicing within their defined scopes of nursing practice. This professional accountability requires nurses to complete their work in a safe, professional, and effective manner. Nurses may be subject to legal liability for failure to perform as expected. The Ohio Administrative Code contains the specific rules and processes established to guide the practice of nursing and ensure that nursing practice is lawful. Some of the topics outlined in the rules include standards of safe nursing practice, continuing education requirements, and principles of delegation. The Board reviews these rules a minimum of every five years in open hearing sessions. Additionally, each November, the Board holds an annual public hearing in which nurses are encouraged to participate. Nurses practicing in Ohio are accountable for the laws and rules regarding the safe practice of nursing in Ohio. Nurses are encouraged to consult the current laws and rules directly for more complete information by using the links below: Ohio Revised Code: All statutes of a permanent and general nature for Ohio, as revised and consolidated into general provisions, titles, chapters, and sections, including all bills passed. For nurses, see ORC Chapter 4723 at: orc/4723. Page 2

5 Ohio Administrative Code: A codification of the administrative agencies of the state, including all rules filed with effective dates. The Ohio Board of Nursing is the agency charged with specifying the rules and processes governing practices and standards that fulfill the requirements of the Nurse Practice Act. See OAC Chapter through at: oac/4723. Another useful resource for changes in nursing scope of practice is the Ohio Board of Nursing Laws and Rules webpage. This provides important information regarding recent legislative changes and other relevant nursing news. See current topics at: gov/law_and_rule.htm. Recent changes to Ohio Nursing Laws and Rules related to scope of practice This chapter highlights amendments to Ohio nursing laws, effective in 2015 and 2016, that directly address nursing scope of practice. Many critical changes to scope of practice that took effect before 2015, including extensively revised dialysis technician guidelines, and new regulations for certification, continuing education, and disciplinary sanctions, are not covered in this chapter. To review this important information, refer directly to Chapter 4723, Ohio Administrative Code (OAC), Nurses at: For a guide to current rules, see the Law and Rules page on the Board of Nursing website: Expanded prescriptive authority Certificate to Prescribe (CTP) holders are authorized to delegate non-controlled drug administration, under specific circumstances, to unlicensed persons. APRNs that hold prescriptive authority are authorized to delegate medication administration as specified in Sections (C) and , Ohio Revised Code (ORC). In doing so, APRNs must comply with the standards of safe practice, including delegation, set forth in the laws and rules, including Chapter , Ohio Administrative Code (OAC). Nursing professionals should be aware that the new authorization in ORC Section (C) supersedes the rule language found in Chapter , OAC, with respect to APRN prescribers. This rule language previously limited the types of medication that could be delegated to an unlicensed person. According to ORC , APRNs who hold a certificate to prescribe may delegate the administration of drugs if the following criteria are met: The authority to administer the drug is delegated by an APRN to a person who is a clinical nurse specialist, a certified nursemidwife, or certified nurse practitioner and who holds a certificate to prescribe. The drug is listed in the formulary (established under section of the Revised Code), but is not a controlled substance and is not to be administered intravenously. The drug is to be administered at: a location other than a hospital inpatient care unit; a hospital emergency department or freestanding emergency department; or an ambulatory surgical facility. The person has successfully completed education based on a recognized body of knowledge concerning drug administration and demonstrates to the person s employer the knowledge, skills, and ability to administer the drug safely. The person s employer has given the APRN access to documentation, in written or electronic form, showing that the person has met these conditions. The following sections from the Ohio Nursing Practice Act and Chapter 4723 of the Ohio Revised Code (ORC), which address scope of practice, were recently added or extensively amended. Changes to nursing scope of practice in Ohio based on these revisions became effective in 2015 and early The APRN is physically present at the location where the drug is administered. The Ohio Board of Nursing has established a link on the front page of their website, entitled Prescriptive Authority Resources that provides licensees with education and awareness of prescribing practices. To access these useful resources, go to ohio.gov/practice.htm#ctp. This page also provides a link to the Ohio Automated Rx Reporting System (OARRS), and guidelines for appropriate opioid prescribing. Ohio Automated Rx Reporting System (OARRS) The Ohio Automated Rx Reporting System (OARRS) is a statewide database that was established in 2006 to collect information on all prescriptions for controlled substances dispensed by pharmacies and personally furnished by licensed prescribers in Ohio. OARRS data is available to: prescribers when they treat patients; pharmacists when presented with prescriptions from patients; and law enforcement officers, but only during active investigations. For more information on OARRS, visit: In 2014, the General Assembly of the State of Ohio passed a law requiring APRNs who hold certificates to prescribe (CTP), and who prescribe opioid analgesics or benzodiazepines, to register with OARRS by January 1, Starting on April 1, 2015, a 12-month query of OARRS must be completed and documented prior to initially prescribing or personally furnishing an opioid analgesic or benzodiazepine. Regular monitoring of these patients is also required if treatment is continued for more than 90 days. CTP holders who are in violation of these laws are subject to disciplinary action. Section of the ORC imposes new requirements for CTP holders related to OARRS that apply when prescribing benzodiazepines and opioid analgesics. In addition, the National Association of Boards of Pharmacy (NABP) issued a Consensus Document in March of 2015 that contains guidelines related to identification of red flags that have been incorporated in revisions to the Rule. Opioid-prescribing guidelines Some of the recent changes to nursing practice relate to Ohio s New Opioid Prescribing Guidelines for Acute Pain, a strategy developed to curtail prescription drug abuse. One of these laws (based on HB 314, and introduced in 2014 with provisions effective in 2015) requires prescribers to follow specific restrictions and informed consent procedures before prescribing opioids to minors. Additionally, an Action Team of clinical professional associations, healthcare providers, licensing boards and state agencies developed new prescribing guidelines for the treatment of acute pain. Links to that information can be found on the Ohio Board of Nursing website. Part II: The Ohio Nursing Practice Act Nurse definitions. As used in this chapter: (A) Registered nurse means an individual who holds a current, valid license issued under this chapter, authorizing the practice of nursing as a registered nurse. Page 3

6 (B) Practice of nursing as a registered nurse means providing, to individuals and groups, nursing care requiring specialized knowledge, judgment, and skills derived from the principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes: (1) Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen. (2) Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions. (3) Assessing health status for the purpose of providing nursing care. (4) Providing health counseling and health teaching. (5) Administering medications and treatments, and executing regimens authorized by an individual who is authorized to practice in Ohio and is acting within the course of the individual s professional practice. (6) Teaching, administering, supervising, delegating, and evaluating nursing practice. (C) Nursing regimen may include preventative, restorative, and health-promotion activities. (D) Assessing health status means the collection of data through nursing assessment techniques, which may include interviews, observation, and physical evaluations for the purpose of providing nursing care. (E) Licensed practical nurse means an individual who holds a current, valid license issued under this chapter, authorizing the practice of nursing as a licensed practical nurse. (F) The practice of nursing as a licensed practical nurse means providing, to individuals and groups, nursing care requiring the application of basic knowledge of biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse or any of the following individuals authorized to practice in Ohio: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. Such nursing care includes: (1) Observation, and patient teaching and care in a diversity of health care settings. (2) Contributions to the planning, implementation, and evaluation of nursing. (3) Administration of medications and treatments authorized by an individual who is authorized to practice in Ohio and who is acting within the course of the individual s professional practice on the condition that the licensed practical nurse is authorized under section of the Revised Code to administer medications. (4) Administration, to an adult, of intravenous therapy authorized by an individual who is authorized to practice in Ohio and who is acting within the course of the individual s professional practice, on the condition that the licensed practical nurse is authorized under section or of the Revised Code to perform intravenous therapy and that licensed practical nurse performs intravenous therapy only in accordance with those sections. (5) Delegation of nursing tasks as directed by a registered nurse. (6) Teaching nursing tasks to licensed practical nurses and to individuals for whom the licensed practical nurse is authorized to delegate nursing tasks as directed by a registered nurse. (G) Certified registered nurse anesthetist means a registered nurse who holds a valid certificate of authority issued under this chapter, authorizing the practice of nursing as a certified registered nurse anesthetist in accordance with section of the Revised Code and rules adopted by the Ohio Board of Nursing. (H) Clinical nurse specialist means a registered nurse who holds a valid certificate of authority issued under this chapter, authorizing the practice of nursing as a clinical nurse specialist in accordance with section of the Revised Code and rules adopted by the Ohio Board of Nursing. (I) Certified nurse-midwife means a registered nurse who holds a valid certificate of authority issued under this chapter, authorizing the practice of nursing as a certified nurse-midwife in accordance with section of the Revised Code and rules adopted by the Ohio Board of Nursing. (J) Certified nurse practitioner means a registered nurse who holds a valid certificate of authority issued under this chapter authorizing the practice of nursing as a certified nurse practitioner in accordance with section of the Revised Code and rules adopted by the Ohio Board of Nursing. (K) Physician means an individual authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery. (L) Collaboration or collaborating means the following: (1) In the case of a clinical nurse specialist, except as provided in division (L)(3) of this section, or a certified nurse practitioner, that one or more podiatrists acting within the scope of practice of podiatry in accordance with section of the Revised Code and with whom the nurse has entered into a standard care arrangement, or that one or more physicians with whom the nurse has entered into a standard care arrangement, are continuously available to communicate with the clinical nurse specialist or certified nurse practitioner either in person or by radio, telephone, or another form of telecommunication. (2) In the case of a certified nurse-midwife, that one or more physicians with whom the certified nurse-midwife has entered into a standard care arrangement are continuously available to communicate with the certified nurse-midwife either in person or by radio, telephone, or another form of telecommunication. (3) In the case of a clinical nurse specialist who practices the nursing specialty of mental health or psychiatric mental health without authorization to prescribe drugs and therapeutic devices, that one or more physicians are continuously available to communicate with the nurse either in person or by radio, telephone, or another form of telecommunication. (M) Supervision, as it pertains to a certified registered nurse anesthetist, means that the certified registered nurse anesthetist is under the direction of a podiatrist acting within the podiatrist s scope of practice in accordance with section of the Revised Code, or under the direction of a dentist acting within the dentist s scope of practice in accordance with Chapter of the Revised Code, or under the direction of a physician, and when administering anesthesia, the certified registered nurse anesthetist is in the immediate presence of the podiatrist, dentist, or physician. (N) Standard care arrangement means a written, formal guide for planning and evaluating a patient s health care that is developed by one or more collaborating physicians or podiatrists and a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner and which meets the requirements of section of the Revised Code. (O) Advanced practice registered nurse means a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner. (P) Dialysis care means the care and procedures that a dialysis technician or dialysis technician intern is authorized to provide and perform, as specified in section of the Revised Code. (Q) Dialysis technician means an individual who holds a current, valid certificate to practice as a dialysis technician issued under section of the Revised Code. (R) Dialysis technician intern means an individual who holds a current, valid certificate to practice as a dialysis technician intern issued under section of the Revised Code. (S) Certified community health worker means an individual who holds a current, valid certificate as a community health worker issued under section of the Revised Code. Page 4

7 (T) Medication aide means an individual who holds a current, valid certificate issued under this chapter authorizing the individual to administer medication in accordance with section of the Revised Code. Amended; Effective 10/15/ Authority of clinical nurse specialist, certified nursemidwife, or certified nurse practitioner to prescribe drugs and therapeutic devices. This section establishes standards and conditions regarding the authority of a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner to prescribe drugs and therapeutic devices under a certificate to prescribe, issued under section of the Revised Code. (A) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not prescribe any drug or therapeutic device that is not included in the types of drugs and devices listed on the formulary established in rules adopted under section of the Revised Code. (B) The prescriptive authority of a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not exceed the prescriptive authority of the collaborating physician or podiatrist, including the collaborating physician s authority to treat chronic pain with controlled substances and products containing tramadol as described in section of the Revised Code. (C) (1) Except as provided in division (C)(2) or (C)(3) of this section, a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may prescribe to a patient a Schedule II controlled substance, only if all of the following are the case: (a) The patient has a terminal condition, as defined in section of the Revised Code. (b) The collaborating physician of the clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner initially prescribed the substance for the patient. (c) The prescription is for an amount that does not exceed the amount necessary for the patient s use in a single, 24-hour period. (C) (2) The restrictions on prescriptive authority in division (C)(1) of this section do not apply if a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner issues the prescription to the patient from any of the following locations: (a) A hospital registered under section of the Revised Code. (b) An entity owned or controlled, in whole or in part, by a hospital, or by an entity that owns or controls, in whole or in part, one or more hospitals. (c) A health care facility operated by the department of mental health and addiction services or the department of developmental disabilities. (d) A nursing home licensed under section of the Revised Code or by a political subdivision certified under section of the Revised Code. (e) A county home or district home operated under Chapter 5155 of the Revised Code that is certified under a Medicare or Medicaid program. (f) A hospice care program, as defined in section of the Revised Code. (g) A community mental health services provider, as defined in section of the Revised Code. (h) An ambulatory surgical facility, as defined in section of the Revised Code. (i) A freestanding birthing center, as defined in section of the Revised Code. (j) A federally qualified health center, as defined in section of the Revised Code. (k) A federally qualified health center look-alike, as defined in section of the Revised Code. (l) A health care office or facility operated by the Board of Health of a city or general health district, or by the authority having the duties of a board of health under section of the Revised Code. (m) A site where a medical practice is operated, but only if: the practice is comprised of one or more physicians who also are owners of the practice; the practice is organized to provide direct patient care; and the clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner providing services at the site has a standard care arrangement and collaborates with at least one of the physician owners who practices primarily at that site. (C) (3) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not issue to a patient a prescription for a Schedule II controlled substance from a convenience care clinic even if the clinic is owned or operated by an entity specified in division (C)(2) of this section. (D) A pharmacist who acts in good faith reliance on a prescription issued by a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner under division (C)(2) of this section is not liable for or subject to any of the following for relying on the prescription: damages in any civil action; prosecution in any criminal proceeding; or professional disciplinary action by the State Board of Pharmacy under Chapter 4729 of the Revised Code. (E) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may personally furnish to a patient, a sample of any drug or therapeutic device included in the types of drugs and devices listed on the formulary, provided that all of the following conditions apply: (1) The amount of the sample furnished shall not exceed a seventy-two-hour supply, except when the minimum available quantity of the sample is packaged in an amount that is greater than a seventy-two-hour supply, in which case the packaged amount may be furnished. (2) No charge may be imposed for the sample or for furnishing it. (3) Samples of controlled substances may not be personally furnished. (F) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may personally furnish to a patient a complete or partial supply of a drug or therapeutic device included in the types of drugs and devices listed on the formulary, provided that all of the following conditions apply: (1) The clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall personally furnish only antibiotics, antifungals, scabicides, contraceptives, prenatal vitamins, antihypertensives, drugs and devices used in the treatment of diabetes, drugs and devices used in the treatment of asthma, and drugs used in the treatment of dyslipidemia. (2) The clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not furnish the drugs and devices in locations other than: a health department operated by the Board of Health of a city or general health district or by the authority having the duties of a board of health under section of the Revised Code; a federally funded comprehensive primary care clinic; or a nonprofit health care clinic or program. (3) The clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall comply with all safety standards for personally furnishing supplies of drugs and devices, as established in rules adopted under section of the Revised Code. (G) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall comply with section of the Revised Code if the nurse prescribes for a minor, as defined in that Page 5

8 section, an opioid analgesic, as defined in section of the Revised Code. Amended; Effective 3/19/ Authority to prescribe or furnish drugs to sexual partner of a patient diagnosed with chlamydia, gonorrhea, or trichomoniasis. (A) (1) Notwithstanding any conflicting provision of this chapter or rule adopted by the Board of Nursing, a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner who holds a certificate to prescribe issued under section of the Revised Code may issue a prescription for or personally furnish a complete or partial supply of a drug to treat chlamydia, gonorrhea, or trichomoniasis, without having examined the individual for whom the drug is intended, if all of the following conditions are met: (a) The individual is a sexual partner of the nurse s patient. (b) The patient has been diagnosed with chlamydia, gonorrhea, or trichomoniasis. (c) The patient reports to the nurse that the individual is unable or unlikely to be evaluated or treated by a health professional. (A) (2) A prescription issued under this section shall include the individual s name and address, if known. If the nurse is unable to obtain the individual s name and address, the prescription shall include the patient s name and address and the words expedited partner therapy or the letters EPT. (A) (3) A nurse may prescribe or personally furnish a drug under this section for no more than two individuals who are sexual partners of the nurse s patient. (B) For each drug prescribed or personally furnished under this section, the nurse shall do all of the following: (1) Provide the patient with information concerning the drug for the purpose of sharing the information with the individual, including directions for use of the drug and any side effects, adverse reactions, or known contraindications associated with the drug. (2) Recommend to the patient that the individual seek treatment from a health professional. (3) Document all of the following in the patient s record: (a) The name of the drug prescribed or furnished and its dosage. (b) That information concerning the drug was provided to the patient for the purpose of sharing the information with the individual. (c) If known, any adverse reactions the individual experiences from treatment with the drug. (C) A nurse who prescribes or personally furnishes a drug under this section may contact the individual for whom the drug is intended. (1) If the nurse contacts the individual, the nurse shall do all of the following: (a) Inform the individual that the individual may have been exposed to chlamydia, gonorrhea, or trichomoniasis. (b) Encourage the individual to seek treatment from a health professional. (c) Explain the treatment options available to the individual, including treatment with a prescription drug, directions for use of the drug, and any side effects, adverse reactions, or known contraindications associated with the drug. (d) Document in the patient s record that the nurse contacted the individual. (2) If the nurse does not contact the individual, the nurse shall document that fact in the patient s record. (D) A nurse who, in good faith, prescribes or personally furnishes a drug under this section is not liable for or subject to any of the following: (1) Damages in any civil action. (2) Prosecution in any criminal proceeding. (3) Professional disciplinary action. Added; Effective 3/23/ Authority to supply naloxone. (A) Notwithstanding any provision of this chapter or rule adopted by the Board of Nursing, a clinical nurse specialist, certified nursemidwife, or certified nurse practitioner who holds a certificate to prescribe issued under section of the Revised Code may personally furnish a supply of naloxone, or issue a prescription for naloxone, without having examined the individual to whom it may be administered if both of the following conditions are met: (1) The naloxone supply is furnished to, or the prescription is issued to and in the name of, a family member, friend, or other individual in a position to assist an individual who there is reason to believe is at risk of experiencing an opioid-related overdose. (2) The nurse instructs the individual receiving the naloxone supply or prescription to summon emergency services as soon as practicable either before or after administering naloxone to an individual apparently experiencing an opioid-related overdose. (B) A nurse who under division (A) of this section, in good faith, furnishes a supply of naloxone or issues a prescription for naloxone is not liable for or subject to any of the following, for any action or omission of the individual to whom the naloxone is furnished or the prescription is issued: damages in any civil action; prosecution in any criminal proceeding; or professional disciplinary action. Amended; Effective 7/16/ Delegated authority to administer drugs. A person not otherwise authorized to administer drugs may administer a drug to a specified patient if all of the following conditions are met: (A) The authority to administer the drug is delegated to the person by an advanced practice registered nurse who is a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner and who holds a certificate to prescribe issued under section of the Revised Code. (B) The drug is listed in the formulary, established in rules adopted under section of the Revised Code, but is not a controlled substance and is not to be administered intravenously. (C) The drug is to be administered at: a location other than a hospital inpatient care unit, as defined in section of the Revised Code; a hospital emergency department or a freestanding emergency department; or an ambulatory surgical facility, as defined in section of the Revised Code. (D) The person has successfully completed education based on a recognized body of knowledge concerning drug administration and demonstrates to the person s employer the knowledge, skills, and ability to administer the drug safely. (E) The person s employer has given the advanced practice registered nurse access to documentation, in written or electronic form, showing that the person has met the conditions specified in division (D) of this section. (F) The advanced practice registered nurse is physically present at the location where the drug is administered. Added; Effective 10/15/2015. Page 6

9 References 1. LA Writer Ohio Laws & Rules, Chapter 4723: Nurses, accessed 6/22/ Ohio Administrative Code: OAC Chapter through , accessed 6/22/ Ohio Board of Nursing: Home Page, accessed 6/22/ Ohio Board of Nursing Laws and Rules page, accessed 6/22/ Ohio Board of Nursing. New APRN law: delegation of authority to administer drugs. Momentum. 2015; 4:14, accessed 6/22/ Ohio Nurses Association, Home Page, accessed 6/22/ Ohio Revised Code: ORC Chapter 4723 at accessed 6/22/ Hyperlinks for Ohio Laws and Rules; Chapter 4723: Nurses, accessed 6/22/ Nurse definitions Board of nursing Immunity Unlicensed practice Amended and Renumbered RC Appointment of executive director - duties Amended and Renumbered RC Minor violations Nursing special issue fund [Repealed effective 12/31/2023] Nurse education grant program Access to information from Ohio law enforcement gateway Administrative rules for nursing delegation as it applies to DD personnel who administer prescribed medications, perform health-related activities, and perform tube feedings Fees Fees in excess of statutory amounts Depositing receipts License application Request for criminal records check Ineligibility for licensure National standardized nursing examination to [Repealed] Grandfather provisions Unlicensed practice Offering services through authorized business entity Administration of medications [Renumbered] Courses of study in the safe performance of intravenous therapy to [Repealed] License or certificate renewal; notice of change of address Continuing education courses in domestic violence and its relationship to child abuse Volunteer nursing certificate , [Repealed] Replacement copies of certificates Disciplinary actions Summary suspension without a hearing - automatic suspensions Establishing practice intervention and improvement program Subpoena power [Repealed] Amended and Renumbered RC Exemptions Protection against retaliatory action Reporting misconduct Immunity [Repealed] Establishing chemical dependency monitoring program Determination of death by certified nurse practitioner or clinical nurse specialist to [Repealed] Renumbered RC Injunctions Requirements for practicing nurse-midwifery or other specialty Issuing certificate Scope of specialized nursing services Standard care arrangements Cooperation in investigations [Repealed] Unauthorized practice Supervision of nurse-midwifery Establishing list of approved national certifying organizations License suspension or revocation [Repealed] Completion of externship; Supervision of prescribing practices Externship certificate to prescribe Renewals [Repealed] to [Repealed] Medication aide advisory council definitions [Repealed] [Repealed] [Repealed] Administration of medications by medication aides Application for certification as medication aide Eligibility for medication aide certificate - issuance - duration Sanctions against certificate applicants or holders Medication aide; certificate required Application for medication aide training program Administration of medications by aides - delegation by nurse required Limitation of liability of delegating nurse or person reporting medication error Board to adopt program implementation rules Advisory group on dialysis Permitted activities Dialysis technicians - prohibited acts Approving operation of dialysis training program Issuing certificate Examinations Dialysis technician intern certificate Renewal of dialysis technician certificate [Repealed] Administrative rules Certification of community health workers program Community health worker certificate Application for certificate Eligibility for certificate Review and renewal of application Denial, revocation or suspension of certificate Community health worker training programs Community health worker standards and procedures [Repealed] to [Repealed] Medication aide advisory council definitions [Repealed] [Repealed] [Repealed] Administration of medications by medication aides Application for certification as medication aide Eligibility for medication aide certificate - issuance - duration Sanctions against certificate applicants or holders Medication aide; certificate required Application for medication aide training program Administration of medications by aides - delegation by nurse required Limitation of liability of delegating nurse or person reporting medication error Board to adopt program implementation rules Advisory group on dialysis Permitted activities Dialysis technicians - prohibited acts Approving operation of dialysis training program Issuing certificate Examinations Dialysis technician intern certificate Renewal of dialysis technician certificate [Repealed] Administrative rules Certification of community health workers program Community health worker certificate Application for certificate Eligibility for certificate Review and renewal of application Denial, revocation or suspension of certificate Community health worker training programs Community health worker standards and procedures Effect of child support default on certificate Compliance with law regarding sanctions for human trafficking Penalty. Page 7

10 NURSING IN OHIO: LAWS AND RULES ( UPATE) Final Examination Questions Choose the best answer for questions 1 through 10 and mark them on the answer sheet found on page 133 or complete your test online at 1. If a task or activity is legally within the scope of nursing practice you need to: a. Evaluate your competency to complete the task according to the standards of safe nursing practice. b. Check the orders and document your actions. c. Complete the task as assigned. d. Delegate the task accordingly to the non-licensed personnel assigned to your team. 2. A newly registered nurse is employed in a hospital that, on night shift, requires the nurse to perform a task or activity that is not within the realm of the nurse practice act as long as the hospital has a written procedure to policy/procedure to protect the nurse. What should the nurse do? a. Carefully read the policy and procedure and perform and document the task according to the guidelines. b. Call the health care provider to get an order so that the nurse may perform the task or procedure. c. Refuse to perform the task or procedure because it is outside of the scope of the nursing practice act for the state. d. Call the Board of Nursing for clarification. 3. If the nurse wanted to look up the laws and rules that govern the Ohio Board of Nursing, the best place to look for the rules is: a. The Charter for the State of Ohio. b. The Ohio Revised Code. c. The Ohio Administrative Code. d. The Ohio Nurses Association. 4. Under new Ohio Law, an Advanced Practice Registered Nurse (ARNP), may delegate the administration of drugs to another nurse providing: a. The ARNP is physically present at the location where the drug is administered. b. The ARNP has a certificate to prescribe. c. The drug is listed in the formulary but is not a controlled substance and is not to be administered intravenously. d. All of the above. 5. What is the purpose of the OARRS database a. To track and monitor human trafficking victims. b. To track and monitor controlled substances dispensed by pharmacies. c. To track and monitor Advanced Practice Registered Nurses in the State of Ohio. d. To track and monitor victims of domestic violence and child abuse. 6. Heidi is a certified clinical nurse specialist. She works in a community health clinic and cares for high-risk families. Mrs. Hamilton expresses a serious concern for her son Riley. Ever since his release from the Army, he as been drinking and taking drugs. Most recently he has overdosed two times on what she believes is heroin. She has encouraged him to go to the VA and to get help, but he simply says everything is under control. Mrs. Hamilton is afraid and asks if she can get some of that medication to give him, should he have an overdose at home. What can Heidi do under Ohio law. a. Heidi must refer Mrs. Hamilton to a physician to get naloxone prescription. b. If Heidi has prescriptive authority in Ohio, she can give Mrs. Hamilton the prescription for the medication. c. If Heidi has prescriptive authority and if Heidi examines Riley, she can prescribe naloxone. d. Riley must go to the drug treatment center to get the prescription. 7. How often does the Ohio Board of Nursing review the Nurse Practice Act: a. A minimum of every 5 years. b. As needed depending on role of nurses in Ohio and the changes of patient needs. c. Every legislative session. d. As requested by the Ohio Board of Medicine. 8. The Nurse Practice Act is found in Chapter 4723 of the. a. The Ohio Board of Nursing. b. The Ohio Revised Code. c. The Ohio Legislative Report. d. The Ohio Administrative Report. 9. The nursing Scope of Practice refers to: a. An area of competence usually obtained via formal study, training, and/or professional experience. b. An area of competence as defined by the employing agency. c. The practice of a nurse as defined by law. d. None of the above. 10. The Ohio Nurse Practice Act is legislated found in Chapter If the nurse wants to read the details of the Nurse Practice Act, it is found at: a. b. c. d. ANCCOH01OLE17 Page 8

11 Cancer Nursing, Prevention and Early Detection for the Adult Patient Release Date: 6/13/2016 Expiration Date: 6/13/2019 Faculty Patricia Yeargin, MN, MPH, RN Patricia Yeargin, MN, MPH, RN, has worked with people with cancer for more than a decade, and has enjoyed working in many different settings and specialties as an RN and as an NP. She spent the last 11 years writing and editing information for people with cancer and their loved ones at the American Cancer Society. She obtained 12 Contact Hours her Baccalaureate degree in Nursing from Georgia State University and Master s degrees in Public Health and Adult Health Nursing from Emory University, and completed a post-master s program in Psychiatric-Mental Health Nursing, also at Emory. Content reviewer Cheryl Lindy, PhD, MS, RN Audience Nurses are regarded as experts in cancer prevention, a subject that garners a great deal of attention in the media. However, cancer research is often misunderstood and media reports are often confusing. Purpose statement This course focuses on cancer prevention, early cancer detection, and nursing care of adults with cancer during and after treatment. This Learning objectives After taking this course, the nurse will be better able to: Educate patients about options for finding (or preventing) colorectal cancer and help them choose a colorectal cancer screening method that they might actually follow. Offer patients specific resources to help them quit smoking. Discuss fertility with patients before treatment to help them select effective options for fertility preservation. Discuss with patient the complications and other risks linked with smoking during cancer treatment. Help patients reduce the severity of cancer-treatment-related fatigue. How to receive credit Read the entire course online or in print which requires a 12-hour commitment of time. Depending on your state requirements you will asked to complete either: An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider # CEP15022; District of Columbia Board of Nursing, Provider Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Nurses are a trusted resource, and in a unique position to correct misinformation and guide people who are looking for reliable information on cancer prevention and risk reduction. course is intended to help nurses provide not only cancer care, but accurate and up-to-date information as well. Intervene to help prevent nausea and vomiting due to cytotoxic cancer drug treatment regimens. Locate information about and recognize the types of interactions that are likely to happen due to CYP enzyme system-based drug incompatibilities. Discuss with patients their understanding of the reasons for different types of cancer treatment, such as curative intent, control of cancer growth, and palliative or comfort treatments. Recognize symptoms suspicious of neutropenic (necrotizing) enterocolitis. Make patients aware of possible time limitations on the availability of their medical records, which may be needed at a later date. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print your Certificate of Completion. # ; Florida Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). Page 9

12 Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent Sponsorship/Commercial Support and Non-Endorsement It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation. Introduction Nurses who work in inpatient or outpatient settings with adult cancer patients face a wide array of challenges. Oncology treatment is a rapidly-changing field with an ever-expanding body of knowledge and compelling opportunities. After a patient is diagnosed with cancer, nurses perform comprehensive assessments to identify potential issues that can affect treatment as well as help the patient identify problem areas and pinpoint major concerns. Nurses are positioned to assist in addressing Cancer is the second leading cause of death in the United States (U.S.). The estimated lifetime risk of developing an invasive cancer in the U.S. is 42% in men and 38% in women, which means that almost one out of two men and roughly one out of three women will develop cancer during their lifetimes. This risk is lower early in life, and increases with age; about 86% of all cancers are diagnosed in people aged 50 years or older. Fortunately, many cancers are preventable [14]. Nearly 1.7 million invasive cancers are expected to be diagnosed in the U.S. in 2016 and well over half a million deaths from cancer are expected [14]. Cancer affects all races and ethnicities. Cancer incidence is rising and the trend is expected to continue as the number of people 65 and older in the U.S. will increase steadily over the next few decades [270]. According to the U.S. Administration on Aging, the proportion of people 65 and older will climb from 14.5% of the total population in 2015 to 19.7% by 2030 [271]. By 2050, the over-65 group is expected to double in size from 2010 numbers [272]. The burden of cancer Incidence of common cancers in the United States Some cancer types are observed much more often than others, e.g. breast and prostate cancers. One in eight women will be diagnosed with breast cancer during her lifetime and one in seven men will be diagnosed with prostate cancer. Lung cancer and colon cancer are the second and third most common types of invasive cancer in both men and women respectively, although they are slightly more common in men than in women [14]. Differences between incidence and cancer deaths Despite being the second most common cancer diagnosed, lung cancer is the number one cause of death for both men and women. The good news is that lung cancer deaths in the U.S. peaked in the beginning of the 21st century and are now on a slow decline. The lung cancer mortality curve correlates to the decline in smoking that has taken place in the past few decades. Colon cancer is the fourth most commonly diagnosed cancer, but it is the second overall cause of cancer mortality in both men and women. Note also that pancreatic cancer, despite being 12th in incidence, is the third most common cause of cancer mortality. Breast cancer and prostate cancer round out the top five [14]. the needs for information, interventions, and referrals as well as offering other helpful measures. Nurses are tasked to help patients understand complex medical regimens, consider options, and make decisions that are suitable for them and their situations. All of this demands a commitment to seek out current information, find and evaluate standards of practice, and adopt the best approaches to patient care. The number of adults being treated each year for cancer is increasing. According to the Agency for Health Care Research and Quality Medical Expenditure Panel Survey program, 4.8% of the U.S. adult population was treated for cancer in In 2011 (i.e. the most recent year for which statistics are available), 6.7% of the U.S. population (i.e. nearly 16 million people) was treated [260]. The American Cancer Society reports that the invasive cancer survival rate has improved over the past 40 years. Although survival varies markedly by cancer type and stage, the five-year relative survival rate for all cancers during was nearly 70%. Compare this to just under 50% in [14]. Survival is not the same as cure, a term that is much harder to define and almost impossible to measure; however, the improved survival rate reflects quite a lot of progress in both improved treatment and earlier detection. Comparing cancer incidence and causes of mortality by sex If the U.S. population is divided by sex, lung cancer is still the number one cause of cancer death, but prostate cancer rises to the second cause of cancer death in men, and breast cancer becomes the second leading cause of cancer death for women. Colon and rectal cancer drop to third and pancreatic cancer becomes fourth for both men and women [14]. After these, however, men and women s cancer incidence and mortality diverge significantly. In men, bladder cancer is the 4th most common cancer diagnosed and melanoma is the 5th most common cancer diagnosed. But, liver cancer and leukemia are the 5th and 6th leading causes of cancer death in men. In women, cancer of the uterus (endometrium) and thyroid are the 4th and 5th most common cancers respectively. But in cancer related mortality in women, ovarian cancer ranks 5th and uterine cancer ranks 6th. Because men do not develop uterine or ovarian cancers due to anatomy, and because these cancers are not as common as breast cancer, these two sex-specific cancers are not represented in rankings for the combined U.S. adult population [14]. Page 10

13 Costs of cancer Table 1. Estimated numbers of cases and deaths for common cancers in the United States, Excerpted from American Cancer Society: Cancer facts and figures 2016 [14]. Cancer type* New cases expected in 2016 Expected deaths in 2016 Breast cancers (women and men). 246, ,600 40, Cancers of the lung and bronchus. 224, ,080 Prostate cancers. 180,890 26,120 Colon and rectal cancers. 134,490 49,190 Bladder cancers. 76,960 16,390 Melanomas. 76,380 10,130 Non-Hodgkin lymphoma. 72,580 20,150 Thyroid cancers. 64,300 1,980 Renal cell and renal pelvis cancers. 62,700 14,240 Leukemias (all types). 60,140 24,400 Endometrial cancers. 60,050 10,470 Pancreatic cancers. 53,070 41,780 *This table does not include skin cancers or most other in situ cancers. About five million skin cancers are expected to be diagnosed in Cancer treatment involves a lot of medical care, and the financial aspects of this cannot be dismissed. There is a growing awareness among healthcare professionals that the cost of cancer care is rising quickly. The term financial toxicity has made its way into the medical lexicon, indicating that there are patients who cannot afford recommended treatments or prescriptions [80]. This directly affects patient care and outcomes. The Agency for Health Care Research and Quality (AHRQ) reported that each year from [273]: More than 1.1 million people had inpatient hospital stays related to cancer million people had hospital outpatient visits or office visits related to cancer. More than five million people had prescription medicines related to cancer. Although individuals often speak of cancer like it is a singular illness, the National Cancer Institute describes cancer as a collection of more than 100 related diseases [202]. Other organizations that keep track have calculated different numbers of cancers [4]. A cancer can begin What is cancer? Medical expenses have increased, with outpatient costs increasing much faster relative to inpatient costs as cancer care increasingly moves to outpatient models. The AHRQ Medical Expenditure Panel Survey (MEPS) found that in U.S. dollars (USD) [260]: Medical spending to treat cancer increased from $56.8 billion in 2001 (adjusted for inflation to 2011 USD) to $88.3 billion in Inpatient expenses were 47% of total spending for cancer treatment in 2001, but went down to 35% by The cost for ambulatory and outpatient care and treatment of cancer went up from $25.5 billion in 2001 to $43.8 billion in Prescription medications from retail pharmacies for cancer climbed from $2 billion in 2001 to $10 billion in (See also Financial Impacts in Emotional & Family Effects. ) almost anywhere in the human body as each body contains trillions of cells. All cancers share the characteristics of abnormal cells growing at uncontrolled/abnormal rates that continue to divide and traffic or grow into surrounding tissues [202]. Normal cell development Normally, human cells grow and divide to form new cells as needed by the body. Normal cells are able to perform their specific functions: they respond to signals and cytokines; and cell division is inhibited by contact and other mechanisms [244]. When cells grow old or become Abnormal cell development When a cancer develops, the orderly process of normal cell division, death, and replacement breaks down. As cells become more and more abnormal, old or damaged cells survive when they should die, and new cells form when they are not needed. These extra cells become able to divide without stopping and may form solid masses or abnormal cells that may be found in the circulatory system [202]. These abnormal cells take over nutrients and blood supply in the area of the cancer, at the expense of the normal cells. Not all cancer cells grow at the same speed, but they tend to reproduce more rapidly than normal cells. damaged, they die, a process known as apoptosis or programmed cell death. Waste products are removed and new cells are generated to take the place of the dead cells [202]. Many cancers form solid tumors or tissue masses. Cancers of the blood, e.g. leukemias, generally do not form solid tumors as abnormal cells reproduce in the hematopoietic (blood-forming) or lymphatic organs of the body [202]. Cancerous tumors can spread into or invade nearby tissues, growing and expanding past normal tissue borders. Another way that cancerous tumors spread is through some cancer cells breaking off and traveling to other locations in the body via blood circulation or the lymphatic system. Some of these migrating abnormal cells form metastases far from the original tumor [202]. Page 11

14 Genetic changes in cancer Cancers have a genetic component, meaning that the abnormal cell cycles are caused by mutations to genes that control the way cells function, especially those that direct growth and division [202]. It often takes many mutations before a cell becomes cancerous. Genetic mutations are constantly happening as cells divide and typically, the errors are detected and the body is able to repair them, while other errors cause malfunction or death of the cell. Some genetic mutations do not cause observable effect on the cell function, but others mutations can start or continue in a chain of events that lead to cancer [26]. Germline vs. acquired genetic mutations Genetic changes that can start a cell on a cancerous path or that allow abnormal cells to grow and divide can be inherited from parents. Germline mutations, because humans begin from a single sperm and a single egg combining DNA (deoxyribonucleic acid), are present in all body cells. Inherited germline mutations can be passed on to offspring depending on recombination and reproduction events. Even seemingly insignificant mutations can produce diseases, for example, an inherited defect in one gene can cause Huntington s Disease [26,215]. Often, the initial genetic mutations that lead to cancer arise during a person s lifetime. These acquired mutations are only present in the abnormal cells, and are called sporadic or somatic mutations. They can result from errors that occur as cells divide, i.e. every time a cell divides there is a chance of this kind of error, or because of damage to DNA caused by certain environmental exposures [26]. Cancer-causing environmental exposures include substances such as the chemicals in tobacco smoke, and radiation, such as X-rays and ultraviolet rays (UV) from the sun [202] (see Cancer risk factors ). Acquired mutations can accumulate over a lifetime, which is part of the reason why older people have a higher risk of cancer. Even an individual with a germline mutation that predisposes that person to cancer need additional genetic mutations before cancer results. The germline mutation provides the foundation of abnormal genetics for acquired mutations to build on. This can speed up the process of cancer development, and is one of the reasons that inherited cancer syndromes often produce cancer earlier in life [26]. Proto-oncogenes, tumor suppressor genes, and DNA repair Genetic changes that contribute to cancer tend to affect three main types of genes: proto-oncogenes, tumor suppressor genes, and DNA repair genes. These changes are sometimes called drivers of cancer [202]. Proto-oncogenes are involved in normal cell growth and division. However, when these genes are mutated in certain ways or become more active than normal, they may go rogue and become permanently activated. If that occurs they are considered cancercausing genes (oncogenes), which allow cells to divide and survive when they should not [202]. Tumor suppressor genes are involved in controlling cell growth and division. When tumor suppressor genes are mutated and if this inactivates them, it can cause cancer or allow a cancer to grow. A prominent example is the TP53 gene, which produces the P53 protein Cancer progression Cancer progression is generally unchecked before effective treatment is started. The malignant cells continue to divide relatively rapidly as the cancer grows, with mutations that confer various advantages to certain cell lines as noted above. These changes mean that the cancer growth may speed up over time, and that certain cell lines may predominate in the cancer. During this time, solid cancers must establish methods for increasing circulation so that nutrients can reach the tumor and nourish its growth. The cancer cells must have what they need to grow, and they exert direct effects on the tumor Page 12 [266]. The P53 protein, among other functions, prevents damaged cells from reproducing. This is an important role, since damaged cells are more likely to contain mutations that lead to cancer. The inactivation of this tumor suppressor gene plays a role in more than half of all cancers [26]. DNA repair genes are involved in fixing damaged DNA. Cells with mutations in the DNA repair genes tend to develop additional mutations in other genes. Together, these mutations may help the cells to become cancerous [202]. As scientists have learned more about the molecular changes that lead to cancer, they have found that certain mutations occur in many types of cancer. For example, in order for a solid tumor to grow more than two millimeters (mm), i.e. about the size of a pinhead, it must develop a blood supply [302]. However, there are multiple pathways to develop a blood supply. Cancers are now sometimes characterized by the types of genetic alterations that are believed to be driving them, not just by where they develop in the body and/or how the cancer cells look under the microscope [202]. As cancer treatments have evolved, genetic testing of cancer tissue can identify specific types of mutation, suggesting potential effective cancer treatments [26]. For example, the HER2 proto-oncogene normally helps cells grow, but when too many copies of the gene occur, HER2 becomes an oncogene (HER2 is an acronym for human epidermal growth factor receptor 2, also known as ERBB2). Women who have breast cancer with this particular oncogene do not respond well to certain types of standard chemotherapy, but there are newer drugs that specifically target HER2. Breast cancer tissue is now tested to determine if the patient will benefit from drugs such as trastuzumab, lapatinib, and pertuzumab. Certain stomach cancers also have an overexpression of HER2 that can be found by testing biopsy tissue, and those may also be treated with these HER2-targeting drugs [26]. Genetic changes in cancer initiation and progression Each cancer has a unique combination of genetic changes. Cancer begins with one abnormal cell that survives and begins to divide out of control. In order for this to happen, there must be changes in the signaling around the cell, so that the cell can bypass the usual controls on cell growth [302]. As the cancer cells continue to divide and growth progresses, all of which must be supported by the microenvironment around the cell, additional genetic mutations occur. The newly-mutated cells divide along with the abnormal cells that arose earlier in the process. This means that even within the same tumor, different cells may have different genetic changes so that there are different clones (clone in this sense refers to a group of identical cells that share a common ancestry) of abnormal cells in the cancer [202]. In cancer development, certain mutations may allow some of the cell lines to divide more quickly, to spread more easily, or to evade immune detection more readily. Some mutations even allow for increased resistance to cancer therapy. This is one reason cancer cells respond to different drug treatments in different ways, and also one of the reasons that cancers can be so difficult to completely eradicate. Advanced cancers have even more variety among their cells, increasing the risk that some of the various mutation patterns of the cells may be more resistant to certain treatments [55]. microenvironment (the area directly around the cancer cells) in order to acquire these nutrients. Genetic mutations, in addition to helping start a cancer, can also increase the production of substances that favor cancer growth or inhibit cellular signaling substances that slow growth. Chemokines are a subset of cytokines which use chemical signals to direct cellular activity. Normally, chemokines are involved in many cellular activities, such as cell migration (e.g. white blood cells

15 trafficking to sites of infection), normal cell growth, and immune responses. Chemokines and their receptors can behave abnormally in cancer, and play important roles in cancer progression and metastases. They can become involved in tumor growth, angiogenesis, evasion of immune detection, and metastasis. For example, chemokines and chemokine receptors that normally induce cell senescence (death of abnormal cells) can be mutated or downregulated in ways that promote tumorigenesis rather than interfere with it. Certain types of cancer cells secrete chemokines that promote growth. Chemokines can support or Cancer metastasis Metastasis is a complex process by which certain cancer cells leave their primary site and enter the bloodstream or the lymphatic system to grow elsewhere. Under the microscope, metastatic cancer cells generally look the same as cells of the primary cancer. Moreover, metastatic cancer cells and cells of the original cancer usually have some molecular features in common, such as the expression of certain proteins or the presence of specific genetic mutations [176]. Although a few types of metastatic cancer can be cured with current treatments, it is rare. Treatments are available for patients with metastatic cancer, but the main goal of those treatments is typically to control the growth of the cancer or to palliate symptoms [176]. In some cases, treating metastatic cancer may help prolong life, although each patient must weigh the pros and cons of such treatment, especially if they will have to deal with the side effects of aggressive treatments near the end of life. Nearly all cancers can form metastatic tumors. Although it is rare, even blood and lymphatic system cancers such leukemia, multiple myeloma, and lymphoma can form metastatic tumors, and spread to the lung, heart, central nervous system, and other tissues [176]. Each type of cancer tends to metastasize to common sites The most common sites of cancer metastasis are the bone, liver, and lung. Although most cancers have the ability to spread to many different parts of the body, each type of cancer typically spreads to a few sites much more often than others. The following table shows the most common sites of metastasis, excluding lymph nodes, for some of the more prevalent types of cancer. Table 2. Common cancers and sites of metastasis. Table adapted from National Cancer Institute (2013) [176]. Cancer types Main sites of metastases* Bladder Bone, liver, lung. Breast Bone, brain, liver, lung. Colorectal Liver, lung, peritoneum. Kidney Adrenal gland, bone, brain, liver, lung. Lung Adrenal gland, bone, brain, liver, other lung. Melanoma Bone, brain, liver, lung, skin/muscle. Ovary Liver, lung, peritoneum. Pancreas Liver, lung, peritoneum. Prostate Adrenal gland, bone, liver, lung. Stomach Liver, lung, peritoneum. Thyroid Bone, liver, lung. Uterus Bone, liver, lung, peritoneum, vagina. *These are listed in alphabetical order both down and across. Brain includes the neural tissue of the brain (parenchyma) and the leptomeninges (the two innermost membranes which cover the brain and spinal cord, the arachnoid mater and pia mater; the space between these layers contains the cerebrospinal fluid). Lung includes the main part of the lung (parenchyma as well as the pleura, which covers the lungs and lines the chest cavity). promote angiogenesis, and forming new blood vessels is a requirement for rapidly-dividing cells and fast-growing tumors [253]. Tumor progression and tumor microenvironments are areas of active research. While it is well known that there are chemokines that normally inhibit tumor cell proliferation, more studies are needed to find out how chemokines and their receptors are co-opted in ways that promote tumor growth and progression. This kind of research might help identify more targets for future treatments. How does cancer spread? A cell s ability to metastasize is acquired, and requires a series of specific changes. Chemokines and their receptors play a role as well: changes in signaling allow some cells to develop a greater capacity for migration and invasion [253]. Cancer cell metastasis usually involves the following steps [176]: 1. Local invasion: Cancer cells invade nearby normal tissue. 2. Intravasation: Cancer cells invade and move through the walls of nearby lymph vessels or blood vessels. 3. Circulation: Cancer cells move through the lymphatic system and the bloodstream to other parts of the body. 4. Arrest and extravasation: Cancer cells arrest, or stop moving, in capillaries at distant locations. They then invade the walls of the capillaries and migrate into the surrounding tissue (extravasation). 5. Proliferation: Cancer cells multiply at the distant location to form small tumors known as micrometastases. 6. Angiogenesis: Micrometastases stimulate the growth of new blood vessels to obtain a blood supply. A blood supply is needed to obtain the oxygen and nutrients necessary for continued tumor growth. Because cancers of the lymphatic system or the blood system are already present inside lymph vessels, lymph nodes, or blood vessels, not all of these steps are required for their metastasis [176]. The ability of a cancer cell to metastasize successfully depends on: The cell s individual properties. The properties of the noncancerous cells, including immune system cells, present at the primary cancer site. The properties of the cells it encounters in the lymphatic system or the bloodstream and at the final destination in another part of the body. Not all cancer cells, by themselves, have the ability to metastasize. In addition, noncancerous cells at the primary site may be able to block cancer cell metastasis. Successfully reaching another location in the body does not guarantee that a metastatic tumor will form. Metastatic cancer cells can lie dormant at a distant site for many years before they begin to grow, if they are able to grow at all [176]. Cancer development is a multistep process, and there are many roadblocks that may or may not be overcome by the cancer cells. This is why cancer development can take such a long time [176]. Symptoms of metastatic cancer Some people with metastatic tumors do not have symptoms and the metastases are found by X-rays or scans. When symptoms of metastatic cancer occur, their type and frequency depend on the size and location of the metastasis. For example, cancer that spreads to the bone is likely to cause pain and can lead to fractures. Cancer that spreads to the brain can cause a variety of symptoms, including headaches, seizures, and unsteadiness. Shortness of breath or dyspnea on exertion may be signs of lung metastasis. Abdominal swelling or jaundice can suggest that cancer has spread to the liver [176]. Sometimes a patient s primary cancer is discovered only after a metastatic tumor causes symptoms [176]. In most cases, when a metastatic tumor is found, the primary cancer is also found. The Page 13

16 search for the primary cancer may involve lab tests, X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, positron emission tomography (PET) scans, and other procedures. However, in some patients, a metastatic tumor is diagnosed but the primary tumor cannot be found despite extensive tests. The pathologist knows that the diagnosed tumor is a metastasis because the cells do not look like those of the organ or tissue in which the tumor was found. Doctors refer to the primary cancer as unknown or occult and the patient is said to have cancer of unknown primary (CUP). Because diagnostic techniques are constantly improving, the incidence of CUP is decreasing [176]. While CUP can be treated with a number of cancer treatments, cure is generally unlikely because the cancer typically has multiple metastatic sites. Cancer can be caused or promoted by external exposures or events, such as smoking, ultraviolet radiation, and medications that suppress the immune system. Cancer can also be caused by other health conditions or problems, including: inherited and acquired genetic mutations; the internal hormonal environment; and poor immune function. These kinds of exposures and conditions can act synergistically and/or in sequence to initiate and promote cancer growth. When there is exposure to a carcinogenic event or substance, it is common for ten or more years to elapse between the exposure and the cancer diagnosis, although it is often much longer than a decade (see section, Cancer Risks and Carcinogens ). This latency period varies by type of exposure and type of cancer as well as other factors [14]. It is very difficult in a given cancer case to pinpoint any one cause. More commonly, health care professionals can only point to a group of risk factors as the most likely to have affected the patient s development of cancer. Sometimes, there are few known risk factors for a person s cancer beyond older age and sex. Information from the Internet or other sources can be unreliable When patients and families want to know about cancer and links to causality, they often do not know where to look for reliable What causes cancer? information. There are so many unfounded theories posing as facts on the internet and social media. Health care professionals can look at reliable sources such as PubMed to find out whether or not an actual peer-reviewed study has been published and what kind of link is postulated (see section, Resources for Nurses ). A lot of the information easily found online does not have any kind of reliable study associated. Although a site or post may refer to research or studies, it is often the case that no citations are given. Unfortunately, even if there are studies, most research does not examine causality; many widely-publicized studies are strictly observational. If a study is only researching correlations, it might report, for instance, that weight loss is correlated with cancer, or with death. This would certainly sound familiar to nurses, because most people lose weight when they have cancer or another serious illness. However, this is statistically termed confounding. Incredulously, some study reports confuse things like this, in this case implying that poor nutrition was the cause of the illness and death. Illness caused the weight loss and not the other way around. Although this may seem like a silly example, non-medical writers often do not understand such obvious issues as reverse causality or confounding. And even statisticians do not always know about basic anatomical processes, e.g. cachexia of chronic disease. Cancer risk factors and carcinogens Cancer risk factors include exposure to chemicals or other substances, as well as certain behaviors. They include things people cannot control, like age and family history. Other risks can be controlled. Lifestyle, diet, and exercise Obesity People who are obese may have an increased risk of several types of cancer, including cancers of the breast (in women who have been through menopause), colon, rectum, endometrium, esophagus, kidney, pancreas, and gallbladder [180]. Conversely, eating a healthy diet, being physically active, and maintaining a healthy weight may help reduce risk of some cancers [115]. These healthy behaviors also help to lessen the risk of some other illnesses, such as heart disease, Type-II diabetes, and high blood pressure (see section Cancer Prevention ). Tobacco Decades of research have consistently established a strong causal link between tobacco use and cancers. Smoking is associated with one out of every three cancer deaths (32%), and four out of every five lung cancer deaths (80%) [14]. Cardiovascular disease, heart attacks, strokes, COPD, ectopic pregnancy, erectile dysfunction, and gingivitis are other health risks that are elevated for tobacco users [27]. Cigarette smoking: According to the National Cancer Institute (NCI), cigarette smoking is strongly correlated with the following cancers or cancer sites [70, 156, 233]: Lung. Oral cavity. Pharynx. Larynx. Esophagus. Page 14 Likewise, some carcinogens can be avoided, but others cannot. Limiting exposure to avoidable risk factors may lower the risk of developing certain cancers [176]. Bladder. Kidney. Pancreas. Stomach. Cervix. Acute myelogenous leukemia. The NCI notes that the body of evidence confirming these links is substantial. Further support is demonstrated by the lung cancer death rates in the U.S., which have mirrored smoking patterns [148]. The risks of lung cancer due to smoking are dose-dependent and increase markedly by the number of years smoked; cancer and other health risks also increase with number of cigarettes smoked per day [174]. Some of the risk increase relates to the smoker s age: in the general population (which includes both smokers and nonsmokers) the average probability of a man developing lung cancer goes from one in 608 from to age 49, to one in 16 when the man is 70 or older [14]. Current smokers, on average, have about 20 times the risk of lung cancer compared to nonsmokers [174]. It is easy to see that young smokers who just started smoking are at much less immediate risk than someone who is older and has smoked 30 years. Daily smoking means constant exposure to harmful chemicals. Of the more than 7,000 chemicals in tobacco smoke, at least 250 are known to be harmful, including hydrogen cyanide, carbon monoxide, and ammonia. Among the 250 known harmful chemicals in tobacco

17 smoke, at least 69 are considered carcinogens. These cancer-causing chemicals include the following [275, 277, 288]: Acetaldehyde. Aromatic amines. Arsenic. Benzene. Benzo[α]pyrene. Beryllium (a toxic metal). 1,3 Butadiene (a hazardous gas). Cadmium (a toxic metal). Chromium (a metallic element). Cumene. Ethylene oxide. Formaldehyde. Nickel (a metallic element). Polonium-210 (a radioactive chemical element). Polycyclic aromatic hydrocarbons (PAHs). Tobacco-specific nitrosamines (TSNAs). Vinyl chloride. Because smoking is the kind of exposure that is fairly easy to measure, this extensive body of evidence has led to the estimation that cigarette smoking causes 30% of all cancer deaths in the U.S. [14]. Smoking avoidance and smoking cessation result in decreased incidence and mortality from cancer [174]. According to the American Cancer Society, smoking shortens the lives of men and women by an average of 12 and 11 years, respectively [27]. Most practicing health professionals know that illness and disability associated with smoking usually begins long before death. Although quitting smoking at younger ages preserves life and health better, quitting can prolong life at almost any age, even after a lung cancer diagnosis [238]. Studies have shown that continued tobacco use after cancer diagnosis is linked to worse outcomes, such as decreased survival and cancer recurrence. In addition, smoking increases the risk of surgical complications and other co-morbidities that can increase deaths from other causes in people with cancer [298]. Secondhand smoke: Solid evidence indicates that exposure to secondhand smoke causes lung cancer as well as other health risks. The U.S. Environmental Protection Agency, the U.S. National Toxicology Program, the U.S. Surgeon General, and the International Agency for Research on Cancer have all classified secondhand smoke as a known human carcinogen. Approximately 3,000 lung cancer deaths occur each year among adult nonsmokers in the U.S. as a result of exposure to secondhand smoke [192]. Compared with nonsmokers who are not exposed to secondhand smoke, nonsmokers exposed to secondhand smoke have approximately a 20% increased risk of lung cancer. Note that this is relative risk, so it is 20% above the average lung cancer risk in unexposed nonsmokers, not a 20% absolute risk [174]. Evidence-based practice: Drug treatments, including nicotine replacement therapies (e.g. gum, patch, spray, lozenge, and inhaler), selected antidepressant therapies (e.g. bupropion), and nicotinic receptor agonist therapy (varenicline), result in better smoking cessation rates than placebo [156]. Cancer risks from alternative tobacco products As cigarette smoking decreases, tobacco companies and other commercial interests are coming up with alternative tobacco products, such as [66,117]: Hookahs, also called water pipes, which are used to smoke special tobacco that comes in different flavors, such as fruits, mint, chocolate, coconut, licorice, and cappuccino. Bidis, small, flavored, hand-rolled cigarettes from southeast Asia, that are wrapped in a tendu or temburni leaf, and often secured with a colorful string at the end. Kreteks, or cigarettes made with tobacco, cloves, and other flavors. These were banned by the 2009 Family Smoking Prevention and Tobacco Control Act due to their clove flavoring but have recently been re-introduced into the U.S. as little cigars. Cigars, including little cigars and cigarillos. Smokeless tobacco. Electronic nicotine delivery systems, such as e-cigarettes, vape pens, and other vapor systems. These alternative products are increasingly being used by teens and young adults. Between 2000 and 2011, the consumption of other combustible tobacco products has increased 123% (that increase does not include smokeless and vapor products). Younger people adopt alternative tobacco products for a number of reasons [117]: The products are not well-regulated. There is the mistaken perception that the products are safer or more natural than cigarettes. The products are flavored to make them more palatable to nonsmokers. They often cost less than cigarettes. Many of these products are not even labeled as harmful to health. Given that most current adult smokers started when they were in their teens or youth, this does not bode well for the future of cancer prevention. Historically, out of every three young smokers, one will quit, and one will die of a tobacco-related illness. Electronic cigarettes and other vape products have not been well researched regarding their long-term health hazards [117]. Cigars, hookahs, bidis, and kreteks all carry the known health risks of combustible tobacco, very much like cigarettes. Smokeless tobacco has known cancer risks, but some of the other oral tobacco products (e.g. tobacco lozenges, orbs, strips, sticks, and meltaways) need more research on their health effects. The one thing all of these alternative products have in common is that they deliver nicotine and are addictive. Cigars: While cigarette consumption declined by one-third in the U.S. between 2000 and 2011, cigar consumption doubled. Cigar smoke has higher levels of tobacco-specific nitrosamines (TSNAs) than cigarettes and higher levels of carbon monoxide, and carries much the same risk as cigarettes and other combustible tobacco [72]. Most cigars are composed of air-cured and fermented tobacco, with a tobacco wrapper. They can vary in size and shape and contain between one and 20 grams of tobacco. Cigars sold in the U.S. are categorized by size [155]: Large cigars can measure more than seven inches in length, and they typically contain between five and 20 grams of tobacco. Some premium cigars contain the tobacco equivalent of an entire pack of cigarettes. Large cigars can take between one to two hours to smoke. Cigarillos are a type of smaller cigar. They are somewhat bigger than little cigars and cigarettes and contain about three grams of tobacco. Little cigars are about the same size and shape as cigarettes, are often packaged like cigarettes (20 little cigars in a package), and contain about one gram of tobacco. Also, unlike large cigars, some little cigars have a filter, which makes it seem they are designed to be smoked like cigarettes (that is, for the smoke to be inhaled) [155]. Many little cigars are smoked exactly like cigarettes and in most states they cost less due to tax loopholes. Chang et al. (2015) looked at 22 studies of cigar smokers and death. They confirmed a strong dose relationship between the number of cigars smoked per day and how deeply the smokers inhaled the smoke and the development of oral, laryngeal, lung, pancreatic, and esophageal cancers as well as coronary heart disease and aortic aneurysm. Even among cigar smokers who reported that they did not Page 15

18 inhale, there was a much higher death risk from oral, laryngeal, and esophageal cancer [72]. Pipes: Even though smoking tobacco in pipes may be enjoying a resurgence with people using natural tobacco, pipes still have about the same risks as cigars. Pipe smokers have an increased risk of death from cancer of the lung, oropharynx, esophagus, colorectum, pancreas, and larynx as well as risks for COPD and cerebrovascular disease. Pipe smoke, even when not deliberately inhaled, is concentrated around and breathed in by the smoker with all of the particulates, toxic gases, and carcinogens from burning tobacco. Although the risks are generally less than with smoking cigarettes, this is mainly due to less time smoking and less inhalation. Risk increases with years of pipe smoking, number of pipes smoked per day, and depth of inhalation [98]. Smokeless tobacco: Smokeless tobacco is tobacco that is not burned; the two best-known forms are chewing tobacco and snuff. It may be called oral tobacco, spit or spitting tobacco, dip, or chew. Most people chew or suck (dip) the tobacco in their mouth and spit out the tobacco juices that build up, although spitless smokeless tobacco has also been developed [193]. There are also newer forms of oral tobacco, such as dissolvable tobacco (flavored lozenges, meltaway strips, pellets, orbs, and sticks that look like toothpicks) and snus (moist snuff in small dose packs that may contain flavorings). Unfortunately, smokeless tobacco is another way for people (especially teens and youth) to try tobacco products. Some will become addicted, and it is unclear how many teens graduate to even more dangerous combustible forms of tobacco. Many of these smokeless tobacco products are easy to ingest and can pose unexpected dangers. Large doses of nicotine are toxic; overdoses can happen to teens and adults as well as kids (or pets) who unexpectedly find these products and ingest them [3]. Even though oral tobacco kills fewer people than smoking, it is still not a safe option. Smokeless tobacco causes oral cancer, esophageal cancer, and pancreatic cancer [109]. At least 28 chemicals in smokeless tobacco are carcinogens [109]. The most harmful chemicals in smokeless tobacco are the TSNAs, which are formed during the growing, curing, fermenting, and aging of tobacco. The level of TSNAs varies by product. Scientists have found that the nitrosamine level is directly related to the risk of cancer. In addition to nitrosamines, other cancer-causing substances in smokeless tobacco include polynuclear aromatic hydrocarbons (also known as polycyclic aromatic hydrocarbons, or PAHs), polonium-210, and lead-210 [109]. Radioactive elements are introduced via fertilizers that farmers use to increase the size of their tobacco crops; tobacco also contains the naturally occurring radionuclide, radium. Radium radioactively decays to release radon, which rises from the soil around the plants. The radon and its decay products cling to the sticky hairs (trichomes) on the bottom of tobacco leaves as the plant grows. The decay products include radioactive elements lead-210 and polonium-210. Rain does not wash them away, and they remain in all forms of commercial tobacco [280]. Some companies make certain smokeless products sound safe, for example, snus, at least those from Sweden, are reputed to have less TSNAs. But, U.S. tobacco companies are not required to label their products with their ingredients, and certainly not with their carcinogen levels. American snus are not processed the same way as Swedish types, and have variable TSNA levels, as do most of the new smokeless tobacco products [263]. Using smokeless tobacco may also cause heart disease, gum disease, and oral lesions other than cancer, such as leukoplakia (a white precancerous lesion) [109]. Like all forms of tobacco, smokeless is addictive because it contains nicotine, which in this case is absorbed directly through the oral mucosa [193]. Smokeless tobacco is just as difficult to quit as smoking. E-cigarettes and other electronic nicotine delivery devices: Devices such as electronic cigarettes, e-cigars, e-hookahs, and vape pens are very similar to one another but very different in composition and design from traditional cigarettes (although some are designed to look like cigars or cigarettes). They come in many shapes and sizes, but are typically comprised of a battery, a heating element, and a reservoir for a liquid solution that most often contains nicotine. Although the use of these devices is often referred to as vaping, the term is inaccurate. Electronic nicotine delivery devices produce an aerosol of liquid droplets, not actually a vapor. Dr. Michele Bloch, chief of the NCI s Tobacco Control Research Branch, explains that very small particles in the aerosol can penetrate deep into the lungs, making the presence of any toxic chemicals in the aerosol potentially hazardous [159]. Electronic nicotine delivery devices are often marketed as a safer alternative to cigarettes, or as a way to cut down or quit smoking. Proponents and distributors like to point out that the main ingredients are generally recognized as safe by the FDA. However, most health care workers know that the FDA s safe list refers to food ingredients, not components to be inhaled, which is quite different. Oils, for example, are safe to eat, but not generally safe to inhale. In addition, manufacturers do not usually list all of the ingredients in the liquids, which vary greatly by maker and flavor. Finally, while the companies typically list the amount of nicotine the product is supposed to deliver, surveys have found that this labeled amount is not always accurate: some labeled no nicotine contained fairly large amounts, and others had much less than labeled. The refill liquids are made in a number of countries, including the U.S. and China as well as European countries [303]. There are serious concerns that the flavors in the liquids more than 7,000 have been catalogued, ranging from bacon to peanut butter chocolate are attractive to teens, making the products a potential gateway to traditional tobacco products. There are data that suggest this is occurring. A 2013 study from the U.S. Centers for Disease Control and Prevention (CDC) found that youths who have used e-cigarettes are twice as likely to say that they might or would probably smoke conventional cigarettes than those who have never used e-cigarettes [67]. There is also a wide degree of quality in the manufacture of electronic vapor devices, a majority of which are made in China. Many Chinese manufacturing companies are not as closely regulated as their counterparts in the U.S., and brands are sometimes counterfeited [47]. There are anecdotal reports of people who have used the devices to quit smoking. However, there are much purer forms of nicotine in carefully controlled doses and safer delivery systems that can be used by people who want to quit smoking. There is even an inhalable form of nicotine available by prescription for those who want to quit smoking safely. Given all this, and the fact that they have only been around a few years, research on anything beyond short-term effects is still pending. This will be the case until these products have been in use long enough for longitudinal studies. Again, as it is known that nicotine is addictive, these are another route for people to become chronic users of nicotine. Helping your patient quit People who use tobacco should be urged to quit; even those who already have cancer can benefit from quitting. There are many forms of nicotine replacement and other drugs that have been proven to help with the physical part of quitting tobacco [194]. Individual or group counseling, telephone quitlines like the CDC s QUIT- NOW, and groups such as Nicotine Anonymous (NicA) are some of the methods that can be used to help with the emotional and mental components of quitting. There is even an online group dedicated to quitting smokeless, at Many of these methods are cost-free or partly covered by insurance. Page 16

19 Nursing consideration: Offer your patients specific resources to quit smoking before cancer treatment starts. Advise patients that evidence shows a higher risk of complications and recurrence in people who continue to smoke during cancer treatment [194]. Alcohol Drinking alcohol can increase the risk of cancer of the mouth, throat, esophagus, larynx (voice box), liver, and breast. This fact is rarely mentioned in media reports on carcinogens, and many people seem unaware of it. The more a person drinks, the higher their cancer risk. The risk of cancer is much higher for those who drink alcohol and also use tobacco [138]. The International Agency for Research on Cancer (IARC) classifies the ethanol in alcoholic beverages as a Group 1 Carcinogen, meaning that it is known to be carcinogenic to humans. The IARC further notes that acetaldehyde, which is produced in the body after consuming alcohol, is known to be carcinogenic as well [106]. The U.S. National Toxicology Program also lists alcoholic beverages as known carcinogens, although acetaldehyde is still on its list of reasonably anticipated to be human carcinogens [228]. The American Cancer Society recommends that people who drink should do so in moderate amounts. Their intake maximums agree with the U.S. Federal government s Dietary Guidelines for Americans, which defines moderate alcohol drinking as up to one drink per day for women and up to two drinks per day for men [10,138]. They further define a standard drink as 12 ounces of beer, five ounces of wine, or 1.5 ounces of 80-proof liquor. All of these serving sizes contain about 0.6 of an ounce of pure ethanol [10]. Researchers have identified multiple ways that alcohol may increase the risk of cancer, including: Metabolizing ethanol acetaldehyde, which is a toxic chemical; acetaldehyde can damage both DNA and proteins. Generating reactive oxygen species (chemically reactive molecules that contain oxygen), which can damage DNA, proteins, and lipids through a process called oxidation. Impairing the body s ability to break down and absorb a variety of nutrients that may be associated with cancer risk, including: vitamin A; nutrients in the vitamin B complex, such as folate; vitamin C; vitamin D; vitamin E; and carotenoids. Increasing blood levels of estrogen, a sex hormone linked to the risk of breast cancer. Some alcoholic beverages may also contain a variety of carcinogenic contaminants that are introduced during fermentation and production, such as nitrosamines, asbestos fibers, phenols, and hydrocarbons [139]. It has been suggested that certain substances in red wine, such as resveratrol, have anticancer properties. However, there is no evidence that drinking red wine reduces the risk of cancer [138]. What happens to cancer risk after a person ceases drinking alcohol? Most of the studies that have examined whether cancer risk declines after a person ceases drinking alcohol have focused on head and neck cancers and on esophageal cancer. In general, these studies have found that stopping alcohol consumption is not associated with immediate reductions in cancer risk; instead, it may take years for the risks of cancer to return to those of never-drinkers [139]. For example, a pooled analysis of 13 case-control studies of cancer of the oral cavity and pharynx combined found that alcohol-associated cancer risk did not begin to decrease until at least ten years after stopping alcohol drinking. Even 16 years after they stopped drinking alcohol, the risk of cancer was still higher for ex-drinkers than for never drinkers [248]. In several studies, the risk of esophageal cancer was also found to decrease slowly with increasing time since alcohol drinking cessation. A pooled analysis of five case control studies found that the risk of esophageal cancer did not approach that of never drinkers for at least 15 years after alcohol drinking cessation [248]. Drugs Exogenous hormones Estrogens, a group of female sex hormones, are known human carcinogens. Although these hormones have essential physiological roles in both females and males, they have also been associated with an increased risk of certain cancers. For instance, taking combined hormone therapy to reduce menopause symptoms (estrogen plus progestin, a synthetic version of the female hormone progesterone) can increase a woman s risk of breast cancer. Menopausal hormone therapy with estrogen alone increases the risk of endometrial cancer and is used only in women who have had a hysterectomy [169]. A woman who is thinking about menopausal hormone therapy should understand the possible risks and benefits before she starts taking it [169]. After the cancer connection was identified, doctors began to prescribe it only for bothersome menopausal symptoms in low doses and for the shortest possible lengths of time. Studies have also shown that a woman s risk of breast cancer is related to the estrogen and progesterone made by her ovaries (endogenous estrogen and progesterone). Being exposed for a long time and/or to high levels of these hormones has been linked to an increased risk of breast cancer. Increases in exposure can be caused by early menarche, late menopause, being older at first pregnancy, and never having given birth. Conversely, having given birth is a protective factor for breast cancer [169]. On the other hand, the risk of ovarian cancer decreases with longer years of having taken oral contraceptives [182]. Diethylstilbestrol (DES) is a form of estrogen that was given to some pregnant women in the U.S. between 1940 and 1971 to prevent miscarriages, premature labor, and related problems associated with pregnancy [169]. DES came in many forms, including pills, creams, and vaginal suppositories. Women who took DES during pregnancy may have an increased risk of breast cancer, as may their daughters. Their daughters ( DES daughters ) have an increased risk of a cancer of the vagina or cervix. DES daughters should have annual pap smears from the vagina and cervix, and follow up any abnormalities with colposcopy. The National Cancer Institute recommends that DES daughters rigorously follow the routine breast cancer screening recommendations for their age group [160]. The possible effects on the sons and grandchildren of women who took DES during pregnancy are still being studied [169]. Other drugs There are a number of other drugs on the American Cancer Society combined list of known carcinogens. Adriamycin, alkylating agents, azacitidine, busulfan, CCNU, chlorambucil, chlorozotocin, cisplatin, cyclophosphamide etoposide, melphalan, nitrogen mustard, procarbazine, semustine, and tamoxifen and are some of the cancer treatment drugs that have made the list so far [32]. As with radiation therapy, there are safety trade-offs; a low risk of a possible second cancer in the future is a risk worth taking to most people facing the much more immediate threat of death from existing cancer. Phenacetin, chloral hydrate, chloramphenicol, pioglitazone, and cyclosporine are drugs on the known carcinogen list that are not designated for cancer treatment [32]. Infectious agents Certain infectious agents can cause cancer in infected people or increase the risk that cancer will form. Some viruses can disrupt normal controls on cell growth and proliferation. They may also increase the chance that a person will be affected by other cancer risk factors, such as UV radiation or substances in tobacco smoke that cause cancer. Some viruses, bacteria, and parasites also cause chronic inflammation, which may lead to cancer. Page 17

20 Most of the viruses that are linked to an increased risk of cancer can be transmitted through blood and/or other body fluids. People can lower their risk of infection from many of these by getting vaccinated, not having unprotected sex, and not sharing needles or equipment if they inject drugs [172]. Globally, infectious agents have been estimated to cause 18% of all cancer cases [237]. The burden of cancers caused by infections is much greater in developing nations (26%) than in developed nations (8%) [148]. Human papillomaviruses (HPVs) Infection with high-risk types of human papillomavirus (HPV) cause nearly all cervical cancers. Infection with an oncogenic strain of HPV is considered a necessary event for later development of cervical cancer, and vaccine-conferred immunity (available to younger people before sexual initiation) results in a marked decrease in precancerous lesions. Oncogenic strains of HPV also cause most anal cancers and many oropharyngeal, vaginal, vulvar, and penile cancers. In the United States, the Advisory Committee on Immunization Practices (ACIP) recommends that children aged 11 to 12 receive an HPV vaccine series that helps to prevent infection with the types of HPV that cause most HPV-associated cancers. Children as young as age nine and adults as old as 26 can also be vaccinated. If an infectious agent is a cause of cancer, then effective anti-infective interventions would be expected in most instances to be effective cancer prevention interventions. This is the expectation with vaccines that protect against infection with oncogenic strains of HPV [148]. HPV infections in the cervix can be found with specific tests. Although HPV infections themselves cannot be treated, the cervical cell changes these infections can cause over time can be treated to prevent future cancers [172]. Human immunodeficiency virus (HIV) Over time, the human immunodeficiency virus (HIV) decimates the immune system which can allow uncontrolled opportunistic infections, including oncogenic agents. People infected with HIV have an increased risk of Kaposi s sarcoma, lymphoma, and cancers of the cervix, liver, lung, and anus. HIV infection often does not cause obvious symptoms until the infection progresses to Acquired Immunodeficiency Syndrome (AIDS) [172]. In addition to the usual known AIDS-related opportunistic cancers, people with HIV have higher risk of more common cancers as well and should be carefully screened. Some cases, (e.g. cervical cancer) should be considered high-risk for screening purposes. People with untreated HIV are at fairly high risk of a number of cancers. People whose HIV infection is treated with effective combination antiretroviral therapy (cart) typically have better immune function and much longer survival than those who are not [217]. Hepatitis B virus and hepatitis C virus (HBV and HCV) Chronic infections with HBV or HCV can cause liver cancer. Since the 1980s, infants in the U.S. and most other countries have been routinely vaccinated against HBV infection. Adults who have not been vaccinated against HBV and have an increased risk of HBV infection should be vaccinated as soon as possible. Vaccination for HBV is especially important for healthcare workers and other professionals who come into contact with human blood [172]. The CDC also recommends that everyone in the U.S. born from 1945 through 1965 be tested for HCV, along with other populations at increased risk for HCV infection. These infections can be asymptomatic, but tests can show whether a person has been infected with either virus. People who test positive for either of these might benefit from treatment, and should also learn how to avoid infecting other people [172]. As of early 2016, there is no vaccine for HCV, although clinical trials are in progress. Human T-cell leukemia/lymphoma virus type 1 (HTLV-1) HTLV-1 is a retrovirus (in the same class as HIV) that can cause a type of lymphocytic leukemia or lymphoma called adult T-cell leukemia/ lymphoma (ATL) [172]. HTLV-1 is transmitted the same ways as HIV (e.g. unprotected sex, shared needles, to infants from mother while in utero, and breastfeeding), although it does not cause AIDS or AIDSlike illness. HTLV-1 is most often found in parts of South America, the Caribbean, Central Africa and parts of Japan. Infection with HTLV-1 is rare in the U.S., but people who engage in high-risk behaviors are more likely to acquire the virus. Once a person contracts the virus, and usually after a long asymptomatic period spanning decades, the chance of developing ATL might be as high as 5% [29]. Epstein-Barr virus (EBV) Infection with EBV, a type of herpes virus that is best known for causing mononucleosis, is life-long (as with other herpes viruses). Most U.S. adults are infected with EBV, although not everyone who becomes infected has symptoms of mononucleosis. After the initial infection, the viral infection is usually asymptomatic, and EBV does not cause serious illness for most people [29]. EBV has been linked to a slightly increased risk of fast-growing lymphomas and cancers of the stomach and nasopharynx [172]. Human herpesvirus 8 (HHV8) HHV8, i.e. Kaposi s sarcoma-associated herpes virus (KSHV), also causes a life-long infection. In people who are immunocompromised, KSHV can cause Kaposi s sarcoma, a slow-growing cancer that typically appears on the skin as purple or brown lesions, but can also affect the mucosa in organs such as the lungs or the gut [172]. Kaposi s sarcoma is endemic in some countries, especially in older people, but in the U.S. is most often linked with HIV infection. This virus has also been linked to some rare blood cancers and multicentric Castleman s Disease [29]. Merkel cell polyomavirus (MCPyV) MCPyV can cause Merkel cell carcinoma, which is a rare type of aggressive cancer affecting cutaneous neuroendocrine cells. About 80% of people are infected with MCPyV by adulthood, but the virus rarely causes symptoms or cancer. In a few, usually fair-skinned people older than 50 years of age, the virus can lead to Merkel cell cancer [29]. This malignancy occurs in skin that is frequently exposed to sunlight, and more often affects people in their 70s, those with HIV, and those who are otherwise immunosuppressed (e.g. organ transplant patients). Even though Merkel cell carcinoma is relatively rare, its incidence in the U.S. tripled in the two decades after the 1990s and continues to climb [262]. Helicobacter pylori (H. pylori) Helicobacter pylori is a gram negative spiral shaped bacterium that burrows into the stomach lining where the immune system cannot easily destroy it [168]. It can cause stomach cancer in the lower part of the stomach and a rare type of non-hodgkin s lymphoma called gastric mucosa-associated lymphoid tissue (MALT) lymphoma in the stomach lining. Of interest, evidence suggests H. pylori might reduce the risk of esophageal adenocarcinoma and stomach cancer in the upper inch or so of the stomach (gastric cardia). The National Cancer Institute notes that studies have shown some strains of H. pylori appear to inactivate tumor suppressor proteins such as p53, which may partly explain its carcinogenicity. The bacterium can also cause stomach ulcers [168]. The estimated prevalence of the infection is 30-40% in the U.S., and much higher in developing countries [99]. It is easy to test for H. pylori infection with a breath test, and infection can be treated [172]. Treatment appears to reduce risk of the associated cancers. Schistosoma spp. parasitic flatworms This parasitic flatworm (fluke), which is found in some countries of Africa, South America, Caribbean, Southeast Asia, the Middle East and parts of China, can cause bladder cancer [69, 172]. Infection with these worms is called schistosomiasis or bilharzia. The worms are not Page 18

21 found in U.S. freshwater bodies, but more than 200 million people are infected worldwide [69]. The parasites that cause schistosomiasis live in certain freshwater snails during most of their lifecycle. The infectious form of the parasite, known as cercariae, emerges from the snail and contaminates the water. A person can become infected when skin comes in contact with contaminated water. Most human infections are caused by Schistosoma mansoni, S. haematobium, or S. japonicum, and can be treated with antiparasitic drugs. The parasites can cause chronic infections which can result in bladder cancer in untreated persons [69]. Ionizing radiation What health care workers call radiation is only one of many types of electromagnetic radiation. Electromagnetic energy travels in waves and spans a broad spectrum, from very long radio waves to very short gamma rays. The human eye can detect only a small portion of this spectrum, called visible light. A radio detects a different portion of the spectrum, and infrared energy can be detected by the nerves in human skin or by a thermometer [135]. Unfortunately, differences between the medical and the scientific use of the word radiation can cause a great deal of confusion in Medical radiation When nurses speak of radiation, he or she (s/he) is typically referring to very specific types of high-energy radiation rather than visible light, microwaves, or radio waves. Ionizing radiation includes radon, X-rays, gamma rays, and other forms of high-energy radiation. Ionizing radiation is defined as radiation with enough energy to remove tightly bound electrons from their orbits, causing atoms to become charged or ionized. Ions formed in the molecules of living cells can go on to react with and potentially damage other atoms in the cell. At low doses (e.g., those associated with background radiation and limited x-rays), the cells repair the damage rapidly. At moderate doses, the cells may be permanently mutated or die from their inability to repair the damage. Cells that are damaged and unrepaired but that do not die, may go on to produce abnormal cells when they divide. In some circumstances, these altered cells may become cancerous or lead to other abnormalities (e.g., birth defects). Defects in the ability to repair damage caused by ionizing radiation may influence the how much radiation exposure increases cancer risk [174]. There is extensive evidence linking exposure to ionizing radiation with the development of cancer. In particular, ionizing radiation is linked to cancer that involves the hematological system, breast, lungs, and thyroid [148]. The National Research Council of the National Academies Committee to Assess the Health Risks from Exposure to Low Levels of Ionizing Radiation put out the Biologic Effects of Ionizing Radiation VII, which is the most widely cited source on the topic. In this report, three lines of evidence were cited documenting the links between ionizing radiation exposure and cancer [148]: The first line of evidence comes from studies of the development of cancer among Japanese atomic-bomb survivors. Even survivors who were exposed to lower doses of radiation were at a significantly increased risk of developing cancer. The second line of evidence comes from epidemiological studies of medically irradiated populations (in which people were medically irradiated for both malignant and benign diseases). Following high-dose radiation therapy for malignant disease, the risk of secondary malignancy is relatively high. The relatively common use of radiation for benign disease between 1940 and 1960 resulted in a substantial relative risk (RR) of developing cancer. The third line of evidence comes from an increased risk of cancerspecific mortality associated with exposure to medical ionizing radiation, for both the recipients of diagnostic X-rays and X-ray Opisthorchis viverrini parasitic flatworm This flatworm (fluke), which is found in Southeast Asia, can cause cholangiocarcinoma, or cancer of the bile ducts in the liver [172]. The flatworm is contracted when eating raw or undercooked fish, including salted, smoked, and pickled fish from parts of Thailand, Laos, and Cambodia. The infection usually is asymptomatic but can be detected by microscopic examination of the stool. It can be treated with antiparasitics [68]. people who now worry about microwaves and radio waves causing cancer. The electromagnetic energy produced by an X-ray machine or by a linear accelerator is called ionizing radiation, and the energy it produces can cause damage to human and animal DNA. Lowerenergy, non-ionizing forms of radiation, such as visible light, wireless networks (Wi-Fi), the energy from cell phone towers, and magnetic fields produced by electricity (including MRI machines) do not damage DNA and have not been found to cause cancer, although a great deal of research and discussion surrounds the topic [187]. personnel. This is one reason that public health interests have worked to lessen the radiation levels for many diagnostic X-rays over the years (with some exceptions), and why radiology staff wear dosimeters to monitor actual exposure to radiation. The report concluded, after a comprehensive review of the medical literature, that no dose of radiation should be considered completely safe, and attempts should be made to keep radiation doses as low as possible. Of note, there are some experts who believe that there might be very low radiation exposure levels (thresholds) below which no harm might be done. It is difficult to measure long-term effects from very low radiation exposures, and it would be unethical to do clinical trials in which people are deliberately exposed to low levels that could possibly cause harm. However, scientific consensus has established the Linear No-Threshold (LNT) model as the most practical one to guide policy and safety measures regarding ionizing radiation exposures. The LNT model assumes that even very low levels of ionizing radiation might cause harm and that the dose-relationship is linear: simply stated, the higher the exposure, the higher the risk [220]. The major sources of population exposure to ionizing radiation are medical radiation (including computed tomography [CT], fluoroscopy, nuclear medicine, and regular x-rays) and naturally occurring radon gas in the basements of homes (see Radon ). Limiting unnecessary CT scans and other radiation-based diagnostic studies as well as reducing radiation exposure doses for these studies are important prevention strategies [132,174,210]. Exposure to ionizing radiation has increased during the last two decades as a result of the dramatic increase in the use of CT scanning. The National Cancer Institute reports that exposure to ionizing radiation associated with CT is in the range where carcinogenesis has been demonstrated [50, 258]. Repeat exposure to radiation from medical imaging (mainly CT scans, but angiography and a few other techniques can use as much or more radiation) further increases cancer risk, assuming that risk is proportional to exposure [131]. One study found that half the subjects who were exposed to radiation from medical imaging underwent repeat imaging within three years. Overall, 0.2% of the nearly one million subjects followed for three years received doses above 50 milliseivert (msv) [89]. For comparison, the International Commission on Radiological Protection recommends a Page 19

22 limit of 50mSv per year for people who work with artificial ionizing radiation, with a five-consecutive-year maximum of 100mSv [306]. For reference, 1mSv is 1/1000 of a Sievert, which is an International System of Units measure for equivalent dose a measure of biological damage to living tissue from radiation exposure. The U.S. measures often use the rem as the basic unit of equivalent dose: 100 rems equals one Sievert; a millirem (mrem) is 1/1000 of a rem; and 1mSv is 100mrems [236]. Table 3: Comparative exposure to ionizing radiation [220, 245, 282]. Exposure or procedure Estimated exposure for an adult* Bone densitometry mSv Air travel per 1,000 miles 0.01mSv flown. Spine X-ray. 1.5mSv Head CT. 2mSv Background radiation, 3.1mSv average yearly U.S. exposure.** CT scan of abdomen and 10mSv pelvis. PET (Positron Emission 25mSv Tomography)/CT scan. Radiation therapy for cancer 20,000-60,000mSv treatment. *These are typical for average-sized adults but will vary based on size and practices. **This will be somewhat lower for people at sea level and higher at higher altitudes; it also varies by radon emission from the ground. This total adds the average cosmic radiation and radon gas exposures. One approach to estimate the potential contribution of exposure to ionizing radiation from medical imaging is to develop statistical models based on the estimated cancer risks associated with a range of dose levels. For example, one estimate that looked at CT scans performed in the U.S. in 2007 predicted that 29,000 (95% confidence interval: 15,000 45,000) cancers might result. One-third of the projected cancers were caused by CT scans done on individuals aged 35 to 54 years. This estimate was derived from risk models based on organ-specific radiation doses from national surveys, frequency of CT scans in 2007 by age and sex from survey and insurance claim data, and the National Research Council s Biologic Effects of Ionizing Radiation VII report [50]. Data are now emerging from studies large enough to directly estimate the cancer risk associated with CT scans. For example, in a cohort of 10.9 million Australians, electronic medical records were used to Ultraviolet radiation The sun is a source of the full spectrum of ultraviolet (UV) radiation, which is a type of electromagnetic radiation above visible light, and a known cause of skin cancer. Sunlamps and tanning beds or booths all give off UV radiation, and the International Agency for Research on Cancer classifies tanning devices as carcinogenic in humans. The National Toxicology Program also states that exposure to sun lamps or tanning beds is known to be carcinogenic to humans. The US FDA requires that all tanning devices have warning labels indicating that the use of the device is contraindicated in people under age 18 or those with skin lesions or open wounds. The warning labels further say that they should not be used by people who have had skin cancer or who have a family history of skin cancer, and that people repeatedly exposed to UV radiation should be regularly evaluated for skin cancer [23]. Page 20 document the diagnostic CT scans of youths who received the CT scans when they were aged 0-to-19 years. This cohort was then linked to the National Death Index and Australian Cancer Database [123]. Compared with those who did not have a CT scan, those who had at least one CT scan were statistically significantly more likely to be diagnosed with cancer as they were followed into young adulthood (RR, 1.24; 95% confidence interval, ; average follow-up in those who had a CT was 9.5 years). A significant dose-response relationship was observed, with cancer risk increasing with each additional CT scan. Thus, the findings of cohort studies with directly measured CT scans now substantiate the statistical models and document the real-world cancer risks associated with exposure to ionizing radiation via medical imaging [148]. Evidence-based practice: Biphasic and repeat CT scanning can increase a person s cancer risk over time. While CT may be an essential part of follow-up monitoring in many cancer patients, it should be kept to a minimum, especially in younger people. MRIs and lower-radiation scans might be acceptable substitutes in some cases [145]. Radiation therapy uses much higher doses than imaging studies to treat cancer, and it carries some future risk of cancer in patients treated with it. If radiation is used in children and teens, the risk of future cancer is higher than when it is used in adults, which in turn is higher than the risk for elderly patients. It is important to be sure that patients scheduled for radiation therapy, especially younger patients, understand the expected benefits and potential risks associated with radiation treatment [187]. Radon ionizing radiation from the ground Radon is a radioactive gas given off by rocks and soil. Radon is formed when the radioactive element radium breaks down. Radium is formed when the radioactive elements uranium and thorium break down. People who are exposed to high levels of radon have an increased risk of lung cancer [187]. Staff alert: Nurses, radiology technicians, and others who work with diagnostic scanning, nuclear medicine, and radiation therapy should have procedures, structures, and other measures to shield them from exposure to ionizing radiation. People who work in these settings should be carefully protected and monitored at all times to ascertain exactly their exposure [306]. People who live in an area with high levels of radon in rocks and soil may wish to test their homes for this gas. Home radon tests are easy to use and inexpensive. Most hardware stores sell test kits, and some university or county extension services (in cooperation with the U.S. Department of Agriculture) offer lower-cost testing. If high levels of radon are found in the home, there are many ways to lower the amount of radon to a safer level [187]. Exposure to UV radiation causes early aging of the skin, and skin damage that can lead to skin cancer. People who tend to burn rather than tan are more susceptible to many types of skin cancer, but skin cancer is found in people with all skin colors. UV radiation is commonly subdivided into UV-A and UV-B [136]. UV-A light rays have long been known to cause skin aging and wrinkles. For many years UV-A rays were not thought to be carcinogenic, but it is now known that UV-A rays penetrate the human skin more deeply than UV-B rays. Newer information is emerging that UV-A damages keratinocytes in the basal epidermis. This layer is where most skin cancers arise: basal cells and squamous cells are both types of keratinocytes, and cancers from these cells are the most common types of skin cancer. UV-A promotes the growth of

23 and may even initiate these types of cancers. Tanning beds put out large amounts of UV-A radiation [257]. UV-A can pass through most windows (depending on type of glass), and is not affected by altitude or weather [300]. UV-B rays are harmful, and are known to cause sunburn. Exposure to UV-B rays increases the risk of DNA damage and other cellular damage in all living organisms, not just humans. Fortunately, about 95% of UV-B rays are absorbed by the ozone in the Earth s atmosphere [136]. But the remaining percentage leaves plenty of cancer-causing UV rays to be absorbed by human skin [257]. UV-B rays are most intense from mid-spring through mid-fall in the U.S., and during the daytime between 10a.m. and 4p.m; however, UV-B rays can damage skin, or even burn it, year-round. This happens more in the southernmost parts of the U.S., at high altitudes, and on surfaces that reflect back sunlight, e.g. water, sand, snow, or ice [136]. UV-B rays are also associated with cataracts, but help the body make vitamin D, a necessary vitamin. UV-B rays do not significantly penetrate windows [300]. Intermittent versus cumulative UV exposure Most evidence about UV radiation exposure and the prevention of skin cancer comes from observational and analytical studies. Such studies have consistently shown that increased cumulative sun exposure is a risk factor for non-melanoma skin cancers, such as basal and squamous cell cancers [86,243]. Exposure to solar UV radiation is the major cause of non-melanoma skin cancers, which are by far the most common malignancies in humans [147]. But the relationship between UV radiation exposure and cutaneous melanoma is less clear than that of non-melanoma skin cancers. In Other carcinogens Any substance that is known to be able to cause cancer is classified as a carcinogen, but carcinogenesis is rarely simple. Many factors influence whether a person exposed to a carcinogen will develop cancer, including the amount, duration, and route of exposure as well as the person s age, and genetic background. Cancers caused by involuntary exposures to environmental carcinogens are most likely to be seen in subgroups of the population, such as workers in certain industries who may be exposed to carcinogens on the job [161]. In fact, that is the way a lot of causal links have been found workers who are exposed to a carcinogenic substance every workday for years are often the first ones found to have higher rates of a certain type of cancer, which often leads to a formal investigation of the substances to which they are exposed. The increased incidence in a small exposed group is much easier to detect and demonstrate than when scattered individuals are exposed occasionally, and might be unable to recall the exposure, even if s/he knew about it when it happened [56]. Some people wonder how many cancers are caused by involuntary (and possibly unknown) exposure to carcinogens in the environment. But this question cannot be answered with certainty. Some researchers have suggested that, in most populations, environmental exposures are responsible for a relatively small proportion of total cancers (less than four percent), whereas other researchers attribute a higher proportion (19 percent) to environmental exposures [161]. Of course, as health professionals we know that even ongoing exposure to carcinogens does not cause cancer in every person. Incidental or brief exposure, even to most of the known carcinogens, is not likely to significantly raise cancer cancer risk because risk is typically dose-related. We also know that there are specific routes of exposure that are most likely to cause problems, i.e. routes the carcinogen is absorbed into the body and the type or types of cancer it can cause. For instance, daily exposure to cigarette smoke by deliberate inhalation is clearly much more likely to produce cancer the case of melanoma, it seems that intermittent acute sun exposure leading to serious sunburn is more important than cumulative sun exposure [93]. Sunburn sustained during childhood or adolescence may be particularly important [113]. And it is also important to know that acral lentiginous melanoma, a very aggressive form of melanoma that usually forms in areas not often exposed to sunlight such as mucous membranes, the palms, soles of the feet or under nails, is much more common among darker-skinned people [256]. Immunosuppression Medications that suppress the immune system are associated with an increased cancer risk. Many people who receive organ transplants take immunosuppressant drugs to ensure the body will not reject the organ. These medications make the immune system less able to detect and destroy cancer cells or fight off infections that cause cancer [85,148]. Research has shown that transplant recipients are at increased risk of a large number of different cancers. Some of these cancers can be caused by infectious agents, whereas others are not. The four cancers which occur more commonly in transplant recipients than in the general population are non-hodgkin s lymphoma (NHL) and cancers of the lung, kidney, and liver. NHL can be caused by Epstein-Barr virus (EBV) infection, and liver cancer by chronic infection with the hepatitis B (HBV) and hepatitis C (HCV) viruses. Lung and kidney cancers are not generally thought to be associated with infection [170]. Infection with HIV weakens the immune system and increases the risk of certain cancers, especially those that are caused by infections (see section Infectious Agents ). HIV infection is also linked to increased risks of cancers that are not thought to be caused by infectious agents, such as lung cancer [170]. than occasional exposure to smoke from a wood fire. People who work with carcinogens every day and do not wash up or use protective equipment are more likely to develop cancer than the hobbyist who is only exposed every few months. Painful questions about a loved one s cancer can mean that patients and families read online stories and theories that arouse fears about everyday exposures. Those who do nothave cancer (or those who have completed treatment) often want to know how to avoid all possible carcinogenic exposures in the future to further protect their health. There is a lot of easy-to-find information online that may seem plausible to the layperson, even though it it has no scientific basis at all. Other online sources raise questions and voice concerns, but do not have much to go on. This is why nurses need to be able to find proven, up-to-date information. Organizations with evidence-based information on cancer and carcinogens A great deal of reliable data for healthcare professionals can be found online. The National Cancer Institute has recommendations on where to look for source information [161]: Since 1971, the International Agency for Research on Cancer (IARC) has evaluated all manner of studies on more than 900 agents, including chemicals, complex mixtures, occupational exposures, physical agents, biological agents, and lifestyle factors. Of these, more than 400 have been identified as carcinogenic, probably carcinogenic, or possibly carcinogenic to humans. The IARC also keeps files on those that are not considered to be carcinogenic, which can be quite helpful in eliminating possible risk factors. The U.S. National Toxicology Program (NTP) has classified 56 substances or exposures as carcinogenic, and nearly 200 more as reasonably anticipated to be human carcinogens. The American Cancer Society also has a special Known and Probable Human Carcinogens list pooled from both of these reliable sources Page 21

24 and listed on a single web page ( along with background information about carcinogens. But to find specifics about a suspect carcinogen (study summaries, routes of exposure, etc.) professionals will still want to see the more detailed reports on the substance or exposure on the IARC or NTP websites [32]. Evidence-based practice: Find reliable, well-researched information and full background research reports about known and suspected carcinogens online at the U.S. National Toxicology Program (NTP) and the International Agency for Research on Cancer (IARC), at and monographs.iarc.fr/, respectively [161]. For substances that cannot be found listed as carcinogens on either of these lists, the first step is to look for other names for the substance. Sometimes the chemical name listed in the reports is not exactly the same one found in other sources. Search engines can often help find information on reliable science websites that list multiple synonyms and common names for chemicals. Having a list like this can help find research-based information for patients with possible carcinogen exposure, or help them to find information for themselves. The U.S. National Cancer Institute (NCI) has information about what causes cancer. See The NCI has links to the Inherited genetic changes There are a number of genetic syndromes which increase cancer risk that can be inherited. A few of the more common ones are discussed here. BRCA1, BRCA2, and breast cancer BRCA1 and BRCA2 are human genes that produce tumor suppressor proteins. When either of these genes is mutated, DNA damage may not be repaired properly. Given that inherited mutations are present in every cell of the body, there are many cells available that will be more specialty groups like the U.S. National Toxicology Program (NTP) and the International Agency for Research on Cancer (IARC), which is part of the World Health Organization. There is also access to good research in websites like PubMed, gov/pubmed/, (see section Resources for Nurses or Disproven Carcinogens and Other Cancer Myths ). Age Advancing age is the most important risk factor for cancer overall, and for many individual cancer types (Figure 1). According to the most recent statistical data, the median age of a cancer diagnosis is 66 years. This means that half of cancer cases occur in people below this age and half in people above this age. One-quarter of new cancer cases are diagnosed in people aged 65 to 74 [137]. A similar pattern is seen for many common types of cancer. For example, the median age at diagnosis is 61 years for breast cancer, 68 years for colorectal cancer, 70 years for lung cancer, and 66 years for prostate cancer [137]. Of course, cancer can occur at any age. For example, bone cancer is most frequently diagnosed among people under age 20, with more than 25% of cases occurring in this age group. And 10% of leukemias are diagnosed in children and adolescents under 20 years of age, whereas only 1% of cancer overall is diagnosed in that age group. Some types of cancer, such as neuroblastoma, are more common in children or adolescents than in adults [137]. likely to develop additional genetic alterations that can lead to cancer. Certain inherited mutations in BRCA1 and/or BRCA2 increase the risk of breast and ovarian cancers, and they are linked to increased risks of some other types of cancer. Breast and ovarian cancers in women with BRCA1 and BRCA2 mutations tend to develop at younger ages than in those without these mutations [140]. A woman s lifetime risk of developing breast and/or Figure 1. Percent of New Cancers by Age Group: All Cancer Sites. SEER , adapted from NCI. All Races, Both Sexes [137]. Page 22

25 ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2 [140]: Breast cancer: About 12% of women in the general population will develop breast cancer sometime during their lives [103]. By contrast, 55-65% of women with a harmful BRCA1 mutation and around 45% of women with a harmful BRCA2 mutation will develop breast cancer by age 70 [43,75]. Ovarian cancer: About 1.3% of women in the general population will develop ovarian cancer sometime during their lives [103]. In contrast, 39% of women who inherit a harmful BRCA1 mutation and 11-17% of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by age 70 [43,75]. Mutations in BRCA1 and BRCA2 account for around 15% of all ovarian cancers [235]. Harmful mutations in BRCA1 and BRCA2 increase the risk of several cancers in addition to breast and ovarian cancer. BRCA1 mutations may increase a woman s risk of developing fallopian tube and peritoneal cancer [52,91]. Men with BRCA2 mutations, and to a lesser extent BRCA1 mutations, are also at increased risk of breast cancer [267]. Men with harmful BRCA1 or BRCA2 mutations have a higher risk of prostate cancer, and men and women with BRCA1 or BRCA2 mutations may be at increased risk of pancreatic cancer [120,90]. Who should be tested for BRCA mutations? Because harmful BRCA1 or BRCA2 gene mutations are relatively rare in the general population, mutation testing of individuals who do not have cancer should be performed only when the person s individual or family history suggests the possible presence of a harmful mutation in BRCA1 and/or BRCA2 [140]. In December 2013, the U.S. Preventive Services Task Force recommended that women who have family members with breast, ovarian, fallopian tube, or peritoneal cancer be evaluated to see if they have a family history that is associated with an increased risk of a harmful mutation in one of these genes [296]. Family history factors that are linked with an increased likelihood of having a harmful mutation in BRCA1 or BRCA2 include [140]: Breast cancer diagnosed before age 50. Cancer in both breasts in the same woman. Both breast and ovarian cancers in either the same woman or the same family. Multiple breast cancers. Two or more primary types of BRCA1- or BRCA2-related cancers in a single family member. Men with breast cancer. Ashkenazi Jewish ethnicity (i.e. ethnic Jews whose families came from Eastern Europe, which constitute the majority of ethnic Jews in the U.S.). People who meet one or more of the above criteria should be referred to genetic counseling for exploration and informed consent. They will learn about the best way to go about the process, other options, what kinds of results might be returned, and what this might mean before they make the decision for the actual test [140]. Risk reduction for those with a BRCA mutation There are actions, such as surgery or drugs, that people with harmful BRCA mutations can take to reduce their risk of BRCA-related cancers. Prophylactic surgery involves removing as much of the atrisk tissue as possible, such as breast and ovarian tissue. Removing the ovaries also reduces the risk of breast cancer in premenopausal women by eliminating a source of hormones that can fuel the growth Chronic inflammation Inflammation is a normal physiological response that causes injured tissue to heal. An inflammatory process starts when chemicals are released by damaged tissue. In response, white blood cells make and release substances that cause cells to divide and rebuild tissue to help of some breast cancers. Typically, this can wait until the woman has completed childbearing. Even surgery does not guarantee that cancer will not develop because not all of the at-risk tissue can be removed. Still, research showed that women who underwent bilateral prophylactic salpingo-oophorectomy had a nearly 80% reduction in risk of dying from ovarian cancer, a 56% reduction in risk of dying from breast cancer, and a 77% reduction in risk of dying from any cause [82,91]. Drugs and medications can reduce breast cancer risk Data from three studies suggest that tamoxifen may be able to help lower the risk of breast cancer in BRCA1 and BRCA2 mutation carriers, including the risk of cancer in the opposite breast among women previously diagnosed with breast cancer [111,96,239]. Oral contraceptives are thought to reduce the risk of ovarian cancer by about 50% both in the general population and in women with harmful BRCA1 or BRCA2 mutations [128]. Evidence-based practice: Women with harmful BRCA mutations can reduce their future breast cancer risk with medications and/or surgery [140]. Enhanced screening can reduce mortality risk The addition of MRI of the breasts to the annual mammography can be used to improve early detection of breast cancers and improve outcomes of treatment [12]. People who have BRCA1 or BRCA2 mutations might also want to enroll in clinical trials open to people with these mutations. Genetic disease and colorectal cancer A small percentage (5-10%) of colorectal cancers (CRCs) occur in people with a genetic predisposition, including familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch Syndrome [21]. That small percentage is only because these genetic syndromes are fairly rare. A person with FAP develops hundreds to thousands of polyps starting as early as the teen years, so screening with colonoscopy is started very early. CRC can develop before age 20 and many cancers can develop during the person s lifetime so that colectomy is sometimes performed to prevent them. The person with FAP is at higher risk of other cancers, especially in the GI tract, but their CRC cancer risk alone is nearly 100% by age 40 [21]. A person with Lynch Syndrome runs a nearly 80% lifetime risk of developing CRC, along with a higher risk of stomach cancer. Women with Lynch Syndrome also have a 50% lifetime risk of endometrial cancer, along with a higher risk of ovarian cancer [62]. Other risk factors for CRC are less important than age, genetics, and family history, but include excessive alcohol use, smoking, diabetes, and obesity. Individuals with Ashkenazi Jewish heritage also have a higher risk of CRC [19]. These risk factors alone do not bump a person into the high-risk category, but they can offer opportunities for selecting a preventive type of colorectal cancer screening (see section Cancer Screening Tests ). Family history Even patients without known or suspected genetic predispositions to cancer may have an elevated risk based on family history. Whether this is in part due to family behaviors or habits, or subtler genetic differences is unclear, but it is possible that either or both play a role [60]. repair the injury. Once the wound is healed, the inflammatory process ends [154]. In chronic inflammation, the inflammatory process may begin even if there is no injury, and it does not end when it should. Why the Page 23

26 inflammation continues is not always known. Chronic inflammation may be caused by infections that do not go away, abnormal immune reactions to normal tissues, or conditions such as obesity. Over time, chronic inflammation can cause DNA damage and lead to cancer. For Sex Hormonal influences mean that women are much more likely to get breast cancer than men. Obviously, women do not develop prostate cancer nor men ovarian or uterine cancer. There are some cancers which affect both sexes that predominate in one sex or the other, but nothing that skews quite as much as breast cancer, which women are nearly 100 times more likely to develop than men. Some of the increased incidence of one sex or another relates to specific behaviors [125]. For example, men developed lung cancer a lot more than Disproven carcinogens and cancer myths Below are some of the popular theories about cancer causation that have been investigated. Either no evidence was found to support these hypotheses or evidence that specifically does not support them was found. A positive attitude can beat (or prevent) cancer To date, there is no convincing scientific evidence that links a person s attitude to his or her risk of developing or dying from cancer [158]. It is normal for people with cancer to feel sad, angry, or discouraged sometimes; cancer often brings a number of losses (such as body image, changes in relationships, changes in self-efficacy, fertility and sexuality changes, concerns over their ability to perform important tasks or functions, among others) that must be grieved. This process can take months or even longer. Not only is this myth false, it can cause emotional harm. Jimmie Holland, a psychiatrist who pioneered mental health care for people with cancer, coined the phrase the tyranny of positive thinking. According to her observations, our expectations of a cheery outlook and condemnation of any sign of sadness or anger constitute an additional burden on the person with cancer. For many people, being expected to be cheerful and upbeat all the time is profoundly discouraging and in some cases, guilt-producing, when they are unable to be positive all the time [102]. Worse, the popular interpretation of the mind-body connection sometimes blames the patient s attitude or emotional state for his or her cancer. There are people who truly believe that if they allow themselves to feel distressed, angry, or upset it will make their cancer grow faster [102]. It is true that it can be helpful to patients to approach treatment with the idea that they can get through it; people with self-efficacy might be more likely to adhere to their cancer treatment regimen, maintain social connections, and stay active. But adherence to the treatment regimen is likely to be the most important component in healing and recovery [158]. Patients who have concerns over their negativity should be informed very clearly that feeling sad, angry, or depressed did not cause their cancer and does not make cancer grow. Mind over matter does not work well with nausea, fatigue, and other aspects of cancer. All other factors being equal, pessimistic people do just as well with cancer as optimistic ones. It is unfortunate that many patients are afraid to allow themselves to feel distressed, but until that myth fades into the background, health professionals may have to keep telling patients that it will not affect their outcome if they allow themselves have negative emotions. Sugar feeds cancer feeds cancer (or makes it grow) This is a common Internet myth that many patients will undoubtedly repeat or ask about. Nurses are aware that normal cells require glucose to function, and that the body can turn almost any kind of food into glucose if needed. Although research has shown that cancer cells Page 24 example, people with chronic inflammatory bowel diseases, such as ulcerative colitis and Crohn disease, have an increased risk of colon cancer [154]. women, but after women began smoking at higher rates, their lung cancer incidence increased as well. Smoking rates in women never quite reached the same level as men, and lung cancer is still somewhat less common in women than in men. Men get more oropharyngeal, urinary, rectal, liver, and skin cancers, as well as leukemias and lymphomas; women get more thyroid and anal cancer. Overall, more women get cancer each year, but more men die from it [14]. consume more glucose than normal cells, no studies have shown that eating sugar will cause cancer, or make it worse. No studies have shown that, if a person stops eating sugar, their cancer will shrink or disappear [158]. However, a high-sugar diet can contribute to excess weight gain, and obesity is associated with an increased risk of developing several types of cancer. But there are many other factors that cause people to gain weight, which have the same effect [158]. It might become a problem when a patient eats so much processed sugary or starchy food that more nutrient-dense foods like whole grains, fruits, and vegetables, are neglected, but having occasional sweets along with a healthy diet does not cause cancer or hinder its treatment. Cancer surgery or biopsy causes cancer to spread The chance that surgery will cause cancer to spread to other parts of the body is extremely low. Following standard procedures, surgeons use special methods and take many steps to prevent cancer cells from spreading during biopsies or surgery to remove tumors. One example is that if they must remove tissue from more than one area of the body, they use different surgical tools for each area [158]. This myth might have begun when others saw a person they thought was healthy get observably worse after surgery or a biopsy, without knowing that the person already had metastatic cancer before the procedure (and indeed, would not have had the procedure at all if they were not symptomatic in some way). Cancer gets worse if exposed to air Exposure to air will not make tumors grow faster or cause cancer to spread to other parts of the body [158]. If this were true, surgery could never cure cancer, which as we all know it sometimes does. Like the above, this myth may come from observing someone who already had advanced cancer, who may feel worse (or whose cancer may continue to progress) after surgery. Artificial sweeteners cause cancer Researchers have conducted studies on the safety of the artificial sweeteners (i.e. sugar substitutes): saccharin (Sweet N Low, Sweet Twin, NectaSweet ); cyclamate; aspartame (Equal, NutraSweet ); acesulfame potassium (Sunett, Sweet One ); sucralose (Splenda ); and neotame, and found no evidence that they cause cancer in humans. All of these artificial sweeteners except for cyclamate have been approved by the Food and Drug Administration for sale in the U.S. [158]. Cell phones cause cancer According to the best studies completed so far, this does not appear to be true. Cancer is caused by genetic mutations, and cell phones emit a type of low-frequency energy that does not damage DNA [158]. Power lines cause cancer Power lines emit both electric and magnetic energy. The electric energy emitted by power lines is easily shielded or weakened by walls

27 and other objects. The magnetic energy emitted by power lines is a low-frequency form of radiation that does not ionize molecules or damage DNA [158]. Antiperspirants or deodorants cause breast cancer The best studies so far have found no evidence linking the chemicals typically found in antiperspirants and deodorants with changes in breast tissue [158]. Many people also believe that toxins are released through sweat, and that these can build up when a person uses antiperspirant. There is no biological basis for this, since sweat consists of fluids and electrolytes, and does not secrete toxic substances. Dying your hair causes cancer There is no convincing scientific evidence that personal hair dye use increases the risk of cancer. Some studies suggest, however, that hairdressers and barbers who are regularly exposed to large quantities of hair dye and other chemical products may have an increased risk of bladder cancer [158]. Cancers are typically named for the organs or tissues where the cancers form. For example, lung cancer starts in cells of the lung, and brain cancer starts in cells of the brain. Cancers also may be described Types of cancer by the type of cell that formed them, such as an epithelial cell or a squamous cell [202]. Cell-specific types of cancer These are the most common types of cancer by cell type. This is the terminology that is found on pathology reports and can be used to help patients understand these reports. Carcinoma Carcinomas are the most common type of cancer. They are formed by epithelial cells, which cover the inside and outside surfaces of the body. Epithelial cells often have a column-like shape when viewed under a microscope, but there are many types of epithelial cells. Carcinomas that begin in different epithelial cell types have even more-specific names: Adenocarcinoma is a cancer that forms in glandular epithelial cells, which produce fluids or mucus. Most cancers of the breast, colon, and prostate are adenocarcinomas. Basal cell carcinoma is a cancer that begins in the lower or basal layer of the epidermis. Squamous cell carcinoma is a cancer that forms in squamous cells, epithelial cells that lie just beneath the outer surface of the skin. Squamous cells are also found in organs like the stomach, intestines, lungs, bladder, and kidneys. Squamous cells look flat, like fish scales, when viewed under a microscope. Squamous cell carcinomas may also be called epidermoid carcinomas. Transitional cell carcinoma is a cancer that forms in a type of epithelial tissue called transitional epithelium, or urothelium. This tissue, which is made up of many layers of epithelial cells that can get bigger and smaller, is found in the linings of the bladder, ureters, the renal pelvis, and a few other organs. Some cancers of the bladder, ureters, and kidneys are transitional cell carcinomas [202]. Sarcoma Sarcomas are cancers that form in bone and soft tissues, including muscle, fat, blood vessels, lymph vessels, and fibrous tissue such as tendons and ligaments. Soft tissue sarcoma forms in soft tissues of the body, including muscle, tendons, fat, blood vessels, lymph vessels, nerves, fibrous tissues such as tendons and ligaments, and the tissue around joints. The most common types of soft tissue sarcoma are leiomyosarcoma, Kaposi s sarcoma, malignant fibrous histiocytoma, liposarcoma, and dermatofibrosarcoma protuberans. Osteosarcoma is the most common cancer of bone [202]. Leukemia Cancers that begin in the blood-forming tissue of the bone marrow are called leukemias. Large numbers of abnormal white blood cells (leukemia cells and leukemic blast cells) proliferate in the blood and bone marrow, crowding out normal blood cells. Low numbers of normal blood cells can result in anemia, thrombocytopenia, and leukopenia, which can cause fatigue, hypoxia, abnormal bleeding, and an increased risk of infection. There are four common types of leukemia, which are grouped based on how the speed of disease progression (acute or chronic) and on the type of hematopoietic cell the cancer starts in (i.e. lymphoblastic or myeloid) [202]. Lymphoma Lymphoma is cancer that begins in T lymphocytes or B lymphocytes (commonly called T cells and B cells). These white blood cells normally help fight infection and are part of the immune system. In lymphoma, abnormal lymphocytes build up in lymph nodes, lymph vessels, and other organs of the body. There are two main types of lymphoma [202]: Hodgkin s lymphoma: People with this disease have abnormal lymphocytes that are called Reed-Sternberg cells. These lymphocytes usually originate from B cells. Non-Hodgkin lymphoma: This is a large group of cancers that start in lymphocytes. The cancers can grow quickly or slowly and can originate from B cells or T cells. Multiple myeloma Multiple myeloma begins in plasma cells, another type of immune cell. The abnormal plasma cells, called myeloma cells, crowd the bone marrow and form tumors in bones all through the body. Multiple myeloma is also called plasma cell myeloma and Kahler disease. Melanoma Melanoma is cancer that begins in cells that become melanocytes, which are specialized cells that make melanin (the pigment that gives skin its color). Most melanomas form on the skin, but melanomas can also form in other pigmented tissues, such as the eye [202]. They can also form under the nails and more rarely, on mucous membranes such as the mouth or genital and perianal areas [33]. Brain and spinal cord tumors There are different types of brain and spinal cord tumors. These tumors are named based on the type of cell in which they formed and where the tumor first formed in the central nervous system. For example, an astrocytic tumor begins in star-shaped brain cells called astrocytes, which help keep nerve cells healthy. Brain tumors can be benign or malignant, but any that continue to grow can be life-threatening [202]. Less common cellular-based cancer types Germ cell tumors: Germ cell tumors begin in the cells that normally give rise to sperm or eggs in the testes or ovaries. These tumors can occur almost anywhere in the body (because germ cells can develop in other parts of the body), although extragonadal germ cell tumors happen most often in the pineal gland, mediastinum, or retroperitoneum. They can be either benign teratomas or malignant (seminomas and nonseminomas) [162]. Neuroendocrine tumors: Neuroendocrine tumors arise from cells that release hormones into the blood in response to a signal from the nervous system. These tumors, which may make higher-than- Page 25

28 normal amounts of hormones, can cause many different symptoms. Neuroendocrine tumors may be benign or malignant [202]. Carcinoid tumors: Carcinoid tumors are a type of neuroendocrine tumor. These slow-growing tumors are usually found in the gastrointestinal system (most often in the rectum and small intestine). Carcinoid tumors may spread to the liver or other sites in the body, and they may secrete substances such as serotonin or prostaglandins, causing carcinoid syndrome [202]. Carcinoid syndrome occurs in about 10% of people with these tumors, Signs and symptoms of cancer Nursing consideration: Most cancers are asymptomatic until they are at an advanced stage. This is why the American Cancer Society, the U.S. Preventive Services Task Force, and other health organizations have specific recommendations about screening asymptomatic people for common types of cancer. Certain cancers are visible almost from the beginning. Skin cancer and melanomas, for example, are often found by the patient. Like most cancers, early intervention increases the chance of survival and decreases the risk of complications of treatment. Typically, very early cancers do not cause pain or other noticeable symptoms. Patients often take pain more seriously than other symptoms, and should be encouraged to see their primary care providers if they have a kind of pain that is new to them, especially if it persists. Cancer can cause pain, along with many other different kinds of signs and symptoms. What the patient is likely to notice in the way of symptoms depends on what type of cancer it is, how advanced it is, and where it is located in the body (see the subsection Does metastatic cancer have symptoms? in the section How does cancer spread? ). Signs and symptoms can mean a lot of things, and there is a difference between the two. A sign is something that can be observed by others, such as skin lesions or abnormal breath sounds. A symptom is something that the person notices but it may not be easy to observe by others, such as tiredness or headache. This is by no means an exhaustive list, but it does cover some of the more common signs and symptoms related to cancer [38,198]. Skin changes, such as: New mole or a change in an existing mole. A lesion or sore that does not heal. Hyperpigmentation. Jaundice. Hirsutism (excessive or abnormal hair growth). Breast changes, such as: Change in size or shape of the breast or nipple. Change in texture or color of breast skin. A thickening or lump (in lymph nodes or other soft tissues). Hoarseness or cough that does not go away. Changes in bowel habits. Difficult or painful urination. Problems with eating, such as: Dyspepsia or other discomfort after eating. Dysphagia (trouble swallowing). Anorexia. Weight gain or loss with no known reason. Abdominal pain. Unexplained night sweats. Unusual bleeding or discharge, including: Blood in the urine. Vaginal bleeding (especially after menopause). Blood in the stool. Fatigue or weakness. and depending on where it is and where it has spread can cause symptoms like: flushing of the face, usually without sweating; abdominal pain or cramping; diarrhea; wheezing or dyspnea; and tachycardia [95]. These symptoms, especially the flushing and diarrhea, may be triggered or exacerbated by stress, alcohol, or foods containing tyramine (such as aged cheeses or pickled meats) [95]. Carcinoids that affect the small intestine can also cause nausea, vomiting, jaundice, dyspepsia, and bloating [166]. It is important that patients know that most often, these signs and symptoms are not due to cancer. They may also be caused by benign tumors, infections, or other problems. But patients should know that if they persist for a couple of weeks, that it is a good idea to seek care so that abnormalities can be diagnosed and treated as early as possible [198]. Women older than 21 years, and men and women aged 50 or older should begin cancer screening tests. If your patient has a family history of cancer (especially in first degree relatives), or some other risk factor, there may be special screening guidelines that apply to them. A first-degree relative is defined as a biological parent, child, or sibling of the patient. A history of cancer in a first-degree relative is typically more significant to the patient s cancer risk than cancer in another family member (see Cancer Screening Guidelines ). Tissue changes that are not malignant Some genetic mutations in cells will eventually cause cancer unless they are detected early. Some tissue changes are benign, and may not require treatment at all unless they cause other problems. Here are some examples of tissue changes that are not cancer, but in some cases, are treated or at least monitored [202]: Hyperplasia occurs when cells within a tissue divide faster than normal and extra cells are produced. These proliferative cells and the way they are organized within the tissues look normal under a microscope. Hyperplasia can be caused by a number of conditions, including chronic irritation. Dysplasia is a more serious condition than hyperplasia. In dysplasia, there is also a proliferation of extra cells. But in dysplasia, the cells look abnormal and there are changes in how they are organized in the tissue. In general, the more abnormal the cells and tissue look, the greater the chance that cancer will eventually develop. Some types of dysplasia may need to be monitored or treated. An example of dysplasia is an abnormal mole (such as a dysplastic nevus) that forms on the skin. A dysplastic nevus can develop into melanoma, although most do not. An even more serious condition is carcinoma in situ. Although it is sometimes called cancer, carcinoma in situ is not cancer because the abnormal cells have not grown or spread beyond the original tissue. Because some carcinomas in situ may become cancer, they are usually treated or removed. However, they are not generally reported to cancer registries as cancer. Benign tumors and brain tumors Unlike malignant tumors, benign tumors do not spread into, or invade, nearby tissues. Although they are sometimes quite large, they usually do not grow back when they are removed, whereas malignant tumors can [202]. Brain tumors are a special exception. Unlike most benign tumors elsewhere in the body, benign brain tumors can become life threatening simply by pressing on vessels and tissues in the brain nearby. Because it is encased in the skull, brain tissue has nowhere to expand in response to tumor growth. This pressure can result in tissue death, neurologic deficits, and fatalities if unchecked [202]. Page 26

29 Cancer staging Treatment depends on diagnosis (primary site and type of cancer) and stage. For example, early stage solid tumors can often be treated by surgery alone, while later stage ones may require chemotherapy and/ or radiation. Staging Stage refers to the extent of the cancer, such as tumor size, invasion, and metastases. Cancer treatments and prognosis are based on the cancer type and stage, and clinical trials are often limited by stage. A cancer is always referred to by the stage at diagnosis, even if it later progresses or metastasizes. Information about how a cancer has progresses over time is added to the original stage. How stage is determined To learn the stage of disease, procedures typically include imaging studies, lab tests, and biopsy. The biopsy may be taken with a needle, endoscope, incision, or incision. A pathologist looks at the tissue sample and does further testing on it [195]. Systems that describe stage There are many staging systems. The TNM staging system (below) is used for many types of cancer, while others are specific to a particular type of cancer. The stage information typically appears on the pathology report. Most staging systems include information about: Tumor location. Cell type. Tumor size. Lymph node involvement. Metastases to other organs. Tumor grade (how abnormal the cells look, which is a marker for aggressiveness). The TNM staging system: Most hospitals and medical centers use the TNM system as their main method for cancer reporting. Different staging systems are often used for brain and spinal cord tumors and blood cancers [195]. In the TNM system: The T refers to the size and extent of the primary tumor. The N refers to the number of nearby lymph nodes that contain cancer. The M refers to whether the cancer has metastasized. When cancer is described by the TNM system, there will be numbers after each letter that give more details about the cancer. For example, T1N0MX or T3N1M0. The following explains what the letters and numbers mean: Primary tumor (T): TX: Main tumor cannot be measured. T0: Main tumor cannot be found. Cancer treatment: Pretreatment assessment Health history, current illnesses, and future plans Health and family history: Before starting any cancer treatment, a full health history and summary of current medical conditions is required. This is important to review, even though the patient may have completed questionnaires and forms. Nurses report often that the patient does not always understand the terminology, and says different answers when the questions are asked in everyday language. This is a good time to ask if patients have had recent vaccines, surgery, dental problems, or other health issues. Follow up on details about any family history of cancer, especially in first-degree relatives (parent, sibling, child). It is especially important to know if the person has ever had cancer before and if so, when and what type it was, and how it was treated at that time; or if they have had radiation therapy. This may require getting release of information forms signed, since most patients cannot T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the more it has invaded nearby tissues. T s may be further divided to provide more detail, such as T3a and T3b, based on specific criteria for that cancer. Regional lymph nodes (N): NX: Cancer in nearby lymph nodes cannot be measured. N0: There is no cancer in nearby lymph nodes. N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. Distant metastasis (M): MX: Metastasis cannot be measured. M0: Cancer has not metastasized to other parts of the body. M1: Cancer has metastasized to other parts of the body. Stage grouping The TNM system describes the cancer in great detail. But the TNM information can also be grouped into five less-detailed stages, called stage groupings. The following summarizes the TNM information in a specific way that alludes to prognosis and treatment [195]. Table 4. The TNM system description of cancer. Stage Stage 0 Stage I, II, or III Stage IV Summary Abnormal cells are present but have not spread to nearby tissue (i.e.) It is not cancer, but might develop into cancer. Also called carcinoma in situ, or CIS. Cancer is present. The higher the number, the larger the cancer tumor and the more it has spread into nearby tissues. The cancer has metastasized to distant parts of the body. Another staging system that is used for many types of cancer groups the cancer into one of five main categories. This staging system is more often used by cancer registries than by oncologists. It is an alternate way to describe stages and may also be used informally [195]: In situ: Abnormal cells are present but have not spread to nearby tissue. Localized: Cancer is limited to where it started, no signs of metastasis. Regional: Cancer has metastasized to nearby lymph nodes, tissues, or organs. Distant: Cancer has metastasized to distant parts of the body. Unknown: Insufficient information to determine stage. provide enough detail. A cancer history can affect treatment choices since radiation and medications with cumulative dose toxicity might not be available for use due to concerns about effects on certain organs from past drug or radiation treatment. Co-morbid conditions can also affect cancer treatment choices and drug doses. Given that many people with cancer are older, there is greater likelihood of co-morbidities. Problems like cardiac arrhythmias, prolonged QT interval, congestive heart failure, lung disease, hypertension, diabetes, kidney disease, HIV, hepatitis B or C, and frequent heartburn or reflux can affect treatment. Drug allergies and intolerances can indicate possible issues with future cancer treatments. Medications and drug use: This assessment must also include daily meds plus a listing of p.r.n. medications, herbs, supplements, and recreational drugs the patient takes must be elicited. Drinking habits Page 27

30 and smoking are important too, as these can sometimes affect drug metabolism. Continuing to smoke can slow healing and increase certain toxicities of cancer treatment. If the patient smokes, this is a good time to assess the person s readiness to quit. Nursing consideration: To improve success and reduce side effects of cancer treatment, encourage patients to quit smoking before cancer treatment begins. Smoking cessations works best when the patient has emotional support with the mental part and pharmaceutical assistance to reduce withdrawal symptoms. It is essential that the professional nurse take such histories in a private location and in a non-judgmental fashion, especially when moving into a discussion of amounts of alcohol used each week, and use of illegal or non-prescribed drugs. This full drug/substance listing can be used, along with the treatment plan, in a drug interaction evaluation. Pregnancy and childbearing plans: It is important to ask about possible pregnancy and pregnancy risk in premenopausal women, since cancer treatment can cause birth defects, fetal wasting, and other harmful effects in the embryo. Men and premenopausal women should also be asked about any plans or thoughts about having children in the future. Patients will need to know that cancer treatment can sometimes cause infertility, and options become much more limited after treatment is started. Knowledge For informed consent purposes, this is a good time to check the patient s understanding of their diagnosis, prognosis, and plan of care, and to correct any misconceptions. By this time there will be a treatment plan of some sort, though it may be subject to changes. Most patients have had a chance to come up with concerns and questions (see also Informed consent and Resources for Patients ). Teaching: Tell the patient that they should let the nurse and the doctor know about any changes they make in the drugs or supplements they are taking. This necessitates the updating of the drug list and repetition of the drug interaction evaluation as well as any time before medication regimens are changed or when side effect management medications are to be added. It is helpful to explain to the patient that there are many drugs, including over-the-counter medicines and supplements that interact with each other in the body in very predictable ways. Some drugs interact with grapefruit and starfruit or with herbs like St. John s wort. Some of these interactions can be enough to cause problems with cancer drug treatments, such as sub-therapeutic drug levels or unexpected toxicities due to the high levels of drug in the body. It is a good time to ask the patient about supplements and herbs, and let them know that grapefruit can cause problems with a lot of medicines. There are other kinds of interactions, such as physical ones that patients may need to understand, e.g. that a calcium supplement or calcium based antacid cannot be taken within a certain number of hours of a drug dose because the calcium in the stomach prevents the drug s absorption. The action of some drugs causes problems with other drugs; for instance, some drugs requiring an acidic environment in the stomach, such as erlotinib, will not dissolve or absorb well when a person is taking stomach acid inhibitors, like proton pump inhibitors, which raise the ph of the stomach for many hours [241]. Interactions with foods are generally much better known, since food in the stomach can help some drugs absorb, but keep others from being absorbed. Most dietary supplements do not appear to cause harm during cancer treatment. For some time, herbal supplements were posited to be harmful when taken during chemotherapy or radiation therapy because high antioxidant levels might interfere with the mechanisms of chemotherapy and radiation. After a lot of debate on the matter, it was generally concluded that while more research is needed, there is little evidence of harm except to smokers receiving radiation therapy, who had shorter survival in a clinical trial where they took high doses Page 28 of beta carotene supplements than smokers who did not take them [51]. In one study, high doses of supplemental vitamin E (taken alone), were linked to a slightly higher rate of prostate cancer in men who had lower levels of selenium in the body [186]. Finally, St. John s wort can accelerate excretion of a number of drugs due to its induction of 2C9, 2C19, and 3A4 in the CYP-450 enzyme system [92]. This can make a number of drugs less effective (see drug interactions ). Different practices and facilities may have different ways to advise patients about these possibilities. Antidepressants and other drugs that affect serotonin levels can precipitate serotonin syndrome, especially when taken with other drugs which also affect serotonin levels, such as opioids, ondansetron, metoclopramide, and certain anticonvulsant drugs that may be used for adjuvant pain management. Sometimes these combinations can be avoided, but patients need to know what to watch for, such as mental status changes, neuromuscular changes (e.g. muscle rigidity, clonus, restlessness, shivering, tremor), and autonomic hyperactivity (e.g. sweating, diarrhea, flushing, tachycardia) so that preventive interventions can be taken quickly [53]. Many people who take these medicines every day (and often, even the doctors who prescribe them) are unaware of this potential problem. Finally, of course, drugs can interact by potentiating each other or magnifying the same effects, e.g. the CNS depressant effects of opioids and benzodiazepines, which can also potentiate those of other drugs or alcohol. Drug side effects During this period, it is also a good time to review common side effects with the patient and get an idea of how well informed they are regarding the risks and benefits of their proposed treatment. In some settings, patients may need to sign a consent form before they start cancer treatment, so the nurse will need to document teachings in the record. This is also a good time for information handouts and sharing reliable resources they can call or visit online with questions, such as the American Cancer Society and the National Cancer Institute (see Patient resources ). It is also a good idea to caution patients that there are a lot of unreliable information sources on the Internet, and many scammers, and useless treatments. Patients can learn more about these issues at the FDA s website, Informed consent for cancer treatment True informed consent is an exchange of information between the patient and provider, and can be revoked at any time. The patient, proxy, or guardian needs to know the diagnosis, proposed treatment, purpose of treatment, expected risks and benefits of the proposed treatment, possible alternatives to the proposed treatment and these likely outcomes (including no treatment), how long treatment is expected to last, and how treatment will affect their normal activities; all this before consenting to treatment. The patient should also be given the chance to ask questions, confer with family or others if needed, and be clearly informed that s/he can take back consent at any time even if a form is already signed. The patient should also understand that s/he will be kept up to date as things change or new information comes to light (for instance, if their labs require changes or delays in treatment, or if new clinical trial information becomes available about the drugs that are being used) [30]. Some practices use a consent form for cancer treatment and others do not, but a consent form cannot replace the process of informed consent. Informed consent starts well before the initiation of treatment, and is continued all the way through treatment completion. Whether or not a form is used, informed consent is an ongoing process over time [264]. For more detail, a modifiable informed consent discussion guide for cancer treatment can be downloaded at no cost from the American Society of Clinical Oncology (ASCO) website. The discussion guide has reminders of the main points that need to be covered and

31 documented in the patient record. For practices that are interested in a consent form, a modifiable example can be found there also (see Resources for Nurses ). Follow-up questions and unexpected problems It is also very important to be sure that the patient and family know how to reach their oncologist including nights, weekends, and holidays. This information, along with a list of what the patient should call regarding (and which concerns should be considered emergencies for immediate notice), should be given in writing. Nurses may have to emphasize this at each visit, as many patients are reluctant to bother the doctor, even if they have life-threatening complications. Cancer treatment Treatment settings The majority of oncology services has shifted to from an historically inpatient model to outpatient care [114]. Patients can receive cancer treatment as inpatients, at home, or as outpatients at a clinic, doctor s office, or hospital. No matter where treatment is given, the nurse and care team will need to check back with the patient often, watch for side effects and help the patient control or manage these [152]. This has a lot of implications for nurses. First, nurses have less time with the patient than with inpatient care, so s/he has less time to monitor, get feedback, assess, educate, or develop trusting relationships. Much of the time with the patient may be designated for tasks, which will be numerous and varied. Second, there is often less formal training for nurses and other staff, and less support toward this end due to smaller staff sizes and less funding. There may be less time alloted to patient preparation and monitoring [114]. Especially in smaller outpatient settings, healthcare professionals have lost some of the departments, procedures, and structures of support for basic patient safety. Professionals must bring the essential components forward, so that no matter where there are policies and procedures that delineate and support safe professional nursing practice. Given the high risks and difficult balances that come with cancer care, nurses and other healthcare professionals must be sure that there is a structure in place for outpatient facilities to maintain safe, effective, timely, and high-quality care. Safe and quality care requires the methods, means, and staff availability to assess and monitor the patient from beginning to end of cancer treatment, and even beyond. This is not just physical care; it is also imperative to have readily available tools to assess mental health and coping in patients and caregivers; prioritize for the most important educational needs; and set up straightforward methods for documenting those assessments and teaching. All cancer care facilities must meet standards of care for the protection of the patients. While hospitals have infection control departments that have policies, procedures, and resource professionals, the guidance is often less detailed, or even missing, in some outpatient settings. Outpatient facilities should have infection control and prevention policies and procedures as outlined by the Centers for Disease Control Basic Infection Control and Prevention Plan for Outpatient Oncology Settings: Minimum Expectations for Safe Care (updated November 2015) [65]. This document can be downloaded at no cost from the CDC website (see Resources for Nurses ). The document includes a helpful checklist to be sure that everything is addressed. The Infection Control Plan covers everything from staff training to vaccines and personal protective equipment, from managing patients or staff with symptoms of contagious illness to cleaning blood glucose monitors. All of these standards are important to patient (and staff) safety [65]. Drug interaction evaluation The full drug and supplement list from the history should be shared with the oncologist along with any new history information. The same list, along with cancer treatment medications and symptom control drugs proposed in the treatment plan should also be submitted to an expert on drug interactions who may be able to identify additional problem areas and propose possible solutions. Generally, the best consultant for this evaluation will be a clinical pharmacist. In some settings, the pharmacist is given time for direct patient teaching regarding medications and side effects, avoiding drug and food interactions, and more. Safety note: Always know the basics of a facility s infection control plan and how to contact the infection control coordinator at all times. The plan should meet the standard of care, be regularly updated, and be consistent with CDC recommendations, both for the safety of the care providers and the patients [65]. Even though the nurse is typically not the one writing the prescriptions, nurses are licensed professionals with a scope of practice for which they are responsible and even liable. As such, nurses must know if the prescription or order is safe and appropriate for the patient, for example: if it is the right drug for the patient s condition; if it is within the correct dosage range; if the drug might worsen the patient s condition; likely side effects; and that it is not contraindicated for any reason. Given its expansion, there has been special attention to quality of care in outpatient oncology practices. In 2010, the American Society of Clinical Oncology (ASCO) launched an initiative to recognize oncology and hematology-oncology practices that were committed to offering quality cancer care. The Quality Oncology Practice Initiative (QOPI) Certification Program (QCP) evaluates the performance of outpatient oncology or hem-onc practices in areas that affect patient care and safety. The QCP is a voluntary program that is based on the ASCO/ONS standards for safe chemotherapy administration. It certifies and enables practices to evaluate and improve the quality of care provided [94]. Since the initiative began, a good deal of observation and research on quality care and documentation in outpatient settings has been published. Calls have also been issued to standardize reporting and tracking of chemotherapy errors and events [118]. With data on the types of events that occur, it becomes possible to design new safety measures and prevention methods. No matter the setting, the nurse is responsible for safe handling of chemotherapy and other drugs. Home care nurses should be sure that patients know how to safely handle and dispose of chemotherapy at home [114]. This can be a challenge when juggling ways to promote adherence to home medications; this can often mean leaving reminders in visible locations, and ensure drugs are out of the reach of children and pets. Frequent follow-up, assessments, and check-ins are necessary to find out whether there are adherence problems or complications that could cause serious problems so that interventions can happen quickly. To remain competent and effective in the complex realm of oncology, nurses must actively keep informed on standards of care, changes in practice, guidelines for cancer care, drug dose ranges, medication toxicities, and an ever-changing array of equipment. According to the Oncology Nursing Draft Standards of Oncology Nursing Education, nurses must become and remain life-long learners [231]. Preparing for treatment: Pregnancy, fertility, and conception Treatment risks associated with pregnancy, fertility and conception Harm the fetus. must be addressed for women of childbearing age as well as men who Damage sperm. might want to father a child before cancer treatment begins. Many Cause temporary or permanent infertility. cancer treatments can: Page 29

32 Pregnancy during cancer treatment Cancer during pregnancy is fairly rare, occurring more often in cancers that occur at younger ages. For example, breast cancer occurs in approximately one in 3,000 pregnant women. Overall survival may be worse in these cases, possibly due to delays in diagnosis [143]. Cervical cancer is also sometimes discovered during pregnancy. Although early stage disease can be treated during the second trimester, more advanced disease (i.e. stages 2-4) is problematic because treatment is needed right away and the usual treatment (i.e. radiation) is toxic for fetuses. Neoadjuvant chemo has sometimes been offered to pregnant women with locally advanced disease after the first trimester, with surgery or radiation after delivery, but data is lacking on long-term outcomes for the mothers so it is unknown if this may pose more risk to the woman [151]. Avoiding pregnancy Women of child-bearing potential are typically tested for pregnancy before radiation therapy or chemotherapy is started, and effective birth control must be used throughout and for some months after treatment in order to avoid fetal damage from teratogenic or mutagenic effects of the radiation/chemo or other harmful effects. Little is known about effects on the fetus when men conceive during or soon after radiation treatment or chemo, but men are also typically advised to avoid conception during and for some months after treatment [7]. Women who are found to be pregnant before they start cancer treatment may still be able to have their cancer treated, but it must be carefully timed based on: how far along the pregnancy is; the type, location, and stage of the cancer; and the woman s wishes. The kinds of treatment with less fetal effect (such as surgery) may be done in early pregnancy, and some cancer treatment drugs can be given later in the pregnancy (after the first trimester), although they can restrict fetal growth and cause premature labor. It is best to work with an oncologist with some experience at treatment during pregnancy involved early in treatment planning [59]. Breastfeeding is generally not recommended during chemotherapy because drugs can be secreted in the breast milk that could affect the infant [143]. Fertility Women Women tend to have a more demarcated window in which they can bear children; however, it is still best to ask about future childbearing plans before treatment begins. Many types of cancer treatments carry the risk of infertility, but this varies by age, location of the cancer, and treatment regimen. Bone marrow and stem cell transplants usually cause infertility due to the pre-transplant regimen [25]. Especially in women older than 35, cancer treatment drugs can cause early ovarian failure with permanent infertility. In young women there may be amenorrhea that reverses after treatment with return of fertility, but they may still go on to have premature menopause. It is also important that women understand, that during treatment, menses do not always indicate fertility, as women can have menses while infertile; a woman can be fertile even when experiencing what appears to be amenorrhea. FSH levels are helpful in determining fertility after treatment. As noted above, pregnancy during most cancer treatments is not recommended and birth control is required, even during times the woman is not having menses [25]. Drug effects on fertility are often very hard to predict for any one woman, so women who know they want children despite chemotherapy may want to go ahead with cryopreservation of fertilized eggs unless they have religious or ethical objections to embryo preservation. Insurance does not always cover this procedure, which can be expensive [25]. Women Cancer surgery Surgery for cancer, especially early stage tumors, is sometimes the mainstay of treatment. With solid tumors, surgery is almost always a part of the treatment plan. Cancer surgery can have different goals, just Page 30 who object to embryo preservation or who do not have a male partner or sperm donor can opt to have unfertilized eggs frozen, but egg banking is a newer procedure. Because the eggs of younger women are more likely to be healthier and more plentiful, some centers have an upper age limit in the mid-thirties for egg freezing. This procedure should be done in centers with a record of experience and success [213]. There are also investigational procedures, like partial removal of the ovary for freezing, but the evidence to support this procedure is sparse. Insurance companies rarely cover these kinds of procedures, and they can be costly. Maintaining frozen tissue (e.g. embryos, eggs, or ovarian tissue) involves annual fees [25]. Pelvic or abdominal radiation can cause ovarian failure if enough radiation reaches the ovaries. Sometimes the surgeon can relocate the ovaries so that they are out of the radiation field, which improves the chances they will continue to function. However, radiation can cause uterine fibrosis as well, so that the uterus cannot expand enough for a full term pregnancy. Radiation to the brain can affect the pituitary gland, which can in turn interfere with hormonal signals to release eggs [25]. Hormone therapy for hormone-receptor-positive breast cancer is available to premenopausal women (e.g. tamoxifen) and is usually continued for five or more years after treatment, but this is contraindicated in pregnancy. Premenopausal women must use careful birth control to avoid pregnancy during treatment with tamoxifen if sexually active. Women who want to have children sometimes postpone this treatment until after pregnancy, or suspend it for a time and then resume it after delivery. Women who are postmenopausal and have hormone-receptor-positive breast cancer can use aromatase inhibitors, which are specifically to be avoided before menopause and during pregnancy [25]. Gynecologic cancers can mean surgical removal of part of the reproductive tract. Sometimes it is possible to preserve fertility, but this depends on a number of factors, including the type and stage of cancer [25]. Women who want more children should involve a fertility specialist in the early stages of cancer treatment planning, well before treatment begins, as it can take a few weeks to harvest ova. Men It is always best talk about future plans for children before cancer treatment starts. Some chemotherapy drugs are more likely than others to cause infertility, and men older than 40 may be less likely to recover fertility. Sperm production usually recovers, if at all, within four years. As in women, bone marrow or stem cell transplants often cause permanent infertility [24]. Radiation to the testicles or lower abdomen can harm sperm production. It is important for men to know that they should avoid impregnating anyone during radiation or chemotherapy and for some time afterward because of possible damage to the sperm. Surgery that removes the prostate or urinary bladder causes men to be unable to conceive during sex, although a fertility specialist might be able to extract sperm from the testes or epididymus. Men who have not yet started cancer treatment can bank sperm at any time. This does involve some costs, including annual fees to maintain the frozen sperm, but it allows great flexibility with future parenthood for up to 20 years out. Insurance plans rarely cover sperm freezing and storage [24]. Nursing consideration: Men and women who want to have biological children after cancer treatment should consider banking sperm, embryos, or eggs before starting cancer treatment [24,25]. like all cancer treatment. Depending on the type of cancer and how advanced it is, surgery can be used to [197]:

33 Remove the entire tumor: Surgery removes localized cancer and may check nearby organs and nodes for metastases for staging purposes. Debulk a tumor (cytoreduction): Surgery removes as much cancer as possible. Debulking is used when removing all of the cancer might cause organ damage. Removing part of it may be done before other types of treatment as neoadjuvant therapy. Palliate cancer symptoms: Surgery is used to remove tumors that are causing pain or pressure. Two other kinds of surgery and surgical procedures are often performed in people with cancer to manage cancer treatments and its effects [5]: Procedures to facilitate treatment: Vascular access devices, local drug delivery devices, peritoneal ports and other devices can be surgically placed to make treatments easier. Reconstructive surgery: Surgery is used to help restore the patient s appearance or function after cancer surgery. It is important that the patient understand the goal of surgery beforehand, and have an idea of postoperative expectations and management. People who still smoke should be offered ways to quit before surgery. Even though many people want to believe that there is no need to quit smoking after they are diagnosed with cancer, it is well documented that wound healing after surgery is slowed in smokers. Studies have shown that continued smokers also have a higher risk of cancer recurrence [194]. Surgical techniques to manage solid tumors are continuously evolving as new procedures are added. Robotic or robot-assisted surgery is common now, in which laparoscopic surgery is performed using robotic arms to control the instruments [5]. Some cancer surgeries have become less invasive as surgeons use laparoscopic surgery and endoscopy to remove cancerous lesions; some are even conducted on an outpatient basis. However, it is important to know that studies have not validated the equivalence of laparoscopic surgery in every instance, and that the surgeon s experience with that particular type of Radiation therapy Radiation, in high doses, kills or slows the growth of cancer cells, but also causes damage to normal cells. Radiation therapy is used with the following goals: Curative intent. Slow or stop the growth of cancer cells, to shrink a tumor before or during other types of cancer treatment. To kill remaining cancer cells after surgery or other treatment, to prevent recurrence. Palliative care (shrink tumors to treat pain, pressure, gut blockage or other symptoms). Radiation therapy does not kill cancer cells right away. It takes days or weeks of treatment before cancer cells begin dying and cancer cells keep dying for weeks or months after radiation therapy ends [188]. Nursing consideration: Helping patients understand the intent and goals of their radiation, chemotherapy, or surgical treatments can help them make better decisions about their preferences. This becomes critically important in advanced or refractory cancer and near the end of life. External beam radiation therapy External beam radiation therapy typically comes from a linear accelerator machine (also called a linac) that aims beams of ionizing radiation toward the cancer from different angles and locations on the body. Radiation is a local treatment but it affects skin and other organs and tissues in its path and can cause some systemic side effects [188]. Intraoperative radiation is an option for some; it is one large dose given during surgery so that radiation does not have to pass through skin [188]. surgery will affect outcomes. Initial cancer surgery for cancer in which multiple organs can be affected, like ovarian cancer, for example, often has two goals: to debulk the cancer, and to stage it. This calls for a surgeon with experience in oncologic debulking, who has expertise in finding and delicately removing abnormal tissue from multiple organs [36]. Open surgeries are typically required for debulking situations. There are also laser surgeries, cryosurgeries, electrosurgeries such as radiofrequency ablation, and other techniques. These procedures do not use a scalpel, but they use other types of energy (lasers, cold, or electricity) to cut or destroy tumor tissue [5]. Nursing management: After cancer surgery, as with other types of surgery, pain management, safety, and infection control are the first priorities. There is also the need to teach the patient about wound care, activities of daily living during recovery, and any specific procedures that will be needed after discharge (e.g. drain maintenance). There may also be body image issues, especially concerning for head and neck cancer, breast cancer, and any cancer surgery in which the results are publicly visible. Patients with mastectomy often need special instruction and exercise for range of motion in the affected upper extremity. Lymphedema is a possibility, especially if a full lymph node dissection was done. For many types of cancer surgery, the patient will want to know if the procedure got it all, and this may require a discussion between the patient and the surgeon. Sometimes the patient will need support and educational reinforcement in coping with the operative findings. Often, the outcome of the surgery will include more complete information on the stage of the cancer, although there may still be some delay for the biopsy (pathology) report, which is needed for the final stage grouping (see also Cancer Staging ). The final staging information often shapes the plan for further treatment as well as prognosis. Depending on the outcome, this can be overwhelming to the patient as s/he may be looking forward to an uneventful recovery or preparing for a long chemotherapy or radiation treatment, or starting hospice care. External beam radiation therapy begins by the patient meeting with the radiation oncologist for the treatment planning process. Planning begins with imaging of the tumor area and its surrounding tissue. CT scanning, MRI, PET, or ultrasounds may be used for this. This first meeting involves a simulation of the radiation treatment, during which time, body molds, face masks, and other devices are constructed to help hold the patient still and in the proper position during treatments. The radiation oncologist calculates the total radiation dose that will be delivered to the tumor and how much will be allowed to hit normal tissues around it as well as the paths that will be used. Temporary skin marks or tattoos may be used mark radiation ports (i.e. entry points on the skin with which beam radiation is aligned) throughout the course of treatment [188]. It is important to offer patients who smoke help in quitting before radiation treatments begin. In a study of patients with advanced head and neck cancer who underwent radiation therapy, patients who continued to smoke during radiation therapy suffered mucositis for a longer time (23.4 weeks) than patients who quit at the time of radiation therapy (13.6 weeks) or patients who did not smoke for at least a month after treatment (18.3 weeks) [252]. People who continue smoking heal more slowly and are more likely to have additional cancer(s) in the future [194]. Most people have external beam radiation therapy with the same dose of radiation once a day, five days a week, on an outpatient basis. Treatment lasts up to six weeks, depending on the type of cancer and the treatment goal [188]. Sometimes, the radiation dose or schedule is changed to reach the total dose of radiation more quickly. This can be done in one of these ways [188]: Page 31

34 Accelerated fractionation, which gives the half of the usual daily dose of radiation twice each day. Hyperfractionation, which is a smaller than usual daily dose of radiation given twice each day. Hypofractionation, which is a larger than usual daily dose of radiation given once a day for up to three weeks. Teach patients to avoid removal of radiation markings until after treatment, or let them know if the mark is tattooed and permanent. Patients will need to cover irradiated skin to protect from sunlight for at least a year after treatment. If the site cannot be covered and sun exposure is unavoidable, they can try a gentle, fragrance-free broad-spectrum sunscreen of 30 SPF or higher. Teach the patient to clean irritated skin very gently with mild soaps, avoid shaving if possible, and to use an electric razor if they must, and to protect the site from rubbing, pressure or irritation by wearing loose, soft fabrics next to the skin. Avoid alcohol-containing liquids, aftershave lotions, powders, depilatories, deodorants, tape, and extreme heat or cold to the area [57]. If skin becomes dry, most treatment centers recommend twice-daily use of moisturizing creams without fragrances, such as Aquaphor, Cetaphil, Eucerin, Vanicream, and Cerave, which are available over the counter at drugstores [129,222]. Radiation therapy can cause acute and chronic side effects, a lot of which depend on the body part being irradiated and the radiation dose. Common acute side effects of radiation, regardless of site, are fatigue and nausea. Depending on the site, the patient may also have: Erythematous or pruritic, tender, dry, or weeping skin at the radiation port. Alopecia at the treatment site, which can become permanent. Dry mouth, dysphagia (difficulty swallowing), odynophagia (painful swallowing), mucositis, dysgeusia (taste changes) from head and neck radiation. Dysphagia, cough, dyspnea from chest radiation. Nausea, vomiting, diarrhea from abdominal radiation. Diarrhea, cystitis, urinary frequency, sexual dysfunction from pelvic radiation. Most of the acute effects end soon after the radiation course is completed [124,188]. Talk with the patient about when to call the office or treatment center, including contact information for the oncologist on nights and weekends, such as when experiencing [129]: Fever of degrees Fahrenheit ( F) or above. Pain. Swelling. Vomiting or severe diarrhea. Blistering, drainage, rash, or skin breakdown in the treated area. Any new symptoms. Some kinds of acute damage can become permanent, such as salivary gland damage. The drug amifostine can help protect the salivary glands if given during radiation treatment. Although research is being done on other ways to protect normal tissues from radiation damage, this is the only drug approved for it as of early 2016 [188]. Late effects, which can occur months or years later, depend on the area of the body treated by radiation. These chronic effects can include: Skin darkening, scarring, and fibrosis, which can cause restricted movement. Bowel damage which can cause diarrhea and bleeding after abdominal treatment. Memory loss and cognitive changes after brain radiation. Infertility after pelvic radiation. Second cancers. Keep in mind that second cancers are more common in people who were treated as children or adolescents [189]. There are other ways to deliver external radiation that use special techniques intended to focus more tightly on the tumor and reduce the damage to normal tissues nearby: 3-dimensional conformal radiation therapy (3D CRT) uses a regular linac to generate and aim the radiation, and also uses an imaging scan with computer mapping to precisely pinpoint tumor location 3-dimensionally and allow a tighter aim of radiation beams. Intensity-modulated radiation therapy (IMRT) uses conformal techniques like 3D CRT, but also allows different strengths of beams to be sent to different areas. Image-guided radiation therapy (IGRT) has scanners built into the linear accelerator machine, so that images of the tumor can be checked before each treatment. This may be more important when a tumor is shrinking or changing shape during the course of treatment, as it lets the doctor tweak the radiation area so that less normal tissue is hit. Stereotactic radiosurgery (SRS) use imaging to give a large dose of radiation to a small tumor in one session, from a number of different angles. Despite the name, no actual surgery is involved. There are a number of machines that do this, like the Gamma Knife, X-Knife, CyberKnife, or Clinac; some deliver the radiation all in one burst while others move around to deliver it from one direction to another but still in one session. These are often used for brain tumors but can be used for small tumors in other parts of the body. Fractionated stereotactic radiotherapy (FSRT) is very much like SRS, above, but the radiation is spread out over several doses. Of note, there are other types of external radiation than the typical photon beams from a linac. Some specialized cancer treatment centers use particle beams like proton beams, neutron beams, and carbon ions. Electron beams can also be produced by a linac, but they have low energy levels and do not penetrate deeply. These are used for skin or structures that are close to the body surface [40]. Internal radiation therapy Internal radiation therapy places a source of radiation inside the body. Radiopharmaceuticals can be taken or injected in liquid form for some types of cancer treatment. More commonly, the radiation source can be implanted (brachytherapy) right into and around the tumor (interstitially) or placed in a body cavity (intracavitary) [7]. Radiopharmaceuticals: In systemic internal radiation therapy, the patient swallows or is given an injection of a radioactive substance, such as radioactive iodine or a radioactive substance bound to a monoclonal antibody. Radioactive iodine (131I) for example, is commonly used to help treat some types of thyroid cancer. Thyroid cells naturally take up radioactive iodine [189]. For systemic radiation therapy for other types of cancer, a monoclonal antibody helps the radioisotope bind to the right cells. The antibody is attached to the radioactive substance, and delivers the radiation directly to tumor cells. For example [189]: The drug ibritumomab tiuxetan (Zevalin ) is used to treat certain types of B-cell non-hodgkin lymphomas (NHL). The antibody part of the drug binds to a protein found on the surface of B lymphocytes. The combination drug regimen of tositumomab and iodine I 131 tositumomab (Bexxar ) is used to treat certain types of NHL. The nonradioactive tositumomab antibodies are given to patients first, followed by treatment with tositumomab antibodies that have 131I attached. Tositumomab binds to the same protein on B lymphocytes as ibritumomab. Other systemic radiation therapy drugs are in clinical trials for different cancer types. Some palliative systemic radiation therapy drugs already in use are used to help relieve pain from bone metastases. For example, the radioactive drugs samarium-153- Page 32

35 lexidronam (Quadramet ), strontium-89 chloride (Metastron ), and radium 223 (Xofigo ) are used for this [189]. Patients who have radioactive liquids injected are typically instructed to follow special precautions for a few days. Restrictions are partly based on whether there are young children in the home, since they tend to require closer proximity and more contact than older children, and because younger people are more affected by radiation than older ones. This needs to be communicated to the patient, who should be sent home with full written instructions. Typical radiation exposure risks for the family of patients going home after 131-Iodine for thyroid cancer or radionuclides for bone metastases are minimal. The total radiation dose to others, even with close prolonged contact, is expected to be low enough that it should not cause harm to other adults. Also, radioactivity drops off quickly. For an extra margin of safety, patients are often given instructions to [97,269]: Sleep in a separate room and use a different bathroom from other family members for two days after treatment. Some practices encourage double flushing after toilet use, with good hand washing after. Avoid public transportation for the first day after treatment. Avoid public places for the first two days after treatment (e.g. restaurants, theaters, shops, etc.). Any pregnant women or children under two years should stay at a different residence for three days after treatment. Chemotherapy and drug treatments for cancer Chemotherapy is what most people think of when they think of cancer treatment, even though drug options have greatly expanded for many types of cancer. Chemotherapy (or chemo) is used to treat many types of cancer but it is usually not the only modality used for cancer treatment. Most often, chemotherapy is given in concert with other cancer treatments. The types of treatment depend on the type of cancer, if the cancer has spread and where, and if there are co-morbidities that call for modification of treatment. Before the patient starts chemotherapy, it is advisable to review previous teaching points, such as treatment plan, the purpose of the chemotherapy, and adjunct treatments. For those who are receiving at least part of their chemo as outpatients, appointments for lab testing and follow-up should be emphasized. Be sure to include family caregivers and other family members who may be called on for help when the patient is incapacitated in some way. Make sure they know when to call, and ways to get help during nights, weekends, and holidays. If the patient is a smoker and has not quit, this is again a good time to discuss possible supports for quitting such as nicotine replacement therapy or other pharmaceuticals. One study showed that patients who were receiving chemotherapy for leukemia who continued to smoke were more likely to have serious pulmonary infections than those who quit [194]. Purpose and goals of chemotherapy Chemotherapy works by stopping or slowing the growth of cancer cells, and is used in the following ways. It is important for the patient to know what their therapy is intended to do [152]: Treat cancer with curative intent: Chemotherapy can be used with the intent to cure, although the patient must obviously know that there is no guarantee that a cure will result. Reduce the risk of recurrence: This type of treatment is used to decrease the chance the cancer will come back by eradicating micrometastases and other cancer cells that could resume growing. Stop or slow cancer growth: Maintenance or chronic treatment in patients with cancer that is too widespread or refractory for the possibility of cure. Palliative care: Can be used for the purpose of minimizing symptoms and reducing discomfort by shrinking tumors that are causing pain and other problems. Maintain a distance of about three feet or more from other people for up to three days after treatment. Clean up any spills of urine, blood or other body secretions carefully. Wash any contaminated linens carefully. Body fluids such as saliva, urine, and sweat can contain small amounts of radioactive material. For those who are sexually active and able to conceive a child, it is recommended to use birth control for at least 30 days after radiopharmaceutical dosing to reduce the risk of fetal effects. Brachytherapy Brachytherapy can take the form of seeds, pellets, ribbons, wires, or capsules that are injected into or near the tumor. Some are left in and others are removed [189]: Permanent brachytherapy devices give off a low total radiation dose to the immediate area, and are left in place while the radioactivity decays quickly over a few weeks. Generally, this is done on an outpatient basis, with few or no precautions for close family members. Low-dose rate implants are only left in for a day or so, up to a week, before being removed. High-dose rate implants stay in for a few minutes at a time and are taken out, although an applicator or catheter is usually left in place until the course of radiation is completed. Staff and family will need to limit the time they spend with the patient while the high-dose and low-dose devices are in place. How chemo is used with other treatments When used with other treatment modalities, chemotherapy can [152]: Shrink a tumor before surgery or radiation therapy (neoadjuvant chemotherapy). Destroy cancer cells that may remain after surgery or radiation therapy (adjuvant chemotherapy). Boost effects of other treatments. Kill cancer cells that have returned or metastasized. Chemo routes Chemotherapy drugs may be given one or more of the following routes: Oral. Intravenous (IV). IM or SC injection. Intrathecal. Intraperitoneal (IP). Intra-arterial (IA). Topical (which the patient usually self-applies at home). Vascular access Despite the availability of other routes for many cancer treatment drugs, reliable venous access is essential for many types of cancer treatment. IV devices designed for short-term medical situations can quickly become impossible to maintain in the face of repeated cycles of chemotherapy. Veins become damaged from frequent entry and cannulation for medications (including irritants and vesicants), fluids, transfusions, and blood draws. It becomes a painful and sometimes futile exercise to try and replace short peripheral IV devices. Over time, the number of failed attempts to start IVs or draw blood for labs rises; and the risk of infiltration and phlebitis also increases as fewer and smaller good veins can be found. All of this poses risk to the patient and necessitates a long-term IV access plan, preferably before peripheral access becomes difficult. Long-term IV chemotherapy is most often given through a wide assortment of devices such as central lines, tunneled catheters, and implanted ports or reservoirs. Some of the specialized vascular access devices have two or three lumens, which can be used to give solutions that cannot be mixed. A port is a small, round disc with a penetrable top membrane connected to a catheter in a large vein, most often in Page 33

36 the chest, which is placed under the skin during minor surgery. Special needles can be inserted into the port for chemo or drawing blood [152]. These long term access devices can also be used to give fluids, blood products, and other drugs. They can be a very convenient to draw blood, which most patients really appreciate. But all of these devices pose the risk of infection. The patient should be taught to watch for and report redness, tenderness, drainage or cording at the catheter site [152]. Pumps are often used to control how fast IV chemotherapy goes in. These may be used for inpatient or outpatient chemotherapy, and may be internal or external. Internal pumps must be positioned under the skin during surgery and refilled at intervals, so follow-up appointments should be emphasized with the patient [152]. If the patient goes home with an implanted pump, s/he must know how to care for it, and know to observe for and report swelling, drainage, redness, or pain near the injection site when any pump is in use. For external pumps, the patient and at least one family member also need to know how to operate the pump and deal with tubing, disconnections, batteries, etc. Other types of access There are also intra-arterial catheters that may be inserted for localized injection of drugs directly into a tumor area. Only trained professionals should use these devices, and patients must be well educated on safety measures and how to handle leakage or bleeding [79]. Intrathecal and intraperitoneal chemotherapy require specialized access devices that are typically inserted by physicians. Training on device use is essential for the nurse, and the patient and other staff must also understand what can and cannot be used in them. The intrathecal space is especially sensitive, and many IV drugs cannot be used for injections there without risk of death or serious damage. It is important that the pharmacist know when a drug is ordered for intrathecal use, to be sure that the right formula makes it to the patient. A bedside double-checking procedure is extremely important here and should be performed independently by two professionals. Patients who are receiving intraperitoneal chemotherapy will need to lie on one side and switch sides periodically. A number of chemotherapy drugs often given via IV can be used for intraperitoneal treatment, and the same side effects tend to result. There are additional side effects from increased pressure, such as abdominal pain, shortness of breath, and diarrhea. Besides the drugs for nausea, pain medications may be needed. Shortness of breath may be helped by raising the head of the bed to reduce pressure on the diaphragm [79]. Nursing management of access devices Many different devices are used in different settings. The nurse should thoroughly understand: how his or her patients devices work; how to use them; device care and maintenance; possible risks and complications of each; and how to determine when they might be failing. Documentation of assessments and maintenance are essential. Patients must be instructed on what to do at home, what to report, and how to deal with unexpected complications as well as provided a 24- hour contact number for emergencies. Targeted therapy Most targeted therapies are either small-molecule drugs or monoclonal antibodies [199]: Small-molecule drugs are small enough to enter cells easily, so they are used for targets that are intracellular. Monoclonal antibodies are not able to enter cells easily. Instead, they attach to specific targets on the outer surface of cells. Who receives targeted therapy Targeted therapy can be used for some types of cancer. Many patients with cancer will have a target for a certain drug, so they can be treated with that drug. In order to find out, the tumor will need to be tested to Chemotherapy regimens There are numerous chemotherapy drugs given in combination. Treatment is based mostly on: The type of cancer. The stage of cancer. Whether the patient has had chemo before. Whether there are co-morbidities such as diabetes, renal failure, or heart disease. Most patients get chemo in cycles. A cycle is a period of treatment followed by a break. For instance, chemo may be given every day for one week followed by three weeks with no chemotherapy. This is one-four-week cycle. The break gives the patient a chance to recover before the next cycle. Regimens may be modified based on the patient s tolerance and side effects. Some side effects like myelosuppression are serious enough to merit a longer break, changing the dose or regimen, or even suspending treatment until the patient recovers enough to resume the same or a modified treatment [152]. It is important when patients return home after treatment, that they and caregivers have a listing of problems for which the doctor must be notified, especially which ones may be emergencies. This partly based on the types of drugs the patient received or will be taking at home, and expected or serious side effects, e.g. [6]: Bleeding or unexplained bruising. Blood in the stool or urine. Fever of F or higher. Shaking chills. Shortness of breath. Cough, sore throat, or burning on urination. Unusual pain, including severe headaches or abdominal pain. Diarrhea of more than two days duration. Vomiting or the inability to keep down medicines. Signs of allergic reaction such as swelling of the mouth or throat, trouble breathing or swallowing, dizziness or faintness, severe itching, or hives. Patient safety and safe medication practices for chemotherapy In the process of preparing and administering chemotherapy medications, nurses need to be sure that there are mechanisms, procedures, and qualified staff to independently verify drug names and doses, times and dates each is due, routes of administration, and patient identification. It is important to be sure that drugs are fully labeled as they leave their original containers (including individual syringes, medicaton containers, or basins), and are transported safely to the bedside. Nurses also must have quick access to extravasation kits in case of vesicant leaks, and procedures to minimize exposures to dangerous drugs in the event of breakage or spills, including safe disposal of cleanup materials. These are just some of the minimum standards covered in the American Society of Clinical Oncology Oncology Nursing Society Chemotherapy Administration Safety Standards (see Nursing Resources for details) [223]. look for targets for which there are drugs. Tumor testing for targets may involve an additional biopsy [199]. How targeted therapy works against cancer Most targeted therapies help treat cancer by interfering with specific proteins that help tumors grow and spread throughout the body. They treat cancer in many different ways. They can [199]: Help the immune system destroy cancer cells. Certain targeted therapies can mark cancer cells so it is easier for the immune system to find and destroy them. Other targeted therapies help boost the immune system to work better against cancer. Page 34

37 Slow or stop cancer cells from growing. Some targeted therapies interfere with proteins that prompt cells to divide. This helps slow a cancer s uncontrolled growth. Stop signals that help form blood vessels. Some targeted therapies are designed to interfere with signals that trigger blood vessels to form and grow. Without a blood supply, tumors stay small. If a tumor already has a blood supply, these treatments can cause blood vessels to die, which can cause the tumor to shrink. Deliver cell-killing substances to cancer cells. Some monoclonal antibodies are bound with toxins, chemotherapy drugs, and radiation. Once the monoclonal antibodies attach to targets on the surface of cancer cells, the cells take up the cell-killing substances, causing them to die. Cells that do not have the target are typically not harmed. Cause cancer cell death. Some targeted therapies can cause cancer cells to go through the normal process of cell death. Starve cancer of the hormones needed to grow. Some breast and prostate cancers require sex hormones to grow. Hormone therapies are a type of targeted therapy that can prevent the body from making specific hormones, while others prevent the hormones from acting on cells, including cancer cells. Genetics, genomics, and treatment with targeted therapy Many targeted therapies depend on testing for tumor genetics before the treatment starts. For example, one well-known test involves Immunotherapy Cancer is able to grow and evolve in part because cells develop ways to elude the immune system. Immunotherapy is a type of cancer treatment that helps the immune system fight cancer. The immune system consists of lymphocytes made by: the bone marrow; the thymus; lymph nodes; spleen; tonsils; and specialized tissues in the mucous membranes of the nose, bronchi, gut, urinary tract, and other tissues. Immunotherapy is a type of biological therapy, which uses substances made from living organisms to treat cancer [171]. Types of immunotherapy Many different types of immunotherapy are used to treat cancer. They include [15,171]: Monoclonal antibodies are drugs designed to bind to specific targets in the body. They can cause an immune response that destroys cancer cells (such as pembrolizumab or nivolumab) or helps to stop them from growing (such as trastuzumab). Other types of monoclonal antibodies mark cancer cells so the immune system can destroy them, which is called targeted therapy (see Targeted Therapy ). Adoptive cell transfer is a treatment that attempts to boost the ability of T cells (T-lymphocytes) to fight cancer. Researchers take T cells from the patient, isolate the T cells that are most active against the cancer or modify the genes in them to make them better able to find and destroy the cancer cells. Researchers then grow large batches of these T cells in the lab over the course of two to eight weeks. The T cells that were grown in the lab are then introduced into the patient. Cytokines are proteins that play important roles in the body s normal immune responses and also in the immune system s ability to respond to cancer. The two main types of cytokines used to treat cancer are called interferons (e.g. interferon alfa) and interleukins (e.g. IL-2). There are also drugs, similar to cytokines but do not occur naturally, like thalidomide and lenalidomide, that boost the immune system. Treatment vaccines work against cancer by boosting the immune response to cancer cells. The treatment vaccines are different from the ones that help prevent disease. An example of this is sipuleucel-t, which is used to treat advanced prostate cancer. BCG, Bacillus Calmette-Guérin, is an immunotherapy that is used to treat bladder cancer. It is a weakened form of the bacteria that looking at estrogen receptors in breast cancer to determine whether anti-estrogen compounds can help with treatment of that particular woman s cancer. Another example from breast cancer is the overexpression of human epidermal growth factor receptors (HER2), indicating that the patient will likely benefit from using trastuzumab. Some call this tumor profiling and others call it individualized or personalized therapy. Tumor tissue testing is different from testing germline mutations, which are present in all the body s cells and can be done with a blood sample. Tumor testing requires a sample of the cancerous tissue and is often done using part of the biopsy sample. This kind of testing can show whether certain targeted drugs can help stop cancer growth. Targeted therapy can cause side effects Side effects of targeted therapy depend on the drug and the patient s responses. The most common side effects of targeted therapy include diarrhea and elevated liver function tests. Other side effects might include bleeding and delayed wound healing, high blood pressure, fatigue, mucositis, nail changes, loss of hair color, and skin problems, like rash or dry skin. Very rarely, a fistula might form through the wall of the esophagus, stomach, small intestine, large bowel, rectum, or gallbladder. Many of these side effects are treatable, and most of them fade after treatment ends [199]. Fistulas and severe diarrhea, although rare, can be life-threatening. causes tuberculosis. When injected directly into the bladder, BCG causes an immune response against cancer cells. It is also being studied in other types of cancer. Immunotherapy may be given via IV, orally, topically (for very early skin cancer, like imiquimod cream), or intravesically and it is typically given on an outpatient basis, every day, week, or month. Some immunotherapies are given in cycles [171]. Immunotherapy is not yet as widely used as surgery, chemotherapy, and radiation therapy. However, immunotherapies have been approved to treat people with many types of cancer, and many others are being studied in clinical trials [171]. Immunotherapy can cause side effects The side effects depend on the type of immunotherapy. Rarely, immunotherapies may also cause severe or even fatal allergic reactions [171]. The most common side effects are skin reactions at the needle site, such as pain, swelling, redness, or itching. They can also cause flu-like symptoms such as [171]: Fever. Chills. Weakness. Dizziness. Nausea or vomiting. Muscle or joint aches. Fatigue. Headache. Trouble breathing. Low or high blood pressure. Other side effects include: Swelling. Weight gain from fluid retention. Palpitations. Sinus congestion. Diarrhea. Risk of infection. Page 35

38 Drug interactions and effects in cancer treatment CYP 450 enzymes: A clinically important system As mentioned in the Pre-treatment Assessment section, most health professionals have heard of the CYP 450 drug interaction issue but many are not sure how it works. CYP 450 enzymes are mostly produced in the liver, but the gut produces them too. About ten of these enzymes can affect drugs in a significant way. These enzymes help to metabolize many drugs so that they can be inactivated and excreted [83]. It is important to know that, not only do the enzymes affect certain drugs, but there are some drugs that can affect the production of the enzymes. This means that one drug can indirectly affect another in significant ways. A drug that requires a certain enzyme to be metabolized is called a substrate of that enzyme. For example, alprazolam (Xanax) is a substrate of enzyme CYP 3A4, which is required to metabolize it. The half-life of this drug is usually about 11 hours (but can vary between six and 27 hours) [219]. This is typically fairly constant in each person, all other things being equal. However, if a person is taking an inducer of CYP 3A4, the alprazolam could leave the body very quickly. If the person is taking an inhibitor of CYP 3A4, the alprazolam blood level could climb much higher and last much longer in the body. Grapefruit and starfruit also act as 3A4 inhibitors, which means that patients taking alprazolam can intensify and extend the activity of this benzodiazepine if they drink grapefruit juice. While this may be a problem, it can be a more severe issue if they are taking a 3A4 substrate such as vincristine or imatinib (Gleevec), which might result in more unpredictable and severe toxicities. The most important of these enzymes are [230]: CYP 1A2. CYP 2B6. CYP 2C8. CYP 2C9. CYP 2C19. CYP 2D6. CYP 2E1. CYP 3A4,5,7 (these are typically grouped since they are related and on the same gene; sometimes the whole group is often called simply CYP 3A or the CYP 3A family). Each of these enzymes has drugs that require that particular enzyme to be metabolized (they are substrates of that enzyme), and other drugs that inhibit that enzyme. Most of the enzymes can also be induced (i.e. have their production increased) by certain drugs. To make things more confusing, some people have genetic mutations which cause them to produce more or less of these enzymes. Those people do not have to take the inhibitor drug or the inducer drug to get an unexpected response to the substrate. The CYP 3A4,5,7 (usually called just group CYP 3A) affects a number of drugs used in cancer treatment. Some antidepressants, a couple of important nausea medicines, and tamoxifen are in the CYP 2D6 substrate column. Some common nonsteroidal anti-inflammatory drugs are CYP 2C9 substrates, along with warfarin and a couple of anticonvulsant drugs that have a number of off-label uses. There is no problem as long as the person produces the normal amount of the enzyme needed to metabolize the drugs and is not taking a CYP 2C9 enzyme inhibitor or inducer [92]. Anti-cancer drugs, antiemetic drugs, and CYP enzyme interactions Some of the antiemetic drugs affect or are affected by other drugs via the CYP 450 enzyme system. The NCCN warns, for example, that aprepitant is a substrate of CYP 3A and induces CYP 2C9, although the effect is more pronounced with oral drugs than IV ones [204]. On the other hand, an expert pharmacology website from Indiana University does not list these effects as clinically significant [92]. Interestingly, both of these statements can be true, since some substrates have other routes of excretion besides the one enzyme; and in vitro measurements of CYP enzyme induction or inhibition do not always predict major problems in vivo due to magnitude of effect and other variables [203,204,205,206]. The Indiana University pharmacology expert table of clinically significant issues with drugs commonly used in cancer treatment and nausea and vomiting (N&V) management identifies these possible interactions due to CYP 450 enzymes [92]: N&V drugs that are affected by the CYP enzyme system: Olanzapine is a 1A2 enzyme substrate. Haloperidol is a 3A family enzyme substrate. Alprazolam is a 3A family enzyme substrate. Cancer treatment drugs that are affected by the CYP enzyme system: Cyclophosphamide is a substrate of 2C19 and 2B6 enzymes. Ifosfamide is a 2B6 enzyme substrate. Paclitaxel is a 2C8 enzyme substrate. Vincristine is a 3A family enzyme substrate. When any of these drugs are given with other medicines that can inhibit or induce these particular enzymes, the drugs can have their excretion delayed or hastened, respectively. It is a good idea to check new drug information regularly. Drugs that speed up the production of a certain CYP enzyme are called inducers of that enzyme. They speed up the metabolism of the enzyme substrate drugs. To compare this system to something simpler, think of a substrate drug as something that is dumped in a certain shower stall (i.e. a particular drug) for cleanup. Normally, the water (i.e. the enzyme) comes from the shower head and washes it away at a standard pace. But, an inhibitor can diminish the water flow so that it takes longer to wash out the substrate drug. A potent inhibitor can slow the shower down to a trickle, leaving the substrate drug around for a very long time. On the other hand, an enzyme inducer speeds ups the water flow for that stall (i.e. enzyme system), and washes out the substrate drug very quickly. Suddenly a person is getting much less of the drug because it is disappearing so fast. If the substrate is the kind of drug with noticeable therapeutic effects, the patient might report that it is not working well anymore. Someone taking imatinib will have the drug washed out by the enzymes induced by the phenytoin (inducer) s/he is also taking. Although the person is not likely to notice the difference in this case, it may affect treatment adversely by reducing the effectiveness of the imatinib. People who are genetically deficient in one or more of these enzymes may metabolize drugs differently even without a drug to cause an interaction. In the above analogy, the patient is missing the shower stall, but an enzyme deficient patient can get little or no effect from a prodrug that requires enzyme activity to be metabolized to its active form, such as tamoxifen or codeine. Torsades de Pointes (prolonged QT interval and cardiac arrhythmias) The NCCN guidelines mention concerns about the abilities of certain antiemetic drugs to prolong the QT interval, which can be dangerous especially to people with congenital QT prolongation or those taking other drugs which can also prolong the interval [204]. According to the CredibleMeds website, the following drugs are potential causes of Torsades de Pointes (TdP) in those with other risk factors for TdP such as [78]: Congenital prolonged QT interval. Congestive heart failure. Bradycardia. Low potassium or magnesium. Use of other drugs that also prolong QT interval. Page 36

39 With any of the above risk factors, the following drugs are typically contraindicated: Ondansetron. Droperidol. Oxaliplatin. In treating cancer and N&V related to cancer drugs, there are a number of other medications that may affect QT interval enough to cause TdP or other arrhythmias in the presence of the risk factors for TdP as noted above, these drugs are not categorically contraindicated as of early 2016, but use caution with [78]: Antiemetic drugs: Granisetron. Olanzapine. Promethazine. Cancer treatment drugs: Arsenic trioxide. Bortezomib. Bosutinib. Ceritinib. Crizotinib. Dabrafenib. Dasatinib. Degarelix. Eribulin. Lapatinib. Lenvatinib. Leuprolide. Nilotinib. Osimertinib. Panobinostat. Pazopanib. Sorafenib. Sunitinib. Tamoxifen. Toremifene. Vandetanib. Vemurafenib. Vorinostat. It is important to continue to follow up on new drug additions to this list as new research is published. And of course, new drugs come out all the time that may add to this list as well. Nursing consideration: Avoiding drug combinations that interact via the CYP enzyme system can maintain effectiveness of drug treatments and reduce the incidence of drug toxicity events. Inherited genetic mutations can affect response to drug treatment Germline (inherited) mutations can also affect responses to treatment. For example, women who were born with CYP 2D6 mutations do not produce enough of the enzyme that metabolizes certain drugs (e.g. CYP 2D6 substrates) (see Drug interactions for more detail). Tamoxifen, which is a commonly used breast cancer treatment that greatly reduces recurrence in women with estrogen receptor-positive breast cancer, must be metabolized by the CYP 2D6 enzyme to its active form, endoxifen. Some studies suggest that women with a germline genetic mutation that lowers CYP 2D6 production do not get the same benefit from tamoxifen as women who metabolize the drug normally. There are other anti-estrogens for women who are not expected to respond to tamoxifen; specifically, the aromatase inhibitors such as anastrozole, letrozole, and exemestane can be used for ERpositive breast cancers. However, there is currently no requirement or recommendation from U.S. experts that women be tested to find out if their CYP 2D6 levels are adequate before starting tamoxifen [81]. Women who have higher CYP 2D6 levels due to a different genetic mutation may get higher levels of active drug, and may be more prone to side effects and toxicities. Unfortunately, there are other germline mutations that can cause problems in cancer treatment. People who have a dihydropyrimidine dheydrogenase (DYPD) mutation can have much higher toxicity and even fatalities with the commonly used cancer drug, 5-Fluorouracil. Thiopurine methyltranserase (TPMT) mutations, which affect about one in 300 people, can result in unexpected toxicity with mercaptopurines. People with UDP-glycosyltransferase 1A1 mutations can have increased toxicity from irinotecan, with dose-limiting diarrhea and leukopenia. Those with methylenetetrahydrofolate reductase mutations (MTHFR) can have much worse toxicity to methotrexate [83]. Again, most of these problems are discovered after chemotherapy begins, if they are discovered at all. Many cancer treatment centers do not test for these genetic mutations even if they have to stop therapy. This is another reason it is so crucial to assess and document responses to cancer treatment. If treatment with the problem drug is allowed to progress in the face of these mutations, it can result in death (see Resources for Nurses ). Hematopoietic stem cell transplants Hematopoietic stem cell transplants (HSCT) provide healthy bloodforming stem cells to replace cells that were destroyed by treatment (and sometimes by disease). The blood-forming stem cells that are used in transplants can come from bone marrow, the bloodstream, or umbilical cords. Transplants can be: Autologous, i.e. the stem cells come from the patient and are eventually infused into the same patient. Allogeneic, i.e. the stem cells come from someone else. The donor may be a blood relative but can also be an unrelated match, including banked cord blood from newborns. Syngeneic, i.e. the stem cells come from a patient s identical twin. To reduce possible side effects and improve the chances that an allogeneic transplant will work, the donor s blood-forming stem cells must match [196]. This matching involves human leukocyte antigens (HLA) that determine a person s tissue type. A match works better when all six of the major HLA antigens match. Sometimes a donor with one mismatched antigen (e.g. a five out of six match) is used. When a transplant uses cord blood from newborns, perfect HLA matching is not as important for success. In unrelated adult donors, sometimes professional will try to match even more than the six major antigens, which requires a deeper look at HLA typing than has been done routinely. Research continues in this area because it can be very difficult to find high level HLA matches for HSCTs [39]. In most cases, stem cell transplants do not work directly against the cancer. Instead, they allow the patient to recover after treatment with very high doses of radiation therapy, chemotherapy, or both. However, in multiple myeloma and some types of leukemia, the stem cell transplant may work against cancer directly through an effect called graft-versus-tumor that can occur after allogeneic transplants. Graftversus-tumor occurs when white blood cells from the donor attack cancer cells that remain in the body after high-dose cancer treatment treatments. This effect improves the success of the treatments [196]. High doses of chemo and radiation work better at killing cancer cells than standard doses, but they also cause the bone marrow to completely stop working. The HSCT rescues the patient from this lethal situation by providing new stem cells to replace the ones killed by the treatment. Most patients stay in the specialized transplant center hospital during at least part of the transplant process, which can take a few months to complete. The process begins with treatment of high doses of chemotherapy, radiation therapy (usually total body irradiation, or TBI), or a combination of the two. This goes on for a week or two. Page 37

40 After a few days of rest, the patient gets an IV infusion of the bloodforming stem cells [196]. After receiving the stem cells, there is the wait for engraftment, when the new stem cells start making new blood cells. Rarely, a graft will not take, i.e. the donor cells can be destroyed. During this procedure, when the patient has little to no immune function (either because the graft has not started working or because of immunosuppressant drugs), latent infections the recipient had can recrudesce and cause complications, some severe. After blood counts return to normal, it takes much longer for the immune system to fully recover: several months for autologous transplants and one to two years for allogeneic or syngeneic transplants [196]. Who receives stem cell transplants? Stem cell transplants are most often used to help people with leukemia, neuroblastoma, multiple myeloma, and some lymphomas. Stem cell transplants for other types of cancer are being studied in clinical trials [196]. Side effects of stem cell transplants The high doses of cytotoxic chemotherapy for conditioning before stem cell transplant can cause severe pancytopenia with anemia and high risk of bleeding and infection. The progress of the transplant is monitored by frequent blood counts. As the newly transplanted stem cells produce blood cells, blood counts go up. Many of the side effects Treatment assessments and interventions At each visit with the outpatient, the nurse should assess adherence to appointment, laboratory monitoring, at-home medications, symptom control, and other parts of the treatment plan. The nurse should also inquire about side effects, new problems and concerns, reassess previously identified problems, and assess for any unmet physical or psychosocial needs, educational and informational needs, and any referral needs. The patient and family may need additional information on drug-food interactions, what to do when doses of medication are missed, oral chemotherapy drugs, and more. Inpatients are easier to observe, but big-picture assessment may be lost in all of the treatment and side effects that are likely to be going on. If the patient has a family caregiver visiting, that is usually a good time to go over the concerns the patient and family have about the treatment effects and coping at home. Involving home caregivers In assessing symptoms during treatment, it is often helpful to talk with family members or others who are caring for the patient at home. An open-ended question about how the patient seems to be functioning at home is a good way to start. Family members who help care for the patient will often share information that gives the cancer team a clearer picture of how fatigue, nausea, pain, and other symptoms are affecting the patient s and family s life. Sometimes the oncology nurse may get a more forthright answer if the patient is not in the room. The caregiver may be taking over more and more of the patient s care on days that the patient is having trouble taking care of himself or herself, which the patient is sometimes reluctant to share. Caregivers often are the first observers to report mental status changes such as confusion and delirium, of which the patient may be unaware or embarrassed to bring up. In-home and family caregiving will not be covered in this course, but there is a list of resources at the end of this module that can help prepare the caregiver for the sometimes-stressful job of caring for a loved one at home during a serious illness. It is important to include caregivers in care planning, teaching, and assessment. Side effects of cancer treatment Chemotherapy and radiation not only kill fast-growing cancer cells, but also can kill or slow the growth of healthy cells that grow and divide quickly, such as those that line the mouth and gut, or hair follicles. Damage to these healthy cells often causes side effects, such are similar to those seen with chemotherapy and high-dose radiation, although there is one side effect that is specific to the allogeneic transplant process, graft-versus-host disease (GVHD). Allogeneic transplant recipients often develop graft-versus-host disease, in which white blood cells from the donor (the graft) recognize cells in the recipient s body (the host) as foreign and attack them. This problem can damage skin, liver, gut, and many other organs. It can occur early or later, and may be short-term or become chronic. Graft-versus-host disease can be treated with steroids or other drugs that suppress the recipient s immune system. The closer the match between the donor and recipient, the less likely graft-versushost disease is to occur [196]. GVHD is related to the graft-versuscancer effect, but the graft-versus-cancer can occur even in wellmatched donor-recipient pairs. Special diet needs, GI disturbances, and chemoradiation side effects The conditioning regimen given before a stem cell transplant can cause side effects that make it hard to eat, e.g. mouth sores and nausea. People who are having trouble eating might find it helpful to speak with a dietitian (see Diarrhea and other problems listed in the Symptom Management section) [196]. The toxicities of chemotherapy are typically magnified due to the extreme doses used in HSCT. as mouth sores, nausea, and hair loss. These kinds of side effects can sometimes be controlled with medications and other measures, and they usually disappear after chemotherapy is finished [152]. There are innumerable side effects of chemotherapy, from the bothersome (such as alopecia or dry skin) to the life-threatening (such as tumor lysis syndrome or Stevens-Johnson syndrome, a blistering, desquamating rash). Some of these are rare and unexpected, some are predictable and preventable, but nearly all respond best to early recognition and intervention. Chemotherapy can be life-threatening for some people. Side effects profiles are different for every cancer drug, and oncology nurses must spend time reviewing them. Of course, some patients pose the challenge of having side effects that are not on the drug s adverse effects list. Most of the common symptoms oncology nurses deal with are drug side effects, although some, such as pain, are sometimes in part due to the cancer. Frequent new drug approvals complicate recognition of side effects: Adding to the difficulty of assessment is the fact that there are many new drugs introduced for cancer treatment every year. For example, 24 drugs were on the newly-fda-approved list for cancer indications in 2014 and 2015 (total for both years). Out of the 24 drugs that were approved for actual cancer treatment over those two years: Seven were for primary cancer treatment as well as second-line treatments. Seven were for specific genetic alterations of a cancer. Eleven were for relapsed, locally advanced, previously treated, refractory, or metastatic cancers (one of these also had a genespecific type so it counts in two categories). Two additional drugs for symptom management were oral antiemetics, one as a combination and one meant to be given in combination with a previously-approved drug. Some of the newer drugs were approved on a fast track, which means that less information is available on their side effects and adverse outcomes than the older ones with which professionals have had more observation time and experience. This means more responsibility on cancer care teams to identify potentially serious new problems with these drugs (i.e. those that are not currently listed in the Adverse Page 38

41 Effects section of the label) and report these to the U.S. FDA. The nurse can report previously-unlisted adverse effects or unexpected serious outcomes directly to MedWatch by calling FDA-1088 or going online for the reporting forms at Select Professionals, then Report a Medical Product Problem to FDA (see Resources for Nurses ). Clearly, no cancer update or cancer drug guide is likely to keep up with this flood of new medications. With the pace of new drug approvals, the nurse who is managing the patient or giving the medications might be looking up a new drug an average of once a month. For nurses who want a head start on new drugs, there are online apps for tablets and smartphones that have complete drug information, and new product information can be found on the FDA website or the drug manufacturer s site (see Resources for Nurses ). Side effect prevention: Cytoprotectant drugs There are just a few drugs available that help reduce the risk or severity of certain side effects from chemotherapy, although research in this area continues. In 2008, the American Society of Clinical Oncology (ASCO) recommended use of the following cytoprotectant drugs [100]: Dexrazoxane is recommended only in metastatic breast cancer for those who have received high doses of doxorubicin, but are likely to have continued benefit from it. They also recommend continued cardiac monitoring while those patients receive the drug. Amifostine can be considered to prevent cisplatin nephrotoxicity and reduce high-grade neutropenia from various chemotherapy drugs as well as decrease xerostomia for people receiving radiotherapy alone for head and neck cancer. The ASCO does not recommend it for host of other complications for which it sometimes thought to be helpful as evidence does not support its use. Mesna is given in divided doses once before and twice after standard and higher ifosfamide doses, although there are concerns about the optimal dosing schedule in very high dose ifosfamide. Mesna can also be used in cyclophosphamide treatments along with saline diuresis. IV mesna is standard but oral dosing can also be used. Palifermin is recommended for stem cell transplants patients who are getting total body irradiation conditioning regimens. A discussion of the data and other considerations can be found on the ASCO publications website at content/27/1/127/t2.expansion.html. Symptom management and palliative care Palliative care is any measure intended to promote comfort or help with pain and symptom relief, but that is not intended to cure the disease. Oncology nurses have been providing palliative care (or what has been called supportive care ) ever since cancer treatment began, for issues like nausea, pain, dyspnea, anxiety, etc. Although the term palliative care is often associated with advanced cancer and end of life, it is used throughout cancer treatment. The difference is that at the end of life, palliative care is usually given by itself, rather than along with curative treatments. The nurse s goal is to keep patient suffering to a minimum while maximizing their comfort throughout cancer treatment and even beyond. Hospice care nurses and social workers also offer palliative Fatigue The most common side effect of chemotherapy treatment is fatigue. Fatigue is not the usual tiredness that goes away with rest, but a persistent sense of exhaustion that interferes with normal function. It rarely occurs in isolation, and is often accompanied by pain, emotional distress, anemia, and sleep disturbances. It is important to assess fatigue before, during, and after treatment. As with pain, fatigue can be ranked on a numeric scale from zero to ten with zero representing no fatigue and ten representing the worst imaginable fatigue [206]. Nurses can help patients prepare for fatigue by [163]: Recommending that patients ask someone to drive them to and from chemotherapy. Plan time to rest during chemotherapy. Suggest that patients ask for help with meals, shopping, housework, and childcare (i.e. delegate tasks and conserve energy). Making a referral to a physical therapist for a consult on an appropriate exercise regimen, with consideration of physical limitations and co-morbidities. Fatigue can affect a patient s work, sense of self, and many other aspects of quality of life, and sometimes extends well past completion of cancer treatment [163]. When fatigue begins, it is important to teach people to pace themselves, set realistic expectations, and continue to delegate tasks to others as much as possible. Distraction such as games, music, and socializing can be used to help with management, along with scheduling important activities for time when they have care for the family s emotional pain and bereavement after the patient s death [214]. In recent years, palliative care teams have formed to help busy cancer treatment teams with a more systematic approach to palliative care. These teams are available for consultation and co-management in some facilities. If such a team is available, patients with complex needs might benefit from consulting earlier the palliative care team rather than later. Below are just a few of the more common symptoms patients with cancer face during treatment, most of them due to the treatments themselves. The list of actual symptoms and side effects is essentially endless, requiring constant communication and diligent observation. the most energy. Some patients find yoga or massage to be helpful. Referral to a mental health professional for assistance with cognitive behavioral therapy, expressive therapies, support groups, etc. may help with fatigue management. People with suspicious sleep problems should be assessed for sleep apnea, which can be precipitated or worsened by cancer treatment. Sleep hygiene instruction is also important for sleeping issues, such as keeping regular sleeping hours, keeping the bedroom dark and quiet, limiting daytime naps to less than one hour, and avoiding caffeine and alcohol within six hours of bedtime [206]. Identification and management of possible contributing causes is often a good starting point for helping with fatigue. Chemotherapy-induced anemia is a well-understood factor, and can be at least somewhat corrected with transfusion, and in some cases with colony-stimulating factors. Nutritional factors can contribute as well, given that the body may be less able to process nutrients at a time when intake may be decreased and energy requirements are often increased. Expert dietary consultation may be helpful [163]. Other underlying causes that can be corrected might include hypothyroidism, hypogonadism, dehydration, and electrolyte imbalances. Pain relief can help some people with fatigue [249]. Consider referral to occupational therapy and physical medicine as well as physical therapy for help in ameliorating and coping with Page 39

42 fatigue. If the patient is near end of life and other causes of fatigue have been ruled out, the NCCN recommends consideration of psychostimulants such as methylphenidate, or even treatment with corticosteroids [206]. Nausea and vomiting (N&V) Chemotherapy-induced nausea and vomiting (CINV) is highly prevalent and extremely distressing. Poorly controlled CINV can result in longer hospitalizations, poorer quality of life, nutritional impairment, dehydration, delirium, depression, physical injury, and inability to continue potentially curable antineoplastic drug treatments. CINV results in higher cost of care and more lost work time for patients [178]. Although most patients receiving chemotherapy are at risk for N&V, the onset, severity, triggers, and duration vary. Tumor-related, treatment-related, and patient-related factors all contribute, including tumor location, chemotherapy agents used, and radiation exposure. Patient-related factors that can increase risk of CINV can include [178]: Nausea and vomiting during past courses of chemotherapy. History of chronic alcohol use. Age younger than 50. Female sex. History of motion sickness or pregnancy-related emesis. Additional causal factors unrelated to chemotherapy treatment may include the following: Fluid and electrolyte imbalances such as hypercalcemia, volume depletion, or water intoxication. Tumor invasion or growth in the gastrointestinal tract, liver, or central nervous system, especially the posterior fossa. Constipation. Certain drugs such as opioids. Infection or septicemia. Uremia. Clinicians treating N&V must be alert to all potential causes and factors, especially in cancer patients who may be receiving combinations of several treatments and medications [178]. Classifications N&V has been classified as acute, delayed, anticipatory, breakthrough, refractory, and chronic [178]: Acute N&V is defined as that experienced during the first 24 hours after chemotherapy administration. Delayed (or late) N&V occurs more than 24 hours after chemotherapy administration. Delayed N&V is associated with cisplatin, cyclophosphamide, and other drugs such as doxorubicin and ifosfamide given at high doses or on two or more consecutive days. Those who have acute N&V are more likely to have delayed N&V as well. Anticipatory N&V (ANV) is nausea and/or vomiting that occurs before a new cycle of chemotherapy is begun, in response to conditioned stimuli such as the smells, sights, and sounds of the treatment room. Breakthrough N&V is that which occurs within five days of prophylactic use of antiemetics and requires rescue medications. Refractory N&V does not respond to treatment. Chronic N&V can occur in patients with advanced cancer and is linked with a variety of potential etiologies. Its causes are not well understood, but might include: gastrointestinal, cranial, or metabolic problems; drugs such as opioids or cytotoxic chemotherapy; and radiation. Page 40 Nursing consideration: Thus far, the best-proven method of managing fatigue, beyond managing underlying causes, is exercise [163]. Get referrals for physical therapy or professional exercise program to help patients remain active or become even more active during cancer treatment. Encourage patients to make exercise plans a priority. The treatment team s goal with chemotherapy is to prevent nausea and vomiting, which is one of the side effects most dreaded by patients with cancer. This goal is not always attainable, but planning for must begin before the first drug is given. Some chemo drugs are classified as highly emetogenic, meaning that more than 90% of patients vomit after receiving them. Moderate emetic risk is between 30% and 90%, per the Oncology Nursing Society (ONS). Low emetic risk drugs cause 10-30% of patients to vomit. Minimal risk means less than 10% of patients vomit [231]. There are lists available from the ONS website, NCCN, ASCO, and others that help classify the emesis risk by drug (see Resources for Nurses ). It is important to know that the risk of N&V for people getting drugs of high emetic risk lasts for at least three days after the last dose, and for at least two days after the last dose of a moderate emetic risk regimen. Patients need antiemetic coverage for that entire time [204]. The NCCN and others have recommendations for antiemetic regimen options for various emetic risk levels, including separate ones for oral chemo drugs. For example, before starting a chemo regimen of high emetic risk, they have three recommended options: desamethasone plus a 5-HT3 receptor antagonist (such as ondansetron, granisetron, dolasetron, palonosetron), along with a neurokinin-1 (NK1) antagonist like aprepitant, fosaprepitant, or rolapitant; netupitant with palonosetron and dexamethasone; or olanzapine with palonosetron and dexamethasone. Antiemetic regimens continue on days 2-4, although dexamethasone doses are reduced and some of the longer-acting drugs do not need to be re-dosed. Some chemo drugs have much longer periods of N&V; for example, emesis after cisplatin peaks at hours and can last six to seven days. If a patient has a history of dyspepsia, antacid drugs like proton pump inhibitors or H2 blockers should be considered along with the antiemetic drugs [204]. In most cases the patient will be getting more than one chemotherapy or cancer treatment drug, and there may be some synergy between them. Obviously, any time one of the drug combination is highly emetogenic, the regimen is considered highly emetogenic. Less obviously, when two moderately emetogenic drugs are given together, their cumulative risk typically is considered high. When two low risk drugs are given together, the risk is upgraded to moderate. In fact, any low-risk drug given with another bumps the risk up a notch. The minimal-risk drugs are considered to not add significantly to emetic risk in combination regimens [231]. There is a tool online from ONS that takes nurses through the steps to help calculate the emesis risk of any chemotherapy regimen. This can help with choosing the best initial regimen for emesis control. Drug interactions and other issues with nausea and vomiting treatment medications are covered in some detail in the Drug Interactions section. Acute and delayed N&V: Vomiting is easier to control with preventive regimens than nausea. Delayed nausea is more common than acute nausea, is harder to control, and can be severely distressing to the patient. Prevention may include around-the-clock antiemetics rather than waiting for complaints of nausea or vomiting [204]. Anticipatory nausea and vomiting (ANV) typically occurs after three or four chemotherapy treatments after which the patient experienced acute or delayed N&V. It can happen in up to one third

43 of patients; good control of acute and delayed N&V can prevent ANV development, but after it develops, interventions are best undertaken by a mental health professional with specific training and experience with ANV. Early identification and referral increase the possibility of success. Cognitive-behavioral therapy with progressive muscle relaxation and guided imagery, hypnosis, biofeedback, and distraction using video games have all been used; research continues on best management. Benzodiazepine drugs may also help; the NCCN recommends alprazolam, even though it is a substrate of CYP 3A (see Drug Interactions ) [204]. Lorazepam is a benzodiazepine with less potential for drug interactions, so it might be used if any CYP 3A inhibitors or inducers are being given [92]. All benzodiazepines can potentiate CNS depressants and may have other kinds of interactions too. Breakthrough N&V is harder to treat. After it starts, interventions may include: Rehydration if needed. Correction of electrolyte abnormalities. Antiemetic medicines from classes not used previously. This usually means giving parenteral or rectal forms of medication, since the oral route is not reliable. Olanzapine or cannabinoids Pain Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage [130]. Pain is one of the most common symptoms people with cancer face. It can be caused by cancer, treatment for cancer, or a combination of factors. Tumors, surgery, radiation therapy, IV chemotherapy, targeted therapy, supportive care therapies such as bisphosphonates, and/or diagnostic procedures may cause pain [146]. It is important to assess pain as to: cause and chronicity; whether it is somatic, visceral, neuropathic or mixed; and the patient s concerns regarding and previous experience with opioids when determining the most appropriate treatments. Whether the patient has any renal or hepatic dysfunction is also important in pain management [145]. Younger patients are more likely to have cancer pain and breakthrough pain than older patients. Patients with advanced cancer are likely to have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends. Basic principles of cancer pain include [146]: Cancer, treatment for cancer, or diagnostic tests may cause pain. Pain can be managed before, during, and after diagnostic and treatment procedures. Different cancer treatments may cause specific types of pain. Cancer pain may affect quality of life and ability to function even after treatment ends. Pain control can improve quality of life. Each patient with cancer-related pain needs a plan for controlling pain. Pain can be controlled in most patients with cancer, although it cannot always be completely relieved. Untreated pain can lead to emotional distress, anxiety, requests for physician-assisted suicide, unnecessary hospital admissions, and visits to emergency rooms. Pain control can greatly improve quality of life during and after cancer treatment [145]. Pain can be managed before, during, and after diagnostic and treatment procedures. Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Sedative drugs may be used to help the patient feel calm drowsy. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with the patient may also help lower anxiety [146]. (dronabinol and nabilone), for example, may be good options for breakthrough N&V. Any patient who has breakthrough N&V should be re-assessed and have antiemetic regimens upgraded before the next cycle of chemotherapy begins. Nursing assessment: The effectiveness of the patient s antiemetic regimen should be reassessed at the end of every treatment cycle. This assessment should include the number of episodes, time of onset (in relationship to doses of chemotherapy drugs and other medications), and duration of nausea, vomiting, or dry heaves. The nurse should also consider the patient s hydration and nutritional status, weakness, weight loss, and mental status. It is important to consider possible causes for N&V beyond chemotherapy, especially if it continues for an unexpectedly long duration after chemo. It is possible that the patient has an underlying problem like gastrointestinal obstruction, increased intracranial pressure, or new metastases [249]. Nursing consideration: Assess the emetogenic potential of the combination of cancer drugs in order to match it with an initial antiemetic drug regimen [231]. Re-assess effectiveness after each cycle and work with the oncologist or palliative care team if a stronger antiemetic regimen is needed, or if antiemetics need to be given for a longer time. Different cancer treatments may cause specific types of pain. Patients may have different types of pain depending on the treatments they receive, including [145,146]: Spasms, stinging, and itching caused by intravenous chemotherapy. Mucositis caused by chemotherapy, radiation, or targeted therapy. Skin pain, rash, or erythodysethesia syndrome (i.e. hand-foot syndrome) caused by chemotherapy (such as 5-FU, capecitabine, liposomal doxorubicine, paclitaxel) or targeted therapy (sorafenib, sunitinib). Arthralgias and myalgias caused by paclitaxel or aromatase inhibitors. Osteonecrosis of the jaw caused by bisphosphonates given for bone metastases. Pain syndromes, including mucositis, inflammation in areas receiving radiation therapy, pain flares, and radiation dermatitis. Cancer pain may affect quality of life and ability to function even after treatment ends. Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control [146]. Each patient needs a plan to control cancer pain. Each person s diagnosis, cancer stage, response to pain, and personal preferences around pain relief are different. The nurse, oncologist, patient, and family can work together to help manage pain. The patient and family will need written instructions to manage pain at home, along with contingency plans for common problems, including how to contact the physician or palliative care team on the weekends or evenings [146]. It is imperative that the cause of the pain is found early and treated quickly. Nurses will need to assess pain intermittently, including [146]: After starting cancer treatment. When there is new pain. After starting any type of pain treatment. Patients are often asked to describe the pain with questions like these [146]: When did the pain start? Page 41

44 How long does the pain last? Where is the pain? What is the pain like (sharp, crampy, dull, throbbing, burning, radiating, etc.)? How severe is the pain on a scale of zero to ten? Have there been changes in where or when the pain occurs? What makes the pain better or worse? Is the pain worse during certain times of the day or night? Is there breakthrough pain (intense pain that flares up rapidly even when pain-medicine is being used)? Are there other symptoms, such as trouble sleeping, fatigue, depression, or anxiety? Does pain interfere with activities of daily life, like eating, bathing, or moving around? A scale from zero to ten is used to measure how severe the pain is and help the cancer team choose pain medication. The World Health Organization (WHO) Pain Ladder categorizes pain on a 3-step scale. Using the 1-10 assessment most often used in clinical settings [145,146]: Zero indicates no pain. One to three indicate mild pain (step 1). Four to six indicate moderate pain (step 2). Seven to ten indicate severe pain (step 3). The patient s past and current pain medications, prognosis, comorbidities, nicotine use, alcohol intake, sedatives, personal or family history of substance abuse as well as other factors in the patient history may be considered in formulating a plan for pain relief. In some cases, patients with complex histories and needs are referred to pain specialists or palliative care teams [146]. Pain medications are prescribed based on whether the pain is mild, moderate, or severe. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain or given with opioids for moderate to severe pain. The following are commonly used NSAIDS: Acetaminophen. Celecoxib. Diclofenac. Ibuprofen. Ketoprofen. Ketorolac. Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects [146]. The NCCN recommends that patients older than 60 are at high risk of renal toxicities, as are those with pre-existing renal abnormalities or nephrotoxic drugs. NSAIDs can worsen or cause hypertension, bleeding, gastric upset, nausea, liver function abnormalities, bleeding complications, and congestive heart failure, especially in high-risk groups [203]. Opioids are used to relieve moderate to severe pain. Opioids work to relieve moderate to severe pain, i.e. step 2 on the WHO scale [145]. Some patients with cancer pain cease receiving pain relief from opioids after a time due to tolerance. Larger doses or a different opioid may be needed if this happens. Tolerance of an opioid reflects physical dependence, and is not the same as addiction (i.e. psychological dependence, in which the patient takes a drug for its euphoric effects). Opioid doses can be safely increased as needed for pain without causing addiction. There are several types of opioids: Buprenorphine. Codeine. Diamorphine. Fentanyl. Hydrocodone. Hydromorphone. Methadone. Page 42 Morphine (the most commonly used opioid for cancer pain). Oxycodone. Oxymorphone. Tapentadol. Tramadol. Methadone is safer for patients with renal failure, and is preferred for those with known opioid allergies because it is synthetic. However, methadone also has disadvantages, including drug interactions, the risk of QT prolongation (an EKG is recommended before starting and 2-4 weeks after starting treatment), and a variable equianalgesic ratio, making rotation (opioid switching) more challenging. Methadone is metabolized by CYP 3A and CYP 2D6. CYP 3A inducers (e.g. certain anticonvulsants and antiretroviral agents) can potentially reduce analgesic effect. These are just some of the reasons why it should only be prescribed by experienced clinicians [145]. Codeine requires metabolism by CYP 2D6 into its active form. People with low CYP 2D6 activity may get poor relief from codeine, but people with high CYP 2D6 activity are rapid metabolizers who can quickly reach toxicity with normal doses. Patients started on codeine should be monitored for pain relief and toxicity until effects are assured [203]. Meperidine is notably missing from this list because it has a neurotoxic and cardiotoxic metabolite, normeperidine, with a long half-life, and cancer pain requires repeat dosing over time. Thus it is contraindicated for chronic pain. Butorphanol and pentazocine are mixed agonist-antagonist drugs and are also not recommended for treating cancer pain because switching from a pure opioid agonist drug could precipitate withdrawal crisis and subsequent difficulty getting pain back under control [203]. Most patients with cancer pain will need to receive opioids on a regular schedule. Receiving opioids on a regular schedule helps control the pain. The dose interval depends on which opioid is being used and occurrence of breakthrough pain. The dose is slowly adjusted until there is a good balance between pain relief and side effects. Outpatients and their family caregivers must know how to safely use, store, and dispose of opioids [146]. The following are the most common side effects: Constipation. Nausea. Drowsiness. Dry mouth. Drowsiness and nausea most often occur when opioid treatment is first started; these patients usually become better within a few days [146]. Other side effects of opioid treatment include the following: Vomiting. Hypotension. Dizziness. Insomnia. Confusion. Delirium or hallucinations. Trouble urinating. Problems with breathing. Severe itching. Problems with sexual function. Hot flashes. Depression. Hypoglycemia. Teach the patient and family what to watch for and report. Bothersome or severe side effects may require a decreased opioid dose, change to a different opioid, or change in route to help decrease the side effects [146].

45 Vomiting occurs in about one-third of patients who take opioids; twice as many have nausea. Antiemetics, such as metoclopramide, may be used preventively; prochlorperazine, promethazine, and olanzapine can be used as well. Constipation is common and a scheduled stimulant laxative is typically started along with opioid treatment unless there is a problem with bowel obstruction or diarrhea, along with encouragement to exercise and take in sufficient fiber. The goal is one bowel movement per day, and the regimen may need to be changed to meet that. Significant respiratory depression can usually be avoided through careful titration of doses. Delirium is linked to opioids but is usually multifactorial and not caused by the opioid. In the event of uncontrolled pain at maximal doses, or neurotoxicity such as myoclonus, hallucinations, vivid dreams, confusion, or tolerance (i.e. less pain relief with the same dose over time), opioid rotation (switching) may be helpful. Adjuvant drugs may be given along with opioids to optimize pain relief. These drugs can potentiate opioids, help with symptoms or relieve certain types of pain [145,203,146]: Antidepressants (such as venlafaxine, duloxetine, desipramine, nortriptylene) for neuropathic pain. Anticonvulsants may also help neuropathic pain. Gabapentin and pregabalin, for neuropathic pain. Local anesthetics for procedural pain. Corticosteroids in conjunction with opioids (although evidence is weak). Stimulants during the day, to help with opioid-induced sedation. Bisphosphonates and denosumab for bone metastases. There are big differences in how patients respond to these drugs, and side effects are common. Some patients have too many side effects from drugs or have pain that needs to be treated in a different way. Other treatments in these cases include [146]: Nerve block is a procedure in which either a local anesthetic or a drug is injected into or around a nerve to block pain that cannot be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures. Surgical neurologic treatments can be done by inserting a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway. Cordotomy is a less common surgical procedure that is used to relieve pain by cutting nerves in the spinal cord. This blocks pain and other sensation. This procedure may be used for patients who are near the end of life and have severe pain that cannot be relieved in other ways. Palliative care team consultation: These providers typically work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of their goals are to: Improve quality of life for patients and their families. Manage pain and non-pain symptoms. Support patients who need higher doses of opioids, have a history of substance abuse, or are coping with emotional and social problems. Radiation therapy Radiation therapy is used to relieve pain in patients with skin lesions, other tumors, or bone metastases. Palliative radiation therapy may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy can help shrink tumors that are causing pain and may help patients with bone pain move more freely and with less pain [146]: External radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision as to whether to have single or divided dose may depend on how easy it is to get the treatments and their cost. Radiopharmaceuticals may be used to relieve pain from bone metastases. A single dose of a radioactive agent given IV may relieve bone pain when there are too many areas to treat with external radiation therapy. Physical medicine and rehabilitation Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help. Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury. Physical methods to treat weakness, muscle wasting, and muscle and bone pain include: Exercise to strengthen and stretch weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart. Changing position (for patients who are unable to move on their own). Limiting movement of painful areas or broken bones. Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain [146]. Complementary therapies Complementary and alternative therapies combined with standard treatment may be used to help treat pain. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to help pain [146]. Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin. Acupuncture may be used as an adjunct to try and help control pain, including pain related to cancer. Hypnosis may help patients relax and is often combined with other thinking and behavioral methods. Hypnosis to relieve pain works best in people who are able to concentrate, use imagery, and who are willing to practice the technique. Support groups help many patients. Patients with religious affiliations may be helped by religious counseling. Pastoral counseling (non-denominational) may also help by offering spiritual care and social support. Cancer pain in older patients is managed more cautiously Elders must be started on lower doses of opioids and titrated slowly to allow for differences in pain thresholds and responses to the drugs. There are some recommendations against using NSAIDs and tricyclic antidepressants in geriatric patients [145]. Meperidine is contraindicated in chronic pain management. It can be especially harmful in patients with decreased renal function or dehydration, and can cause delirium in older patients [203]. After pain control medications and other measures are started, and especially after each modification or addition, the nurse and the cancer treatment team must continue to assess how well it is working, monitor for side effects, and make changes if needed. Mucositis (Stomatitis) and mouth pain Ulcerative mucositis occurs in about 40% of patients receiving chemotherapy, and typically starts seven to ten days after treatment starts, remaining for about two weeks after it is finished. Chemotherapy often damages healthy cells in the mouth and gut, causing problems with eating and drinking liquids. Pain and inflammation can also be caused by fungal infections (thrush), viral infections, radiation to the head and neck. Susceptibility to these infections can be caused by direct toxicity to the mucosa as well as neutropenia and dysfunction of the salivary glands. There are no agents that prevent this toxicity, although dental and periodontal infections can be treated. Some infections can be prevented by oral rinses with 0.12% chlorhexidine gluconate and gentle brushing and Page 43

46 flossing. Peroxide rinses were once recommended to help remove bacteria but peroxide can damage fibroblasts and keratinocytes and delay mucositis healing [181]. Cancer treatment agents most commonly associated with mucositis are [145,302]: Cytarabine. Doxorubicin. Etoposide. 5-fluorouracil. Methotrexate. Epidermal growth factor receptor inhibitors (such as afatinib, cetuximab, erlotinib, gefitinib, lapatinib, panitumumab). Multitargeted tyrosine kinase inhibitors (such as cabozantinib, ceritinib, crizotinib, pazopanib, regorafenib, sorafenib, sunitinib, vendetanib). Mammalian target of rapamycin inhibitors (such as everolimus, temsirolimus). Complications can be acute (developing during treatment) or chronic (developing months to years afterward). In general, cancer chemotherapy causes acute symptoms that resolve following treatment, with recovery of damaged tissues [181]. Primary preventive measures should begin before chemotherapy starts; appropriate nutritional intake, effective oral hygiene practices, and early detection of oral lesions are important pretreatment interventions. Patients who smoke should be offered help with cessation before treatment begins, since smoking reduces microcirculation and delays healing and is known prolong mucositis after radiation therapy [181]. Dental consultation a few weeks before cancer chemotherapy starts can sometimes help prevent complications by treating problems and starting a program of oral hygiene. Specific interventions are directed at [181]: Mucosal lesions. Dental caries and endodontic disease. Periodontal disease. Ill-fitting dentures. Orthodontic appliances. Temporomandibular dysfunction. Salivary abnormalities. If the patient is already myelosuppressed at the time of dental treatment, some corrections or prophylaxis may be needed (e.g., platelet transfusions or antibiotics if ANC less than 2000). Mucositis should be managed by good oral hygiene, and avoidance of spicy, acidic, hard, and hot foods and drinks. Dental brushing and flossing should be performed daily with assistance from professional staff [181]: A soft nylon-bristled toothbrush should be used two to three times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus and keeping them free of bacterial plaque. Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma. Oral rinsing with water or normal saline three to four times while brushing will further aid in removal of dental plaque. Peripheral neuropathy Chemotherapy-induced peripheral neuropathy (CIPN) is a result of damage to the peripheral nerves. Symptoms depend on which peripheral nerves (sensory, motor, or autonomic) are affected. CIPN usually starts in the feet and hands that may spread proximally to arms or legs [179]. It is one of the most common reasons that cancer patients stop treatment early. It can sometimes be lessened by lowering the chemotherapy dose or delaying doses, which might diminish the pain. Other patients report symptoms last long beyond chemotherapy treatment for months or years [153]. Page 44 Rinses containing alcohol should be avoided. Toothpaste with a relatively neutral taste should be considered because flavorings can irritate oral soft tissues. Brushes should be air-dried between uses. Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use. Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. While toothbrush disinfectants have been suggested, their routine use to clean brushes has not been proven of value. The mouth should be cleaned after meals [181]: If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary. Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals. Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary. Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. Foam toothbrushes have limited ability to clean teeth but may be useful for cleaning other areas of the mouth, palate, and tongue. Management of discomfort and dryness [181]: Topical anesthetics like lidocaine in gels, ointments or sprays can help, as can diphenhydramine solution. Mucosal coating agents like Amphojel, kaolin-pectin suspension, hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin), and Gelclair (approved by the U.S. FDA as a device). Water-soluble lubricating agents, such as artificial saliva, can be used for xerostomia. A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for four hours or longer. Its application to damaged mucosa does not cause burning. Topical morphine has been shown to be effective for relieving pain, but there is concern about dispensing large volumes of the medication. Topical fentanyl prepared as lozenges in a randomized placebocontrolled study showed relief for pain of oral mucositis. Systemic analgesia (such as opioids) should be used for pain unrelieved by these measures. NSAIDs are contraindicated when thrombocytopenia is present. Head and neck radiation typically causes not only acute oral toxicities such as mucositis in almost all recipients. In contrast to chemotherapy stomatitis, which tends to resolve after treatment ends, head and neck radiation can induce permanent tissue damage (to mucosa, bone, taste buds and more) that result in lifelong risk for the patient. Amifostine can be used to help prevent damage to the salivary glands [181]. Patients who do not respond well to topical treatments and symptomatic nursing management should be referred for dietary consultation to avoid dehydration and weight loss. Drugs associated with CIPN: Platinum compounds (cisplatin, carboplatin, oxaliplatin). Plant alkaloids (vincristine, vinblastine, vinorelbine, etoposide) [17]. Taxanes (docetaxel, paclitaxel, cabazitaxel). Epothilones (ixabepilone). Bortezomib. Thalidomide. Lenalidomide [153]. Eribulin [17].

47 Damage to sensory nerves can cause [179]: Tingling, numbness, or pins-and-needles in feet and hands. Inability to feel heat or cold in extremities. Inability to feel pain in the extremities. Hyperesthesia (increased sensitivity to heat, cold, or pressure) [17]. Damage to motor nerves can cause: Weak or achy muscles, loss of balance, difficulty with fine motor function (buttoning shirts or opening jars). Twitching, cramping, or muscle wasting. Dysphagia or dyspnea if chest or throat muscles are affected. Damage to autonomic nerves can cause: Gut motility problems such as constipation or diarrhea. Hypotension with dizziness and lightheadedness. Sexual problems: Men may have erectile dysfunction and women may not reach orgasm. Sweating too much or too little. Urinary issues, such as leakage or incomplete bladder emptying. Injury prevention is important after CIPN develops. Advise affected patients to take actions to [179]: 1. Prevent falls: Get help moving rugs out of pathways to reduce the risk of tripping. Wear sturdy shoes with soft soles, not slippers that feet can accidentally slide out of. Home care services may be needed to put rails along the walls and in the bathroom. Use gripper bathmats in the shower or tub. Get up slowly after sitting or lying down, especially if the patient reports dizziness. 2. Take extra care in the kitchen and shower: Use potholders in the kitchen to protect hands from burns. Be careful when handling knives or sharp objects. Use oven gloves to handle hot pans, oven racks, and dishes. Ask someone to check the water temperature, or use a thermometer to make sure bath or shower water is not too hot. Set hot water heaters between 105 and 120 F to reduce risk of scalding when washing hands or dishes. 3. Protect hands and feet: Wear shoes, both inside and outside. Wear protective gloves when gardening, cleaning, or doing repairs. Check arms, legs, and feet for cuts or scratches every day. When the weather is cold, wear warm clothes, gloves, and socks to protect hands and feet. 4. Slow down and ask for help: Let others help with difficult tasks. Slow down and allow more time to do things. For patients with long-term CIPN, nurses may also want to ask the doctor to offer a referral to occupational therapy to help the patient with safety and mobility in the home and community [17]. Pain management for CIPN In 2014, the American Society of Clinical Oncology put out a review of evidence and a recommendation noting that no agents have been proven to prevent CIPN, and recommended duloxetine as a proven pain reliever for CIPN. They further added that tricyclic antidepressants (such as nortriptyline), gabapentin, and a topical gel containing baclofen, amitriptyline HCL, and ketamine, might all be offered because there is data that supports their efficacy in other types of neuropathic pain [101]. However, more research is needed on these agents for CIPN. The ASCO also had a long list of medications and supplements that they specifically recommended against, including amifostine, amitriptyline, calcium and magnesium infusion, vitamin E, glutathione, all-trans-retinoic acid, nimodipine, acetyl-l-carnitine, and others. Some patients with incomplete pain relief may be helped somewhat by distraction and practices such as massage, physical therapy, yoga, guided meditation, acupuncture, and other modalities [179]. Neutropenia Chemotherapy, radiation therapy, and stem cell transplants (which usually involve both chemo and RT) can lower the white blood cell count [208]. Especially important are the granulocytes or neutrophils that have an important role in fighting infection. Many chemotherapy drugs can depress the entire bone marrow production, not just white cells but also red blood cells (erythrocytes) and platelets. This leads to defects in fighting infection as well as oxygenation and blood clotting. Practice note: Look on the lab report for the white blood count differential (most often done with a complete blood count, CBC): sometimes neutrophils show up listed as segs, which refer to segmented neutrophils, or mature neutrophils; bands, which are less mature neutrophils; or to polys, which are polymorphonuclear leukocytes, yet another term for neutrophils. An absolute neutrophil count (ANC) of 500-1,000 is considered mildmoderate neutropenia, is severely neutropenic, and an ANC less than 100 is profoundly so. To calculate the ANC, add together the percentage of bands plus segs, polys, or neutrophils, then multiply by the number of total number white blood cells. For example, a person with a total white blood count of 550 with 60% segs and 4% bands would have an ANC of 352 (550 x 0.64 = 352). This person has neutropenia and should be watched for any signs of infection because an immediate fever workup and antibiotics would be indicated. This is especially important if the patient s white count is still dropping after a cycle of chemotherapy. In people with cancer, there is some urgency to completing this sequence because infection can sometimes progress to septic shock and death very quickly. Fever workups: Make em stat A fever workup in the neutropenic patient usually starts with two sets of blood cultures. If the patient has a port or a CVL, one set of blood cultures is taken from the line and the other from a peripheral site. However, given that many people with cancer have very poor peripheral venous access it is sometimes necessary to take both from the line. Generally, a CBC with differential is taken as well, along with electrolytes, BUN, creatinine, and liver function tests. A chest X-ray, sputum cultures, and pulse oximetry would typically be conducted if the patient had respiratory symptoms. If the patient has skin lesions/ drainage, UTI symptoms or a urinary catheter, additional cultures are taken from these sites. Stool for enteric pathogens may be done if the patient has diarrhea, with a probe for Clostridium difficile toxins if the patient has had antibiotics in the past few weeks (see Diarrhea ). Additional history is taken to find out if the person has any other new symptoms such as sore throat, skin or mucosal ulcers, etc., which are then usually cultured or tested for viruses. People with localizing symptoms such as abdominal pain or a new headache, stiff neck, etc., might need additional scans or tests. As soon as cultures are completed, broadspectrum antibiotics are typically administered until more information becomes available from the cultures and scans to focus the antibiotic therapy on the causative organism [208]. Case study: A 54-year-old woman with acute myelogenous leukemia has a WBC of 400 with 40% segs and 5% bands near the end of her first treatment (intended to induce remission). This calculates out as an ANC of 180 ( =0.45; 400 x 0.45 = 180). You note that her Page 45

48 ANC has been below 500 for the a days and still seems to be declining. With an ANC of 180 she has fairly significant neutropenia. At this time, she does not have fever or other signs of infection. What are your concerns? Case discussion: With this ANC, your patient is at increasing risk for infection and must be watched closely for signs of infection. In general, the longer and more severe the neutropenia is, the higher the risk for serious infections. She may be a candidate for prophylactic antibiotics if the neutropenia is expected to worsen or to continue for more than ten days. For example, the ASCO recommends prophylaxis for patients whose ANC is expected to go below 100 for seven days or more [211]. Fluoroquinolone antibiotics (such as ciprofloxacin, levofloxacin, and gemifloxacin) are often used preventively, along with antifungal and even antiviral prophylaxis drugs until the neutopenia resolves. With high risk patients, preventive antibiotics specifically for pneumocystis pneumomia (trimethoprim + sulfa, atovaquone, and others) are often added; this is known as PCP prophylaxis [208]. Anemia Anemia is common and it is found in 30-90% of patients with cancer. It can be a major contributor to fatigue. Anemia is caused by low production of red blood cells (RBCs), destruction of RBCs, or bleeding [205]. The impact of anemia on the patient varies depending on factors such as [163,205]: Speed of onset (patients can acclimate to gradual declines up to a point). Patient age (older patients may have worse outcomes). Plasma-volume status (dehydration can make hematocrit appear more normal but cause more problems). The number and severity of comorbidities (can mean less ability to adapt to lower hemoglobin levels). Anemia can be categorized as mild to life-threatening based on hemoglobin level [205]: Mild anemia: Hemoglobin of 10g/dL to lower limit of normal. Moderate anemia: Hemoglobin of 8 to <10g/Dl. Severe anemia: Hemoglobin of 6.5 to <8g/Dl. Below this level is considered to be life-threatening and the next category is mortality. In patients with a hemoglobin level less than or equal to 11g/dL (or 2 g/dl or more below baseline), an evaluation for possible causes is recommended by the NCCN, starting with a CBC with RBC morphology and reticulocyte count. Different types of anemia can be determined based in part on the size of the RBCs, with different etiologies based micro or macrocytosis (small or large RBCs) versus normocytic anemia. The number of reticulocytes shows how many immature red cells are in the circulation and gives an idea of the capacity of the bone marrow to produce red cells. A check for bleeding, such as a check of the stool for guaiac or sometimes endoscopy, may be done. A bone marrow exam, iron studies, vitamin B12 levels, red cell folate levels, and ferritin levels may be conducted, and the Coombs tests and others may be done to check for hemolysis. Thrombocytopenia and bleeding Thrombocytopenia in a patient after recent chemotherapy or radiation is usually accompanied by anemia and leukopenia as a result of the bone marrow suppression common to these treatments. It is usually managed by careful assessment, supportive care (bleeding precautions) and platelet transfusions as needed [249]. Page 46 Myeloid growth factors can be used for some patients With other diagnoses, such as solid tumors and non-myeloid cancers, myeloid growth factors (such as filgrastim, pegfilgrastim, and other granulocyte colony stimulating factors) might be considered for people at high risk (>20%) of febrile neutropenia. This includes people with liver or renal dysfunction, recent surgery, age >65 getting full-dose chemotherapy, or bone marrow involvement by the tumor, among others. A patient with AML is not a candidate for myeloid growth factor use as that is a myeloid cancer. Growth factors are not recommended for routine use, but patients who have had febrile neutropenia or a dose-limiting neutropenic event after a chemotherapy cycle may be considered for addition of a myeloid growth factor on subsequent chemo cycles [207]. Patients with sepsis, neutropenia expected to last more than ten days, invasive fungal infections, or an ANC < 100 may also be considered for immediate use of a myeloid factor, although this use has not been shown to reduce mortality in adults. Myeloid growth factors are not without risks, which are typically mild, but occasionally allergic reactions, capillary leak syndrome, sequestration of WBCs in the lungs, adult respiratory distress syndrome, and splenic rupture (with some fatalities) have occurred [207]. When no specific cause is identified, the culprit may be anemia of chronic disease or secondary to myelosuppressive chemotherapy [205]. There is no absolute trigger point for transfusion to be considered. Multiple factors should be reviewed and the decision should be individualized. If the patient is asymptomatic and has no significant comorbidities, s/he can be observed and re-evaluated periodically. Patients who are asymptomatic but have comorbidities such as lung disease, vascular disease, or recent progressive decline with chemo or radiation (i.e., it is expected to continue to decline) should be considered for transfusion. Symptomatic patients are typically transfused. Symptoms often include tachycardia, tachypnea, dyspnea on exertion, fatigue, dizziness, and/or syncope preventing the patient s usual activity [205]. Most patients will suffer uncomfortable symptoms of anemia if the hemoglobin falls below 7g/dl. Symptoms in patients with heart or lung diseases may occur at much higher hemoglobin levels. Transfusion of one unit of packed RBCs raises the hemoglobin by about 1gm/dL [212]. Erythrocyte stimulating agents can be useful for some Erythropoiesis-stimulating agents (ESAs) can also be used in some patients to correct anemia if the need for correction is not immediate. However, there are risks of increased thrombotic events and a possible decrease in survival along with a shorter time to tumor progression. Because of this, ESAs are typically reserved for patients who are not receiving curative cancer treatment, and who can wait for a more gradual improvement in anemia symptoms. The patient or the patient s representative typically must be informed of these risks, be given a chance to ask questions of their health care provider, and sign a consent form to allow use of erythropoiesis-stimulating agents. The patient should be monitored for hypertension and be informed of the signs of allergic reaction, deep vein thrombosis, stroke, and pulmonary embolus [205]. With a low platelet count, it is important to assess for bleeding and bleeding risk as well as to follow the platelet count over time. Patients with platelet counts below 50,000/mm3 need routine assessment for bleeding, including observing for bleeding gums, epistaxis, bruising, conjunctival bleeding, hematuria, melena, and petechiae. Platelet transfusions may be needed in the event of bleeding, or preventively if the counts are below 10,000/mm3. If the patient should sustain a fall or

49 injury, immediate transfusion may be needed. With patients scheduled for invasive procedures, it is typical to infuse platelets until the count is 50,000/mm3 beforehand, although some are infused during the procedure [249]. Outpatients with dropping counts on a Friday may need transfusions before Monday even if they have not quite reached 10,000/mm3 [116]. Patients with thrombocytopenia should be taught to avoid activities that increase the risk of injury or bruising, and to use soft toothbrushes, electric razors, and to avoid constipation. Nurses should avoid invasive procedures like suppositories, use of rectal thermometer, enemas, IM injections, catheterization, deep suctioning, and NG tubes. Diarrhea The reported prevalence and severity of diarrhea vary greatly. Some chemotherapy regimens are associated with diarrhea rates as high as 50% to 80%, especially those containing fluoropyrimidine antimetabolites (such as capecitabine, floxuridine, and fluorouracil), or irinotecan. Diarrhea is also common in patients with carcinoid tumors and those receiving radiation therapy to abdominal or pelvic fields, or in patients after gastrointestinal surgery, or undergoing hematopoietic stem cells transplants [164]. There are a number of causes of diarrhea in people with cancer: Surgery. Chemotherapy. Radiation therapy. Bone marrow transplantation. Antibiotic therapy. Stress and anxiety associated with cancer diagnosis and treatment. Infection. Typical infections are of viral, bacterial, protozoan, parasitic, or fungal etiology. Diarrhea may be caused by pseudomembranous colitis, which is commonly caused by the bacterium Clostridium difficile. Diarrhea can also be caused by: the bacteria Clostridium perfringens, Bacillus cereus, Salmonella spp., Shigella spp., and Campylobacter spp.; the parasites Giardia lamblia, Cryptosporidium spp.; or by viruses such as Rotavirus [164]. Other causes of diarrhea in patients with cancer include the underlying cancer, responses to diet, or concomitant diseases (see Table 2). Common causes of diarrhea in patients on opioid pain medications include difficulty adjusting the laxative regimen or impaction leading to leakage of stool around the fecal obstruction [164]. The consequences of diarrhea can be life-threatening. According to the National Cancer Institute (NCI), more than half of patients receiving chemotherapy for colorectal cancer experienced diarrhea of grade three or grade four (i.e. seven or more stools per day above baseline, incontinence, requirement for hospitalization, and potential life-threatening consequences). Grade five is death. These situations require treatment changes or the reduction, delay, or discontinuation of therapy. A review of several clinical trials of irinotecan plus highdose fluorouracil and leucovorin in colorectal cancer revealed early death rates of 2.2% to 4.8%, primarily due to gastrointestinal toxicity, although some cases could have been due to neutropenic enterocolitis (discussed below) [251]. Certain chemotherapeutic agents can alter normal absorption and secretion functions of the small bowel, resulting in diarrhea. Examples of chemotherapy agents with diarrhea-related potential are capecitabine, cisplatin, cytosine arabinoside, cyclophosphamide, daunorubicin, docetaxel, doxorubicin, 5-fluorouracil, interferon, irinotecan, leucovorin, methotrexate, oxaliplatin, paclitaxel, topotecan, and lapatinib [164]. Patients receiving concomitant abdominal or pelvic radiation therapy or recovering from recent gastrointestinal surgery will often experience Subcutaneous injections should be given with very small needles, and as with venipunctures, the site should be subjected to direct pressure for five minutes after [249]. In cancer patients, thrombocytopenia is caused by chemotherapy in around two thirds of cases, but it is important to remember that thrombocytopenia appearing by itself (without other myelosuppression), or apart from cancer treatment, may very well be due to another problem [240]. Sometimes there are other factors contributing to low platelet count, such as antibiotics, infections, or coagulopathies which can be treated [116]. A careful history is essential. more severe diarrhea. Surgery can affect the body by mechanical, functional, and physiological alterations [164]. Radiation therapy to abdominal, pelvic, lumbar, or para-aortic fields can result in changes to normal bowel function. Acute intestinal side effects occur at approximately 10Gy (or 10,000 millisieverts) and may last eight to 12 weeks post-therapy. Chronic radiation enteritis may present months to years after completion of therapy and necessitates dietary modification and pharmacological management and, in some instances, surgical intervention [164]. Radiation and conditioning chemotherapy can also contribute to or cause diarrhea in hematopoietic stem cell transplant patients. Graftversus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation, and the intestinal tract, skin, and liver are commonly affected. Acute GVHD usually manifests within 100 days after transplant, although it can occur as early as seven to ten days after transplant. Symptoms of gastrointestinal GVHD include nausea and vomiting, severe abdominal pain and cramping, and watery diarrhea. The volume of accompanying GVHD-associated diarrhea may reach up to ten liters per day and indicates the degree and extent of mucosal damage. It may resolve or develop into a chronic form requiring long-term treatment and dietary management [164]. Diarrhea with pain and fever may mean neutropenic enterocolitis Some of the more severe cases of diarrhea may be due to neutropenic enterocolitis (also known as necrotizing enterocolitis or typhlitis). Symptoms typically start days after starting cytotoxic chemotherapy, especially cytosine arabinoside, vinca alkaloids, and doxorubicin. There have been reports linking it to alemtuzumab, pegylated interferon, anthracyclines, and a number of other chemotherapy drugs as well. Neutropenic enterocolitis is often a missed diagnosis, since it may present like appendicitis at first and there is no official case definition. Symptoms include right lower quadrant pain, fever, watery or bloody diarrhea (in about a quarter to a half of patients), nausea, vomiting, and/or bloating. Inflammation of the bowel wall can lead to perforation and peritonitis; bacteremia is fairly common, and fungemia can also occur. This condition typically involves the cecum, and when it is distended, the blood supply can be compromised and lead to further damage [265]. The incidence rate in adults on cytotoxic chemo (e.g. for leukemias), is roughly 4-6%, although a report of 12% incidence was reported in patients with hematopoietic stem cell transplant. Complications can include bowel obstruction, perforation, abscesses, GI bleeding, sepsis, and death. The mortality rates are widely variable, and average about 40-50%. Treatment, to date, ranges from aggressive supportive care with antibiotics and antifungals to surgical management. Further chemotherapy must be withheld until complete recovery and possibly with primary prophylaxis. Patients who recover and need more chemotherapy may benefit from a right hemicolectomy before proceeding [265]. Page 47

50 Nursing consideration: Early recognition and treatment of neutropenic enterocolitis, which often mimics appendicitis in neutropenic patients, can improve outcome [265]. Management of chemo-related diarrhea Early assessment and aggressive interventions are essential in diarrhea. In uncomplicated diarrhea, treatment is often empiric and nonspecific. Whenever possible, underlying causes such as fecal impaction should be treated. Medications such as bulk laxatives and promotility agents (e.g., metoclopramide) are discontinued if being used for opioid management. Dietary changes are commonly used to help stop or lessen the severity of diarrhea. Some recommend that patients eat foods that build stool consistency, are low in fiber, and do not stimulate or irritate the gastrointestinal tract [297]. In some cases, dietary modification for diarrhea management includes advising patients to eat small, frequent meals and avoid lactose-containing food (e.g. milk and dairy products), spicy foods, alcohol, caffeine-containing foods and beverages, certain fruit juices, gas-forming foods and beverages, high-fiber foods, and high-fat foods [126]. For mild diarrhea, the BRAT (bananas, rice, apples, toast) diet may reduce the frequency of stools. Patients with diarrhea are encouraged to increase clear liquid intake to at least three liters per day (e.g., water, sports drinks, broth, weak decaffeinated teas, caffeine-free soft drinks, clear juices, and gelatin) [164]. Pharmacologic treatment is commonly used for diarrhea. Its goals include inhibition of intestinal motility, reduction in gut secretions, and promotion of absorption. Absorbents include agents that form a gelatinous mass that makes fecal material denser. Methylcellulose and pectin are most commonly used, but there is little data to support their efficacy. These bulk-forming agents may not be tolerated in some patients because of the large volume required for therapeutic effect and the associated abdominal discomfort and bloating. Adsorbents such as kaolin, clays, and activated charcoals have been used extensively, but no data support their use. Furthermore, they may inhibit absorption of other oral antidiarrheals that may be administered [164]. Opioids bind to receptors in the gut and reduce diarrhea by reducing transit time. Loperamide is the most common opioid used, due to its availability and reduced effect on cognition, although codeine and other opioids can also be effective. Common loperamide doses begin with 4mg, followed by 2mg after each unformed stool with a maximum of about 12mg/day. Regardless of dose, loperamide may be less effective in patients with grade three or four diarrhea [63]. Mucosal prostaglandin inhibitors, also referred to as antisecretory agents, include aspirin, bismuth subsalicylate, corticosteroids, and octreotide, may help. Aspirin may be useful for radiation-induced diarrhea. Bismuth subsalicylate is believed to have direct antimicrobial effects on the bacterium Escherichia coli. This agent is contraindicated in patients who should not be taking aspirin, and large doses can produce toxic salicylate levels [164]. Corticosteroids reduce edema associated with obstruction and radiation colitis and can reduce hormonal influences of some endocrine tumors [164]. Other pharmacologic therapies for the relief of diarrhea may be specific to the underlying cause. Delayed diarrhea (>24 hours) occurs with irinotecan and can be severe. In a small study of seven patients, six patients obtained relief with oral neomycin, 1,000mg, three times daily. This relief occurred without reduction in the active metabolite of irinotecan, SN-38; thus, the poorly metabolized antibiotic did not alter efficacy of the chemotherapeutic agent [110]. In another small study of 37 patients with non-small cell lung cancer receiving irinotecan, investigators alkalized the feces through oral administration of sodium bicarbonate, water, and ursodeoxycholic acid, while speeding transit time of the drug metabolites (thought to reduce damage to the intestinal lumen by reducing stasis of the drug) through the use of magnesium oxide. The incidence of delayed diarrhea was significantly reduced in this group when compared with 32 patients receiving the same chemotherapeutic regimen without oral alkalization and controlled defecation [268]. GVHD diarrhea In addition to antidiarrheal agents and immunosuppressive medications, a specialized five-phase dietary regimen may be instituted to effectively manage the diarrhea associated with GVHD [73]. Phase-1 consists of total bowel rest until the diarrhea is reduced (NPO). Phase-2 reintroduces oral feedings consisting of beverages that are isotonic, low-residue, and lactose-free. If these beverages are well tolerated, Phase-3 may reintroduce solids containing minimal lactose, low fiber, low fat, low total acidity, and no gastric irritants. In Phase-4, dietary restrictions are progressively reduced as foods are gradually reintroduced and tolerance is established. Phase-5 includes the resumption of the patient s regular diet, but most patients usually remain lactose intolerant [164]. Mild cognitive impairment Cognitive changes with a cancer diagnosis are very common, with patients complaining of short term memory loss, mental fogginess, difficulty concentrating, and loss of ability to multitask or perform mathematical calculations. These cognitive changes can start during and/or after cancer treatment, and some have even been observed as occurring before treatment began. Although it is often called chemobrain, the full etiology of this problem is unclear. Studies that look at people after cancer treatment cannot account for other effects of diagnosis, treatment, or baseline differences. A multifactorial problem: Researchers are also looking at other factors that affect cognitive function. For example, surgery and anesthesia have at least a short term effect on cognition, especially in older patients, which typically resolves over a period of days to months. The stress of diagnosis and treatment, endocrine changes, nausea medications, low blood counts, depression, hormone changes, fatigue, anxiety, normal aging, and cardiovascular disease can all affect cognitive function, and some of these factors may play a role in cognitive changes before, during, and after cancer treatment [133]. Subjective complaints vs. objective measures: Subjective observations of cognitive decline do not always match objective cognitive testing. Some studies have observed that patient perceptions of cognitive impairment are often not enough to make a noticeable difference on most neurocognitive tests, although there is some evidence that patients receiving chemotherapy were using cognitive reserves during some of these tests (e.g., showing more brain activity to deal with the testing problems, which may reflect their perception of having to work harder to process problems and information). However, studies that objectively measure cognitive function have found a higher rate of cognitive impairment among people who have been treated with chemotherapy. This tends to improves over time for the majority of patients, but some differences likely persist in a few [133]. Research continues into the mild cognitive impairment related to cancer treatment, but there is no specific medical treatment for it at this time. It is important to validate patients symptoms as normal and suggest that they not be too hard on themselves for lapses and omissions. Nurses can help patients come up with ways to cope, such as reminder systems, keeping a written or electronic calendar and medication log, setting up and following routines, and getting support from others who are going through or have been through similar experiences [249]. Page 48

51 Sexuality changes Cancer can affect sexual and intimate relationships of patients in a number of ways. Body image changes: chemotherapy and radiation all have different effects, some of which last months or years after treatment. Although cancer treatment teams are better at educating patients about chemotherapy and cancer treatment, sexual concerns are not usually specifically addressed. However, these concerns can be a source of distress that can negatively impact the patient s quality of life. Unfortunately, more than 75% of health professionals wait for the patient to bring up sexual changes rather than asking the patient about their sexual concerns [249]. In premenopausal women, cancer treatment (surgery, radiation, or chemo) can cause precipitous menopause, with symptoms like sudden onset of dyspareunia, decreased libido, vaginal dryness, mood swings, fatigue, and other effects, with little time to adjust to them. The antiestrogen drugs used to treat breast cancer only serve to heighten these symptoms for many women [249]. Men treated for prostate cancer often have erectile dysfunction, dry ejaculation, some degree of urinary incontinence, and penile shortening. These effects are more immediate with prostatectomy, developing more slowly with radiotherapy. Hormonal therapy for prostate cancer can lead to hot flashes, weight gain, osteoporosis, low libido, and depression [37]. Nurses are not likely to be able to perform an in-depth assessment of sexual concerns and function. But nurses should at least ask about concerns or problems related to sexual dysfunction, and refer the patient and sexual partner to a therapist with expertise in sexuality and cancer [249]. Cancer impact on the patient and family Emotional effects on the patient and family Cancer is a dreaded diagnosis. Its mention, even to people without cancer, prompts recollections of stories about people who had awful experiences with cancer, or who died from it. Even people with early stage cancer and excellent prognoses can feel very anxious, fearful, and vulnerable at times. It is well known that treatments can be arduous, with painful emotional fallout for patients, families, and loved ones. The financial impacts, which are rarely discussed, can affect families financial security for many years. Among the long-standing issues familiar to oncology nurses are the life disruptions that cancer brings as well as the emotional effects on the entire family and support systems and the patient who may be facing mortality for the first time. The patient and his or her loved ones may be dealing with the effects of cancer on: family and friend relationships or spiritual crises. Patients may be learning that they need a lot more emotional and logistical support than before. And patients often go through the slow-motion roller coaster of denial, shock, anger, sadness, despair, and many other emotions as they work their way through the minefield of mourning and learn to accept the changes and losses as they adjust to the new normal in their lives. Some seem to accept a cancer diagnosis calmly, trying to keep the effects to a minimum. It is not safe to assume that all is well just because a patient looks OK, as even these people often are working hard to keep a brave face while they privately worry over what will happen to them and their loved ones. It is acceptable to offer patients an ear if they need one, but some do not want to be pushed to talk about it. On the other hand, complimenting strength may backfire, as patients may feel the need to remain stoic even when they need help. There are no guarantees with cancer, and its uncertainties are hard to live with. This sometimes means the nurse s role entails patience, empathy, promotion of healthy coping, and sometimes referral for specific types of help. With patients who have misconceptions, nurses can be a caring listener as well as a source of accurate information that can alleviate some of the fears and uncertainties. Financial impact Cancer can cause loss of income as a person must cut back their working hours or become unable to work while and medical bills begin. Unfortunately, people who are uninsured have trouble with medical bills much more often than those with health insurance. That is why most people work to keep health insurance. Often, a plan is not enough for many people with cancer, as health insurance can be no guarantee of financial well-being. According to the Kaiser Family Foundation, medical debt triggers many types of hardship and financial instability, and can have serious and long-term consequences. People often cut back on necessities, like food, clothing, and household expenses, but the costs may still exceed what they can pay. Collection agencies can become involved, and lowering credit scores so that qualifying for needed medical loans to help pay for treatment becomes very difficult or impossible. Even if a loan is approved, interest rates are usually much higher, which increases the spiral of financial distress. Sometimes these hits on a person s credit score cause trouble with acquiring a new job after treatment, car loans, or utilities as well as causing difficulties in other situations in which credit histories are checked. These problems can follow a family for many years after cancer treatment is completed [242]. During and after treatment, people may resort to borrowing money from family, taking out second mortgages on their homes, and raiding retirement funds. These actions may help in the short term, but contribute to financial instability later as these may lead to loss of a home, inability to retire, and complicated relationships with family members. Discussing cancer treatment costs with patients can be difficult, which may be one of the reasons it is not done often enough. While more than half of cancer patients want to discuss costs with their doctors, more than 80% do not. Patients often have more concerns about effectiveness than cost; patients sometimes do not want to consider costs when making decisions about treatment. They might not want their doctors to consider costs out of fear that the plan chosen partially because of low cost might be substandard or less likely to be effective. The patient might also feel embarrassed to ask about costs and concerned about the discussion taking up too much of the doctor s time. But if the patient brings up costs after treatment is begun, there is no chance of reducing the out-of-pocket cost for the patient. Once financial distress has begun, patients sometimes become non-adherent to drug regimens, avoid recommended procedures, and skip doctors appointments to save money. This can cause serious health problems in the long term [307]. The patient and family may also lose housing and financial security in the future because of the expenses involved in cancer care. Bankruptcy due to medical expenses is getting more common. People report feeling shame and frustration at not being able to pay their bills. Nursing leadership consideration: To help everyone learn more about financial effects, nurses who work with hospitals and treatment centers that use electronic Patient Reported Outcomes (PROs) can request that they add financial distress along with the other outcomes such as nausea, neurologic side effects, and fatigue [307]. The nurse can ask the patient and family about financial concerns. One way to open the discussion is to ask whether a patients and caregivers are worried about how the costs of cancer treatment are affecting the ability to support themselves or their family. Or inquire if they are concerned about their financial future due to cancer treatment costs. Page 49

52 Patient costs can often be reduced without sacrificing quality of care. This is an important message for patients with financial concerns. Depending on the patient s concerns and priorities, the nurse can encourage discussions with the oncologist about treatment goals and different options that might work for the patient. It is important to be sure that the patient is empowered to ask about the purpose of a medicine or procedure, and exactly how it is expected to contribute to the patient s quantity and quality of life. Many patients would be surprised to know that for some of the newer and very expensive cancer drugs, studies have only documented a median of an extra couple of months of life (sometimes less) above the older treatment regimens [48]. On the other hand, some of the new drugs offer a median survival improvement of two years or more for those who can afford and tolerate the drug. Another reason for the expensiveness of new drugs is side effects. For example, a drug may costs 50 times more than the drug that it is designed to replace, and not work any better; however, the new drug may have a smaller incidence of a certain side effect. Doctors have the option of trying the older drug to find out if that effect is a problem for the patient before switching to the newer and more expensive one [48]. Choosing drugs that can still meet the patient s needs and cost less money requires the active assistance of the doctor or care provider. This is a highly personal decision, which greatly depends on the patient s medical situation. A very expensive drug may be worthwhile to some people because of the expected benefit, but not so much for others. In order for any of these options and choices to be available, the patient must have a frank discussion with the doctor about the proven benefits of the recommended treatment options and why one drug might be better than or equivalent to another. This is also an aspect of ongoing informed consent. When current financial barriers are identified, it can also help to refer the patient to the financial staff to find out about working with their insurance coverage. A medical social worker might be appropriate to refer the patient to other sources of help, such as Prescription Assistance Programs, local charity funding, and government programs for which they might qualify. People with health insurance nearly always have the right to make an appeal if coverage for an essential service is denied. Medical social workers or financial counselors at the facility can also help with this, and more information can be found online at Case study: Robert is a 62-year-old man with extensive-stage small cell lung cancer. He has had combination chemotherapy with carboplatin, etoposide, cyclophosphamide, doxorubicin and vincristine. He is back in the hospital with pneumonia three months after completing four cycles of chemotherapy. Scans have shown some progression of his disease, with larger metastases in his other lung. His doctor has now recommended a second-line treatment of IV paclitaxel weekly for eight doses after he goes home. When you talk with Robert about going home, he says that he does not think he wants this treatment and he is thinking of asking his doctor about one of those new targeted pills I ve heard so much about from his lung cancer support group. He thinks it might produce a cure, and is hoping it will cost less than the IV treatment. You are concerned about this, and recommend that Robert talk with his doctor about the goals of treatment. You further explain that most people with extensive-stage small-cell lung cancer are treated to slow the growth of the cancer. When you come in again later, he and his wife are talking about taking out a second mortgage on the house to cover the cancer treatment he has already received and to help with future costs. You ask them if their finances are causing problems, and find out that he has learned his private health insurance plan counted some of his visits to specialists as out of network. Even for in-network care, copays have added up Page 50 quickly. His illness is also causing him trouble at work and he is afraid he will lose his job and his health insurance. What do you do now? 1. Ask him if he has talked with his insurance administrator about his billing, and whether he has appealed the decision of his insurance company to withhold payment for his prescribed specialty care. 2. You explain that even though targeted drugs are helpful in nonsmall-cell lung cancer, most have not been shown to be as helpful in small-cell cancer, although research is still ongoing. You further mention that most of the targeted oral drugs are reimbursed in a different way than IV drugs, so that they often cost the patient more. This is also something he could discuss with his doctor. 3. Since you have already spoken with him about talking with his doctor about goals of treatment, and he is not asking more about that, do not bring it up again unless he has specific questions. 4. You ask if he has ever thought about clinical trials for people with extensive small-cell lung cancer in his situation, since some of the expenses might be covered by the trial administrators. This is something else he could bring up with his doctor. 5. Suggest that he discuss his health coverage and job situation with a medical social worker. Let the couple know that if he does quit or lose his job, he has a 60 days to enroll in a new health plan on the Health Insurance Marketplace, even if it does not happen during the annual open enrollment period. He can call or go online to to get started. This is called a Special Enrollment Period [274]. 6. All of the above. Depending on how much time you have, and how he responds to the discussion, answer six may be most appropriate. You are concerned that Robert does not understand that his prognosis is very limited, but you have already given him some information and suggested that he discuss this with his doctor. Now there is the additional issue that he is looking for less expensive treatments by asking for a treatment that not only is likely to cost him more, but is unlikely to accomplish what he hopes it might. A lot of people do not know that they can appeal an insurance plan s decision. Most health insurance plans are required to review their decisions when asked, and in some cases the patient can even request an external review. It could be very useful for this patient to pursue an internal appeal, and if that doesn t work, resort to an external appeal. More information can be found online at if he searches appeal a health plan decision. The financial staff or medical social worker should be able to help too. Although some 60% of children with cancer are enrolled in clinical trials, fewer than 5% of adults are [18]. This is likely one of the reasons that cancer treatment has evolved more slowly in adult care. Health insurance companies in the past sometimes denied treatment coverage to people who were in clinical trials, but regulations have changed with the Affordable Care Act. Now health insurance plans largely do not put up barriers to participation in clinical trials. The difficulty is finding one for which the patient qualifies, since some exclude patients on certain medications or with co-morbidities. Patients can find out about clinical trials and possible matches using the Clinical Trials Matching Service from the American Cancer Society (see Patient Resources ). Most people who have health insurance coverage at work can keep their health coverage even if they lose or must quit their jobs, through a program called COBRA. However, this tends to be a fairly costly option for most people. Another option for them might be the State Health Care Marketplace, which has an annual Open Enrollment Period near the end of each year during which people who do not qualify for other health coverage can sign up. But people who have changes in their life situation during the year that results in loss of health coverage (or if they gain an immediate family member through

53 marriage, childbirth, or adoption) typically qualify for a Special Enrollment Period on the Marketplace. The patient must sign up within 60 days after their coverage is lost. However, if a person loses health coverage because they did not pay premiums, they do not qualify for a Special Enrollment Period [276]. If Robert loses his job and his spouse is employed in a workplace that offers family or dependent health plans to employees, he may be able to sign on to his spouse s workplace policy. However, that option must be exercised even more quickly than the Marketplace option, as the special enrollment period is typically 30 days after loss of a health plan to sign onto a family member s workplace insurance [279]. Finally, if Robert is concerned about his ability to do his job or concerned he will lose his job, it might be helpuful for him to talk with his employer about Family and Medical Leave, so he can take time off for treatment. If side effects are a problem, the Americans With Disabilities Act may help him with some accommodation from his employer as long as he can do the essential duties of his job. If Robert waits too long while his cancer treatment is interfering with his work and is fired, he will lose access to benefits that he could have used if he had asked for help soooner. He does not have to share his diagnosis with his employer but he may need help from his doctor with legal paperwork. Posttreatment assessment, education, interventions: Survivorship There are differing definitions of cancer survivor. The National Cancer Center Network (NCCN) and some others define a cancer survivor as a person who has been diagnosed with cancer, for the rest of their lives [209]. But some people do not want to call themselves survivors until after treatment is over and if they have a good prognosis. The first part of this module focused on the diagnosis and treatment phases of survivorship. This section (like many survivorship plans) pertains mainly to the after-treatment phase of survivorship, especially that time in which nursing intervention and education is most needed. After treatment Patients often anticipate the end of their cancer treatment with a mixture of relief and dread. They are often happy that they do not have to get more cancer treatment, at least for now, but they usually understand that there is a risk of recurrence, or the possibility that the cancer is still there. However, at this time they will be losing the frequent careful follow-up of their oncology care team. Patients who are ending their cancer treatment need very specific types of information, which can help them be healthier in their post treatment lives [31,247]: The cancer type and stage; pathology reports from biopsy results, copies of imaging test results such as CT and MRIs (usually in DVD or other digital form) and any genetic testing results. Treatments prescribed, including any surgical reports, medication names, doses, and length of treatment; radiation site and dose; and any ill effects observed, as well as potential late effects of those treatments. If the patient was in the hospital, a copy of the discharge summary. Specific instructions about when and where to have follow-up care (oncologist vs. primary care provider, for example). Preventive health recommendations including screening for other cancers and health maintenance. Practical legal/financial protections regarding future employment and health insurance. Community resources for psychosocial support. Getting copies of medical records right away is extremely important for patients, who probably do not know that their medical records might not be there in perpetuity. Many records are destroyed after only a few years. Patients need to understand that these records must be kept for their reference and sometimes for their children as well (for purposes of maintaining their family histories). Patients should also understand that these records can be copied by their future doctors, but that they should always keep the originals for themselves. For those who want to use digital record storage, there are tools for that. The U.S. Department of Health and Human Services (DHHS) created the Blue Button Connector to help with this (see Resources for Patients ) [31]. Nursing consideration: Advise patients about the need to keep copies of their own cancer treatment records (and offer specifics on how to get those records from treatment facilities). Having records can help them with follow-up and prevention. Requirements for retention of medical records varies by state and type of practice, but can be as short as five to ten years after the patient is last seen at that office or facility [71]. At the end of treatment, an assessment of persistent symptoms and other problems should be undertaken in order to plan for unmet needs. Many patients still have fatigue, pain, emotional distress, cognitive dysfunction, and specific toxicities related to their cancer treatment. The NCCN has a guideline specifically addressing the post-treatment needs, including a focused assessment that can be used as a jumpingoff point for evaluating patients after treatment. Patients should be routinely screened at intervals during follow-up visits for emotional distress, such as anxiety, depression, and panic as well as for sleep disorders and sexual dysfunction. The NCCN Survivorship guideline contains short sexual symptom checklists for both men and women that can be used to start the conversation (see Resources for Nurses ). There are also special considerations for patients with lymphedema, ostomy, and post-stem-cell transplant, among others. This can inform additional planning and specific referrals tailored to the patient s continued needs [209]. Patients whose family histories indicate the possibility of genetic mutations should be referred for genetic risk assessment and possible genetic testing. Patients who are known to have genetic mutations that increase cancer risk should be informed of any changes in screening conferred by the new risk awareness [209]. Patients should know about typical symptoms of recurrence, which are based on the type of cancer treated as well as other symptoms or problems for which they are to call the oncologist or the primary care provider. They should know the general follow-up schedule for rechecks with the oncologist as well as when they might need to see their primary care provider. In addition to follow-up testing that looks for recurrence, cancer screening for other types of cancer should be discussed. Most patients should follow the average risk screening guidelines except for cancer sites for which they may need extra screening in light of the type(s) of cancer they have had. For instance, a woman who was treated for colon cancer is probably going to be on an every-fiveyear colonoscopy schedule for as long as she is healthy enough to tolerate treatment. But she would not likely need MRI in addition to mammography unless she has a high risk for breast cancer due to family history or genetics. The cancer rate is higher in people who have survived cancer than in the general population. A history of a certain cancer type usually indicates a higher than average future risk of that cancer, such as with breast cancer (if the woman still has any breast tissue after treatment). A number of cancer treatments, including certain chemotherapy drugs and radiotherapy, can confer a higher risk of specific types of second cancer cancers in the future. This means that some cancer patients will not receive average-risk Page 51

54 recommendations for every cancer screening type after their treatment [209]. Other wellness planning includes future vaccine considerations as well as exercise and dietary plans tailored to the patient s current status and needs. As an additional resource in its Survivorship guideline, End of life Despite all of the progress that has been made in cancer care, many people who have cancer still die due to cancer. For some people the cancer recurs; for others, especially those whose cancers were found in late stages, the cancer went into remission. Some people do not want to accept that there is little that can be done for them, and prefer to keep receiving aggressive treatment. Others do not want the additional side effects and activity limitations, and are ready to move on. For a lot of people, it is a difficult transition from treatment (or diagnosis) to looking toward the end of life. Clear communication can help It is important to communicate clearly with the patient about what is happening. Some doctors are reluctant to speak directly about death with a patient, and often use ambiguous or optimistic terms when talking about prognosis and care plans. But patients who are aware of their terminal status have a higher quality of life and are more likely to receive care that is consistent with their preferences. According to the NCI, nearly 90% of patients want to be informed about their life expectancy, and more than half want to know about end of life decisions [185]. It is possible to simply ask the patient how much they want to know about the likely course of their illness; some people want details while others like key points. Some would rather it be discussed with family members instead, but that should happen only if the patient states that as a preference. And a corollary question is how much say patients want themselves or family members to have in making decisions about care [45]. It is also important to emphasize that it is okay to ask any questions, even those that might not have a clear answer. For the vast majority of patients who want to know, nurses can open a conversation with open-ended questions such as: How are you feeling about ending treatment? What do you see yourself doing next? What concerns do you have about your cancer at this point? Most patients are aware that they are not going to live as long as they hoped or expected, and some want to talk about it even though it is an emotional topic. The nurse can validate the sadness and other emotions without false reassurance by listening to the patient and pointing out that it is normal to grieve and go through a lot of different emotions in this situation. These emotions can include anger, fear, anxiety, sadness, and depression, among others [35]. Guilt, regret, and despair may emerge as the patient reflects on their life. Concerns about pain, being a burden to others, loss of dignity and control, and feeling alone are also common themes when patients think of impending death [35]. The nurse can reflect back the patients concerns with some reframing on what the patient might be able to do and what the oncology team or palliative care/hospice team can do to address these concerns, depending on what has already been planned or discussed. The nurse will need to share with the oncologist any new information gained about the patient preferences from this discussion as well patients information or treatment needs that go beyond the nurse s knowledge or scope of practice. Advance directives Near the end of life, it is important to involve family and home caregivers in discussions and planning. Discussions about advance directives and patient preferences near end of life are most likely to be implemented if those that are closest to the patient are aware of them and able to advocate to have the patient s wishes followed [9]. Any time the patient is being admitted or re-admitted to the hospital is a Page 52 NCCN also has a listing of websites and organizations for the health professional and the patient, that cover many topics and needs, such as legal and work-related issues, nutrition and weight management, heart health, and smoking cessation as well as other survivorship guidelines [209]. good time to review orders about attempts at resuscitation or do-notresuscitate orders. Advance directives only take effect when the patient becomes unable to make decisions and speak on his or her own behalf. The directives can take several forms, the best known of which is the living will. The living will lists the measures the patient does and does not want under different circumstances (such as CPR, IV fluids, or being on a ventilator). Because it is impossible to foresee all of the possible circumstances that may arise, it is a good idea to appoint a trusted family member or friend to make such decisions at any point the patient becomes unable to speak for himself or herself. That kind of advance directive is a Health Care Power of Attorney or a Durable Power of Attorney for Health Care. Neither of these advance directives can be used to make financial or legal decisions on behalf of the patient; they only apply to health care. They must be in writing and signed by the patient; some states require witnesses and other measures [9]. The National Hospice and Palliative Care Organization s website CaringInfo offers forms and information at no cost that are accepted by each state (see Patient Resources ). There are other types of directives, for example, the Five Wishes form, which is recognized in 42 states as of This lists the person the patient wants to make their health care decisions if they cannot, and outlines the patients wishes and choices [9]. It is available online for a small fee (USD $5 as of early see Patient Resources ). Hospice Hospice is a team-oriented approach to providing expert medical care, pain management, and emotional and spiritual support for patients whose life expectancy is no longer than six months. Most hospice care is delivered in the home, and many require the 24-hour presence of an in-home caregiver [185]. Hospice eligibility criteria The criteria for hospice eligibility are based on state and federal regulations. A physician needs to certify that the patient is suffering from a life-limiting illness, with a life expectancy of no longer than six months. The patient must sign a statement choosing hospice instead of other forms of treatment. Hospice may be considered when a patient who has cancer: Presents with distant metastatic disease. Has progressed from an earlier stage of illness to metastatic disease and: shows continued decline in spite of therapy; refuses active treatment; and/or chooses palliative and hospice care. Has a poor prognosis; for example, patients with pancreatic and brain cancers can be eligible for hospice without meeting all of these criteria [185]. Concerns about hospice enrollment patients, families, and doctors Patients and caregivers might assume that hospice is only for the final days of life. Unfortunately, doctors often have trouble predicting life expectancy and often wait until death is only days away before the patient is referred for hospice. This tends to make hospice admission a hasty transition, and the patient reaps few benefits of hospice care [185]. Patients, families, and even doctors may have negative perceptions of hospice, believing that it will hasten death. Studies have shown that this is not the case; in fact, mean survival tends to be longer for some people in hospice, especially with diagnoses like lung or pancreatic

55 cancer. A big issue is that patients are often referred to hospice just a few days prior to death [28]. The patient and family may also believe that accepting hospice care means giving up hope. They may not understand that for many people, hospice care can afford them more symptom relief which can give them the chance to do what is most important to them, such as spending some quality time at home with loved ones. It may be important for patients and families to know that they can change their minds about hospice even if they have already been admitted to hospice care [28]. Hospices own enrollment policies may contribute to their underuse in the United States [28]. Results from a national survey of 591 U.S. hospices showed that 78% had at least one enrollment policy restricting access to care for patients with higher-cost medical care needs, such as chemotherapy, radiation, transfusions, and total parenteral nutrition. Such policies are more likely to be found at smaller hospices, for-profit hospices, and hospices in rural areas of the country [2]. For patients who choose hospice or other in-home care, it is important for caregivers to know what to expect as death approaches. For example, caregivers may find it alarming or jarring when the patient starts to show little interest in food and drinks less liquid. Mental status changes, pain, constipation, and other issues can be managed with help from hospice or home care nurses. It is important that all the caregivers know that, if the patient does not want life-sustaining measures, they should call hospice or home care providers for any problems, rather than calling Emergency Medical Services (EMS). In most cases, calling 911 means that EMS must take resuscitation measures and route the patient to emergency care, unless the patient is conscious and can verbally refuse such care [35]. Cancer screening can help find and treat several types of cancer early. Early detection is important because when abnormal tissue or cancer is found early, it is typically less complicated to treat, and treatment tends to be more successful. By the time symptoms appear, cancer might have begun to spread which makes it harder to treat, averaging less successful outcomes. However, there are hundreds of possible screening methods with varying levels of supporting evidence, and each with its own possible benefits and harms. Because of this, there are organizations that review the evidence, evaluate the pros and cons of various cancer screening methods, and make recommendations for clinical practice. Given the potential fallibility of public health measures, this is a serious task that requires wide-ranging vision and careful consideration. Even with these caveats, a surprising number of groups participate. Some physician groups make recommendations within their practice areas (for example, the American Congress of Obstetricians and Gynecologists and the American College of Gastroenterology). Even cancer treatment centers will have their own interpretations of cancer screening guidelines. So when health professionals speak of cancer screening guidelines, it is important to know which guidelines are under discussion. Cancer screening This section will focus on the best-known national groups that have been making broad cancer screening recommendations for many years. These include the U.S. Preventive Services Task Force (an independent panel of volunteer health experts since 1984) and the American Cancer Society (a donor-supported nonprofit since 1913) [283,8]. Both are reputable and well-respected. Their cancer screening recommendations are different in a few places, but agree on many points. Sometimes the differences are based on how certain research findings are valued or weighted, and often indicate issues that need more research or consideration. Health care providers can choose options from one or the other set of cancer screening guidelines based on the patient s values and preferences, health insurance situation, and even what is available in the geographic area. Screening recommendations change from time to time as new tests are studied and new evidence comes in to support or counterbalance the older studies. It is a good idea to visit these websites ( uspreventiveservicestaskforce.org and and review their cancer screening guidelines at least once a year to find out what changed. Limitations of cancer screening Even the best cancer screening tests are imperfect, and fail to detect every case of cancer. Sometimes abnormalities are found that are not cancer. Several screening tests have been shown to be fairly reliable at detecting cancer early and reducing the chances of dying from that cancer. Other screening tests have been shown to detect cancer early, but less reliably. Some cancer screening tests work well in the hands of experienced health care providers, but not so well in those who are new to it or who do not do it often. And others may be reliable enough but have not yet been shown to reduce the risk of death overall. In some cases, the screening is too new for research to have been conducted, but in other cases, the research has been done but has not shown improvement in the death rate from cancer. Reducing the death rate is the gold standard for cancer screening tests [149]. Higher levels of cancer risk may modified screening methods The screening guidelines discussed most often are aimed at people of average cancer risk, and health professionals may have to look to source documents to find the most recent recommendations for higher risk patients. Professionals also have to verify what constitutes high risk because not every factor that may seem relevant has been shown to truly increase cancer risk. People at high risk of certain types of cancers may need to start screening at younger ages, have more frequent screening tests, or even have extra screening tests than those at average risk of cancer [149]. It is also important to know that even the most innocuous cancer screening tests have potential harms as well as benefits [149]. False-positive tests An obvious concern is a false-positive result, in which the test suggests cancer is present even when it is not. False-positive tests can cause stress and anxiety, and often require follow-up testing and procedures that are more invasive and have more potential harm. The ability of a test to exclude people who do not have the condition (or only give true positives) is called specificity. The concern in this case is that the follow-up procedures following the positive test are more invasive and more likely to have complications than the screening test itself. For example, a positive mammogram may require a breast biopsy. A positive stool fecal occult blood test (FOBT) or fecal immunochemical test (FIT) typically requires a colonoscopy for follow up, which might include polyp removal and biopsy. Positive Pap tests often require colposcopy and sometimes biopsy procedures. Less obviously, biopsies may result in finding a low-grade cancer which might be treated even though it would be unlikely to cause problems in the person s lifetime. Technically, this is a true positive (i.e., it is a true case of cancer), but its treatment might be unnecessary (see Overdiagnosis and Overtreatment for discussion). Page 53

56 False-negative tests Less obvious but possibly more concerning are false-negative tests. The test can sometimes indicate that cancer is not present even though it is actually present. False-negative test results may provide false reassurance and lead to delayed diagnosis. A false-negative result may prompt a patient to postpone seeking medical care even if symptoms develop. The ability of a test to detect a condition when it exists is called sensitivity. Colonoscopies, despite being the gold standard for colon and rectal cancer screening, have been reported to miss as many as six percent of cancers, with an even higher rate of missing adenomatous polyps (pre-cancerous lesions) [42]. Adequacy of colonoscopy preparation is cited for some of this problem, as stool can obscure the view of the colon wall [41]. Some sources also cite higher rates of missing polyps that are flat or depressed. Although we may think of polyps as raised or pedunculated, some are not. Large, flat, and depressed lesions may be more likely to be severely dysplastic, although this remains under study [165]. Overdiagnosis and overtreatment Historically, the word cancer has meant a disease that ended in death if untreated. While this was mostly true at a time in history when people were diagnosed with cancer because they had signs or symptoms, it began to change when healthcare professionals became able to detect cancer while still asymptomatic. One of the ways overdiagnosis was noticed was that the death rates from certain cancers found early did not always decline, or they did not decline at a rate commensurate with the rise in cases detected. Scientists and health professionals are starting to understand that, despite historical assumptions, some cancers grow quickly, some grow slowly, and some may even stop growing spontaneously [301]. This is a confusing concept for health care providers and the public alike. Overdiagnosis happens when a test correctly shows that a person has cancer, but the cancer that is found is a slow-growing type that would not likely have harmed that person in his or her lifetime [134]. For example, in much older people, especially those with comorbidities, a slow-growing cancer is likely to be outpaced by another illness. It is becoming clear that a number of people who are screened actually have low-grade cancers unlikely to cause serious harm or death. Treatment of such cancers is called overtreatment, which in many cases causes real and lasting harm. So far, this trend is showing up in retrospect because it can be difficult to predict whether any one person s cancer is likely to spread and cause health problems or death. The observation is already changing screening guidelines in the U.S. After prostate cancer screening was re-evaluated in light of this kind of evidence, the American Cancer Society recommendations changed from universal screening with prostate-specific antigen (PSA) tests to discussing prostate cancer screening with the patient. The patient and provider ideally make a shared decision about screening based on informed consent, including the patient s history and priorities for care, before offering PSA testing [304]. However, the U.S. Preventive Services Task Force went so far as to recommend against screening with PSA tests for prostate cancer. This means that they actively discourage using PSA screening in general, although with the addendum that it should not be offered without discussion of harms and a fully informed choice by the patient [295]. This implies that it could be offered to men who understand and choose to get the screening, but that the test should not be routine. Right now, cancer researchers and public health experts are starting to talk about breast cancer screening. Mammograms have clearly been shown to reduce the death rate from breast cancer in women 40 and older, but they do not reduce this rate as much as predicted. The National Cancer Institute notes that although there are uncertainties in determining the rate of overdiagnosis in breast cancer, long-term, well-conducted studies on excess incidence found that at least 20% of screening-detected breast cancers are likely overdiagnosed [142]. A closer look reveals this example: when a woman is diagnosed with ductal carcinoma in situ (DCIS), she often ends with a mastectomy. But DCIS is considered a Stage 0 cancer (see Cancer Staging ) a non-invasive cancer very unlikely to progress to a lethal condition. More than 60,000 women are expected to be diagnosed with it in 2016 alone [122]. Recommended screening tests for cancer by cancer site Colorectal cancer screening There is a range of testing options for colorectal cancer (CRC) screening. See below for specifics and recommendations for each. Colonoscopy and sigmoidoscopy also help prevent CRC because they can detect polyps that can be removed before they develop into cancer. CRC risk increases dramatically with age: 90% of all colorectal cancers are diagnosed after age 50, and 93% of CRC deaths occur after that age [19]. Expert groups generally recommend that people who are at average risk for CRC have screening from ages 50 through 75 [191]. Screening can detect CRC earlier and impact survival The five-year relative survival for localized CRC is 90%, but only 40% of people are diagnosed at this stage, in part because screening is underused. In contrast, five-year relative survival for people with regional CRC is 70%; for those with distant metastases, it is 13% [19]. Nursing consideration: Help patients reduce colorectal cancer mortality risk or even prevent colon cancer by educating them about different colorectal cancer screening options. Help them choose an option that they might actually follow. Most patients will still need screening after cancer treatment, though options will be different if cancer involved the colon or rectum [191]. High-sensitivity fecal occult blood tests (FOBT) Both polyps and colorectal cancers can bleed, and FOBT checks for tiny amounts of blood in feces that cannot be seen. Blood in stool may also indicate the presence of non-cancerous conditions such as hemorrhoids, but should never be assumed to be the cause when an FOBT is positive. Two types of FOBT are approved by the U.S. FDA Page 54 to screen for colorectal cancer: the older guaiac FOBT, or gfobt; and the fecal immunochemical (or immunohistochemical) test, or FIT, and also known as ifobt. With both types of FOBT, stool samples are collected by the patient using a kit, and the samples are returned to the doctor. Note that tests are performed using stool that remains on a gloved finger after a rectal exam are not adequate for screening [11]: Guaiac FOBT uses a chemical to detect heme, a component of hemoglobin. Because the guaiac FOBT can also detect heme in some foods (e.g., red meat), people have to avoid certain foods before having this test. FIT uses antibodies to detect human hemoglobin specifically. Dietary restrictions are typically not required for FIT [54,234]. Studies have shown that guaiac FOBT, when performed every one to two years in people aged 50 to 80 can reduce the number of deaths due to colorectal cancer by 15-33% [54,234]. If FOBT is the only type of colorectal cancer screening test performed, the U.S. Preventive Services Task Force recommends yearly testing [290]. The American Cancer Society notes that it is slightly more effective when a sigmoidoscopy every five years is added to the annual FOBT for people of average risk [29]. The American Cancer Society further notes that patients with an abnormal FOBT will need a colonoscopy [11]. Sigmoidoscopy In this test, the rectum and sigmoid colon are examined using a sigmoidoscope, a flexible lighted tube with a lens for viewing and a tool for removing tissue. This instrument is inserted through the anus

57 into the rectum and sigmoid colon as air or carbon dioxide is pumped into the colon to expand it so the colon lining can be seen more clearly. During sigmoidoscopy, abnormal growths in the rectum and sigmoid colon can be removed for biopsy. The lower colon must be cleared of stool before sigmoidoscopy, but the preparation is less involved than that required for colonoscopy. People are usually not sedated for this test [200]. One randomized controlled clinical trial found that even just one sigmoidoscopy screening between 55 and 64 years of age can substantially reduce colorectal cancer incidence and mortality [44]. Sigmoidoscopy is limited in where it can detect cancer, since it can only look at the most distal portion (sigmoid), rather than the whole colon (the more proximal sections such as the ascending and transverse colon can harbor malignancy even though no abnormalities show up in the distal portion). This is a concern, since according to the National Cancer Institute, about three percent of patients with no distal adenomas have advanced proximal neoplasia. The NCI states that if colonoscopy is performed only in patients with distal polyps, about half the cases of advanced proximal neoplasia will not be detected [157]. The U.S. Preventive Services Task Force recommends sigmoidoscopy every five years along with FOBT every three years for people at average risk who have had negative test results [290]. Sigmoidoscopy cuts CRC mortality, as people over age 50 years who have regular sigmoidoscopy have a 60-70% lower risk of death from CRC versus those with no cancer screening [84,255]. The American Cancer Society notes that sigmoidoscopy every five years is slightly more effective when combined with an annual FOBT in people average risk [19]. They further note that patients with an abnormal sigmoidoscopy (polyps, cancer, or other problems) will need a colonoscopy. Standard (or optical) colonoscopy In this test, the rectum and entire colon are examined using a colonoscope, a flexible lighted tube with a lens for viewing and a tool for removing tissue. Like the shorter sigmoidoscope, the colonoscope is inserted through the anus into the rectum and the colon as air or carbon dioxide is pumped into the colon to expand it so the colonoscopist can see the colon lining more clearly. Evidence-based practice: Engaging the patient about colonoscopy prep beforehand in the patient s native language, along with simple written instructions, improves the quality of bowel preparation and supports the sensitivity of colonoscopy, reducing false negatives and the need for repeat colonoscopy due to poor visibility [41]. During colonoscopy, abnormal growths in the colon and the rectum can be removed, including growths in the upper parts of the colon that are not reached by sigmoidoscopy. Polyps and other lesions removed during colonoscopy are typically treated as biopsies, and sent to pathology for examination. The kinds of lesions that can be detected include [165]: Nonneoplastic polyps (hyperplastic, juvenile, hamartomatous, inflammatory, and lymphoid polyps), which are not usually considered precursors of cancer. Neoplastic polyps (adenomatous polyps and adenomas) which are benign lesions that can undergo malignant transformation and become cancer. These are classified into three histologic types, with increasing malignant potential: tubular; tubulovillous; and villous, respectively. Cancers. A thorough cleansing of the entire colon is necessary before this test. Most patients receive some form of sedation during the test and will need a chaperone to get home safely. Indirect evidence suggests that colonoscopy reduces deaths from colorectal cancer by about 60-70% [246]. Additional studies are currently underway to more directly evaluate how effective colonoscopy is as a primary screening method in reducing death rates. Diagnostic use: The colonoscopy is not only used as a basic CRC screening test, but as a follow-up diagnostic test when any other type of CRC screening suggests an abnormality. Also, once a patient has CRC or an adenoma with high-grade dysplasia, their future screenings will no longer be the average risk person schedule and method. After such a diagnosis, the frequency of CRC screening typically increases, and the standard CRC test usually becomes colonoscopy rather than the less-invasive test options. Less obviously, if a polyp is found and removed during a screening colonoscopy, that colonoscopy may be billed and coded as a diagnostic procedure despite the original intent. This may mean the patient sees a change in their co-payment. There will also be pathology charges and other charges that are not seen with a screening procedure. CRC risk changes with family and personal history: The lifetime risk of CRC in the U.S. is about one in 20 (5%). But, a history of CRC in a first-degree relative more than doubles a person s CRC risk. If a relative was diagnosed before age 45, or if more than one relative has had CRC, the risk is quadrupled. If the patient has previously had CRC or high risk adenomas, the CRC risk is also high. Finally, people with inflammatory bowel disease such as ulcerative colitis or Crohn s Disease have more than double the usual risk of CRC [19]. In contrast, the more common condition of irritable bowel syndrome (IBS) does not increase the risk of CRC [21]. High-risk screening: Because higher CRC risk status varies by family history, genetics, and medical condition, there is no single high risk screening schedule for CRC. People with inherited genetic mutations like FAP should be screened starting at younger ages and more often than people at average CRC risk, but even people who have had adenomatous polyps may need closer followup. The American Cancer Society has guidelines on managing many different risk situations and how they should affect future screening or diagnostic colonoscopy: from hyperplastic polyps (same as average risk), to having colon cancer surgically removed (colonoscopy a year later; if normal, repeat in three years); to Lynch syndrome (colonoscopy every one to two years starting at age 20 to 25, or ten years before the youngest case in the immediate family). Patients at increased and high risk should be referred to an expert gastroenterologist to fully evaluate risk and perform colonoscopy as indicated. See Colorectal Cancer Prevention and Early Detection at colonandrectumcancerearlydetection/index or call ACS-2345 for the details of high risk screening. Double-contrast barium enema This is a much older X-ray test that can detect large polyps and cancers by imaging the entire colon, although it is somewhat less sensitive than colonoscopy in finding smaller polyps or cancers. Barium sulfate flows into the colon through a tube placed in the anus to partly fill the colon, then air is introduced to expand the lumen of the colon and improve visibility. The double-contrast barium enema (DCBE) requires a full bowel preparation but does not usually involve sedation. However, polyps cannot be removed nor biopsies performed during the test. It also involves exposure to a low dose of radiation, and is not used much because of the ready availability of colonoscopy. Also, as time goes on, fewer radiologists know how to perform the procedure. A standard or optical colonoscopy is needed if abnormalities are found. False positive tests can occur. The American Cancer Society recommends it as an option for CRC screening every five years [14]. The U.S. Preventive Services Task Force does not recommend it as a screening method for colorectal cancer in part because it is less sensitive than colonoscopy. Page 55

58 Computed tomographic colonography (or virtual colonoscopy) This test requires the same preparation as standard colonoscopy, but is less invasive and does not require sedation. Air is still pumped in through the anus before the patient goes through the CT scanner. However, polyps cannot be removed nor biopsies performed during the test. It also involves exposure to a low dose of radiation. It requires an optical colonoscopy if abnormalities are found, preferably on the same day otherwise another prep must be done and there will be some delay. The American Cancer Society endorses the CT colonography as similar to the standard colonoscopy in detecting invasive cancers and polyps that are a centimeter or greater in size, but it has not yet been shown to reduce CRC deaths [19]. As of early 2016, the U.S. Preventive Services Task Force does not recommend this screening method, and some insurance companies do not cover it [284]. Stool DNA testing This is a newer type of colorectal cancer screening test, exemplified by the Cologuard test (FDA-approved in 2014), that uses a kit to collect a stool sample at home and requires no dietary changes or other preparation. In one study of people who were at average risk for developing colon cancer and had no symptoms of colon problems, this test detected more cancers and adenomas than the FIT test (i.e. it was more sensitive). However, the Cologuard test also had more falsepositive results than the FIT, so it was not as specific [200]. This type of test is recommended by the American Cancer Society as a method to detect colon cancer although, like FOBT, it will miss most polyps. Their newest guidelines recommend that this test be performed every three years [14]. Like the FOBT, it requires an optical colonoscopy if abnormalities are found [11]. Unlike the FOBT, it is expensive and anyone who wants this these should check with their insurance plan to be sure that it will be covered. The U.S. Preventive Services Task Force does not recommend this screening method as of early 2016, but is reviewing the evidence for possible inclusion at a later date [284]. Blood test for colorectal cancer screening approved by FDA, April 2016 The Epi procolon is a new blood test offered as a screening test for patients who are at average risk for colon cancer if they are due for screening but do not want any of the other approved tests for colon cancer. It is not recommended for people at high risk or as a confirmation test for colorectal cancer [87]. The Epi procolon test has not been on the market long enough for the American Cancer Society or the U.S. Preventive Services Task Force to weigh in on it, but the online brochure for the test has a lot of information. It mentions that the Epi procolon test was positive two out of ten times when colorectal cancer was not present, and negative three out of ten times when colorectal cancer was present. The false negative rate of 30% seems somewhat high, and could be misleading to a lot of patients (see Limitations of cancer screening ). In addition, the patient who has a positive test will need to be referred for a diagnostic colonoscopy [87]. Complications of colonoscopy and sigmoidoscopy Many colonoscopies are used for follow-up of an abnormal screening test, but colonoscopy and sigmoidoscopy are also considered first-line screening options for colorectal cancer. Most screening tests are less invasive than these, which can, on rare occasions, have more serious complications than other screening tests. Because of that, they deserve special mention here. The preparation for colonoscopy, which involves a clear liquid or lowresidue diet, laxatives and sometimes enemas, can cause electrolyte imbalance and dehydration, especially in elders and those with comorbidities. Sigmoidoscopy prep is usually briefer and likely involves less risk. Serious complications of colonoscopy and sigmoidoscopy can include bleeding, bowel perforation, and bleeding, which are more common when polyps are removed. According to the American Society for Gastrointestinal Endoscopy, serious complications in people undergoing screening colonoscopy number fewer than three per every 1000 patients [42]. However, the National Cancer Institute notes that, when polyps are removed, seven to nine per every 1000 patients have a major complication such as perforation or bleeding [119,221,299]. Note that bleeding can present during or after the colonoscopy, and for up to several weeks after. Most patients are sedated during the colonoscopy procedure, which can also cause complications such as hypoxia, hypotension, or shock, and cardiac events such as arrhythmia or myocardial infarction (MI); this is somewhat dependent on what medications are used. One study also found slightly higher incidence of cardiovascular events in the month after the procedure, including angina, myocardial infarction, stroke or transient ischemic attack (about 1.4 events per every 1000 patients). This was in a Medicare population so most of the patients were in a higher-risk age group [42]. Less severe complications for patients undergoing colonoscopy and sigmoidoscopy include bloating and abdominal pain or discomfort, usually due to air being pumped in during colonoscopy to allow visibility of the intestinal walls [42]. Lung cancer screening for people with a heavy smoking history This is a relatively new addition to the cancer screening test recommendations, but it only applies to people who are or have been heavy smokers. This screening recommendation is based on results from the National Lung Screening Trial (NLST), which randomly assigned participants to one of two ways of detecting lung cancer: low-dose helical computed tomography (CT), also called spiral CT; and standard chest X-ray. Helical CT uses X-rays to obtain a multipleimage scan of the entire chest, while a standard chest X-ray produces a single image of the whole chest in which anatomic structures overlie one another. Each participant had three annual exams with either helical CT or chest X-ray. The NLST had more than 53,000 US participants aged 55 to 74 who had smoked at least 30 pack-years but who were otherwise fairly healthy and had no signs, symptoms, or history of lung cancer (packyears are calculated by multiplying the average number of packs of cigarettes smoked per day by the number of years a person has smoked). The study findings revealed that participants who received low-dose helical CT scans had a 15% to 20% lower risk of dying from lung cancer than participants who received standard chest X-rays. This is equivalent to approximately three fewer deaths per 1000 people screened in the CT group compared to the chest X-ray group over a period of about seven years of observation (17.6 per 1,000 in the CT group versus 20.7 per 1,000 in the chest X-ray group). On average over the three rounds of screening exams, 24.2% of the low-dose helical CT screens were positive and 6.9% of the chest X-rays were positive. In both arms of the trial, the majority of positive screens led to additional tests whether or not cancer was found [177]. Adenocarcinomas and squamous cell carcinomas were detected more frequently at the earliest stage by low-dose helical CT compared to chest X-ray. Small-cell lung cancers, which are very aggressive, were infrequently detected at early stages by low-dose helical CT or chest X-ray. Low-dose helical computed tomography to screen for lung cancer has been shown to reduce lung cancer deaths among current or former Page 56

59 heavy smokers ages 55 to 74. Inclusion criteria more or less match those of the National Lung Screening Trial (NLST). In 2013, both the American Cancer Society (ACS) and the US Preventive Services Task Force (USPSTF) made official recommendations to screen adults within the age range of the NLST who had a 30 pack-year history of smoking who still smoked or had quit within the previous 15 years [13,294]. The USPSTF recommendations allow screening as late as age 80, although the ACS Breast cancer screening for women 40 and older Mammography Screening mammograms are used to check for breast cancer in asymptomatic women, and usually involve two X-ray views of each breast. The X-ray images make it possible to detect tumors that are too small to be palpated. Screening mammograms can also find microcalcifications (tiny arrays of calcium deposits) that sometimes indicate the presence of breast cancer [175]. Evidence-based practice: Asking patients what they have heard about mammography can help nurses address concerns. Mammographic screening for breast cancer has been shown to reduce mortality from the disease among women ages 40 to 74, especially those aged 50 or older [175]. For asymptomatic women of average risk, the American Cancer Society (ACS) strongly recommends starting annual mammography at age 45, observing that the years of life gained through mammography screening are very similar between the ages of 45 and 49 to those gained between ages 50 and 54. Women age should be screened annually, and should transition to biennial screening at age 55 or opt to continue with annual screenings. The ACS recommends that mammography screening should continue until a woman is in poor health or has a life expectancy less than ten years, rather than selecting a specific age to stop screening [12]. The ACS further recommends that all women be familiar with the potential benefits, limitations, and harms of mammography. The ACS allows for women who value the potential benefit over potential risk to start screening at age 40, and for them to switch to biennial screening at age 55 or maintain an annual schedule with informed consent. The ACS has expressed concern about screening women who have serious or terminal health conditions, which still seems to be common practice, because of the low likelihood of improving life expectancy or other outcomes and possibility for potential harms [229]. This recommendation is somewhat different from the U.S. Preventive Services Task Force, which recommends biennial mammography for asymptomatic women of average risk starting at age 50 and continuing through age 74. However, they are also careful to include the possibility that women may elect to begin as early as age 40 if they value the potential benefits more than they are concerned over potential harms. They further note that there is insufficient evidence of benefit in screening women aged 75 and older [292]. Women at higher risk: The American Cancer Society has an extra guidance for women at higher risk for breast cancer, recommending the addition of annual breast MRI (along with annual mammography) for women who have any of these factors that increase risk for breast cancer, such as: BRCA gene mutation (personally or in a first-degree relative if the patient has not been tested). History of radiation therapy to the chest between ages Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome (these two related genetic conditions are mutations in the PTEN gene and may be called PTEN Hamartoma Tumor Syndrome), or Li- Fraumeni syndrome (personally or in a first-degree relative if the patient has not been tested) [218]. limits it to age 74 as in the original study. The USPSTF says that lowdose spiral CT should be stopped once the person has not smoked for 15 years or develops a health problem that limits life expectancy or the capacity to have lobectomy for lung cancer. Because the research to date has not yet addressed the potential for overdiagnosis and overtreatment, the possibility that this might occur is very real when screening for lung cancer with CT [105,121]. Lifetime breast cancer risk of 20-25% using models (such as the Claus model) that calculate breast cancer risk largely based on family history [12]. The ACS recommends against MRI screening in women whose lifetime breast cancer risk is calculated to be less than 15% [12]. The ACS further says that there is insufficient evidence to recommend for or against MRI screening in the following: For women who have had breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), or atypical ductal or lobular hyperplasia (ADH or ALH). For women with dense breast tissue as seen on a mammogram [12]. When following these recommendations, there is no particular mention of newer forms of mammography, which may have advantages. Digital mammography stores images as computer files, which allows for closer examination of suspicious areas without always necessitating the patient return for more X-rays. Digital screening has higher sensitivity in women with dense breasts and makes records easier to share [175]. Three-dimensional (3D) mammography, also known as breast tomosynthesis, is a type of digital mammography in which X-ray machines are used to take pictures of thin slices of the breast from different angles and computer software is used to reconstruct a 3-dimensional image. It is generally performed at the same time as standard mammography, with a slightly higher radiation dose. This has not been compared with 2D mammography in randomized studies, so researchers do not know if it is better or worse at avoiding falsepositives or finding early cancers [175]. Implants and mammography Women with breast implants should have mammograms on the same schedule as other women. A woman who had an implant following a mastectomy should ask her surgeon whether a mammogram of the reconstructed breast is necessary, as it might be if any breast tissue was left behind. It is important to let the mammography facility know about breast implants when scheduling a mammogram. The technician and radiologist must be experienced in performing mammography on women with breast implants. Implants can hide some breast tissue, making it more difficult for the radiologist to detect an abnormality on the mammogram. If the technician performing the procedure is aware that a woman has breast implants, steps can be taken to make sure that as much breast tissue as possible can be seen on the mammogram. A special technique called implant displacement views may be used [175]. Mammogram reports: Breast Imaging Reporting and Database System (BI-RADS ) The American College of Radiology (ACR) has established a uniform way for radiologists to report mammogram findings. The system, called BI-RADS, includes seven standardized categories for a mammogram report. Each BI-RADS category has a follow-up plan to help manage the patient s care. Page 57

60 Table 4: Breast Imaging Reporting and Database System (BI-RADS). Adapted from National Cancer Institute, 2014 Mammograms [175]. Category Assessment Follow-up 0 Need additional imaging evaluation. Additional imaging needed before a category can be assigned. 1 Negative. Continue regular screening mammograms (for women over age 40). 2 Benign (noncancerous) finding. Continue regular screening mammograms (for women over age 40). 3 Probably benign. Receive a six-month follow-up mammogram. 4 Suspicious abnormality. May require biopsy. 5 Highly suggestive of Requires biopsy. malignancy. No screening for male breast cancer Note that, even though men develop breast cancer, male breast cancer occurs at a rate about one percent of that of women. There are no recommendations to screen men for breast cancer. However, men should be informed that they can get breast cancer, rare though it is. Men should report lumps, changes, and thickening in the nipple, breast, and armpit to their health care providers and seek prompt medical attention for any new growths or changes to the breast area. Diagnostic mammograms Mammograms that are used to check for breast cancer after a lump or other sign or symptom of it are no longer called screening mammograms. These follow-up exams are called diagnostic mammograms. They are coded and billed differently, so that the patient whose health plan does not require out-of-pocket payments for a screening mammogram may have a co-pay for a diagnostic one. Besides a lump, reasons for diagnostic mammograms can include: Breast pain. Thickening or other changes of breast skin. Nipple discharge. Change in breast size or shape. Evaluate changes found during a screening mammogram. View of breast tissue when a screening mammogram is difficult because of special circumstances, such as the presence of breast implants. Diagnostic mammograms can help determine if and where a biopsy is needed [175]. Future technologies for breast cancer screening The National Cancer Institute is supporting the development of several new technologies to detect breast tumors, and other research continues to look at fine-tuning breast cancer screening. This research ranges from methods being developed in research labs to those that are being studied in clinical trials. Efforts to improve conventional mammography include magnetic resonance imaging (MRI), positron emission tomography (PET) scanning, and diffuse optical tomography, which uses light instead of x-rays to create pictures of the breast [175]. Cervical cancer screening for women 21 and older Pap smears and human papillomavirus (HPV) testing reduce the incidence of cervical cancer because they allow abnormal cells to be identified and treated before they become cancer. Testing is generally recommended to begin at age 21 and to end at age 65 for women of average risk, as long as recent tests had adequate samples and normal results [254]. More details on each screening test follow. Evidence-based practice: Pap and HPV testing have been proven to reduce deaths from cervical cancer. These are started in women of average risk at age 21 and typically continue at 3-5 year intervals, depending on testing method used, through age 65 [191]. The USPSTF reports strong evidence for the following recommendations for screening for cervical cancer for women at average risk: Women aged 21 to 65 years should be screened with cytology (Pap) every three years. Women aged 30 to 65 years who want a longer screening interval can be screened with a Pap plus HPV testing every five years. The USPSTF recommends against screening: With HPV testing in women younger than 30. Women younger than 21. Women older than 65 at average risk of cervical cancer whose tests have been normal in the previous ten years, assuming they have had adequate testing. Women who have had a hysterectomy with removal of the cervix if they have never had a high-grade precancerous lesion (CIN2 or CIN3) or cervical cancer [289]. The American Cancer Society recommendations are quite similar. Although they prefer HPV testing plus Pap every five years in average-risk women aged 30-65, they note that the Pap alone is acceptable if used every three years. The ACS further adds that HPV-vaccinated women should follow the same age-specific recommendations as unvaccinated women at average risk [254]. The above recommendations do not apply to women at high risk of cervical cancer, such as immunocompromised women (e.g. HIV-infected or post-organ transplant), women who were exposed to the drug DES, or those who have had cervical cancer or a highgrade cervical lesion in the past. These individuals might need more intensive screening, or other alternative screening based on their condition or situation [254,289]. Pap test Regular screening (with removal of precancerous cells) in women aged 21 to 65 for cervical cancer with the Pap test reduces cervical cancer incidence and mortality by at least 80% compared to no screening [150]. The benefits of screening women younger than 21 years are small because of the low prevalence of lesions that will progress to invasive cancer. Screening has not proven beneficial in women older than 65 years if they have had recent negative tests [104]. Studies that compare the Pap test against repeat Pap testing have found that the sensitivity of any abnormality on a single test for detecting high-grade lesions is 55-80% [49,261]. Because of the usual slowgrowing nature of cervical cancer, the sensitivity of a program of regular Pap testing is likely higher, i.e. if a cancer is missed on one test the next test is likely to find it [150]. The National Cancer Institute reports that the risk of developing invasive cervical cancer is much greater in women who have not been screened with a Pap test and in women with a long gap after the last normal Pap [150]. But screening every two to three years has not been found to significantly raise the risk of finding invasive cervical cancer more than annual screening [108,112]. Findings on Pap tests: Noninvasive cervical squamous cell abnormalities are graded by the pathologist as CIN 1, CIN 2, or CIN Page 58

61 3, according to the severity of cell changes and the percent of the epithelium replaced by abnormal cells. CIN 3 is a reasonably standard diagnosis, and it is known to have about a 30% risk of developing into invasive cancer over many years if untreated [127]. CIN 2 has more variable outcomes over time [64]. CIN 3 is better understood and therefore a better endpoint for clinical trials, while CIN 2 serves as a threshold for treatment, to provide an extra measure of safety for the patient [150]. HPV testing HPV testing looks only for carcinogenic HPV strains [184]. HPV infection is linked to nearly all cases of cervical cancer. Approximately 15 cancer-associated (high-risk or carcinogenic) HPV genotypes cause virtually all cases of cervical cancer and precursor lesions of CIN 2 and CIN 3. Carcinogenic HPV infections are very common, particularly in young women, and most clear without treatment within one to two years. Screening with HPV DNA or HPV RNA testing also detects high-grade cervical dysplasia, a precursor lesion for cervical cancer. But a positive HPV test alone does not mean that cervical cancer or premalignant disease will develop; in one study, nearly 87% of women with positive HPV tests had no problem even after more than ten years of follow-up [74]. Additional clinical trials show that HPV testing is superior to other cervical cancer screening strategies, even though it identifies numerous infections that will not lead to cervical dysplasia or cervical cancer, especially in women younger than 30 years, in whom rates of HPV infection may be higher. Because a positive HPV test calls for a colposcopy, there is a risk of harm in younger women who have HPV but have not had a chance to clear the infection. In April 2014, the U.S. Food and Drug Administration approved an HPV DNA test that can be used alone for the primary screening of cervical cancer risk in women aged 25 years and older [150]. Co-testing with Pap and HPV DNA Screening every five years with the Pap test and the HPV DNA test (co-testing) in women 30 years and older is more sensitive in detecting cervical abnormalities, compared with the Pap alone. This also means more false positive tests, which require extra testing. Screening with the Pap plus HPV DNA test reduces the incidence of cervical cancer. HPV-based screening provides 60-70% greater Not recommended: Other screening tests The National Cancer Institute lists a number of tests that are unproven or that have evidence against them for cancer screening: Alpha-fetoprotein blood test (AFP): The AFP test is sometimes used, along with ultrasound of the liver, to try to detect liver cancer early in people at high risk of the liver cancer. The reported sensitivity of AFP for detecting HCC varies widely in both hepatitis B virus (HBV)-positive and HBV-negative populations, which is attributable to overlap between study designs. When AFP is used for screening of high-risk populations, a sensitivity of 39-97%, a specificity of 76-95%, and a positive predictive value (PPV) of 9-32% have been reported. It is important to know that AFP is not specific for HCC. Titers also rise in acute or chronic hepatitis, in pregnancy, and in the presence of germ cell tumors [173,191]. CA-125 test: This blood test, which is often conducted along with a transvaginal ultrasound, may be used to try to detect ovarian cancer early, especially in women with an increased risk of the disease. Although this test can help in diagnosing ovarian cancer in women who have symptoms and can be used to evaluate the recurrence of cancer in women previously diagnosed with the disease, there is evidence that it is not effective as an ovarian cancer screening test [191]. The NCI reported on a randomized controlled trial in which the ovarian cancer mortality rate was 3.1 protection against invasive cervical carcinoma, compared with cytology (Pap) alone [150,250]. Liquid-based cytology testing Newer techniques that employ liquid-based cytology (such as ThinPrep) are intended to improve the sensitivity of screening. As with the Pap, the optimal studies to determine the sensitivity and specificity of liquid-based cytology have not been done. Some studies showed sensitivity was modestly higher for detecting any degree of cervical intraepithelial neoplasia (CIN), with somewhat lower specificity, but these studies had weaknesses that rendered their findings uncertain. One study that was done more carefully showed that conventional Pap testing was slightly more sensitive and specific than liquid-based cytology [77,150]. The evidence is also mixed about whether liquid-based techniques improve rates of test adequacy. One advantage of liquid-based cytology is that HPV testing can be done on the same preparation if needed, but the liquid-based approaches cost more than conventional Pap testing. No study has yet examined whether liquid-based cytology actually reduces the number of women dying of cervical cancer compared with conventional Pap testing [150]. Women at higher-than-average risk of cervical cancer Depending on medical history, some women may need more frequent or additional screening for cervical cancer than the above guidelines. For example, women who [201]: Are HIV infected (HIV-positive, whether or AIDS has developed). Have a weakened immune system. Were exposed in utero to diethylstilbestrol (DES), which was once prescribed to pregnant women. Had a recent abnormal Pap test or biopsy result. Have had cervical cancer. Screening a woman without a cervix Based on solid evidence, screening is not helpful in women of average risk who do not have a cervix as a result of a hysterectomy for a benign condition. No study has shown that screening for vaginal cancer reduces mortality from this rare condition. Among women without cervices, fewer than one in every 1000 patients had abnormal Pap test results [150]. If a woman had a hysterectomy because of DES exposure, cancer, or other high-risk condition, this does not apply. deaths per 10,000 women in the screened group and 2.6 deaths per 10,000 person-years in the usual-care group. Of screened women, 9.6% had false-positive results that resulted in 6.2% undergoing surgery [183,191]. Regular breast self-exams: The NCI reports that routine selfbreast examination (SBE) has not been shown in randomized controlled clinical trials to reduce deaths from breast cancer [191]. Based on solid evidence, formal instruction and encouragement to perform SBE leads to more breast biopsies and diagnosis of more benign breast lesions. The biopsy rate was nearly twice as high (1.8%) among the study population compared to the control group (1.0%) [142]. But monthly SBE is different from breast selfawareness, and it is important for any woman (or man) to know that if there is a lump or other unusual change in the breast, it should be checked right away. Clinical breast exams: The current evidence is insufficient to assess the additional benefits and harms of clinical breast exam (CBE; examination by a health care provider) [191]. The one randomized controlled trial, the Canadian National Breast Screening Study (NBSS), compared high-quality CBE by nurseexaminers with CBE plus screening mammography. It showed equivalent benefit for both modalities, but accuracy of CBE in the community setting might be lower than in the NBSS [46,142]. Page 59

62 PSA test: This blood test, which is often done along with a digital rectal exam, is able to detect prostate cancer at an early stage. However, expert groups no longer recommend routine PSA testing for most men because studies have shown that it has little or no effect on prostate cancer deaths and leads to overdiagnosis and overtreatment (see Overdiagnosis and Overtreatment ) [191]. Skin exams: Doctors often recommend that people who are at risk for skin cancer examine their skin regularly or have a health care provider do so. Such exams have not been shown to decrease the risk of dying from skin cancer, and they may lead to overtreatment [191]. However, people should be aware of changes in their skin, such as a new mole or a change to an existing mole, and report these to doctors promptly. Transvaginal ultrasound: This imaging test, which can create pictures of the ovaries and uterus, is sometimes used in women who are at increased risk of ovarian cancer (because they carry a harmful BRCA1 or BRCA2 mutation) or of endometrial cancer (because they have a condition called Lynch syndrome). But it has not been proven to reduce deaths from either cancer [191]. Other types of cancer screening not recommended for the general population Ovarian cancer screening: At this time, studies are not promising for screening the general population for ovarian cancer. The U.S. Preventive Services Task Force has set up a plan to evaluate the evidence for ovarian cancer screening methods as of March 2016 [291]. The American Cancer Society has no recommendations for ovarian cancer screenings (see information above regarding CA-125 and transvaginal ultrasounds). Prostate cancer screening: The U.S. Preventive Services Task Force recommends against PSA use for prostate cancer screening [293]. It has no current guidelines to screen for prostate cancer. They are revisiting the topic of prostate cancer screening guidelines now (March 2016) [287]. The American Cancer Society recommends that asymptomatic men receive information about the risks, benefits, and uncertainties of prostate cancer screening. This information should be provided to average-risk men with a life expectancy at least ten years who are 50 years and older, or at earlier ages for men at higher risk of prostate cancer. Screening should not take place without informed decision-making [304]. Cancer Prevention and Risk Reduction Skin cancer prevention and risk reduction Because we know that UV rays cause cancer, nurses can counsel patients to avoid tanning beds, cover their skin and eyes (including hats and UV-blocking sunglasses), and seek shade, especially when outside during the times of day when UV rays are strongest. This is usually between the hours of 10AM and 4PM. Encourage patients to learn about their local UV index which describes on a numeric scale how strong UV radiation is in a particular area on specific dates. The daily UV index for an area can be found online, in some weather forecasts, or via an app for smart phones from the Weather Channel, among others (see Resources for Patients ). Different skin types are at different risks It is important to let patients and families know, that despite the risk strata, people with darker skin can also get skin cancer and that UV exposure increases that risk. Information about UV index can be an important tool for everyone, but patients who are most susceptible to skin cancer should be given repeated counseling regarding the topic. People who spend a lot of time outdoors, those with a family history of skin cancer, and those who have had blistering sunburns in the past should avoid such exposures in the future (see also Ultraviolet Radiation in Risk Factors section). The Canadian Dermatology Association uses the Fizpatrick skin type classification to help stratify skin cancer risk. Skin can be classified from Type-1 to Type-6, depending on genetic disposition, reaction to sun exposure, and tanning habits. Type-1 and Type-2 are at the greatest Colorectal cancer prevention Screening with colonoscopy or sigmoidoscopy finds precancerous lesions that can be removed, and as such, serves dual role for prevention and screening. Every year or two, reports pop up that aspirin reduces the risk of colorectal cancer. Keeping in mind the limitations of these studies, and the fact that the news reports rarely mention dose requirements or the harms of long-term aspirin use, it is understandable that people are interested in this as a possible method of cancer prevention. The USPSTF did a thorough review of evidence on the effects of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) on colorectal cancer (CRC) incidence and mortality. They looked at the efficacy of aspirin and NSAIDs in reducing CRC, adenomatous polyps, and cancer Page 60 risk of skin cancer. Although there are more details to determine exactly who fits into which category, here is a general description of the skin types (skin color refers to unexposed skin) [58, 256]: Type I: Always burns, blisters and peels, never tans; light reddish skin; freckles easily. Type II: Usually burns and peels, and then tans; very pale skin; some freckling. Type III: May burn and peel, but tans well; pale with beige tint; may have a few freckles. Type IV: Rarely burns and tans well; light brown skin. Type V: Very rarely burns, tans easily, brown skin. Type VI: Very rarely burns, tans easily, very dark skin. When UV exposure is unavoidable and other measures are unacceptable, using a broad-spectrum sunscreen of SPF 30 might help reduce the risk of DNA damage in the skin as well as reduce the risk of sunburn [300]. Sunscreens are often applied too sparingly and may come off with sweating, so remind people to use a palm-full and to re-apply every two hours while in the sun. An interesting point here is that, although some groups strongly recommend it, the National Cancer Institute reports that the evidence for sunscreens protecting against skin cancer is still less than adequate, in part because of the years of follow-up required to show differences, problems with reporting, and other influences on skin cancer risk [147]. In the U.S., broad-spectrum sunscreen has been around a much shorter time than the older, less protective types, so there has been less time to study it. incidence. They also looked at mortality, including the dose-dependent effects and harms linked to aspirin and NSAID use in healthy adults. The USPSTF concluded that short-term aspirin does not reduce CRC incidence, but found some evidence that long-term use of higher-dose aspirin (in the range of mg per day) and NSAIDs are linked with lower CRC incidence. For example, looking at the long-term Nurses Health Study, the USPSTF reported that those who took more than 14 aspirin tablets (325mg tabs) a week for more than ten years had a CRC risk of about half what would have been expected. They also found that aspirin and NSAIDs reduce colorectal adenomas, especially at the higher doses. It is possible that high-dose aspirin could reduce CRC deaths, but most of the studies were not able to show that. Even the Nurses Health Study did not show a reduction in

63 deaths from CRC; a lot of nurses took more than 14 aspirin tablets per week for longer than ten years [285]. A 2016 publication by Cao et al. showed a more modest reduction in CRC incidence with lower-dose aspirin use as well as a small reduction in other GI cancers, when aspirin was taken for at least six years [61]. However, the USPSTF did find evidence of significant harms to aspirin use, including dose-related incidence of gastrointestinal bleeding and hemorrhagic stroke. They reported on one meta-analysis (of 16 randomized controlled trials) that looked at GI complications, and found an odds ratio of 5.36 for perforations, ulcers, and bleeding with the use of NSAIDs. Studies that looked at NSAIDs for other purposes have also found an increase in acute renal failure in those over 65, and elevations in blood pressure. These complications might be more pronounced in the older adult population, which is the group that most stands to benefit from CRC prophylaxis [285]. The USPSTF specifically recommends against using aspirin and NSAIDs for only colorectal cancer prevention in people who are at Breast cancer risk reduction for women at high risk Women known to have significantly increased breast cancer risk can use chemoprevention in the form of tamoxifen (for premenopausal women) or raloxifene (for postmenopausal women), which have both been FDA-approved for this purpose. Studies show an overall relative risk reduction of about 38% for this preventive measure. This means that woman with an 8% risk of breast cancer in the next five years (which is pretty high) would see their absolute risk cut to about 5% with this drug treatment. But healthy women at age 60 would have about a 1.7% chance of breast cancer over the next five years, and a 38% risk reduction would drop their absolute risk to about 1.05%. The absolute benefit is clearly much less for women at average risk of breast cancer [34]. Tamoxifen only decreased estrogen receptorpositive cancer and DCIS, but the effect lasted for 16 years after starting tamoxifen (11 years after finishing the 5-year course). These drugs also have risks, which is another reason they are not recommended for general use in breast cancer prevention. Tamoxifen can cause symptoms of menopause and slightly increase the risk of Carcinogen exposure People are generally interested in reducing their exposure to carcinogenic substances whenever possible. In fact, the state of California passed a law (Proposition 65, also called the Safe Drinking Water and Toxic Enforcement Act of 1986) that set up its own registry and labeling requirements for products that contain or possibly contain carcinogens or that might cause reproductive toxicity. Unfortunately, the labels do not say what or how much is in the product, or the likelihood of exposure with normal use, so it is not especially helpful to most people who want to make judicious decisions about exposure (unless they have enough time to contact each manufacturer, learn what is in the product, and then find information on the target substance) [16]. Workplace exposures: Regulations have been put in place in the U.S. to reduce exposures to known carcinogens in the workplace, and to allow workers to find out about substances at work that may be carcinogenic or toxic in other ways. average risk of CRC [285]. However, in late 2015, the USPSTF released a draft guideline which recommends prophylactic aspirin for adults in adults aged 50 to 59 years old who are at a ten percent or greater risk of CVD over a ten-year period, which also offers CRC risk reduction to those same people. Adults age 60 to 69 can take aspirin if they meet the same CVD risk criteria and still do not have an increased risk of bleeding, assuming that they have a life expectancy of at least ten years. The USPSTF reported insufficient evidence to balance risks and benefits of adults younger than 50 or older than 69 [286]. Of note, the American Cancer Society has no recommendations at this time for use of NSAIDs or aspirin for people at average risk of CRC. It is interesting that the U.S. Food and Drug Administration approved the NSAID celecoxib for reducing polyps in people with familial adenomatous polyposis (FAP). This drug may cause less GI bleeding than other NSAIDs, but it might also increase heart attack and stroke risk [20]. Of course, the risk-benefit ratio is different in people with FAP because of their extremely high risk of CRC. cancer of the uterus, and both drugs can rarely cause blood clots (DVT or pulmonary embolus). Women who are pregnant, breastfeeding, at high risk of blood clots, or taking estrogen should not take either drug for breast cancer prevention. Women who smoke or are obese, hypertensive, or diabetic are at increased risk of blood clots. Tamoxifen should not be used in women who have had uterine cancer or precancerous lesions (atypical hyperplasia) of the uterus [34]. Aromatase inhibitors have shown that they can also reduce breast cancer risk in postmenopausal women at increased breast cancer risk, but have not been approved for that purpose as of 2016 [141]. Prophylactic bilateral mastectomy can also reduce risk in women with strong family histories of breast cancer [141]. Premenopausal women with BRCA gene mutations who undergo prophylactic oophorectomy have lower breast cancer incidence. Oophorectomy or ovarian ablation is linked to decreased breast cancer incidence in normal premenopausal women and in women with increased breast cancer risk resulting from thoracic irradiation [141]. Table 5: Cancers associated with various occupations or occupational exposure. Adapted from: Agency for Toxic Substances and Disease Registry, CDC: Chemicals, Cancer and You, 2009 [1]. Cancer Substances or processes Lung Arsenic, asbestos, cadmium, coke oven fumes, chromium compounds, coal gasification, nickel refining, foundry substances, radon, soot, tars, oils, silica. Bladder Aluminum production, rubber industry, leather industry, 4-aminobiphenyl, benzidine. Nasal cavity and sinuses Larynx Pharynx Mesothelioma Lymphatic and hematopoietic Skin Soft tissue sarcoma Liver Lip Formaldehyde, isopropyl alcohol manufacture, mustard gas, nickel refining, leather dust, wood dust. Asbestos, isopropyl alcohol, mustard gas. Formaldehyde, mustard gas. Asbestos. Benzene, ethylene oxide, herbicides, x-radiation system. Arsenic, coal tars, mineral oils, sunlight. Chlorophenols, chlorophenoxyl herbicides. Arsenic, vinyl chloride. Sunlight. Page 61

64 Outside of the workplace, most people can take steps to limit their exposure to known carcinogens, such as: Testing basements for radon. Avoiding tobacco smoke and tobacco use. Reading labels before using chemicals and substances (for example, some common insecticides and herbicides were upgraded in 2015 to possibly or probably carcinogenic in humans by the IARC [107]). Limiting UV exposure. Maintaining a healthy weight [161]. Limiting alcohol intake. Dietary and exercise recommendations for cancer prevention The National Cancer Institute reports that the evidence for influence of dietary factors and cancer is uncertain. There is difficulty evaluating the impact of diet on cancer risk because while lifelong dietary patterns or dietary intake during specific life stages may be important in cancer development, they are not likely detected by relatively shortterm randomized clinical trials [148]. Attempts to quantify the role of diet have been based on systematic reviews of epidemiologic evidence, which found that the greatest consistency was seen for non-starchy vegetables and fruits [227,305]. These were linked to probable decreased risk for upper GI cancers. Fruits were also linked to a probable decreased risk for lung cancer. In relation to human cancer, diets reflect the sum total of a complex mixture of exposures. No dietary factors appear to be uniformly relevant to all forms of cancer [148]. Nevertheless, the American Cancer Society has specific dietary and physical activity recommendations. The following are adapted from American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention [115]: 1. Maintain a healthy weight. Stay lean without being underweight. Avoid excess weight gain. If currently overweight or obese, start by losing small amounts. Use regular exercise and limit high-calorie foods to reach or maintain a healthy weight. 2. Cultivate physically active habits. Each week, adults should exercise at least 150 minutes at moderate intensity or 75 minutes at vigorous intensity or equivalent, spread throughout the week if possible. Teens and children should exercise at least one hour (moderate or vigorous intensity) each day, with vigorous intensity on at least three days of the week. Limit time spend sitting, reclining, watching TV and other electronic screens. 3. Eat a healthy diet that emphasizes plant foods. Limit intake of processed meats (e.g. bacon, bologna, sausage, luncheon meats, hot dogs, cured meats) and red meats (e.g. beef, pork, lamb). Eat five servings (about 2.5 cups total) of a variety of vegetables and fruits every day. Choose whole grains instead of foods with refined grains and high sugar content. Of course, there is no guarantee that any or all of these measures will prevent any one person s cancer, but as public health measures, they should reduce cancer risk overall. Dietary supplements for cancer prevention Patients and family will often inquire what they can take to prevent cancer. They might want to know about dietary supplements because they are interested in a natural approach to health. But dietary supplements are a broad category that can include vitamins and minerals, herbs, or botanicals (products made from plants). Others supplements are made from animal parts, algae, yeasts, fungus, or seafood, among many other things [22]. Some dietary supplements have been shown to be beneficial for certain health conditions. For example, folic acid supplements used by women of childbearing age who may become pregnant reduces the risk of some birth defects. Another example is crystalline vitamin B12, which helps people over age 50, a time when many have a reduced ability to absorb naturally occurring vitamin B12 from foods [281]. While many herbal supplements are carefully grown, tracked, harvested, and prepared under clean controlled conditions, there are others that are not. Many supplements sold today have fillers and contaminants that are not on the label. Supplements have had to be recalled by the FDA because of proven or potential harmful effects. Reasons for these recalls include [281]: Microbiological, pesticide, and heavy metal contamination. Absence of a dietary ingredient claimed to be in the product. The presence of more or less than the amount of the dietary ingredient claimed on the label. Although some may find it disappointing, there is nothing inherently safe about natural plants and animal parts unless they are well understood, carefully prepared, and properly used. Some of the most toxic substances and potent allergens in the world occur naturally [22]. Hemlock and poison mushrooms are natural but are quite dangerous if taken internally. There have been some concerns about the content of many herbal preparations sold in the U.S. When herbal supplements have been purchased and tested by researchers, many of them have been found to contain contaminants or fillers. Some supplements did not contain any of the substances listed on their labels, which in 2015 led to legal action by the state Attorney General of New York [225,226]. One major supplement retailer signed an agreement to authenticate supplements and adopt new standards as a result [224]. Unfortunately, a few manufacturers produce so-called natural supplements that are covertly adulterated with actual drugs that are known to have harmful side effects. For example, many weight loss products and men s supplements contain prescription drugs (for example, sibutramine, anabolic steroids, tadalafil), some of which have been banned by the FDA because they were harmful to human health [76]. In fact, according to the IARC, androgenic (anabolic) steroids are probable carcinogens [32]. It is also important for patients to know that dietary supplements do not have to prove effectiveness or safety before being marketed; they are considered safe until proven otherwise. The U.S. FDA regulates food supplements like food because it expects them to have no more effect than food does. The FDA also regulates claims that can be made by supplement sellers as well as the types of materials that are allowed in the supplements, but laws are sometimes broken [22]. Based on the evidence about nutrition and dietary supplements, the American Cancer Society advises that it is better to eat healthy foods to obtain antioxidants and vitamins rather than take them as supplements. No dried supplement is equivalent to eating whole foods, fruits, and vegetables. Food is the best source of vitamins and minerals [115]. Most vitamins and other supplements do not cause problems in normal doses, but high doses of supplemental vitamin E (taken alone), in one study, were linked to a slightly higher rate of prostate cancer in men who had lower levels of selenium in the body [186]. Commonly available herbs cannot cure or prevent cancer Although some studies suggest that alternative or complementary therapies, including some herbs, might help patients cope with the side effects of cancer treatment, no herbal products have been shown to be effective for treating cancer. Page 62

65 It is helpful to ask cancer patients open-ended questions about vitamins and herbal supplements and any other complementary therapies they may be using when reviewing their current medications [158]. Health concerns for nurses treating cancer patients As nurses and caregivers, those who prepare and administer hazardous drugs need special training and procedures to avoid skin contact, splashes, and aerosols. Mechanical protection such as compounding biologic safety cabinets are used along with careful splash-minimizing procedures during drug preparation. Those administering dangerous and cytotoxic drugs should use personal protective equipment (PPE, such as disposable chemotherapy gloves, gowns, and goggles) for reducing the risks of splashes, aerosols, and other exposures. Used PPE must be disposed of appropriately, along with bags, syringes, tubing, and other administrative equipment. Reusable goggles should be carefully cleaned following procedures that minimize possible contamination of the health care worker or the work environment. NIOSH has a list of hazardous drugs in healthcare settings along with how those drugs were chosen, and what those hazards are online at [216]. Eye-wash stations and drenching hoses are also strongly recommended by OSHA in areas near areas where cytotoxic drugs are prepared and administered and near possible bloodborne pathogen exposures. These are intended to manage potentially hazardous splashes after the fact, but they are not a substitute for preventive measures [278]. Summary This continuing education course covered cancer prevention, cancer nursing, early detection, myths about cancer and cancer prevention, drug interactions, dangers to the nurse and the patient from cancer treatment, financial issues, and standards of care. Cancer prevention and cancer nursing are broad topics with many interesting facets and complex challenges, from the molecules of drugs to patient interactions. As each patient s story unfolds, it is easy to see the impact that a cancer diagnosis can have. There is so much to know that cannot Resources for nurses Cancer screening, prevention, and treatment information The National Cancer Institute has cancer information including PDQs for professionals at hp with evidence to support many aspects of cancer including treatment, palliative care, prevention, genetics, and complementary and alternative treatments. Much more can be found at NCI.gov or by calling CANCER. The American Cancer Society has cancer screening guidelines, complementary and alternative medicine information, carcinogen lists, and information on cancer types and stages, survival and treatment at or ACS The National Comprehensive Cancer Network (NCCN) has guidelines for care both for various cancer types and stages as well as supportive care for symptoms like nausea, fatigue, pain, palliative care, survivorship and more. Free of charge to health professionals (requires registration) at The U.S. Preventive Services Task Force health recommendations, including cancer screening information and evidence, at The Joint Commission for inpatient and outpatient practice standards, at Practice standards and safety information National Institute for Occupational Safety and Health for safety information, technical assistance for safety issues at work; antineoplastic and hazardous drug information: gov/niosh/topics/antineoplastic/effects.html. The Occupational Safety and Health Administration has regulatory standards for health care workers and others, such as Material System Data Sheet (MSDS) requirements at The Centers for Disease Control Basic Infection Control and Prevention Plan for Outpatient Oncology Settings: Minimum Expectations for Safe Care at guidelines/ambulatory-care+checklist_508_11_2015.pdf; also smoking and tobacco, infections that can cause/promote cancer at be covered in education modules like this, which can only examine small bits of the big picture in the hope that some of it will be useful to the nurse caring for these patients and families. But given the scope of the information for which there is not space, following are some resources that might be of help in inpatient and outpatient settings, for the nurse and to share with patients and the people who (almost) never get a day off, caregivers. Oncology Nursing Society (ONS) has information for patient care, nursing standards, and professional information at org. American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards (2013) can be found at files/2013chemostandards.pdf. The American Society of Clinical Oncology (ASCO) has a discussion guide for informed consent for cancer treatment as well as a sample consent form at informed-consent-chemotherapy-administration. The Association of Community Cancer Centers has listings of Cancer Program Guidelines at publications/cancerprogramguidelines-4.asp#section. FDA MedWatch has information on reporting new adverse events of drugs at HowToReport/ucm htm or the nurse can call during regular business hours. Specialized cancer and treatment-related information The U.S. Food and Drug Administration (FDA) has drug and dietary supplement information, regulations, and new drug approvals at or INFO-FDA. There is a sign-up for notices on new drug approvals, safety alerts, radiological health, and recalls at ContactFDA/default.htm. The National Library of Medicine, PubMed, has free scientific information about nearly any medical topic in searchable data base: FDA DailyMed has detailed information for health professionals on thousands of drug at index.cfm (search by name or browse by class). Clinical Trials is an online listing of clinical trials worldwide: NTP for toxicology information, including monographs with research summaries on carcinogenic agents at gov/; the 13th Report on Carcinogens, 2014, is at nih.gov/pubhealth/roc/roc13/index.html. Page 63

66 IARC for cancer-related information and information, including monographs on known and probable human carcinogens, possible human carcinogens, and substances that have been researched for carcinogenic potential, at The National Center for Biotechnology Information has Medical Genetics Summaries, a growing collection which describe the impact that specific genetic variations have on health, like variants that underlie inherited conditions, affect the risk of developing a disease, or influence how an individual may respond to a specific drug. View full contents at NBK CredibleMeds contains lists of drugs that are known or suspected to cause Torsades de Pointes and/or should not be used in people Resources for patients and families Cancer and cancer treatment information The American Cancer Society has information on: many different cancer types, including prevention, treatment, and caregiving; living with cancer; sexuality; insurance and financial issues; talking with children in the family about cancer; advanced cancer and end of life issues; legal and job-related issues; carcinogens; and myths and misconceptions about cancer. Some information is also available in Spanish: or ACS (24/7). The National Cancer Institute has information on different types of cancer and treatment routines for patients, coping with cancer, research and clinical trials, lists of and links to more information about cancer drugs. Some information available in Spanish at: or CANCER. The National Comprehensive Cancer Network (NCCN) has patient information about some types of cancer and cancer treatment. Requires free registration. Cancer prevention and early detection The Skin Cancer Foundation has information on skin cancer prevention at along with information on skin types and cancer risk. The National Weather Service lists the projected daily UV index by U.S. cities and date at php?prodtype=ultraviolet. The U.S. EPA has an app for Smart Phones called SunWise ( for UV index. The website has UV index that can be corelated with skin type but the website has advertisements. Help with quitting tobacco: QUITNOW (free counseling and info by phone); NicA (support group for nicotine addiction; find groups at org (free online support for people quitting smokeless tobacco). See also American Cancer Society ( and National Cancer Institute ( for more on carcinogens, healthy living for cancer survivors, and cancer screening guidelines. The American Cancer Society monograph, Does This Cause Cancer? is a good place to help people start thinking about ways to investigate concerns over cancer causation, at cancer.org/cancer/cancercauses/othercarcinogens/does-this-causecancer. Special information and services related to cancer and health: General health information, encyclopedia of illnesses, health topics, drugs and dietary supplements online (free) at nlm.nih.gov/medlineplus. Health insurance: state health insurance marketplace: healthcare.gov for information, special enrollment, and more; or call with congenital long QT syndrome: (free but registration required). Cytochrome P 450 substrates, inhibitors, and inducers are listed on the Indiana University website (this is the clinically relevant table, not the research table) at ddis/clinical-table. For more extensive listings, SuperCYP is a bioinformatics database that allows entry of multiple drugs to be checked, and it displays a yellow interaction highlight for substrates and inhibitors or inducers. It lists non-interacting options for the selected drugs. Another section lists genetic mutations/polymorphisms that affect drugs at charite.de/supercyp. Clinical Trials Matching Service: find out about clinical trials and possible matches through the Clinical Trials Matching Service from the American Cancer Society; call or visit and search clinical trials. Setting up Electronic Health Records. See the Blue Button Connector from the U.S. Department of Health and Human Services at to get started. For more information, the patient or family member can visit Advance directive forms and information by state, offered at no cost from the National Hospice and Palliative Care Organization: , or caringinfo@ nhpco.org. Five Wishes form (health care advanced directive) can be downloaded from for a nominal fee. Available in multiple languages. Complementary and alternative medicine information: The U.S. Food and Drug Administration (FDA) has drug and dietary supplement information, and health scams and sunscreen information at or INFO-FDA. National Center for Complementary and Integrative Health (NCCIH) Toll-free number: ; TTY: ; website: for information on complementary and alternative therapy and clinical trials (formerly NCCAM). Memorial Sloan Kettering Cancer Center About Herbs and Botanicals website: integrative-medicine/about-herbs-botanicals-other-products For scientific information about supplements, herbs, and more. Caregiver resources Family Caregiver Alliance at has information for new and long-term care givers, long distance caregivers, and online support groups for caregivers. The American Cancer Society has helpful information for family and in-home caregivers including the booklet Caring for the Patient with Cancer at Home at: caregivers/index or ACS-2345; the ACS also has a Cancer Survivor Network with a special section for caregivers at (free registration required). The National Cancer Institute: patient-education/caring-for-the-caregiver or CANCER. Help for Cancer Caregivers has information on caregiving, burnout, and respite care at org/. Family caregivers may find information about cancer and its treatment; see the Resources for Patients and Families section for more. Page 64

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71 303. Wilkes GM, Barton-Burke M. Oncology Nursing Drug Handbook. Burlington MA: Jones & Bartlett, Williams M (2013). Electronic cigarette liquids and vapors: Is it harmless water vapor? University of California, TRDRP Electronic Cigarette Webinar. Retrieved from on March 28, Wolf AM, Wender RC, Etzioni RB, et al. (2010). American Cancer Society guideline for the early detection of prostate cancer: update CA Cancer J Clin, 60(2): World Cancer Research Fund/American Institute for Cancer Research (2007). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR. Retrieved from on April 15, Wrixon AD (2008). New ICRP Recommendations. Journal of Radiological Protection, 28(2). Retrieved from on March 18, Zefar Y, Abernethy AP (2013). Financial Toxicity Part II: How Can We Help with the Burden of Treatment-Related Costs. Retrieved from financial-toxicity-part-ii-how-can-we-help-burden-treatment-related-costs on February 29, Oh JK, Weiderpass E (2014) Infection and cancer: global distribution and burden of diseases. Annals of Global Health, 80(5): Graham S, Brookey J (2008). Do Patients Understand? The Permanente Journal 12(3). Retrieved from on May 16, Gobel BH, Goudreau KA, Koetters T, Knobf MT, McGuire DB, Ponto JA, Stanley JM (2008). Oncology Clinical Nurse Specialist Competencies. Retrieved from files/cnscomps.pdf on May 16, van Leeuwen RWF, Swart EL, Boven E, Boom FA, Schuitenmaker MG, Hugtenburg JG (2011). Potential drug interactions in cancer therapy: a prevalence study using an advanced screening method. Annals of Oncology. Retrieved from early/2011/02/22/annonc.mdq761.full on May 16, McBride R (2010) Talking to Patients About Sensitive Topics: Techniques for Increasing Reliability of Patient Self-Report. Retrieved from on May 16, Overcash JA (2008) Comprehensive Geriatric Assessment. In Cope DG, Reb AM (Eds) An Evidence-Based Approach to the Treatment and Care of the Older Adult with Cancer. Pittsburg: Oncology Nursing Society pp Scripture CD, Figg WD (2006). Drug Interactions in Cancer Therapy. Retrieved from medscape.com/viewarticle/ on May 17, Holle LM, Michaud LB (2014). Oncology Pharmacists in Health Care Delivery: Vital Members of the Cancer Care Team. Journal of Oncology Practice, 10(3): e142-e National Cancer Institute (2014). Targeted Cancer Therapies. Retrieved from about-cancer/treatment/types/targeted-therapies/targeted-therapies-fact-sheet on May 17, Bond SM, Hawkins DK, Murphy BA (2014). Caregiver-Reported Neuropsychiatric Symptoms in Patients Undergoing Treatment for Head and Neck Cancer: A Pilot Study. Cancer Nursing, 37(3): Belgacem B, Auclair C, Fedor MC, Brugnon D, Blanquet M, Tournilhac O, Gerbaud L (2013). A caregiver educational program improves quality of life and burden for cancer patients and their caregivers: a randomised clinical trial. European Journal of Oncology Nursing, 17(6): CenterWatch (2016). FDA Approved Drugs for Oncology. Retrieved from com/drug-information/fda-approved-drugs/therapeutic-area/12/onocology on March 22, Berlin RJ (2009). Examination of the Relationship Between Oncology Drug Labeling Revision Frequency and FDA Product Categorization. American Journal of Public Health. 99(9): American Cancer Society (2014) Coping with Cancer in Everyday Life. Retrieved from cancer.org/acs/groups/cid/documents/webcontent/ pdf.pdf on May 17, United States Food and Drug Administration (2016). Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS). Retrieved from ProductsIngredientsComponents/ucm htm on May 18, United States Preventive Services Task Force (2016). Final Recommendation Statement: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. Retrieved from aspirin-to-prevent-cardiovascular-disease-and-cancer on May 18, American Urological Association (2013). Early Detection of Prostate Cancer: AUA Guideline. Retrieved from Detection.pdf on May 19, Centers for Disease Control and Prevention (2016). Ventilation Does Not Effectively Protect Nonsmokers from Secondhand Smoke. Retrieved from fact_sheets/secondhand_smoke/protection/ventilation/ on May 23, Centers for Disease Control and Prevention (2016). Genital HPV Infection Fact Sheet. Retrieved from on May 23, American Cancer Society (2015). Skin Cancer: Merkel Cell Carcinoma. Retrieved from cancer.org/acs/groups/cid/documents/webcontent/acspc pdf.pdf on May 24, Centers for Disease Control and Prevention (2014). About Epstein-Barr Virus (EBV). Retrieved from on May 23, Page 69

72 Cancer Nursing, Prevention, and Early Detection for the Adult Patient Self Evaluation Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet. 1. Two reliable organizations that evaluate potential carcinogens that can be found online are: a. US National Toxicology Program (NTP) and the International Agency for Research on Cancer (IARC). b. World Cancer Organization (WCO) and the US Cancer Studies Group (CSG). c. American Cancer Research (ACR) and its international counterpart, Worldwide Cancer Research (WWCR). d. US Toxics Prevention Association (TPA) and the International Cancer Prevention Organization (ICPO). 2. The American Cancer Society mentions cervical cancer screening for women who have been fully vaccinated against human papillomavirus (HPV). What is their recommendation? a. Cervical cancer screening should be exactly the same for women as for women who haven t been vaccinated for HPV. b. Women who have been vaccinated for HPV don t need cervical cancer screening. c. Cervical cancer screening should be done in vaccinated women, but it should start at age 30 and can be done every 7-10 years. d. Cervical cancer screening intervals can be lengthened to every 10 years, since risk of HPV will be lower for vaccinated women. 3. Women who have had complete hysterectomies with cervical removal for a benign condition should not have Pap or HPV testing unless they have other risk factors. a. True. b. False. 6. Now that screening for lung cancer in asymptomatic people has finally been recommended, it applies to a fairly small subset of people. What is true about lung cancer screening? a. Only people who have been heavily exposed to radon should be screened for lung cancer. b. People who have smoked heavily and then quit are the only ones who should be screened. c. People aged 55 to 74 who have smoked heavily are candidates for lung cancer screening whether or not they ve quit smoking, although some guidelines allow for screening at older ages. d. Heavy smokers aged 35 to 55 are the ones who have proven most likely to benefit from screening and should start annual screening immediately. 7. According to the NCI, cancer is a collection of more than how many related diseases? a. 50. b c d. 1, Regular self-breast exams have been proven to reduce deaths from breast cancer. a. True. b. False. 9. Repeated CT exams can raise future cancer risk, especially in younger people. a. True. b. False. 4. Women with breast implants should not have mammograms between ages 50 and 60. a. True. b. False. 5. Patients who will be getting 2 chemotherapy drugs classified as moderately emetogenic should get an antiemetic regimen suited to moderately emetogenic cancer treatment. a. True. b. False. 10. Removal of polyps during colonoscopy carries some risk of: a. Diarrhea lasting 3-6 days that spontaneously resolves. b. Vomiting after meals. c. Short-term dysgeusia. d. Acute or delayed GI bleeding. Answers: 1.A 2.A 3.A 4.B 5.B 6.C 7.B 8.B 9.A 10.D Page 70

73 Pathophysiology of the Cardiovascular System Release Date: 6/30/2016 Expiration Date: 6/30/2019 Faculty Carol Gelman, MD, MS, HC. Dr. Gelman received her medical degree in South Africa. She has now lived in the United States for the past 16 years and now considers this her home. Dr. Gelman considers medicine to be an essential part of who she is. Since arriving in the U.S., she realizes how important communication is in understanding, implementing, and working in health care. This led her to return to school for a degree in health communication from Metropolitan College, Boston. The blend of 4 Contact Hours medicine and health communication has provided Dr. Gelman the perfect foundation for writing and educating. Elite is privileged to have Dr. Gelman as a course writer. In her spare time, Dr. Gelman, who lives in Atlanta, cares for two lovely girls, aged 9 and 17, a Golden Retriever, and a stray cat. She also enjoys creating vintage digital French graphics. Content reviewer Irene Owen, ARNP Audience This adult focused course is for all generalist nurses who care for adults. The course includes practice standards, best practices Purpose statement Caring for diseases of the cardiovascular system are part of every day nursing care. This course reviews the pathophysiology of the Learning objectives Describe the anatomy and physiology of the heart. Discuss the pathophysiology of pumping and non-pumping diseases of the heart. Describe the causes and etiology of pumping and non-pumping diseases of the heart. How to receive credit Read the entire course online or in print which requires a 4-hour commitment of time. Depending on your state requirements you will be asked to complete either: An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider # CEP15022; District of Columbia Board of guidelines, and therapies related to assessment and care of patients with disease of the cardiovascular system. cardiovascular system, and updates current standards and therapies. It is a vital course of contemporary best practices nursing care. Recognize signs and symptoms of pumping and non-pumping diseases of the heart. List three various tests used for diagnosis. Determine pharmacologic and non-pharmacologic treatment of the various diseases. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print your Certificate of Completion. Nursing, Provider # ; Florida Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Page 71

74 Disclosures In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/Commercial Support and Non-Endorsement It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. The cardiovascular system centers on the heart, which pumps blood through a closed system of blood vessels. The primary function of the cardiovascular system is to transport nutrients, water, gasses, wastes, and chemical signals throughout the body [1]. Anatomy of the heart The heart is coned shaped muscular organ situated in the chest cavity between the lungs and behind the sternum. The heart is generally the size of a fist and can weigh between grams [3]. Overview of the Cardiovascular System The cardiovascular system consists of three parts: the heart which pumps the blood; the blood vessels via which blood flows (including the systemic and pulmonary circulation); and the blood which transports oxygen, carries nutrients, and disposes of waste products. The layers of the heart The heart consists of three layers: the pericardium which surrounds the heart; the myocardium; and the endocardium, or heart wall. The heart wall is made up of three layers: the epicardium, the myocardium, and the endocardium [4]. The epicardium (outermost layer) is composed of coronary arteries and nerves that innervate the heart. The myocardium The chambers of the heart The heart consists of four chambers. The two upper chambers are the right and left atria and the two lower chambers are the right and left ventricles. The right ventricle pumps blood into the pulmonary The heart valves Heart valves function to ensure unidirectional flow of blood through the heart. The heart contains two types of valves: the atrioventricular valves (AV valves); and the semilunar valves. The AV valves separate the atria from the ventricles and are the tricuspid valve on the right and the mitral valve on the left [5]. The The blood vessels Arteries carry blood away from the heart and veins carry blood towards the heart. Arteries have thick walls to allow them to withstand changes in blood pressure, while veins have relatively weak walls with Heart blood flow The right and left sides of the heart work together simultaneously as a doublepump [5]. The right side is a pump to the pulmonary circulation and the left side is a pump to the systemic circulation. The right atrium receives deoxygenated blood from the vena cava and from the coronary veins. The right ventricle receives deoxygenated blood from the right atrium via the right AV valve (tricuspid). This deoxygenated Page 72 (middle layer) is composed of cardiac muscle. The endocardium (innermost layer) contains the Purkinje fibers; the main function of Purkinje fibers is the conduction of electrical impulses which cause the heart to contract and relax [2]. circulation. The left ventricle pumps blood into the systemic circulation. The atria and ventricles are separated by closable one way valves [2]. tricuspid valve separates the right atria from the right ventricle and the mitral valve separates the left atria from the left ventricle. The semilunar valves separate the ventricles from the major arteries. The pulmonary valve separates the right ventricle from the pulmonary artery. The aortic valve separates the left ventricle from the aorta. Normal heart sounds are caused by the closing of the heart valves [5]. one way valves which assist in the movement of blood towards the heart. The exchange of substances occurs across capillaries. blood travels via the pulmonary valve to the pulmonary arteries in the lungs and becomes oxygenated in the lungs. The oxygenated blood travels via the pulmonary vein to the left atrium of the heart and flows via the left AV valve (mitral) to the left ventricle and then to the systemic circulation via the aortic valve [4].

75 The coronary circulation The right and left coronary arteries lie on the surface of the heart. The coronary veins drain into the coronary sinus which then drains to the right atrium. Pathophysiology of diseases of the heart The heart can be considered as a double pump and diseases of the heart can be classified according to pumping and non-pumping diseases. Pumping diseases of the heart Heart failure Heart failure is the inability of the heart to supply adequate oxygenated blood to the peripheral tissues and organs to meet metabolic Terminology [8] Cardiac output is the volume of blood pushed out of the left ventricle per minute. Stroke volume is the amount of blood ejected from the left ventricle during one contraction. Cardiac output = stroke volume x heart rate. Cardiac output is dependent on several factors: Preload, afterload, contractility, and heart rate. Preload is the amount the ventricles have stretched at the end of the diastole/relaxation stage. It is also known as the left ventricular diastolic pressure (LVEDP). Afterload is the amount of resistance the left ventricle has to overcome to push the aortic valve open and push blood into the systemic circulation. It is also known as systemic vascular resistance. Contractility is the force of ventricular contraction. Heart rate is the number of times the heart beats per minute. Heart rate is important because it is a major contributor to cardiac output. Normal heart rate is between beats per minute. Heart failure does not mean that the heart has stopped beating, but rather that the heart, which is a muscle, is not pumping properly. As The renin-angiotensin aldosterone system Lack of perfusion/oxygenation of the kidneys signals the activation of the renin-angiotensin aldosterone system. Renin is released by the kidneys in response to low blood pressure and this transforms angiotensinogen to angiotensin in the liver. Angiotensinogen is a precursor protein made in the liver for a hormone called angiotensin I. Renin catalyzes a reaction that converts angiotensinogen protein into angiotensin I, which is a precursor hormone that is converted to an active hormone called angiotensin II by an enzyme known as angiotensin-converting enzyme in the lungs [65]. Angiotensin II is a Etiology of heart failure [9] The main causes of acute heart failure include: Severe infections such as viruses that attack the heart muscles; allergic reactions; blood clots in the lungs; certain medications; and other illnesses that affect the whole body. The main causes of chronic heart failure include coronary artery disease (e.g. myocardial infarction/heart attack); high blood pressure; and valvular problems of the heart. Further causes of chronic heart failure are listed alphabetically: Alcohol abuse; aortic valve disease; arrhythmias; cardiac drugs (e.g. beta-blockers, calcium antagonists); cardiac tamponade; cardiomyopathy; congenital abnormalities; fever; hypertension; mitral valve disease; myocardial infarction; myocarditis; demands [6]. To understand heart failure, it is important to understand how the heart works [8]. a result it is unable to pump sufficient blood to the rest of the body. As the heart muscle weakens and the pumping action of the heart decreases, blood can build up in the lungs, liver, and/or legs. This can result in shortness of breath, i.e. dyspnea, and swelling of the legs, i.e. edema. It can also result in inadequate blood supply to organs, and long-term, can lead to organ failure from lack of oxygen. Heart failure can occur acutely, but it is usually a chronic illness that develops over time [6]. Heart failure results in a cascade of compensatory mechanisms. Baroreceptors and chemoreceptors cause the activation of the sympathetic nervous system and the renin-angiotensin adotrone system. Baroreceptors monitor blood pressure and when these receptors detect a lowering of blood pressure, they stimulate the cardiac center in the brain which in turn signals sinoatrial receptors in the heart to fire more rapidly and increase contractility and heart rate. Chemoreceptors detect changes in oxygen and trigger the sympathetic nervous system, leading to an increase in adrenaline and noradrenaline, resulting in vasoconstriction. This is a physiological attempt to normalize blood pressure [6]. vasoconstrictor which leads to an increase in blood pressure and causes the release of aldosterone. Aldosterone promotes the reabsorption of sodium and water in an effort to increase blood pressure. ADH is released by the pituitary which causes vasoconstriction and the retention of sodium and water. Peripheral resistance is also increased, which increases cardiac output temporarily as the increase in blood pressure results in the heart having to pump even harder. The end result is further impairment of cardiac function [6]. pericardial disease; pregnancy; pulmonary heart disease; rheumatic heart disease; severe anemia; systemic lupus erythematosus; thyroid disease (especially hyperthyroidism); and tricuspid valve disease. These conditions damage the heart muscle, making it stiff and impairing heart function. Heart failure affects contractility and/or relaxation of the heart. A decrease in contractility results in the heart being unable to push out sufficient blood to the rest of the body and/ or the inability to relax sufficiently to allow for adequate filling of the ventricles. Page 73

76 Pathophysiology of heart failure [60] Heart failure can be a result of right ventricular failure, left ventricular failure, or a combination of both. With left ventricular failure, there is a decrease in cardiac output, causing an increase in back pressure towards the pulmonary veins. If pulmonary capillary pressure exceeds the oncotic pressure of plasma proteins, fluid leaves the capillaries and enters the interstitial space and alveoli, causing pulmonary edema and decreasing pulmonary compliance and increasing the work of breathing. In right ventricular failure, there is an increase in systemic venous pressure; if systemic capillary pressure exceeds the oncotic pressure of plasma proteins, fluid leaves the capillaries and moves into the interstitial space, causing peripheral edema and potentially edema in abdominal viscera/organs. If this occurs in the peritoneal cavity it is known as ascites. Liver congestion causes a decrease in hepatic function and a decrease breakdown of aldosterone causing further water retention. Heart failure usually begins on the left side of the heart because the left ventricle is the main pumping chamber of the heart. When the left ventricle cannot contract enough, the ventricle is unable to push sufficient blood out of the heart; this is called systolic failure. When the left ventricle cannot relax enough, it cannot fill with enough blood; this is called diastolic failure [1]. Figure 1. Types of heart failure. Courtesy of Left-sided heart failure In left ventricular failure, ventricular filling is reduced, and ventricular contractility is impaired, resulting in a decrease in cardiac output and Right-sided heart failure Right ventricular failure is usually a result of left-sided heart failure. When the left ventricle fails, blood is essentially pushed back into the lungs, resulting in back pressure and failure of the right ventricle. Congestive heart failure A person can have a combination of both types of heart failure; this is known as congestive heart failure. The term congestive heart failure means that blood is backing up/congesting in the liver, Diagnosis and management of heart failure It is important for the correct diagnosis to be made as soon as possible to prevent irreversible damage. The symptoms of cardiac failure are The signs and symptoms of heart failure Patients with heart failure can report a number of symptoms including: Shortness of breath; difficulty breathing when lying down; swelling of the legs/abdomen; right-sided liver pain; yellowing of the skin and eyes; and weakness and/or fatigue [8]. Dyspnea, i.e. shortness of breath, is usually the first sign of heart failure. When the left ventricle is unable to eject sufficient blood into the systemic circulation, there is an increase in pressure in the left ventricle, which often leads to increased pressure in the pulmonary circulation, leading to pulmonary edema. Nocturnal dyspnea occurs when a patient is supine, i.e. lying down. When supine, there is an increase in peripheral venous return from the extremities, and this leads to an increase in pressure in the left ventricle from an increase in blood return resulting in an increase in pressure back to the lungs because the heart is unable to eject sufficient blood into the systemic circulation. Edema is an increase in fluid in the interstitial space as a result of congestion of the blood in the periphery, i.e. fluid seeps out of the blood vessels into the interstitial space. It occurs with both right and an increase in pressure in the pulmonary veins. This often results in pulmonary edema. When the right side of the heart fails or has decreased pumping power, blood backs up in the veins, resulting in swelling of the lower extremities/peripheral edema, the abdomen, and the liver/ascites [9]. the abdomen, the lower limbs, and lungs. Not all heart failure is congestive, there can be symptoms of heart failure without blood backing up in the rest of the body [8]. often nonspecific, so a detailed history and clinical examination is necessary to exclude other possible causes. congestive heart failure. Edema can occur in the ankles, the legs, the abdomen, the sacrum, and the scrotum. Ascites are the accumulation of fluid in the abdomen as a result of right and congestive heart failure. Ascites can result in right hypochondrial or liver pain due to congestion of the liver. The liver becomes engorged with blood and liver function becomes impaired and bilirubin accumulates, leading to jaundice (i.e. yellow discoloration of the skin and conjunctivae). Although patients with heart failure may present with an increase in weight from the accumulation of fluid, some patients with severe heart failure and intestinal edema are unable to absorb food adequately, resulting in malabsorption and anorexia. Very often, patients with ascites have no appetite and feel nauseous and this can result in muscle wasting. Many patients with heart failure present with fatigue and lethargy which can be the result of dyspnea, muscle wasting, and/ or malabsorption. Patients with heart failure often struggle to sleep at night because of nocturnal dyspnea. Reduced oxygenation of the brain can lead to altered mental states or confusion [7]. Page 74

77 Clinical examination of heart failure The clinical signs of heart failure depend on the cause, i.e. right sided heart failure, left sided heart failure, or both [7]. Right-sided heart failure: The clinical signs of right-sided heart failure include: Non-tender pitting edema in the feet/ankles; abdominal swelling with or without ascites; liver enlargement with tenderness; and or a visible jugular venous pulse. Severe right-sided heart failure can result in generalized edema or anasarca. Cardiac findings upon palpation of the heart may show right ventricular enlargement. Tests used in the diagnosis of heart failure [8] Routine blood tests: Routine blood tests for cardiac failure diagnosis include: A metabolic panel including urea and electrolytes; a full blood count; liver function tests; thyroid function tests; a glucose level test; and a complete lipid profile. Specialized blood tests: Serum natriuretic peptide (SNP): This is a hormone secreted by the heart as a result of increased ventricular stretch and it is considered a useful marker in the diagnosis of cardiac failure. Management of heart failure Management of cardiac failure requires pharmacologic and nonpharmacological interventions [8]. Note that many of these drugs are used in other cardiac conditions and learning them now will allow for ease of learning later in the module. Auscultation may reveal a murmur of tricuspid regurgitation or incompetence. Left-sided heart failure: The clinical signs of left-sided heart failure include shortness of breath/dyspnea, cyanosis, and hypotension. Palpation of the heart may reveal a displaced apical heartbeat, and auscultation may reveal a third and/or fourth heart sound. Pulmonary investigation may reveal crackling sounds at the base of the lungs, and in the case of a pleural effusion, dullness to percussion and decreased breath sounds at the bases of the lungs. Other diagnostic tests: A 12-lead ECG can show evidence of ventricular hypertrophy/ enlargement, cardiac disease, and associated arrhythmias such as atrial fibrillation. A chest x-ray can show enlargement of the heart i.e. cardiomegaly, pulmonary congestion, and respiratory disease. Respiratory function tests are used to exclude respiratory causes of the above-mentioned symptom and signs. Echocardiography is considered the gold standard for diagnosing cardiac failure, as it provides information on the underlying structure of the heart and the amount of dysfunction. It can also be used to exclude other causes. Figure 2. Pharmacologic treatment of cardiac failure. From: study.com/academy/lesson/what-are-diuretics-definition-types-sideeffects-examples.html. Pharmacologic treatment of heart failure [14] Diuretics are the drug of choices as a first line treatment of heart failure. Diuretics keep fluid from accumulating in the body and increase urination [11]. There are three types of diuretics used to treat heart failure: Loop diuretics. Thiazide diuretics. Potassium sparing diuretics. Loop diuretics: Loop diuretics (e.g. furosemide) work in the Loop of Henle by increasing sodium and water secretion, and in the distal tubule of the kidney by increasing potassium secretion [11,14]. If using furosemide intravenously, it should be given slowly, as rapid infusion can lead to tinnitus and deafness. The most important side effects to monitor in this situation are hypokalemia and dehydration. Thus it is important to monitor serum urea (i.e. increased in dehydration) and electrolyte panels (i.e. K levels). Hypokalemia (low K) can be managed by switching to potassium sparing diuretics or using potassium supplements. Hypokalemia can cause cardiac arrhythmias and can be fatal. Thiazide diuretics: Thiazide diuretics work in the distal tubule by inhibiting sodium and chloride reabsorption, resulting in an increased secretion of sodium and chloride by the kidneys [11,14]. Thiazide diuretics are usually given in combination with loop diuretics. The main side effect is hypokalemia, thus urea and potassium levels need to be monitored. Side effects of thiazide diuretics include hypotension (i.e. low blood pressure), headaches, and dizziness. Potassium sparing diuretics/aldosterone antagonists: Potassium sparing diuretics (e.g. spironolactone, amiloride) work in the distal tubule of the kidney by increasing sodium and chloride secretion [11,14]. This group of drugs causes the retention of potassium, and is weaker than the diuretics already described. These are usually combined with either loop or thiazide diuretics. The most common side effects include hyperkalemia, dehydration, hypotension, and gastrointestinal upset. Beta-blockers, e.g. atenolol, metoprolol: Beta-blockers slow the heart rate and reduce blood pressure [11,12]. Beta-blockers were once contraindicated in patients with heart failure, but medical trials have shown them to be effective for the treatment of heart failure; in fact, Page 75

78 beta-blockers often decrease mortality. When combined with diuretics and ACE inhibitors, beta-blockers improve the signs and symptoms of left-sided heart failure. Beta blockers decrease heart rate, so care should be taken when they are administered because they can lead to bradycardia, conduction disorders, fatigue, and bronchospasm, especially in patients with a history of asthma. The most common side effects of beta blockers include fatigue, cold hands, headache, gastrointestinal upset, and dizziness [12]. Precautions of beta-blockers include: They should not be used in people with asthma as they may trigger bronchospasm; in patients with diabetes, they may block signs of low blood sugar; and they can cause an increase in triglycerides. Beta blockers should not be stopped suddenly because of an increased risk of heart attack. Angiotensin-converting enzyme drugs (ACE inhibitors), e.g. enalapril, lisinopril, or captopril: Ace inhibitors are a type of vasodilator, i.e. they relax blood vessels to lower blood pressure, resulting in an increase in blood flow and a decrease in workload on the heart [11,14,23]. ACE inhibitors are used in chronic heart failure cases as they work on the renin-angiotensinaldosterone system. Normally, renin is released from the kidneys when there is a decrease in kidney perfusion, stimulating angiotensin I to be converted to angiotensin II in the liver. Angiotensin II is a potent vasoconstrictor and also causes the release of aldosterone from the pituitary gland in the brain. Aldosterone causes the retention of sodium and water which in return increases blood pressure to maintain perfusion of the organs. Ace inhibitors act by inhibiting angiotensin II as well as aldosterone release by the pituitary; there is no increase in sodium and water retention by the kidneys and blood pressure is lowered. ACE inhibitors also lead to an increase in bradykinin (i.e. a vasodilator) which can be responsible for some of the side effects of ACE inhibitors including dry cough, hypotension, and angioedema. ACE inhibitors Non-pharmacologic treatment of cardiac failure Although pharmacologic treatment is the first line of treatment, nonpharmacologic treatments improve long-term prognosis. These consist of education, lifestyle advice, and exercise [8]. Nursing care: [58] Vital signs are directly affected by both right and left sided cardiac failure including: Pulse rate and rhythm: The pulse rate is often increased as a result of compensatory mechanisms for hypoxia and low cardiac output. Patients can have arrhythmias, indicating a poor cardiac output from a failing heart. Blood pressure: Blood pressure is likely to be abnormal, evidencing a low systemic blood pressure. The diastolic blood pressure can be abnormally elevated and this is indicative of congestion as a result of decreased blood return to the heart and the resulting inability of the heart to pump sufficient blood into the systemic circulation. Oxygen saturation: The percentage oxygen saturation is often decreased as a result of circulatory congestion and a causes a low oxygen saturation rate. Respiration: Respiratory rate is often increased due to hypoxia, but it is usually shallow because of general fatigue. can cause a sudden decrease in blood pressure, and as a result, a small test dose is usually administered first. Precautions regarding ACE inhibitors include a decrease in the effectiveness of non-steroidal antiinflammatory drugs. They should not be used in pregnancy because of the risk of birth defects. ACE inhibitors are contraindicated in patients with aortic stenosis [8]. Positive inotropes, e.g. dopamine, dobutamine: [14] Drugs which increase cardiac contractility are known as positive inotropes. They act by increasing the sympathetic nervous system stimulation. Dopamine is normally produced in the adrenal medulla and the brain. Dopamine acts on the heart, leading to an increase in cardiac contractility, and on the kidney, causing an increase in renal perfusion and an increase in urine output. Dopamine needs to be given by a central venous catheter because it causes necrosis (i.e. damage) to the surrounding tissues if any extravasation (i.e. leakage) occurs. The main side effects of dopamine are tachycardia, hypertension, arrhythmias, headaches, nausea, and vomiting. Patients need to be monitored closely and require initial and hourly observation of vital signs. Dopamine can also lead to vasoconstriction [8]. Cardiac glycosides digoxin, e.g. digitalis: Digoxin works directly on cardiac muscle; it slows down heart rate and increases the force of contraction. This leads to improved circulation and reduced swelling of the extremities. It is more likely to be given to patients with cardiac arrhythmias and/or when cardiac failure is worsening despite pharmacological treatment [11]. Several conditions lead to digoxin toxicity including hypercalcemia, hypokalemia, hypomagnesemia, and kidney disease [13]. Anticoagulants are prescribed for heart failure patients with atrial fibrillation, or sinus rhythm with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus [8]. Body temperature: Low levels of oxygenation of the body, i.e. hypoxia, lead to a lower metabolic rate and a lower body temperature. Providing oxygen and keeping the patient warm and on bed rest is an important component for treating cardiac failure. Lifestyle modification: The patient should be advised to: Acutely reduce activity to decrease the workload of the heart; stop smoking; and abstain from drinking alcohol. Dietary modification: The patient should be on a low-salt and a low-fat diet. A salt-free diet decreases the incidence of fluid retention and a low fat diet minimizes the risk for ischemic heart disease. Small meals are recommended to decrease the work of the heart. Weight needs to be assessed. Medication and oxygen therapy should be assessed. Digitalis/digoxin is commonly prescribed to increase the contractility of the heart and therefore improve cardiac output. Diuretics are used to enhance the elimination of excessive fluid from the body and decrease pulmonary and peripheral edema. Angiotensin converting enzyme inhibitors: ACE inhibitors decrease aldosterone production, resulting in a decrease in the reabsorption of sodium and water. Complications of heart failure The complications of heart failure include organ damage (i.e. kidneys, liver, spleen, and/or brain) and heart valve problems (e.g. if the heart is enlarged). The non-pumping diseases of the heart This section will cover the non-pumping problems of the cardiovascular system including: Atherosclerosis/plaque; hypertension; coronary artery disease; peripheral artery disease; deep venous Page 76 thrombosis; valvular diseases of the heart; cardiac inflammation; myocardial ischemia; myocardial infarction; cardiomyopathies; rheumatic fever; and arrhythmias.

79 Atherosclerosis [15] Atherosclerosis, i.e. the hardening of the medium and large arteries, is a condition in which plaque builds up on the artery walls. Plaque is made up of cholesterol, fatty substances, cellular waste, and fibrin (i.e. a clotting material in the blood). Risk factors for atherosclerosis and The pathogenesis of atherosclerosis [61] Primary events causing atherosclerosis are repeated damage to the endothelial lining of the artery. The possible causes of damage to the wall of the artery include increased blood level lipids, high blood pressure, smoking, diabetes, and inflammation. Atherosclerosis begins when repeated injury to the artery wall mediates an inflammatory response, in turn causing white blood cells to adhere to the area of damage. These white blood cells transform into foam cells and collect cholesterol and cause the proliferation of smooth muscle cells in the wall of the artery. With time, these fat laden cells proliferate and build Types of lipids The two main types of lipids are triglycerides and cholesterol. Cholesterol is manufactured in the liver, and helps cells to function normally. Increased cholesterol is a result of consuming foods which are high in cholesterol. When a person eats an excessive amount of fats, excesses are stored in the liver as triglycerides. Elevated triglycerides are associated with an increased risk of atherosclerosis and often result in heart disease. There are no signs or symptoms of plaque formation include: Elevated lipid levels; increasing age; family history of heart disease; high blood pressure; smoking; diabetes; and obesity [16]. Plaque accumulation in the walls of arteries can lead to partial or complete obstruction of arteries. up in the wall of the artery, causing patchy deposits, i.e. atheroma. Calcium is attracted to these atheromatous plaques and builds up, causing atherosclerosis, a hardening of the arteries. The consequences of plaque formation are as follows: A piece of plaque can break away from the surface of the plaque; and/or a blood clot can form on the surface of the plaque. This can result in a cerebrovascular accident or a myocardial infarction. If this occurs in the periphery, it can result in gangrene [15]. atherosclerosis until the blood vessels become narrowed, therefore routine monitoring of blood lipid levels provides an early indication of potential problems. There are four different lipids which need to be monitored: Total cholesterol, triglycerides, HDL (high-density lipoprotein), and LDL (low-density lipoprotein). Although the mechanism is unknown, HDL is cardioprotective [17]. Management of Patients with Elevated Blood Lipid Levels Non-pharmacologic treatment of hyperlipidemia First line management of elevated blood lipid levels involves lifestyle management with diet and exercise. When this does not help to reduce lipid levels, several drugs are used to treat hyperlipidemia. It is Pharmacologic treatment of hyperlipidemia Lipid lowering drugs are also cardioprotective. There are different types of lipid lowering drugs, which are classified according to their mechanism of action. These mechanisms include: Bile acid binders; fibrin acid; niacin; cholesterol absorption inhibitors; omega-3 fatty acids; and statins [59]. Statins: Statins are the drug of choice for hyperlipidemia as they lower LDL cholesterol and decrease cardiac morbidity and mortality. Hypertension (HT) High blood pressure or HT is a disease which causes intermittent or a constant increase in blood pressure in the arteries. In the majority of cases, the cause is unknown; however, lifestyle factors have been Pathogenesis of hypertension Blood pressure (BP) is defined as cardiac output (CO) multiplied by total peripheral resistance (TPR). Therefore, an increase in blood pressure is the result of an increase in cardiac output, or an increase in Risk factors of hypertension [18] Age: Men over 45; and women over 55 years of age. Race and ethnicity: Hypertension is increased in African Americans. Family history: A family history of hypertension is increases the risk of developing hypertension. Obesity: Obesity increases the risk of hypertension. Obstructive sleep apnea: This is present in a lot of patients with hypertension. important to note these drugs must have lifelong use after initiation of use [16]. Statins inhibit hydroxymethylglutaryl CoA reductase, the main enzyme in cholesterol synthesis. Desirable lipid levels in adults [59] : Total cholesterol: <200mg/dl. LDL cholesterol: <100mg/dl; if diabetic <70. HDL cholesterol: >40mg/dl. Triglycerides: <150mg/dl. shown to play an important role in the development of hypertension [18]. total peripheral resistance, or both [62]. In most cases of hypertension or primary hypertension, cardiac output is normal or slightly increased and total peripheral resistance is increased. Lifestyle factors: These include smoking, a diet high in sodium, alcohol, sedentary habits, and stress. Additional risk factors: These include primary aldosteronism, renovascular disease, pheochrocytoma, Cushing s syndrome, congenital adrenal hyperplasia, thyroid disorders, and drug induced or coarctation of the aorta [67]. Blood pressure is the force applied to the arteries as blood passes through them. Hypertension is the result of an increase in cardiac Page 77

80 output and/or an increase in total peripheral resistance [19]. Although the body can adapt to these changes in blood pressure, over time the heart may enlarge, i.e. hypertrophy, leading to a condition called cardiomyopathy. Cardiomyopathy is a major cause of heart failure. High blood pressure can lead to organ damage as well as damage to the peripheral arteries and arterioles. There are two measurements used to determine high blood pressure: Systolic pressure (SBP) is the pressure measured when the heart Types of hypertension [19] 1. Primary hypertension is also known as essential or idiopathic hypertension, where the cause is unknown. About 90% of all hypertension is primary and the causes are thought to be multifactorial and related to a host of lifestyle and genetic factors. Diagnosis of hypertension [19] Symptoms: Hypertension is often known as the silent killer because there often are no reported symptoms until vital organs become damaged. Routine blood pressure monitoring during yearly physical examinations is therefore recommended. Blood pressure measurement is not very accurate or sensitive because it can be affected by a variety of factors including stress and exertion. Patients should not smoke, exercise, or consume caffeinated beverages prior to measurement. False low blood pressure readings are often the result of an arm cuff that is too wide and/or patient dehydration. False high blood pressure readings are often a result of a cuff that is too small and/or stress, caffeinated beverages, smoking, and recent exertion. Blood pressure readings taken during office visits are often higher than normal. This is known as white coat syndrome and is a result of stress associated with a doctor visit, although BP readings can be normal when at home. Variations in BP readings cause the need for different types of monitoring which include: Ambulatory monitoring where an ambulatory BP monitoring device is worn for 24 hours; and home monitoring where the patient monitors BP at home as recommended by the American Heart Association. Management of a patient with hypertension This includes pharmacological and non-pharmacological interventions. The non-pharmacological management includes lifestyle changes contracts and forces blood into the body; an elevated systolic blood pressure causes greater end organ damage and circulatory problems. Diastolic pressure (DBP) measures pressure in the arteries when the heart is at rest; an elevated diastolic pressure is a predictor of possible heart attack and stroke. A systolic blood pressure greater than 140 mmhg and/or a diastolic blood pressure greater than 90 mmhg indicates hypertension [68]. It is important to note that blood pressure fluctuates throughout the day and can be affected by exertion and stress. 2. Secondary hypertension is caused by an underlying medical condition. The most frequent causes of secondary hypertension include kidney disorders, endocrine disorders, and certain medications. Medical history: It is important to inquire regarding family and past medical history, especially as relates to hypertension, stroke, kidney disease, and diabetes as well as risk factors for hypertension which include a sedentary lifestyle, smoking, cholesterol levels, salt intake, diet, and medications. Clinical examination: In patients with hypertension, there are often very little clinical findings upon clinical exam except for elevated blood pressure. It is important to determine pulse rate and look for distended neck veins, an enlarged thyroid, and/or an enlarged heart as well as murmurs, and the abdomen and leg pulses. Tests: An electrocardiogram is routinely used in patients with hypertension. An exercise stress test is performed when a patient has symptoms of coronary artery disease. An echocardiogram may be ordered to determine if there is heart enlargement as a result of high blood pressure, incompetent valves, or heart failure. A Doppler ultrasound may be used to determine the perfusion of the kidneys and an ultrasound may be used to determine damage to the kidneys. addressing exercise, weight reduction, cessation of alcohol consumption, a low fat, low salt diet and cessation of smoking. Non-pharmacologic management of hypertension [22] Dietary Considerations: Sodium: Lowering salt intake to less than 1,500mg per day is highly beneficial to any patient with hypertension. Potassium: A diet rich in potassium (e.g. bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas, nuts, potatoes, or avocados) has been found to be beneficial in reducing hypertension provided there are no contraindications. Contraindications to increased potassium consumption include patients who have decreased kidney function, and patients who are taking medications which limit potassium excretion by the body (e.g. ACE inhibitors, digoxin, and/or potassium-sparing diuretics). Fiber: Increasing daily fiber can help to reduce hypertension. Omega-3 fatty acids: Some studies have found fatty acids helpful in keeping blood vessels more flexible. Calcium: Hypertension causes an increase in calcium loss by the body. Calcium regulates the tone of smooth muscles lining the blood vessels, and some studies have shown calcium to be beneficial in reducing hypertension. Other considerations include: Sleep: Sleep apnea, along with any other chronic sleep disorder, is associated with hypertension. Stress: Elevated stress levels are also associated with hypertension. Pharmacologic management of hypertension [22] Diuretics: As discussed, diuretics help the kidneys eliminate excess salt and water. The three main types of diuretics include the thiazide diuretics, potassium-sparing diuretics and loop diuretics. The firstline drugs of choice for managing a patient with hypertension are the thiazide diuretics. roblems associated with diuretics: Loop and thiazide diuretics can lead to low potassium levels, or hypokalemia, which can result in arrhythmias and cardiac arrest. Potassium-sparing Page 78 drugs can lead to high potassium levels, or hyperkalemia, which can result in arrhythmias and difficulty in breathing. Thiazide diuretics can lead to erectile dysfunction and potentially gout [20]. Common diuretic side effects include fatigue, depression, irritability, urinary incontinence, dizziness, hypotension, and erectile dysfunction. Beta blockers: The primary function of beta-blockers is to reduce the heart rate and to reduce blood pressure. They are usually used in

81 combination with other drugs such as ACE inhibitors and diuretics. Sudden cessation of beta-blocker therapy can cause a rebound increase in heart rate and blood pressure and can lead to angina and myocardial infarction. Problems associated with beta-blockers: Common betablocker side effects include fatigue, lethargy, vivid dreams, depression, memory loss, decreased exercise tolerance, dizziness, bradycardia and erectile dysfunction. ACE inhibitors: The primary function of ACE inhibitors is vasodilation and therefore decreasing the workload of the heart. Patients with a previous history of cardiac disease are good candidates for this class of drug. ACE inhibitors are often combined with Aspirin and can be used safely in combination. Problems associated with ACE inhibitors: Common ACE inhibitor side effects include increased potassium retention by the kidneys leading to hyperkalemia, which can result in cardiac arrest; they can also result in dry cough and angioedema. ACE inhibitors SHOULD NOT be combined with potassium-sparing diuretics. Angiotensin receptor blockers (ARB): Angiotensin receptor blockers are similar to ACE inhibitors in that they block the conversion of angiotensin I to angiotensin II and lead to enlargement of blood vessels and as a result, decrease blood pressure. They have fewer side effects than ACE inhibitors (especially coughing) and are often prescribed as an alternative therapy. Common ARB side effects include low blood pressure, dizziness, hyperkalemia, drowsiness, and nasal congestion. They are contraindicated in pregnant women. Calcium channel blockers: Calcium channel blockers prevent calcium from entering the heart and blood vessel walls, and lead to vasodilation. Calcium channel blockers also decrease heart rate, resulting in decreased blood pressure, relief of chest pain, and control of irregular heartbeat. Common calcium channel blocker side effects include peripheral edema, constipation, fatigue, gingivitis, erectile dysfunction, and potentially harmful interactions with grapefruit and oranges [21]. Alpha blockers: Alpha blockers cause vasodilation in the small blood vessels. They are generally not the first-line choice for hypertension, but are used in combination with other anti-hypertensive drugs. One of the most difficult problems when treating patients with hypertension is a lack of compliance because hypertension causes minimal symptoms, and patients are often non-compliant. Standard nursing protocol for primary hypertension in adults Primary hypertension with no underlying cause is defined as a systolic blood pressure greater or equal to 140mmHg, and a diastolic blood pressure of greater or equal to 90mmHg on at least two occasions. Secondary hypertension has an underlying cause. More can be found at: [22]. Complications of hypertension The most serious consequence of hypertension is damage to organs including the kidneys, eyes, and heart. Hypertension is the causative factor for 75% of strokes. Hypertension is the main causative agent for hypertensive heart disease. Hypertensive heart disease includes Coronary artery disease Coronary artery disease is also known as ischemic heart disease and is the result of atherosclerosis. The coronary arteries become hardened due to the calcification of the plaque in the walls of the blood vessels Heart attack A heart attack is the result of one of two disease processes: Plaque develops fissures and tears, platelets adhere to the fissure or tear, and a blood clot forms which further decreases blood flow through the Risk factors for coronary artery disease The risk factors for coronary artery disease mirror the risk factors for all cardiac diseases and include age, gender (i.e. increased risk in males), genetic factors, family history, and race and ethnicity (i.e. Medical conditions Several medical conditions are associated with increased risk of heart disease. Obesity and metabolic syndrome as well as excess body fat in the abdominal region are associated with increased risk Symptoms of coronary artery disease Common symptoms of coronary artery disease include chest pain/ angina, shortness of breath on exertion, and rapid heartbeat. In many cases, coronary artery disease is asymptomatic. Angina is the chest pain felt as a result of lack of oxygen, or myocardial ischemia, to the heart tissue. There are two types of angina: Stable angina, which is predictable; and unstable angina, which is coronary artery disease, heart failure, and cardiac arrhythmias. Organ damage includes stroke, diabetes, kidney disease, dementia, eye damage, and sexual dysfunction. leading to narrowing of the arteries and a reduced flow of blood. Atheromatous coronary arteries are more susceptible to injury, and clot formation which usually results in a heart attack. arteries; or the artery becomes blocked as a result of plaque formation leading to decreased blood flow and ischemia of the heart tissues. increased risk in African Americans). Lifestyle factors that increase risk include smoking, sedentary habits, poor diet, and obesity [23]. of cardiovascular disease as well as increased levels of low-density lipoprotein/ldl, hypertension, diabetes, peripheral artery disease, and depression. unpredictable and is often more serious. The intensity of the pain from angina has no correlation to the amount of heart tissue damage [25]. Page 79

82 Pathogenesis of coronary artery disease The underlying pathology of coronary artery disease is atherosclerosis: As the atheromatous plaque grows it causes obstruction of the lumen of the coronary artery. In some cases, an atheromatous plaque can rupture, resulting in activation of platelets and a coagulation Stable angina and chest pain The pain of stable angina is predictable, meaning it is usually triggered by certain events or activities, of which the patient is fully aware, e.g. exercise, cold weather, emotional stress, and large meals. Stable angina is usually relieved by rest and responds well to nitroglycerin. Angina Symptoms of angina Chest pain experienced from angina has classic symptoms, and is often described as a crushing pressure in the chest. It is characteristically a dull pain which radiates to the neck, the jaw, the left shoulder, and arm. It is rarely described as a sharp stabbing pain. Other symptoms which may accompany angina include shortness of breath (SOB), nausea, Unstable angina and acute coronary syndrome Unstable angina is potentially fatal and usually occurs when a coronary artery becomes blocked or occluded. Unstable angina occurs Other types of angina Prinzmetal s angina: This occurs with coronary artery spasm or vasospasm. It usually occurs at rest and often accompanied by arrhythmia. The pain is rapidly relieved by nitroglycerin. cascade, causing thrombus formation that can lead to coronary artery obstruction, or acute coronary artery disease, or myocardial infarction [63]. is not affected by breathing or change of position. The commonest time for stable angina to occur is between six AM and noon. A typical attack lasts minutes, but in the event of a much longer duration, the diagnosis of angina is usually excluded [26]. vomiting, cold sweats, indigestion, unexplained fatigue, dizziness, and palpitations. It is important to note that women usually experience atypical symptoms of angina which include abdominal discomfort, nausea, fatigue, and weakness as opposed to the typical chest pain. just prior to a heart attack or infarct; it is usually sudden and without warning. Silent ischemia: People with silent ischemia have no pain during an angina attack, but these individuals have a higher incidence of serious morbidity and mortality because of the lack of the warning signs experienced with angina. Other causes of chest pain Muscular pain, arthritis, heartburn, and asthma as well as heart-related chest pain account for less than fifty percent of chest pain. Diagnosis Tests used to diagnose the type of chest pain are dependent on the severity of the symptoms. The normal course of progression is to start with the simplest tests first [23]. Routine non-invasive tests Electrocardiogram: An electrocardiogram (ECG) is the firstline test for the diagnosis of myocardial ischemia even though 50% of patients have normal ECG findings in the presence of ischemia. An ECG is used for the diagnosis of most cases of heart disease [25]. The ECG measures the electrical activity of the heart and the various waves that are seen on the ECG correspond to the sequence of the cardiac cycle. The P wave occurs with atrial contraction, the QRS series corresponds to ventricular contraction, and the T wave occurs after ventricular contraction. The most important finding with myocardial ischemia is ST segment elevation and Q waves. These waves are indicative of coronary artery occlusion, but are not the only factors needed to make the diagnosis of myocardial ischemia. Exercise stress test: The exercise stress test is used to determine heart function during physical activity or increased workload on the heart [24]. It is used to diagnose coronary artery disease, and arrhythmias and is also used as a guide for the treatment of other heart diseases. The patient is connected to an ECG machine while exercising. The risks associated with an exercise stress test include low blood pressure, arrhythmias, and rarely, a myocardial infarction. Echocardiogram: The echocardiogram uses ultrasound to visualize the heart and is useful to determine if the heart muscle Page 80 has been damaged and the extent of the damage. Although it is much more expensive than an ECG, it is a valuable test for assessing the damage. A stress echocardiogram can also be used; this procedure is similar to an exercise stress test as it is performed on a treadmill or stationary bike and determines heart function via echocardiogram. Radionucleotide imaging: Radionucleotide procedures use imaging techniques to visualize radioactive elements in the various regions of the heart to determine damage. It is useful for diagnosing the severity of unstable angina and the severity of coronary artery disease as well as serving as an indicator to determine success rates for coronary artery surgery and diagnosing whether a myocardial infarction has occurred. Myocardial perfusion (blood flow) imaging test (thallium stress test): This test is used to determine blood flow to the heart muscle and is usually done in conjunction with an exercise stress test. It is a reliable indicator of severe heart events. Radionuclide angiography: This is a technique for visualizing the major blood vessels and chambers of the heart. Magnetic resonance angiography: This provides a threedimensional view of the major arteries supplying the heart. Computed tomography (CT scan): CT scans can be used to visualize the coronary arteries.

83 Calcium-scoring CT scan: This test is used to determine calcium deposition in the coronary arteries which normally occurs with plaque formation. A person with a low calcium score is unlikely to have coronary artery disease and vice versa. CT angiography: This test can be used to assess the coronary arteries, but it is not as reliable as angiography and therefore not a diagnostic test of choice. Invasive tests Angiography: Is used to determine the exact anatomy or location of disease in the coronary arteries by injecting radioactive dye into the coronary arteries via the arm or leg. An x-ray shows the flow of blood through the arteries. Treatment: Lifestyle changes are the first-line approach for the treatment of coronary artery disease, and are usually combined with medication [23]. There are a variety of medications used to treat coronary artery disease. These include anti-platelet and anticoagulant drugs, betablockers, ACE inhibitors, nitrates, and calcium channel blockers. Surgical intervention is indicated for people with unstable angina which does not respond to medical treatment, recurrent episodes of angina which have a duration of longer than twenty minutes, acute coronary syndrome, and severe coronary artery disease. The two main types of surgery for coronary artery disease are coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI or angioplasty). With CABG, the surgeon creates a graft using a blood vessel from another part of the patient s body to bypass coronary artery obstruction(s). CABG is an invasive procedure and is usually reserved for cases with multiple narrowed coronary arteries [25]. Angioplasty involves the placement of a catheter with a deflated balloon into the narrowest part of the coronary artery. The balloon is inflated to compress plaque deposits against the artery walls and improves blood flow [26]. The risks associated with CABG include bleeding, arrhythmias, infection of the chest wound, stroke, and myocardial infarction [27]. There are risks associated with angiography which include: Blood clots in the stent; re-obstruction of the coronary artery by plaque formation; and a small increase in the risk of myocardial infarction, stroke, and life threatening bleeding. Coronary artery surgery does not cure coronary artery disease and it is of utmost importance to adopt a healthy lifestyle by decreasing obesity, following a low-fat diet, and exercising as well as smoking and alcohol cessation [23]. Medications used to treat coronary artery disease [23,26] Anti-platelet and anticoagulant drugs: The normal blood clotting mechanism is a cascade of events triggered by injury to the blood vessels; this sets up an inflammatory response whereby chemical signals trigger the platelets to accumulate at the site of injury. Once the platelets arrive at the site of injury, they aggregate and clump at the wound and release thromboxane. Thromboxane is the enzyme necessary to facilitate clotting of the blood, and it acts to allow prothrombin to be converted into thrombin. In turn, thrombin acts to allow fibrinogen to be converted to fibrin resulting in blood clot formation. Both anti-platelet and anticoagulant drugs prevent the formation of blood clots, but they have different mechanisms of action. Antiplatelet drugs prohibit platelets from sticking together and prevent the formation of blood clots. Anticoagulant drugs are blood thinners prohibit blood from clotting and prevent blood clot formation. In patients with coronary artery disease, anti-platelet drugs are the drug of choice whereas anticoagulants are used for patients with atrial fibrillation or a heart valve prosthesis. It is important to note: A thrombus is a blood clot that forms in a blood vessel and stays in situ (in position), and an embolus is a blood clot that dislodges from its primary position and travels to another location in the body. Both thrombi and emboli can lead to occlusion and deprive the local tissues of oxygen. In the heart this is equivalent to a myocardial infarction. Aspirin: Is a non-steroidal anti-inflammatory (NSAID); it prohibits platelets from sticking together and prevents blood clot formation [28]. Aspirin inhibits the production of thromboxane in the clotting mechanism, and without the release of thromboxane, platelets will not stick together. Aspirin helps in the prevention of myocardial infarction and stroke. It is important to note that long term use of aspirin can lead to the same side effects as long-term use of any NSAID and increase the risk of bleeding from the stomach. A daily dose of 75-81mg is usually the drug of choice for preventing heart disease and stroke in patients with no prior history of heart disease or stroke. Other anti-platelet drugs: Clopidogrel (Plavix): Works to inhibit the production of thromboxane. This is the standard treatment for acute coronary syndrome and is used in patients who are allergic or cannot tolerate aspirin. Beta-blockers: Can also be used to treat coronary artery disease as they reduce the workload on the heart by slowing heart rate and decreasing blood pressure [11,12]. Beta-blockers are used in the majority of patients who have had a myocardial infarction or acute coronary syndrome, and they are also the drug of choice for older patients with stable angina and silent ischemia. A nasal form of propranolol can be used to prevent exercise-induced angina. The side effects of beta blockers have already been discussed, but it is important to note that beta blockers can reduce HDL, the cardioprotective lipoprotein, and they should not be used in patients with asthmas, emphysema, or chronic bronchitis. Patients should never suddenly discontinue beta blockers as this can lead to a rebound increase in heart rate and blood pressure. Angiotensin converting enzyme: ACE inhibitors are important cardio-protective drugs, especially in patients with hypertension, diabetes, and left-sided heart failure [11,23]. The mechanism of action and side effects have been discussed earlier, but it is important to note that the commonest side effect of ACE inhibitors is an irritating cough. Other important side effects include hyperkalemia, allergic reactions, excessive decrease in blood pressure, and angioedema. Nitrates: Nitrates release nitric acid which relaxes the smooth muscle of the vascular walls, leading to vasodilation and reducing oxygen demand of the heart by improving blood flow [23]. Nitrates can be absorbed by the gastrointestinal tract, or the skin as well as sublingually and bucally, e.g. pocketed between the upper lip and the gums. Rapid acting nitrates: These are used for the treatment of acute episodes of angina. The recommended treatment protocol for rapidly acting nitrates is: At the onset of an attack the patient takes one tablet; if the pain is not relieved after five minutes, a patient can take another every five minutes; if after three doses the pain does not subside, the patient should go to the emergency room as soon as possible. Nitroglycerin is an unstable compound and certain precautions should be taken when storing this drug including: Not keeping more than 100 tablets in the original container; discarding the cotton filler; and keeping the container in a cool dark place and closed. Intermediate and long acting: These have a slower onset of action and are often used to prevent exercise-induced angina. Long-acting nitrates often lose their effectiveness over time, and as a result, patients are prescribed nitrate breaks to prevent tolerance. Side effects of nitrates: Common side effects include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, Page 81

84 sweating, and flushing of the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. Side effects are made worse by alcohol, beta-blockers, calcium channel blockers, and antidepressants. Patients taking nitrates cannot take medication for erectile dysfunction as these drugs, when combined, cause a decrease in systemic blood pressure and coronary blood flow, which can be fatal. Other serious side effects include fever, joint or chest pain, sore throat, skin rash, abnormal bleeding or bruising, weight gain, and swelling of the ankles. Withdrawal from nitrates should be done slowly to prevent rebound angina. Peripheral artery disease Peripheral artery disease is similar to coronary artery disease and is caused by the narrowing of the peripheral arteries supplying oxygen to the legs, stomach, arms, and head; it most commonly affects the legs. Both coronary and peripheral artery disease are caused by the buildup Symptoms of peripheral artery disease Many people with peripheral artery disease do not have any symptoms, but some patients experience claudication. Claudication ranges from mild discomfort to debilitating pain, and is characterized by cramping in the muscles of the hip, thigh, and calf. It is often aggravated by climbing stairs. It can even occur during rest, causing sleep disturbances. Claudication can be relieved temporarily by hanging Etiology of peripheral artery disease The commonest cause of peripheral artery disease is plaque formation or atherosclerosis of the peripheral arteries, but it can also be a result of injury, blood vessel inflammation, anatomical deviation, and Complications of peripheral artery disease [30] Critical limb ischemia: Decreased blood supply to the extremities, combined with injury and infection can result in death of the surrounding tissue and/or gangrene, leading to amputation. Diagnosis of peripheral artery disease [30] Signs of peripheral artery disease: An absent or weak pulse may be found on clinical examination, evidence of poor wound healing, decreased blood pressure in the affected limb and bruits may be heard on auscultation. Tests used for the diagnosis of peripheral artery disease: Ankle brachial index: This compares blood pressure readings of the upper and lower extremities. Treatment of peripheral artery disease There are two main goals for the treatment of peripheral artery disease: (1) to manage symptoms to allow for physical activity; and (2) to stop the progression of atherosclerosis and reduce the incidence of myocardial infarction, gangrene, and stroke [30]. The non-medical treatment of peripheral artery disease incorporates lifestyle changes discussed earlier, and cholesterol lowering medications to reduce plaque formation. Cholesterol-lowering medication/statins: Statins work to reduce the amount of cholesterol synthesized by the body by blocking an enzyme called HMG CoA reductase. Due to this cholesterol cannot be synthesized [31]. Statins are known as HMG CoA reductase inhibitors and may also help with cholesterol reabsorption from plaque buildup Calcium channel blockers: Calcium channel blockers work to reduce the heart rate, dilate coronary blood vessels, and improve the oxygen supply and decrease the oxygen demands of the heart [21,23]. They also decrease blood pressure. Calcium channel blockers have varied efficacy and are often used in patients who cannot tolerate beta blockers. However, there is no strong evidence that the use of calcium channel blockers improves survival rates. Long-acting calcium channel blockers may be beneficial to patients with angina. Best results are obtained when combining calcium channel blockers with other drugs for the treatment of angina. Short acting calcium channel blockers are contraindicated for the treatment of stable or unstable angina and can have serious side effects, including sudden cardiac death. of fatty deposits on the wall of the arteries, leading to artery narrowing and decreased oxygen supply [29]. With peripheral artery disease, the extremities do not have adequate blood flow and oxygen supply, causing pain on walking, i.e. claudication [30]. the leg off the side of the bed, or gentle walking. Other symptoms of peripheral artery disease include: Leg numbness and/or weakness; lesions of the foot, heel, and toes which do not heal; coldness of the lower legs; a change in color or loss of hair; slower growth of toenails; shiny skin; an absent pulse; and erectile dysfunction. radiation exposure. The risk factors for peripheral artery disease are the same as that of coronary artery disease. Stroke and myocardial infarction: Atherosclerosis from peripheral artery disease usually occurs in other blood vessels, especially the heart and the brain, and can lead to myocardial infarction and stroke. Ultrasound: Doppler ultrasound can identify blocked or narrow blood vessels and can be used to evaluate the severity of the condition. Angiography: This allows for visualization of blood flow through the narrowed blood vessels using x-ray imaging or computerized tomography angiography (CTA). Catheter angiography is a far more invasive procedure, but allows for simultaneous dilation of the narrowed artery. Blood tests: Cholesterol, triglycerides, CMP and blood sugar levels need to be investigated. within arteries [32]. One of the biggest problems with statins is their discontinuation because of intolerable side effects. Side effects: [33] Muscle pain can vary from mild to severe, and in rare cases result in rhabdomyolysis, life-threatening muscle damage. Statins can lead to inflammation of the liver so monitoring of liver function is important. They can cause an elevation in serum glucose levels and can cause or worsen Type-II diabetes. Statins have been associated with memory loss and confusion. The risk of developing side effects from statins is increased by taking multiple medications for the treatment of elevated cholesterol. Other risk factors include smaller body frame, age over 65 years of age, kidney or liver disease, and excessive alcohol consumption. Page 82

85 Certain foods and drugs interact with statin metabolism. Grapefruit interferes with the breakdown of statins in the gastrointestinal tract. Certain drugs may interact with statins leading to an increased incidence of side effects, e.g. amiodorone which is used for the treatment of arrhythmias, other cholesterol-lowering drugs, protease inhibitors, antifungals and immunosuppressants. Other medications include hypertension medication, blood sugar medication, and antiplatelet medication. Medication to reduce the symptoms of peripheral artery disease: Cilostazol has a dual function of increasing blood flow to the limbs by vasodilation and it also acts as a blood thinner. It is used primarily to Deep venous thrombosis (DVT) In DVT, a blood clot forms in a vein deep within the body [34]. It primarily affects large veins of the leg and thigh, but can even occur in the veins of the arms. Deep venous thrombosis is most common after the age of 60, but it can occur at any age. There are several factors which increase the risk of a DVT, including: Bed rest or sitting in one position for a long period of time, e.g. a long trip on a plane; family history of blood clots; fractures of the pelvis or legs; postpartum or Pathophysiology of deep venous thrombosis In the lower extremities, DVT is the result of impaired venous return. This occurs in cases of immobilization, and in patients that are post-surgery, obese, or have taken long trips [64]. Other decrease the symptoms of claudication. The commonest side effects include headache and episodes of diarrhea. Angioplasty and surgery: The treatment of peripheral artery disease is similar to treatments used for coronary artery disease. Angioplasty stretches the artery open to reduce obstruction to blood flow, and a stent may be left in place. Bypass surgery allows blood to be diverted around the obstruction. Thrombolytic therapy: A thrombolytic/clot-dissolving agent can be injected into the affected artery in an attempt to dissolve a blood clot. A supervised exercise program improves the symptoms of peripheral artery disease. pregnancy; obesity; recent surgery causing immobility; an increased production of red blood cells by the bone marrow, i.e. polycythemia; a longterm blood vessel catheter; and/or post procedure pacemaker catheter. There are also several conditions which increase the risk of DVT including cancer, certain autoimmune disorders, smoking, and oral contraceptives. causes include endothelial injury following trauma or fractures and hypercoagulability. Clinical signs and symptoms of deep venous thrombosis A blood clot can cause changes in skin color, and skin that is warm to the touch as well as leg swelling and pain. A warm, red, swollen leg which is tender to the touch is the classic sign of a DVT. Tests to diagnose a DVT: [35] Doppler ultrasound: Is used to determine the presence/absence of a blood clot. Treatment of deep venous thrombosis The treatment of DVT involves the use of anticoagulants. Heparin is usually the drug of choice. Heparin prevents the formation of new blood clots and prevents old clots from enlarging. A blood thinning drug, e.g. Warfarin, is usually started at the same time as Heparin, and D-dimer blood test: Is a blood test used to measure a substance that is released when a blood clot breaks up. Blood tests: Several blood tests are required to determine the presence of increased blood clotting, including active protein-c and-s, anti-thrombin levels, antiphospholipid antibodies, complete blood count, and lupus anticoagulant. when warfarin levels are at the correct level, Heparin is discontinued. Warfarin causes increased bleeding even when levels are adjusted correctly. Pressure stockings are also prescribed to improve blood flow and reduce the incidence of complications. Long-term complications of DVT Pain and skin color changes are common side effects of DVT. Some patients will have long-term pain and swelling and this is known as post-phlebitic syndrome. Blood clots from the legs can travel to the Overview of anticoagulants Anticoagulants are reserved for the treatment of life-threatening diseases, these include myocardial infarction, pulmonary embolism, disseminated intravascular coagulation/dic, and deep vein thrombosis [35]. The therapeutic window for clot dissolution is approximately six hours. Anticoagulants consist of a variety of different drugs which fall into different classes and have different mechanisms of action, routes of administration and side effects: Fibrinolytic agents, e.g. Streptokinase, degrade fibrinogen and their primary action is to eliminate formed blood clots. Anticoagulants, e.g. heparin and warfarin, inhibit the clotting cascade and prevent the formation of a thrombus. It is important to note that Warfarin has a narrow therapeutic index: It is 99% bound lungs (i.e. pulmonary embolus) and even the brain (i.e. cerebrovascular accident). to plasma albumin; it is eliminated by the liver (via cytochrome P450); and it is the prototype of drug-drug interactions. Warfarin is completely contraindicated in pregnancy. Certain drugs always interact with Warfarin, aspirin, cimetidine and phenytoin. Alcohol interferes with the metabolism of Warfarin by interacting with cytochrome P450. The anti-platelet drugs, e.g. Acetylsalicylic acid, interfere with platelet adhesion or aggregation and they are used for the prevention of initial blood clot formation. Page 83

86 Cerebrovascular accident (stroke or CVA) A cerebrovascular accident occurs when areas of the brain are deprived of blood and oxygen, leading to cell death [36]. Types of cerebrovascular accident: Ischemic: An ischemic stroke occurs when there is obstruction to brain blood flow. The majority of strokes are ischemic. A thrombotic stroke occurs when plaque builds up in the artery wall, leading to obstruction of blood flow, or when a blood clot (i.e. embolus) dislodges from an artery wall in the periphery of the body and is swept towards the brain where it becomes lodged in a narrower brain artery. An ischemic stroke from an embolus is a complication of deep venous thrombosis. A transient ischemic attack (TIA) is also the result of an embolism but in these cases, the symptoms are transient and usually disappear within twentyfour hours. TIAs are often precursors for a larger stroke. Hemorrhagic: A hemorrhagic stroke occurs when a blood vessel supplying the brain bursts or leaks. Hemorrhagic strokes can occur with uncontrolled hypertension or from overtreatment with Complications of stroke A stroke can lead to temporary or permanent disability and the complications are related to the length of time the affected area is deprived of oxygen [36]. The complications include paralysis, difficulty talking/swallowing, memory loss, aptitude, loss of vision, and emotional problems. Pain from paralysis, decreased mobility and Pulmonary embolus The most common cause of a pulmonary embolus is a blood clot that dislodges from a DVT of the legs or pelvis [37]. The blood clot breaks off from the DVT and travels (i.e. embolus) to the lungs where it becomes trapped in the blood vessels of the pulmonary system. Less frequent causes of a pulmonary emboli are the same as causes for Pathogenesis of a pulmonary embolus [65] As a consequence of DVT, a clot can break free and travel in the venous system to the right side of the heart and then lodge in the lungs, causing a partial or complete obstruction of a pulmonary artery. The consequences of a pulmonary embolus depend on the size of the Symptoms of pulmonary embolus The predominant symptom of pulmonary embolism is chest pain that occurs under the sternum or on one side of the chest. The pain characteristics vary from sharp or stabbing pain to burning or aching heavy pain. Pain from a pulmonary embolus is usually made worse by deep breathing and a patient may bend over or hold their chest in anticoagulants. Congenital abnormalities such as arteriovenous malformations (i.e. an abnormal tangle of thin-walled blood vessels) can rupture without warning. Types of hemorrhagic stroke include intracerebral hemorrhage, where blood leaks out of the blood vessel into the surrounding brain tissue. Brain cells around the leak are deprived of oxygen, leading to cell death. The most common causes of intracerebral hemorrhage are high blood pressure, trauma to the head, vascular abnormalities, and overtreatment with blood thinners. A subarachnoid hemorrhage occurs when an artery close to the surface of the brain bursts and leaks into the space between the skull and the surface of the brain. This is signaled by a sudden incapacitating headache. A subarachnoid hemorrhage is caused by the rupture of an aneurysm; an aneurysm is a small pouch on the surface of a blood vessel. After this kind of rupture, blood vessels supplying the brain erratically vasodilate and vasoconstrict, leading to further damage. Risk factors for a CVA are the same as those for coronary artery disease. muscular contraction is an ongoing complication following a stroke and central pain syndrome where a person may be super-sensitive to temperature and touch is known as central pain syndrome. Central pain syndrome is difficult to manage because the origin of the pain is from within the brain. DVTs and include air bubbles, fat droplets, amniotic fluid, parasites, and tumor cells. Certain disorders lead to an increased incidence of a pulmonary embolus, including diseases of the immune system, cancers, and inherited disorders affecting blood clotting. embolus as well as the functioning of the lungs and the right ventricle. A small embolus may have no consequences while a large embolus may cause mortality. A saddle embolus occurs at the bifurcation of the right and left pulmonary arteries; saddle emboli are usually fatal. response to pain. Other symptoms include bluish discoloration of the skin, dizziness, fast heart rate, wheezing, anxiety, leg pain, and low blood pressure as well as episodes of coughing and blood-stained mucus, sudden shortness of breath, and clammy skin. Signs of pulmonary embolus Clinical signs of a pulmonary embolus include a distressed patient with evidence of cyanosis (i.e. bluish clammy skin), rapid respiration or wheezing, tachycardia (i.e. rapid heart rate), and hypotension. Tests used for the diagnosis of a pulmonary embolus Arterial blood gasses measure oxygen, carbon dioxide, and acidity levels of the blood to determine how well the lungs are functioning. Pulse oximetry can also be used to measure oxygen levels, but it is not as accurate as an arterial blood gas measurement. Blood tests are usually done to determine the possibility of conditions causing an increased incidence of blood clots. Imaging tests are used to determine the location of a blood clot. These include chest x-ray, chest CT angiogram, a ventilation-perfusion scan (VQ scan), and a pulmonary angiogram. Other tests include a chest CT scan, d-dimer blood test, Doppler ultrasound of the legs, and echocardiogram. Treatment of pulmonary embolus A pulmonary embolism is a life-threatening condition. Treatment involves the use of anticoagulants to thin the blood, and thrombolytics Page 84 to dissolve blood clot(s). The prognosis of pulmonary embolus is dependent on the underlying cause.

87 Inflammation of the heart or carditis Inflammatory diseases of the heart are named according to the layer of the heart affected. Inflammation of the endocardium is known as endocarditis. Inflammation of the myocardium is known as myocarditis, and inflammation of the pericardium is known as Rheumatic fever [38] Rheumatic fever is an inflammatory heart disease that is a complication of inadequately treated strep throat or scarlet fever, caused by type-a beta-hemolytic streptococcus spp. bacteria. The disease involves inflammation of all the layers of the heart (i.e. pancarditis) during the acute phase. The chronic form of the disease Risk factors for rheumatic fever [39] Rick factors for rheumatic fever include a family history of the condition, immunodeficiency, infection with Type A streptococcus Pathogenesis of rheumatic fever [40,41] Group A beta-hemolytic Streptococcus spp. bacteria cause an antibody-mediated Type-II hypersensitivity reaction. In this autoimmune event, the immune attacks the tissues of the heart, skin, and the central nervous system, causing inflammation. As the disease becomes chronic, fibrous scarring replaces the inflammation and causes damage to the valves of the heart. The mitral valve is most Clinical manifestations of rheumatic fever [41] The clinical manifestations of rheumatic fever affect several systems in the body. In the joints there is synovial inflammation but no chronic or residual scarring occurs. Upon biopsy, Aschoff bodies are found; these are granulomas which consist of leukocytes, monocytes, and interstitial collagen. In the skin, subcutaneous nodules (i.e. small lumps) under the surface of the skin occur and these are also characterized by aschoff bodies during biopsy. The skin manifestations include areas of erythema marginatum on the trunk and limbs [69]. The pericarditis. Inflammation of all the layers of the heart is known as pancarditis, and this occurs with rheumatic fever and rheumatic heart disease. is known as rheumatic heart disease. The disease occurs most frequently in children from five to fifteen years of age. The incidence of rheumatic fever in the United States (U.S.) is decreasing due to the use of antibiotics. bacteria, and environmental factors including overcrowded living conditions, poor sanitation, and malnutrition. commonly affected. The valve leaflets become scarred and shortened, leading to either stenosis of the mitral valve or incompetence of the mitral valve. Stenosis is when the valve leaflets become rigid and deformed and often fused together, obstructing blood flow. Incompetence or regurgitation occurs when the valve fails to close, allowing for backward flow of blood. CNS manifestations of rheumatic fever include sydenham chorea; this is characterized by personality changes, muscle weakness, and involuntary movements of the body. Erythema marginatum and sydenham chorea are characteristic signs of acute rheumatic fever [69]. The cardiac manifestations of acute Rheumatic Fever include mitral regurgitation, pericarditis, and potentially, aortic regurgitation. In chronic rheumatic heart disease, there is evidence of mitral stenosis and aortic regurgitation. The clinical symptoms and signs of rheumatic fever [41] The symptoms of rheumatic fever typically occur two to three weeks after an untreated streptococcal infection: Joints: Patients often complain of painful and tender joints, and the pain characteristically migrates from joint to joint and is known as a migratory polyarthritis. This is usually accompanied with fever. The smaller joints are frequently involved, but the pain can affect the ankles, knees, hands, and feet. The skin: Subcutaneous nodules occur on the extensor surface of the large joints; this usually occurs in combination with arthritis and carditis. Erythema marginatum: A flat or slightly raised painless rash that usually occurs on the trunk and extremities but not on the face. The edges of these macules and/or papules are raised and the centers are clear. Sydenham chorea: Consists of rapid irregular jerking movements which can be precipitated by laughing or crying. This usually begins in the hands and becomes generalized to include the feet and face. The heart: Patients complain of high fever, chest pain and rapid heart rate/tachycardia. The clinical findings include a pericardial rub, cardiac enlargement and heart failure. Although all the layers of the heart are involved the most common clinical finding is inflammation of the valves of the heart; this is diagnosed by auscultation and the finding of murmurs especially of the mitral and aortic valves. The clinical manifestations of heart failure may also occur. Diagnosis of rheumatic fever The diagnosis of rheumatic fever is based on modified Jones Criteria and requires either two major manifestations, or two minor and one major manifestations as well as the evidence of Type-A streptococcal infection (GAS). Diagnostic tests include: Testing for evidence of a GAS infection; ECG; echocardiography; ESR; and C-reactive protein. Jones criteria major findings [41] : Carditis. Chorea. Erythema marginatum. Polyarthritis. Subcutaneous nodules. Jones criteria minor findings: Polyarthralgia. Elevated ESR. Fever. Prolonged PR interval on ECG. The protocol for treating acute rheumatic fever includes antibiotics, aspirin and corticosteroids. Page 85

88 Endocarditis Endocarditis is the inflammation of the inner lining of the heart and the heart valves [42]. Endocarditis rarely occurs when the heart is healthy: Inflammation occurs when bacteria or fungi enter the bloodstream and Infective endocarditis [42] Two predisposing factors are necessary for infective endocarditis: An abnormality of the endocardium; and bacteria or fungi in the bloodstream. Risk factors include: Congenital abnormalities of the heart; rheumatic valvular disease; bicuspid aortic valves; cardiomyopathy; prior endocarditis; and artificial heart valves. Microorganisms which infect the heart usually originate from distant sites of infection such as gum disease or tooth decay, urinary tract infections, central venous lines, medical and surgical procedures, dental procedures, and intravenous drug usage. The most common organisms involved are streptococci bacteria, staphylococci bacteria, and various fungal infections. Pathophysiology: The first step in the pathogenesis of endocarditis is damage or injury to the heart valves. This damage leads to local deposition of platelets and fibrin [42]. These sterile vegetations become infected by bacteria when pathogens enter the blood-stream. The organisms and vegetations become covered by a thin layer of fibrin and platelets (i.e. biofilm) which prevents an adequate immune response. Local consequences of infective endocarditis: The consequences can be the formation of myocardial abscesses and the destruction attach to abnormal heart valves or damaged heart tissue. There are two types of endocarditis: Infective and non-infective. of cardiac tissue, leading to conduction abnormalities and valvular incompetence. These can in turn lead to heart failure and death. Systemic consequences of infective endocarditis: The most serious systemic complication is the embolization of infected material to distant sites. On the right side of the heart, this results in pulmonary emboli leading to pulmonary infarction. On the left side of the heart, this results in systemic emboli to the spleen, kidney, and central nervous system. Retinal emboli are also common. Endocarditis is classified according to its onset: Acute bacterial endocarditis: Starts suddenly and progresses rapidly, and the source of infection is usually apparent. It can affect normal heart valves, although it is rare and occurs in only ten percent of cases. Subacute bacterial endocarditis: Develops and progresses slowly; often the source of infection entry is not apparent. This is the most common form of endocarditis and it accounts for 90% of cases. Prosthetic valvular endocarditis: Develops in a small percentage of patients following valve replacement. Symptoms and clinical signs of infective endocarditis The biggest variant in the different types of infective endocarditis is their onset. Initially, symptoms are non-specific such as a low-grade fever, night sweats, malaise, and weight loss with or without arthralgia and chills. The initial signs of endocarditis include fever, valvular incompetence or regurgitation, heart murmurs, and tachycardia. Retinal emboli can be seen upon funduscopy and are characterized by Roth spots which have small white centers. Skin manifestations include petechiae of the trunk, mucous membranes, and extremities. Diagnosis, prognosis, and treatment of endocarditis The symptoms and signs of endocarditis are non-specific so a variety of tests need to be performed to confirm the diagnosis. Blood cultures are used to confirm the presence of infection and these are done in combination with a complete blood count to confirm elevated white blood cells (i.e. infection) and anemia. A chest x-ray is done to determine evidence of cardiac enlargement and an ECG can detect irregular heart beat and tachycardia. An echocardiogram Painful subcutaneous nodules at the tips of the fingers and toes are called Osler nodes, and non-tender macules on the palms of the hands and soles of the feet are called Janeway lesions and splinter hemorrhages when under the nails. Transient ischemic attacks of the CNS can occur. Emboli traveling to the kidneys can lead to flank pain and emboli to the spleen can result in upper quadrant pain. Long-term consequences of endocarditis include clubbing of the fingers and/or toes and splenomegaly. is used to detect vegetation on the heart valves. All these diagnostic tests, combined with the clinical findings are needed to confirm the diagnosis of endocarditis [42]. Prognosis of infective endocarditis is usually poor even with correct diagnosis and treatment. Treatment involves prolonged (e.g. two to eight weeks) intravenous antibiotics specific to the organism involved. Valve debridement, repair and/or replacement may also be necessary. Myocarditis Inflammation of the middle layer of the heart, i.e., the cardiac muscle, is known as myocarditis [43]. It can affect the heart muscle cells and the conduction system of the heart, causing heart failure and arrhythmias. The causes of myocarditis [43] The most common viral cause is infection with coxsackie B virus. Other viral causes include infection with parvovirus B19, epstein-barr virus, echoviruses and rubella virus. The human immunodeficiency virus (HIV) commonly causes myocarditis in patients who have progressed to utoimmune deficiency syndrome (AIDS). The most The causes of myocarditis are viral, bacterial and/or parasitic infection of the myocardium. common bacterial causes are staphylococcus spp. and streptococcus spp. infections. Parasitic causes include trypanosoma cruzi, and toxoplasma gondii and fungal causes include infection with candida and histoplasma spp. Page 86

89 The pathophysiology of myocarditis Myocarditis is caused by an autoimmune inflammatory response to a viral or bacterial infection [44]. During this inflammatory response, T-cells and cytokines target the myocardium; this can result in myocyte Symptoms and clinical signs of myocarditis Many cases of myocarditis are initially asymptotic, or there is evidence of a mild viral infection, e.g. a headache, general body pain, joint pain, fever, and sore throat [43]. Shortness of breast is usually the first symptom associated with myocarditis followed by chest pain, irregular Tests used for the diagnosis of myocarditis [43] Blood tests: A complete blood count may show evidence of eosinophilia (rare) as well as an elevated erythrocyte sedimentation rate and elevated cardiac enzymes. In cases of viral infection, viral antibody titers will be detectable and/or elevated. ECG: An electrocardiogram may show tachycardia, ST segment elevation, and T wave changes, but these are generally nonspecific. Treatment and complications of myocarditis [44] Antibiotics, antimicrobials and antiviral medications are prescribed according to the type of infection diagnosed. Immunoglobulins and steroids are used to treat inflammation. Health care professionals Pericarditis The outermost layer of the heart is known as the pericardium, and consists of two layers. The outer layer is fibrous and the inner layer is serous and the space between these two layers is the pericardial cavity which normally contains less than 50mL of pericardial fluid. The Types of pericarditis Acute pericarditis can be fibrinous or effusive and the types of effusions are either serous, purulent, or hemorrhagic. Chronic Causes of pericarditis [46] The most common causes of pericarditis include: Infection (e.g. bacterial, viral, or fungal); cancer; high dose radiation exposure to the chest; autoimmune disease (e.g. systemic lupus erythematosus, Pathogenesis of pericarditis The pericardium is attacked by an infectious or unknown agent causing an inflammatory response and the release of the chemical mediators of inflammation. As the inflammation progresses, it leads vasodilation, hyperemia, edema, and the formation of an exudate. Symptoms and clinical signs of pericarditis Acute pericarditis is characterized by a sharp stabbing pain over the sternum with radiation to the neck, arms and back. It is different from the pain of myocardial ischemia in that it is sharp and stabbing, and made worse with deep inspiration. This is characteristic of pleuritic pain. Other symptoms include heart palpitations, fever, generalized malaise, cough, and peripheral edema [46]. The classic sign of pericarditis is a pericardial friction rub, which is audible upon auscultation of the heart. Pericardial friction rub is caused by the layers of the pericardium rubbing together. Other signs of pericarditis resemble those of heart failure. death and damage to the myocardium. Undiagnosed myocarditis can lead to heart failure and death. heart-beat, and swelling of the ankles and feet. Clinical signs of acute heart failure due to myocarditis include tachycardia and valvular regurgitation or heart murmurs [45]. Echocardiogram: This is used to exclude other causes of heart failure and to evaluate cardiac function. Scintigraphy: This is used to diagnose inflammation of the myocardium. It is very accurate. Endomyocardial biopsy (EMB): Biopsy of the myocardium is the gold standard for the diagnosis of myocarditis. also provide supportive treatment for heart failure and arrhythmias. Myocarditis can result in permanent damage to heart muscle and result in heart failure, stroke, arrhythmias, and sudden death. pericardium supports and protects the heart. In pericarditis, there is inflammation of the pericardium, usually accompanied by an effusion in the pericardial cavity [46]. pericarditis is also known as constrictive pericarditis and is characterized by a thick fibrous pericardium. rheumatoid arthritis, or rheumatic fever); certain drugs; myocardial infarction; and trauma to the chest (e.g. surgery). The causes of pericarditis are often unknown, i.e. idiopathic, or viral. Finally, the inflammation resolves but can be replaced by fibrous tissue and scarring. The most common complication of acute pericarditis is pericardial effusion. Tests used for the diagnosis of pericarditis [46] ECG: The ECG may show elevated ST segments and diminished QRS segments corresponding to pericardial effusion. Chest x-ray: Enlargement of the heart is seen on CXR. Echocardiogram: An echocardiogram can be used to visualize fluid in the pericardial cavity and can be used to diagnose an enlarged heart. CT scan: A CT scan is able to provide more detailed imaging of the heart and also used to exclude other abnormalities. Cardiac MRI: This can be used to diagnose thickening and inflammation of the pericardium. Page 87

90 Complications of pericarditis [46] The complications of pericarditis are life-threatening, and early diagnosis is key to preventing complications. Constrictive pericarditis occurs with chronic scarring of the pericardium. The accumulation Treatment of acute pericarditis [46] Bedrest for the duration of the fever, and medication to decrease inflammation of the pericardium are common treatments for pericarditis. Anti-inflammatories are used to treat mild pericarditis. Colchicine can be used to reduce inflammation; this also reduces the risk of recurrence, but is not safe for use in those with kidney disease Clinical manifestations of cardiac tamponade Beck s Triad consists of low blood pressure with narrowing pulse pressure, an increase in central venous pressure with distention of the neck veins, and muffled heart sounds. Other signs and symptoms include: Difficulty with breathing when supine, i.e. orthopnea; sweating, i.e. diaphoresis; anxiety; cyanosis; a rapid, weak peripheral of fluid in the pericardial cavity, i.e. pericardial effusion, leads to constriction of the heart and inadequate filling, causing a sudden drop in blood pressure, i.e. cardiac tamponade. or those taking certain medications. Corticosteroids are reserved for more severe cases of pericarditis. Treatment of cardiac tamponade is an emergency pericardiocentesis where the fluid is drained from the pericardial cavity and antibiotics are injected locally into the pericardial cavity. pulse rate; and a pulses paradox, i.e. blood pressure decreases with inspiration. The tests used to diagnose cardiac tamponade are the same as those used for the diagnosis of pericarditis. Characteristically there are ST elevation on ECG with no Q waves. Disorders of Cardiac Structure Valvular heart diseases [47] The flow of blood through the heart is regulated by four heart valves. On the right side of the heart are the tricuspid valve and pulmonary valve, and on the left side of the heart are the mitral and aortic valves. When these valves do not open correctly, it is known as stenosis and when these valves do not close correctly, it is known as regurgitation Table 1. Descriptions of valvular heart diseases [47]. or incompetence. Occasionally a valve can have both stenosis and regurgitation. Valves can be replaced by either mechanical valves or bio-prosthetic valves harvested from a pig or a cow. Mechanical valves require the use of anticoagulants. Mitral regurgitation. Etiology Symptoms Diagnosis Complications Treatment Mitral valve prolapse; rheumatic Asymptomatic. Physical exam; murmur at apex; Heart failure; arrhythmias; Mitral valve replacement. fever; LV dilation. echocardiogram. endocarditis. Mitral stenosis. Rheumatic fever. Heart failure. Physical exam; murmur at apex; echocardiogram. Tricuspid regurgitation. Dilation of the RV. Often asymptomatic. Physical exam; echocardiogram; holosystolic murmur. Tricuspid stenosis. Rheumatic fever. Neck fluttering; fatigue; cold skin. Physical exam; echocardiogram; presystolic murmur. Pulmonary regurgitation. Pulmonary hypertension. Asymptomatic. Physical exam; echocardiogram; decrescendo diastolic murmur. Pulmonary hypertension; atrial fibrillation; thromboembolism. Rare. Rare. Right-sided heart failure. Diuretics; aldosterone agonists; rarely requires valve replacement. Rarely requires valve replacement. Diuretics; aldosterone agonists; rarely requires valve replacement. Aortic valve replacement. Pulmonary stenosis. Congenital. Asymptomatic until adult-hood. Crescendo-decrescendo murmur. Rare. Balloon valvuloplasty. Aortic regurgitation. Valvular degeneration; rheumatic fever; endocarditis; marfan syndrome. Dyspnea; orthopnea; paroxysmal nocturnal dyspnea; palpitations; chest pain. Physical exam; echocardiogram; widened pulse pressure; early diastolic murmur. Left ventricular hypertrophy; Left-sided cardiac failure. Aortic valve replacement. Aortic stenosis. Congenital; rheumatic fever. Syncope; angina; exertion dyspnea. Physical exam; echocardiogram; crescendo decrescendo murmur. Cardiac failure; arrhythmias. Balloon valvuloplasty; aortic valve replacement. Cardiomyopathy [48] Cardiomyopathy is a disorder of the heart muscle. There are three types of cardiomyopathy, dilated, hypertrophic, and restricted and these are based on pathology. The clinical symptoms and signs of Dilated cardiomyopathy [49] This is also known as congestive cardiomyopathy and is caused by severe damage to the myocardial muscle cells of the ventricles. The ventricles enlarge or dilate and weaken (over time this includes the cardiomyopathy are the same as those found with heart failure, but they can present with chest pain, syncope, and sudden death. atria), and are unable to pump sufficient blood, leading to heart failure. Dilated cardiomyopathy usually affects both ventricles. Dilated cardiomyopathy etiology and pathophysiology The most common causes include coronary artery disease, viral infections, and hormonal disorders. Regardless of the cause, the myocardium dilates and hypertrophies in compensation for the loss of function. Mural thrombi commonly form in the walls of the ventricles; this is further complicated by arrhythmias. Page 88

91 Dilated cardiomyopathy symptoms Symptoms depend on the side of the heart most affected and often present with atypical chest pain. Dilated cardiomyopathy tests A chest x-ray shows cardiomegaly and the ECG may show sinus tachycardia and ST-segment depression. An echocardiogram shows evidence of cardiac dilation and a cardiac MRI shows evidence of abnormal cardiac tissue. Dilated cardiomyopathy prognosis and treatment The prognosis for DCM is poor a 20% death rate in the first year of diagnosis. Treat the underlying causes, treat heart failure and use anticoagulants if necessary. Hypertrophic cardiomyopathy [50] The features of hypertrophic cardiomyopathy include ventricular hypertrophy with diastolic dysfunction. Hypertrophic cardiomyopathy etiology and pathophysiology The most common causes of hypertrophic cardiomyopathy are congenital abnormalities. The most marked characteristic is hypertrophy of the upper ventricular septum; this results in a stiff Hypertrophic cardiomyopathy symptoms The usual age of presentation is during infancy and adolescence, and the classic symptoms include chest pain, shortness of breath (i.e. dyspnea), palpitations, syncope, and even sudden death. Hypertrophic cardiomyopathy diagnostic tests and treatment Cardiac MRI is the diagnostic test of choice as it is able to detect damaged myocardium. The aim of treatment is to decrease cardiac contractility and allow for increased filling of the ventricles. Diuretics, Restrictive cardiomyopathy [51] Restrictive cardiomyopathy is characterized by stiff and/or noncompliant ventricular walls, causing a decrease in ventricular filling, especially on the left. The cause is usually unknown. ventricle with decreased filling, causing an increase in pulmonary venous pressure. Cardiac output decreases over time. ACE-inhibitors, and Angiotensin II blockers should be completely avoided because they decrease left ventricular size and function. Restrictive cardiomyopathy pathophysiology There is decreased ventricular filling from a thick or hypertrophied ventricle. Endocardial thickening can also occur, leading to mitral and aortic valve regurgitation. Mural thrombi can form as well, causing systemic emboli. Restrictive cardiomyopathy symptoms The most common presenting symptom is exertion fatigue. Restrictive cardiomyopathy diagnostic tests and treatment Diagnosis is made by an echocardiogram. Without identifying the cause, treatment is often unsuccessful, but diuretics can be used, with caution, to avoid lowering preload. Arrhythmias [52] The term arrhythmia refers to any change in the normal electrical activity of the heart. Any abnormal electrical activity directly affects Types of arrhythmias Atrial fibrillation: The atria contract irregularly. Bradycardia: Heart rate is <60 beats/min. Tachycardia: Heart rate is >100 beats/min. cardiac function by causing a decrease in the blood pumped to the rest of the body. This can cause organ damage due to under-perfusion. Ventricular fibrillation: The ventricles contract irregularly. Premature contraction: The heart contracts early. Page 89

92 Etiology of arrhythmias [52] Any heart disorder, e.g. congenital or acquired, can affect rhythm. Systemic conditions that affect rhythm include: Electrolyte abnormalities (e.g. low potassium, low magnesium); hypoxia; Pathophysiology of arrhythmias [54] Normally, electrical conduction begins at the sinoatrial node (the heart s natural pacemaker ). In certain conditions the sinoatrial node develops an abnormal rhythm or other cells in the myocardium begin hormonal disturbances (e.g. thyroid); and drugs or substances including alcohol and caffeine [53]. their own electrical activity, so that another portion of the heart acts as a pacemaker. Rhythm abnormalities are caused by abnormalities of impulse formation, impulse conduction, or a combination of both. Symptoms of arrhythmias Rhythm disorders are often asymptomatic, but can cause palpitations, shortness of breath, syncope, and cardiac arrest. Diagnostic tests and treatment of arrhythmias The clinical diagnosis of arrhythmia is usually made by ECG. The basis for treating any arrhythmia is to normalize electrolytes, control atrial and ventricular contraction, and give appropriate medication [57]. Sinus tachycardia occurs as a compensatory response to heart Atrial fibrillation Atrial fibrillation is the most common cause of arrhythmia and can have serious consequences such as stroke, heart failure, and other heart failure and if it does not subside with treatment for heart failure, the underlying cause needs to be investigated. Generally, it is then treated with beta blockers. complications [54,55]. It is characterized by an irregular, rapid heart rate caused by the two atria contracting out of sync with the ventricles. Atrial fibrillation etiology Abnormalities and damage to the heart structure are the most common causes of atrial fibrillation, but in some cases the cause is unknown. Symptoms of atrial fibrillation Many people with atrial fibrillation have no symptoms; however, the most common symptoms are palpitations, weakness, reduced exercise tolerance, dizziness, and chest pain. Atrial fibrillation pathophysiology In atrial fibrillation, the atria receive abnormal electrical contraction signals, causing the atria to quiver. As a result, the atrioventricular node (i.e. the node that conducts the signal between the atria and the ventricles) also receives abnormal electrical contraction signals. The result is a rapid and irregular heart rate, usually between beats per minute. Atrial flutter is similar to atrial fibrillation, but the electrical signals are less irregular. The risk factors for atrial fibrillation are the same as those for any heart disorder, but there are hereditary elements. Atrial fibrillation complications The most serious consequence of atrial fibrillation is stroke followed by heart failure. Atrial fibrillation diagnostic tests An ECG is the gold standard for the diagnosis of atrial fibrillation; however, because atrial fibrillation can be erratic, it is often diagnosed Atrial fibrillation treatment The goal for treatment of atrial fibrillation is to reset the normal heart rhythm and prevent blood clots. Heart rhythm can be reset using electrical cardioversion. This is an event where the heart is shocked back into normal rhythm while the patient is under sedation. Ventricular fibrillation [56] Ventricular fibrillation is a cardiac electrical conduction disorder where the heart beats non-uniformly and/or erratically. As a result of the irregular beats, the ventricles quiver and are unable to pump blood by a halter-monitor which is a wearable 24-hour ECG monitor. In terms of blood tests, it is important to rule out thyroid disorders. Rhythm can also be reset with pharmacologic cardioversion using anti-arrhythmic drugs. Anticoagulants are used to prevent blood clot formation. to the rest of the body. Ventricular fibrillation is a life-threatening emergency. Page 90

93 Ventricular fibrillation etiology In most cases of ventricular arrhythmia, the underlying cause is damage to the heart from a previous myocardial infarction which caused scarring of the heart muscle tissue. Ventricular fibrillation risk factors Risk factors for ventricular fibrillation include previous heart attack, previous episode of ventricular fibrillation, cardiomyopathy, illegal drug use, and/or electrolyte abnormalities. Pathophysiology of ventricular fibrillation Underlying damage to the myocardium can lead to distortion of the electrical impulses from the AV node, causing irregular or erratic electrical activity where the ventricles contract out of rhythm with the atria. Ventricular fibrillation symptoms Symptoms of ventricular fibrillation include chest pain, tachycardia, dizziness, nausea, shortness of breath, and loss of consciousness. Ventricular fibrillation diagnosis Ventricular fibrillation must be diagnosed in an emergency situation [56]. An ECG is used to diagnose ventricular fibrillation, but this usually happens after cardiopulmonary resuscitation and defibrillation. Other cardiac tests, including echocardiogram, cardiac catheterization, blood tests and cardiac MRI are conducted after the patient is stabilized. Treatment of ventricular fibrillation after emergency stabilization Anti-arrhythmic drugs as well as beta-blockers are used to stabilize the patient. An implantable cardioverter monitors heart rhythm, and if the heart rate is too low, it sends out low grade electrical shocks to correct the heart s pace. Coronary angiography and stent placements are used when there is underlying coronary artery disease and coronary artery bypass surgery is performed if necessary. References 1. Cardiovascular Physiology. 06 Apr. 2016: 2. Overview of the Cardiovascular System. Web. 06 Apr. 2016: science/robertsk/biol101/heart.htm. 3. Mader, Sylvia S., and Michael Windelspecht. Cardiovascular System. 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Web. 13 May 2016: Copyright: 2015 Amakali K. 15. Atherosclerosis. Web. 15 May 2016: WhyCholesterolMatters/Atherosclerosis_UCM_305564_Article.jsp#.VypvDGNH2V Guide to care for patients: Atherosclerosis. Web. 16 May 2016: journalarticle?article_id= Cardioprotection with High-Density Lipoproteins. Web. 16 May 2016: content/92/3/258.full. 18. Blood Pressure (high). Nursing Times. Web. 17 May 2016: High Blood Pressure. University of Maryland Medical Center. Web. 18 May health/medical/reports/articles/high-blood-pressure. 20. Hyperkalemia. University of Maryland Medical Center. Web. 19 May 2016: medical/altmed/condition/hyperkalemia. 21. High Blood Pressure (hypertension). Calcium Channel Blockers. Web. 18 May 2016: mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/calcium-channel-blockers/art Standard Nurse Protocol for the Management of Hypertension in Adults. Web. 18 May 2016: dph.georgia.gov/sites/dph.georgia.gov/files/2015 DPH Nurse Protocol for Hy-pertension.pdf. 23. Coronary Artery Disease. University of Maryland Medical Center. Web. 19 May 2016: edu/health/medical/reports/articles/coronary-artery-disease. 24. Stress Test. Mayo Clinic. Web. 19 May 2016: Coronary Artery Disease. Treatment Web. 20 May 2016: Angina Treatment: Stents, Drugs, Lifestyle Changes What s Best? Mayo Clinic. Web. 20 May 2016: Coronary Bypass Surgery. Risks Web. 21 May 2016: Anti-Clotting Agents Explained. Web. 23 May 2016: STROKEORG/LifeAfterStroke/HealthyLivingAfterStroke/ManagingMedicines/Anti-Clotting- Agents-Explained_UCM_310452_Article.jsp#.VztNRmNH2V About Peripheral Artery Disease (PAD). Web. 22 May 2016: Conditions/More/PeripheralArteryDisease/About-Peripheral-Artery-Disease-PAD_UCM_301301_ Article.jsp#.Vz3isGNH2V Peripheral Artery Disease (PAD). Overview Web. 23 May 2016: diseases-conditions/peripheral-artery-disease/home/ovc Hypertriglyceridemia Medication: Fibric Acid Agents, Omega-3 Acids, Lipid-Lowering Agents, Other, Lipid-Lowering Agents, Statins. Web. 23 May 2016: article/ medication. 32. Statins: Are These Cholesterol-lowering Drugs Right for You? Mayo Clinic. Web. 23 May 2016: Statin Side Effects: Weigh the Benefits and Risks. Mayo Clinic. Web. 23 May 2016: mayoclinic.org/statin-side-effects/art Deep Venous Thrombosis. University of Maryland Medical Center. Web. 24 May 2016: edu/health/medical/ency/articles/deep-venous-thrombosis. 35. Deep Venous Thrombosis (DVT). Merck Manuals Professional Edition. Web. 23 May 2016: Stroke. Symptoms and Causes Web. 23 May 2016: Pulmonary Embolus. University of Maryland Medical Center. Web. 24 May 2016: health/medical/ency/articles/pulmonary-embolus. 38. Rheumatic Fever. Mayo Clinic. Web. 24 May 2016: rheumatic-fever/basics/definition/con Rheumatic Fever. Risk Factors. Web. 24 May 2016: rheumatic-fever/basics/risk-factors/con Pathology of Rheumatic Heart Disease. Overview, Etiology and Pathophysiology, Clinical Features. Web. 24 May 2016: Rheumatic Fever. Merck Manuals Professional Edition. Web. 24 May 2016: merckmanuals.com/professional/pediatrics/miscellaneous-bacterial-infections-in-infants-andchildren/rheumatic-fever. 42. Infective Endocarditis. Merck Manuals Professional Edition. Web. 25 May 2016: merckmanuals.com/professional/cardiovascular-disorders/endocarditis/infective-endocarditis. 43. Myocarditis. Mayo Clinic. Web. 25 May 2016: myocarditis/basics/definition/con Myocarditis: A Shock to the Heart. Nursing Made Incredibly Easy. Web. 24 May 2016: journals.lww.com/nursingmadeincrediblyeasy/fulltext/2015/03000/myocarditis A_shock_to_the_ heart.4.aspx. Page 91

94 45. Myocarditis Clinical Presentation: History, Physical Examination. Web. 25 May 2016: emedicine.medscape.com/article/ clinical#b Pericarditis. Causes. Web. 26 May 2016: basics/causes/con Heart Valve Disease. Mayo Clinic. Web. 26 May 2016: Overview of Cardiomyopathies. Merck Manuals Professional Edition. Web. 26 May 2016: Dilated Cardiomyopathy. Merck Manuals Consumer Version. Web. 27 May 2016: Hypertrophic Cardiomyopathy. Merck Manuals Professional Edition. Web. 27 May 2016: Restrictive Cardiomyopathy. Merck Manuals Professional Edition. Web. 28 May 2016: About Arrhythmia. Web. 30 May 2016: AboutArrhythmia/About-Arrhythmia_UCM_002010_Article.jsp#.V1CN02NH2V Overview of Arrhythmias. Merck Manuals Professional Edition. Web. 1 June 2016: merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-disorders/ overview-of-arrhythmias. 54. Atrial Fibrillation. Merck Manuals Professional Edition. Web. 02 June 2016: merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-disorders/ atrial-fibrillation. 55. Atrial Fibrillation. Overview Web. 02 June 2016: Ventricular Fibrillation. Mayo Clinic. Web. 03 June 2016: Heart Failure. Merck Manuals Professional Edition. Web. 03 June 2016: com/professional/cardiovascular-disorders/heart-failure/heart-failure. 58. Clinical Care for the Patient with Heart Failure: A Nursing Care Perspective. E-Science Cen-tral. Web. 03 June 2016: Dyslipidemia. Merck Manuals Professional Edition. Web. 03 June 2016: com/professional/endocrine-and-metabolic-disorders/lipid-disorders/dyslipidemia. 60. Heart Failure. Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure. 61. Atherosclerosis. Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: merckmanuals.com/professional/cardiovascular-disorders/arteriosclerosis/atherosclerosis. 62. Overview of Hypertension. Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: Overview of Coronary Artery Disease. Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: overview-of-coronary-artery-disease. 64. Deep Venous Thrombosis (DVT). Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: Pulmonary Embolism (PE). Merck Manuals Professional Edition. N.p., n.d. Web. 07 June 2016: pulmonary-embolism-pe. 66. Web. 21 June 2016: Overview of Hypertension. Merck Manuals Professional Edition. N.p., n.d. Web. 21 June 2016: Bell, Kaye, June Twigs, and Bernie Olin. Hypertension--The Silent Killer. C.ymcdn. N.p., 1 June Web. 21 June Rheumatic Fever. Dermnet, Web. 21 June Appendix 1: Protocol for the management of Hypertension: Hypertension-Protocol.pdf. Page 92

95 Pathophysiology of the Cardiovascular System Self-Evaluation Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet. 1. What makes up the cardiovascular system? a. The heart, the lungs, and the blood vessels. b. The heart, the coronary circulation and the pulmonary circulation. c. The pulmonary and vascular system. d. The heart, the blood vessels and the blood. 2. What are the layers of the heart? a. The endocardium, pericardium, myocardium. b. The endocardium, the epicardium and pericardium. c. The myocardium, the myometrium and myocardium. d. The pericardium, the endocardium and epicardium. 3. Which of the following statements is true about the heart valves? a. The right side of the heart: tricuspid and pulmonary valve. b. The left side of the heart: mitral and pulmonary valve. c. The right side of the heart: the aortic and pulmonary valves. d. The left side of the heart: the tricuspid and mitral valve. 4. What does heart failure mean? a. The heart is broken. b. The heart cannot pump sufficient blood to supply the body with oxygen. c. The heart is not contracting well. d. The heart is not relaxing well. 5. Lack of perfusion activates the renin-angiotensin-aldosterone system to do what? a. Decreases sodium retention. b. Decreases total peripheral resistance. c. Increases water secretion. d. Increases the release of aldosterone to cause salt and water retention. 6. What is the most common sign of heart failure? a. Difficulty breathing when lying down. b. Swelling of the ankles. c. Shortness of breath. d. Fatigue and lethargy. 7. Loop diuretics are indicated in the treatment of heart failure, what does one need to monitor? a. Sodium levels. b. Hypokalemia. c. Hyperkalemia. d. Chloride levels. 8. Beta blockers should not be used in people with the following conditions? a. Hypoglycemia. b. Asthma and diabetes. c. The common cold and influenza. d. Hypercalcemia. 9. The risk factors for atherosclerosis do not include: a. Hypertension. b. Diabetes. c. Smoking. d. Thyroid disorders. 10. What is the first-line drug therapy for hypertension? a. Beta blockers. b. Calcium channel blockers. c. Thiazide diuretics. d. Angiotensin receptor blockers. Answers: 1.D 2.A 3.A 4.B 5.D 6.C 7.B 8.B 9.D 10.C Page 93

96 Patient and Family Anger: What to do When Frustration Spills Into the Workplace Release Date: 12/1/2016 Expiration Date: 12/1/2019 Faculty Adrianne E. Avillion, D.Ed., RN Adrianne E. Avillion is an accomplished nursing professional development specialist and healthcare author. She earned her doctoral degree in adult education and her M.S. in nursing from Penn State University and a BSN from Bloomsburg University. Dr. Avillion has held a variety of nursing positions as a staff nurse in critical care and physical medicine and rehabilitation settings with emphasis on neurological and mental health nursing as well as a number of leadership roles in nursing professional development. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing Audience The potential for angry and frustrated patients and family may occur in every health care setting. This course is therefore appropriate for all nurses working in any setting. 3 Contact Hours education and nursing professional development. Dr. Avillion owns and is the CEO of Strategic Nursing Professional Development, a business that specializes in continuing education for healthcare professionals and consulting services in nursing professional development. Her most recent publications include The Path to Stress- Free Nursing Professional Development: 50 No-Nonsense Solutions to Everyday Challenges and Nursing Professional Development: A Practical Guide for Evidence-Based Education. Content reviewer Stephani Hunt, MSN, RN, WCC, OMS, ONC Purpose statement Workplace violence in healthcare settings can affect anyone who works or volunteers in such areas. Violence can also affect other patients, families, and visitors. It is imperative that persons who work in healthcare know the factors which trigger violent behavior and which actions to take to reduce the potential for that violence. Learning objectives Discuss the incidence and prevalence of violence in the workplace. Identify barriers to reporting incidents of workplace violence. Predict what factors trigger violence in healthcare work settings. Relate how communication affects the ability to reduce/ preventworkplace violence in healthcare settings. How to receive credit Read the entire course online or in print which requires a 3 hour commitment of time. Depending on your state requirements you will asked to complete either: Page 94 An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Nursing, Provider # ; Florida Board of Nursing, Provider #50- They must also know how to deal with violence, whether it is verbal or physical, if and when it does occur. This education program is designed to help nurses reduce the occurrence of workplace violence and to intervene effectively when it does occur. Identify strategies to reduce the potential for workplace violence in healthcare settings, and prepare staff on how to deal with it when it occurs. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print your Certificate of Completion. 4007; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017).

97 Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/Commercial Support and Non-Endorsement It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2017: All Rights Reserved. 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Examples in practice Serena is an RN who works 7 am to 7 pm in the Emergency Department of a 500-bed medical center. She arrives at work to find the department in a state of near chaos. People are crying and several police officers are attempting to restore order. It seems that a gunshot victim s brother stabbed a physician and a nurse after shouting that no one cared if his brother lived or died! Bob is a physical therapist who works in an outpatient clinic. He has a new patient, Mrs. Gray, who is scheduled for her initial evaluation and therapy session at 2 pm. Mrs. Gray has a rapidly progressing form of multiple sclerosis (MS). Her cognitive state and motor skills are quickly deteriorating. Unfortunately, another therapist has called in sick, and in helping to cover her patients therapies, Bob is running Introduction The preceding scenarios could be taking place at any time in any healthcare facility throughout the country. Workplace violence in healthcare settings can affect anyone who works or volunteers in such settings. The violence can also affect other patients, families and visitors. It is imperative that persons who work in healthcare know late. Mrs. Gray and her husband have had to wait for over 20 minutes. Mrs. Gray is tearful and Mr. Gray is furious. When Bob arrives Mr. Gray confronts him by stepping to within a few inches of Bob s face and shouting, How dare you make my wife sit and wait like this! She is a sick woman and you had better be prepared to deal with me! Hannah is an RN who works on the stroke rehabilitation unit. Her patient, Mrs. Clark, is running a slight fever and has developed a cough. Mrs. Clark is often confused as to time and place. As Hannah attempts to auscultate Mrs. Clark s lungs, Mrs. Clark screams, What are you doing to me? You are trying to kill me! She makes a fist and attempts to punch Hannah in the face. the factors which trigger violent behavior and which actions to take to reduce the potential for that violence. They must also know how to deal with violence, whether it is verbal or physical, if and when it does occur. Incidence and Prevalence of Workplace Violence The prevention of workplace violence is a critical safety issue. Such violence can take many forms including verbal abuse, threats, physical battery, and even murder. The healthcare workplace, indeed all workplaces, must be made as safe as possible for employees, volunteers, patients, families, and visitors. The good news regarding workplace violence in the U.S. is that from 2002 to 2009 the rate of non-fatal workplace violence has declined by 35%. This follows a 62% decline in the rate from 1993 to 2002 (United States Department of Justice, 2011). The bad news is that it still occurs. According to data from the Centers for Disease Control and Prevention (CDC), between 1992 and 2012 there were 14,770 workplace homicide victims. This indicates that, on average, over 700 homicides occur annually. The largest number of homicides in one year occurred in 1994 (n=1080), and the lowest number (n=468) occurred in 2011 (Centers for Disease Control and Prevention, 2014). In March, 2011, the United States Department of Justice (2011) published a special report, Workplace Violence: This report is a summary of the National Crime Victimization Survey and the Census of Fatal Occupational Injuries. In order to effectively implement measures to stop or reduce workplace violence, it is important to understand the incidence and prevalence of such violence. Here is a summary of the key highlights of this report from findings related to the years 2005 through 2009: Preliminary data from 2009 indicates that 521 persons of age 16 or older were homicide victims in the workplace. The majority of workplace homicide victims were male and middle-aged. Four out of five workplace homicide victims were men, and 48% of all workplace homicide victims were between the ages of 35 and 54. In addition, 21% of the victims were of the age 55 or older and about 10% of the victims were between the ages of 16 to 24. About half of all workplace homicide victims were Caucasian. About a fifth of all victims were black, 16% were Hispanics, and 11% were Asian. Healthcare practitioners accounted for 1.1% of workplace homicide victims of 16 years of age or older. Page 95

98 About 28% of workplace homicide victims worked in sales in related jobs. About 17% worked in protective service occupations. The majority of workplace homicides (70%) were committed by robbers and other assailants. About 21% were committed by work associates. Shootings were responsible for 80% of workplace homicides. Firearms were used in 5% of non-fatal workplace violence. Law enforcement officers, security guards, and bartenders experienced the highest rate of workplace violence. The highest number of non-fatal workplace violence events was committed by strangers against males (53%) and females (41%). In the hospital setting, workplace violence occurs most often in psychiatric units, emergency departments (EDs), waiting rooms, and geriatric units. Research shows that 35% to 80% of hospital staff members have been physically assaulted at least once during their careers. In the ED, the vast majority of the people who commit violence are patients, their family members, and their visitors (United States Department of Justice, 2011). Examples in practice Charles is the chief executive officer (CEO) of a small rural community hospital. He and his administrative team are working to develop a policy regarding workplace violence based on OSHA recommendations. Even as they work, Charles does not feel that this is a major problem for his organization. After all, he thinks to himself, we really don t have much of a problem in our little town. Why, the most serious problems the local police department faces are drunk driving and maybe a brawl at the only bar in town on Saturday nights! Charles asks his team how they would define workplace violence. What exactly is it we re supposed to prepare to deal with? Are we talking about somebody coming in here with a gun or what? Melanie is a respiratory therapist. One of her patients is a 22-year-old man who developed pneumonia after being hospitalized for multiple fractures sustained in a motorcycle accident. He requires assessment and breathing treatments and Melanie dreads going into his room. He continually makes sexual comments and yesterday tried to grab Melanie s breast during a treatment. Melanie is reluctant to report the incident. She tells herself that nothing actually happened and she is both embarrassed and afraid that no one will believe her. The man is Evidence-based practice alert! The evidence shows just how serious the problem of workplace violence is in the healthcare setting. Therefore, it is imperative that nurses and other healthcare professionals understand the scope of the problem and how to deal with the various types of workplace violence. These statistics show that workplace violence is a significant occupational risk. There is a real need for employers and employees to develop and implement workplace violence prevention policies and procedures. The Occupational Safety and Health Administration (OSHA) has made recommendations and identified strategies for the prevention and reduction of workplace violence (OSHA, 2015). However, many organizations still struggle to develop and, more importantly, to properly implement such strategies. Compounding this problem is the issue of proper reporting of violence in the workplace. It is suspected that many occurrences of workplace violence are not reported because no significant harm came to the victim, or because the victim believed that such violence was just part of the job (OSHA, 2015). Workplace violence is not something that should ever be considered a normal risk of certain occupations. the son of a prominent, wealthy businessman who is on the hospital s board of directors. Henry is a physical therapist who is working to improve the mobility skills of an 80-year-old lady who has suffered a stroke. She is occasionally confused and this morning she punched Henry in the jaw as he attempted to help her transfer from bed to wheelchair. Henry decides not to report the incident. He doesn t want to admit that a frail, elderly lady hit him. Dana is an RN on a surgical unit. One of her patients, Mr. Henry, is continually complaining about the care he receives from the nurses, the food, his physician, and even how the volunteers deliver flowers and the mail. This afternoon he starts shouting loudly as she enters the room to give him his pain medication. He calls her just a stupid nurse and says he is tired of waiting for his medicine while all you and the other lazy cows around here sit and do nothing! Someday I ll make you all sorry. Dana wants to report the incident as an adverse occurrence according to the hospital s workplace violence policy. However, her nurse manager tells her to forget about it. She tells Dana, Words can t hurt you! Barriers to the Reporting of Workplace Violence The preceding scenarios illustrate just how many barriers there are to reporting of workplace violence. They range from a failure to comprehend the scope of the problem, inconsistency of definitions, embarrassment, fear, and a lack of managerial support. Different definitions of workplace violence Statistical reports of workplace violence cannot be completely accurate because of inconsistencies and/or failure to report the problem. One of the most obvious inconsistencies is a lack of a standardized national definition of workplace violence (OSHA, 2015). Despite the existence of policies and procedures, even employees of the same organization may define workplace violence differently. For example, does workplace violence include verbal aggression or is it limited to actual physical harm? Does the definition also include the threat of physical harm, even if actual harm does not occur? What level of verbal aggression is considered to be a type of workplace violence? If a patient shouts at a staff member, is this workplace violence? How severe does verbal abuse have to be to constitute workplace violence? There are no simple answers to the preceding questions. Most people would agree that actions that cause physical harm are forms of Page 96 workplace violence. However, what level of harm must exist? For instance, compare a slight pinch of the skin to a black eye. Are both examples of workplace violence? OSHA defines workplace violence as any act of threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assault and even homicide (OSHA, 2016). Ultimately, it is up to each organization to define and explain to employees what does and does not constitute workplace violence. It is likely that most organizations would include both verbal and physical aggression (including the threat of physical aggression) as part of the definition of workplace violence according to OSHA guidelines (OSHA, 2016; OSHA, 2015).

99 All levels of staff should have input when policies and procedures concerning workplace violence are written and/or revised. It is critical that the persons most likely to encounter violent situations, such as those who provide direct patient care, security guards, and secretaries and clerks who may be the first to greet or encounter patients and visitors, contribute to the establishment of sound workplace violence policies and procedures. By having input, they will be more likely Failure to understand the scope of the problem In the first scenario at the beginning of this section, Charles, the CEO of a small rural community hospital, did not believe that workplace violence was a problem for him. This attitude, although not as common as it once was, still exists. And this attitude is not only a barrier to reporting workplace violence, but poses a danger to staff, visitors, and patients as well. If the CEO, and/or others at the executive level fail to understand that the possibility of workplace violence affects all healthcare organizations, staff members will not be prepared to prevent (whenever possible) and/or deal with it when it finally does occur. Joint Commission Standard LD mandates that Leaders create and maintain a culture of safety and quality throughout the organization (American Nurses Association, 2015). The standard further emphasizes that leaders are to develop a code of conduct that defines both acceptable behaviors and those behaviors that compromise a culture of safety. Leaders are also admonished to create and implement a process for managing behaviors that undermine an organization s culture of safety (American Nurses Association, 2015). The fact that the Joint Commission places such importance on the issue of workplace safety encourages organizational leaders and staff members to work together to create a culture of safety. All members of an organization are responsible for establishing and maintaining a culture of safety. However, some employees may be reluctant to learn about the potential for violence in their workplace. Some employees (or volunteers) may believe that the threat of violence in healthcare settings is a problem that only direct patient care providers have to deal with. However, workplace violence can occur anywhere in the workplace and all employees need to be educated about the problem and how to deal with it (OSHA, 2015). to follow, encourage others to follow, and to support policy and procedure implementation. However, no matter how committed employees are to stopping workplace violence, and no matter how well-written are the policies and procedures, a violence prevention program must have the support of management and administration to be effective (OSHA, 2015). Nurses should never assume (or accept) that violence is just part of the job. The American Nurses Association (ANA) has identified workplace violence as one of the most dangerous occupational hazards that nurses must deal with. In 2011, the ANA conducted a survey of more than 4,600 nurses and found that 11% of those surveyed had been physically assaulted in the previous 12 months. Survey results also showed that slightly more than 50% of respondents had been threatened or verbally abused. About 33% of surveyed nurses identified on-the-job assault as one of their top three safety concerns (LaGrossa, 2013). Studies show that nurses who work in emergency departments are especially vulnerable to workplace violence. In addition to the emergency department, patients and settings that are common sources of both verbal and physical violence against nurses include (LaGrossa, 2013): Agitated clients in mental health facilities. Elderly patients with dementia in medical and geriatric settings/ units. Long-term care facilities. Rehabilitation centers. Any patients who have a history of assault in mental health, hospital, and community health settings. Employers and employees who fail to comprehend the scope and risk of workplace violence may be perceived as barriers to reporting its existence. They may not define violence according to hospital policy and procedure. They may choose to ignore co-workers concerns or reports of violence. They may simply, mistakenly, assume that violence is part of the job. Such attitudes are not only barriers to accurate reporting, but are barriers to implementing an effective workplace violence prevention program (OSHA, 2015). Nursing consideration: There is a large, unmet need for the safe and effective use of opioid analgesics. As such, the employment of prescription opioids is widespread and likely increasing. At the frontline in patient contact and communication opportunities, nurses are in an ideal position to ensure appropriate narcotic usage. Lack of managerial support and commitment The managers lack of understanding of the scope of the workplace violence problem may have a significant impact on how willing their employees and peers are to report incidents of workplace violence. OSHA, in its guidelines for a violence prevention plan, emphasizes the importance of managerial commitment to reducing and preventing the incidence of workplace violence (OSHA, 2015). Additionally, nurses experiences of how they are treated by colleagues and supervisors are critical. If they do not have organizational and managerial support, they may be reluctant to report and address the problem (Stevenson, Jack, O Mara, & LeGris, 2015). Consider the scenario at the beginning of the section in which the RN Daria experienced escalating verbal abuse committed by a patient. Daria s desire to report the problem as per the hospital s workplace violence policy was squashed by her nurse manager. The manager s comment, Words can t hurt you, indicates not only a failure to understand the scope of the problem, but an obvious lack of managerial support and commitment. Just how long is Daria supposed to wait to report escalating aggression? What, in the manager s opinion, has to occur before it is deemed to be workplace violence? The answers to these questions go back to organizational policies and procedures and the development of a true culture of safety. Lack of managerial support and commitment has an adverse effect on employees. In this type of environment, staff members may be reluctant to report what they believe to be workplace violence, even though, as in Daria s case, the verbal aggression is escalating. Escalating behaviors often indicate that potential danger to employees is also escalating (Joint Commission, 2010; Leckey, 2011). Suppose Daria s concern and/or fear of Mr. Henry interferes with her ability to concentrate on her job responsibilities and she makes an error? Is Daria s manager equally to blame since she did not support Daria? Or is Daria to blame since she had the option of filing a report and/or filing a grievance? These are difficult questions to answer, and there Page 97

100 are probably no clear-cut right or wrong responses. The point is, lack of managerial commitment can impact the organization in a variety of ways. These include (LaGrossa, 2013; OSHA, 2015): Increased potential for injury: If staff members are reluctant to, or even prevented from reporting workplace violence, no measures are taken to deal with the person or persons who are aggressive. This may allow the aggression to increase until physical harm occurs. Distrust of management: If management is seen as unwilling to support measures to increase the safety of the workplace, resent among staff members may grow. This leads to a hostile work environment. Potential for increased filing of grievances: If employees feel that their legitimate concerns are ignored and organizational policy and procedures are being violated, there may be an increase in the number of employee grievances filed against management. Legal consequences: Failure to provide a safe environment may have legal consequences for management. Deliberately failing to adhere to workplace violence policies and procedures may make the manager liable to legal action in the event of injury to employees. Increased number of adverse occurrences: Staff members who are distracted by an unsafe work environment may find it more difficult to concentrate, thereby increasing the risk for errors. Embarrassment Employees may be embarrassed that they cannot defuse an aggressive situation (The Joint Commission, 2013). Think of Henry, the physical therapist who was punched by a frail stoke patient. Henry may have been embarrassed that this frail, elderly woman was able to strike Fear A good example of fear is the scenario that describes why Melanie, a respiratory therapist, is reluctant to report the workplace violence she experienced. The person committing the violence, which consisted of inappropriate sexual comments and an attempt to grab her breast, was the son of a member of the hospital s board of directors. Fear can be triggered by a number of causes. These include (Joint Commission, 2016; OSHA, 2015): Fear of reprisal: Some workplace violence may involve threats of future harm. For example, a staff member may be told: If you tell anybody about this, I ll make sure you re sorry after I get out of here. Intimidation may prevent a staff member from documenting workplace violence. Fear of management s disapproval: Some employees may fear that if they report incidents of workplace violence, it may appear It s just part of the job There are some hospital employees who are more likely than others to be at risk for workplace violence. Security guards and emergency department personnel are a few examples. Even those employees who do not work in high-risk areas may believe that experiencing workplace violence is just part of the job (LaGrossa, 2013). Results of a study conducted on nurses working in emergency departments, intensive care units, and general units in a regional medical center showed that about 50% of participants stated that Examples in practice An infant is born with numerous, severe congenital abnormalities. It is doubtful, even with supportive treatment, that the baby will live a year. The infant s pediatrician sits down with his parents to discuss options. He wants to present them with all possible options in light of the fact that their baby is seriously ill and suffering. The baby has developed Difficulty with recruitment and retention activities: If an organization develops a reputation as a workplace that is unsafe or that does not support its employees, there may be problems recruiting qualified personnel. There may also be problems retaining staff members. Why would managers fail to adhere to workplace violence policies and procedures? Not understanding the scope of the problem may be only one reason. Others may include (OSHA, 2015): Belief that employees are exaggerating the danger: Some managers may honestly believe that certain employees exaggerate the danger of a given situation or may even be perceived as troublemakers. These are subjective feelings and should not interfere with a manager s ability to provide a safe work environment. Fear that increased reporting will create a negative reputation: Managers may fear that if a number of reports of workplace violence are filed administration will think that they cannot run their units/departments properly. Managers may not want their units/departments to be known as a dangerous place, which can hamper recruitment efforts. Regardless of the reasons, managers need to understand the scope of the workplace violence problem, and be committed to doing everything possible to enhance safety and reduce the risk of aggression. him. Nevertheless, verbal and physical violence should embarrass no employee. The danger for injury is real and all incidents of workplace violence should be reported. that they cannot do their jobs, which may include dealing with aggressive patients, families, and visitors. Fear of political consequences: As in Melanie s case, some perpetrators of violence may be prominent members of the community or related to such people. Sadly, political ramifications may be a distinct possibility. However, protecting a violent person is never acceptable, regardless of how prominent or how much influence that person may have. Nursing consideration: Fear can be a significant barrier to reporting workplace violence. It is imperative that as part of the organization s culture of safety, all employees work together to support each other and to decrease workplace violence. incidents of violence against nurses were never reported in writing. Explanation of this failure to report was based on the belief that such incidents were part of the job and that reporting the violence would not serve any helpful purpose. Other reasons given included feeling empathy for frightened, angry patients and family members and that if no physical injury actually occurred, there was no reason to report attempted violence (Gacki-Smith, Juarez, Boyett, Homeyer, Robinson, & SacLean, 2009). an infection and the physician suggests supportive measures rather than aggressive antibiotic treatment. The baby s parents are distraught and the father attempts to punch the physician screaming, You are a murderer! You want to kill my son! All life is sacred no matter what! Page 98

101 Why does workplace violence occur? Nancy is a speech therapist working with a closed head injury patient. The patient is quite disoriented and, when Nancy pauses to consult her notes, he reaches out and scratches her face, which begins to bleed. Mark is a security guard in the emergency department. A teenager is helped into the department by two friends. He has been stabbed in the right arm. The boy s friends begin to call out loudly for help and push and shoves around the waiting room. As Mark approaches the boys, Joint Commission findings On June 3, 2010 the Joint Commission published some recommendations on preventing violence in the healthcare setting. An analysis of the Sentinel Event Data base concerning criminal events helped to identify the following causative factors that were most often identified in the last five years; these findings are still being used as a resource for violence prevention programs (Joint Commission, 2010): Flaws in leadership: In 62% of events, problems with policy and procedure development, as well as the implementation of such policies and procedures, were cited as having contributed to the violence. Human resources-related factors: In 60% of events, factors such as the need for staff education regarding workplace violence and assessing (or failing to assess) the competency of staff to deal with or prevent workplace violence were cited. Assessment: In 59% of events, assessment was cited as a contributing factor to workplace violence events. Assessment involved such issues as lack of psychiatric assessment, failure of staff to adequately observe patients, and inadequate tools for proper assessment. Fear Fear is a common reaction among hospitalized patients and their families. Lack of control over what is happening to them or, in the cases of families, over what is happening to their loved ones, significantly contributes to fear and anxiety (Bigelow, 2014; Leckey, 2011). These feelings are not limited to persons in the inpatient setting. Consider the patient who is receiving chemotherapy at an outpatient clinic or the patient who is receiving bad news about his/her health in a physician s office. Fear occurs in all healthcare settings. Fear is often a normal response when dealing with the unknown, with pain, with the need to face the reality of a serious or terminal illness or injury. Fear lowers an individual s tolerance to stress and he/she may react angrily at even the slightest provocation, such as failure to receive the proper breakfast, or having to wait an extra 15 minutes for a treatment or outpatient visit. Conflict of values Values are beliefs about the right and wrong way to conduct one s life, including personal and career behaviors. Differences in values can lead to conflict (Scott, 2015). Such conflict can evolve into violence, verbal or physical behaviors, or both. Consider the scenario that described distraught parents whose infant was born with terminal congenital abnormalities. Their fear was compounded by a physician s attempt to discuss difficult options for the baby s care. The parents values, all life is sacred, may be perceived by the parents as in conflict with the physician, who is attempting to present a variety of options to the parents. Values are influenced by upbringing, religious beliefs, age, and culture (Scott, 2015). Medical options that come into conflict with the values of the patient and/or family can cause considerable stress and add to fear and anxiety. This kind of conflict can also deteriorate into violence. one of them pulls out a knife and tries to stab him. All three teenagers smell strongly of alcohol. The preceding scenarios illustrate a number of reasons why violence occurs in healthcare settings. Fear, anger, confusion, values conflicts, and substance abuse all can contribute to violent behavior. It is important that healthcare workers comprehend the various factors that can trigger violence in healthcare work settings. Failures in communication: In 53% of events, inadequate communication among staff, patients, and families were noted. The physical environment: In 36% of events, safety deficiencies in the environment as well as deficiencies in security procedures and actions were cited as contributing factors. Patient care issues: Less frequently mentioned as contributing factors were problems with the patients plans of care, patient education, and management of patient information. In 2016, the Joint Commission launched an online resource center to help prevent workplace violence in healthcare settings. This resource is called The Workplace Violence Prevention Resources Center and offers resources for healthcare organization, healthcare professionals, and the general public. Resources include policies, procedures, guidelines, research, case studies, white papers, and toolkits. The center is designed to serve as a living library and encourages contributions to help expand resources and decrease the incidence of workplace violence (Occupational Health Safety, 2016). By recognizing and acknowledging fear, healthcare workers may be able to help reduce the emotion and reduce the potential for violence (Bigelow, 2014). Fear should never be dismissed as over-reacting. The need for diagnostic procedures and treatment affects each person (and each family member) differently. One person may stoically receive a diagnosis of cancer while another may weep hysterically. Objectivity on the part of healthcare workers is necessary. It is unfair and unrealistic to compare different patients responses or to compare a patient s response with how the healthcare worker feels he/she should respond. Patients and families who sense that they are being judged by their healthcare providers may quickly become angry, and that anger may eventually escalate to violence. Even something as harmless as mistakenly serving a meal containing meat to a vegetarian can incite conflict. The values of the vegetarian are offended by this mistake. If the person making the mistake apologizes and corrects the mistake by ordering another meal, the issue will likely resolve itself. But if the staff person reacts by dismissing the patient s concern, conflict may escalate. Staff members must be alert to patients values and not judge as to what values are important and what are not. When a patient s values come into conflict with the healthcare professional who is providing patient care, it is up to the staff member to maintain objectivity. This may be challenging in some cases. Consider how a patient with late-stage lung cancer values his quality of life. His treatments leave him sick and exhausted. He decides to stop treatment and instead opt for measures that will allow him to remain as comfortable as possible for as long as possible. A nurse who believes that every option for treatment should be utilized may be Page 99

102 tempted to try to change the patient s mind. Attempting to do so will cause not only stress, but may lead to conflict. It is not appropriate to challenge a patient s values. Once the healthcare team has presented all options to a patient, it is up to the patient to direct his plan of care and the team must respect the patient s values and decisions (Bigelow, 2014; Brooks, 2015). Culture Cultural (and religious) values and customs are usually deeply important to persons embracing them. Healthcare workers should make every effort to respect the culture and religious beliefs of the patients they care for. For instance, some older female Hispanic patients may defer to their husbands as the decision-maker in matters of health and wellness (Gagalanti, 2016a). This may contradict the values of a healthcare professional who believes that each patient should make her or his own decisions about treatment, follow-up care, etc. But the staff member must respect the patient s own values and not attempt to change them. Attempting to do so may cause considerable conflict, but respecting such values and including the patient s husband in all aspects of decision-making will more than likely facilitate satisfactory patient care. For example, suppose a young male patient is dealing with a diagnosis of diabetes. This will require changes in diet, exercise, and in many Substance abuse Having to deal with patients, families, and visitors who are under the influence of alcohol, prescription drugs, or illegal drugs is a fairly common problem in the healthcare setting. People under the influence of such substances may exhibit a wide range of behaviors, from being withdrawn, to euphoric, to depressed, to belligerent and combative (Elliott, Geyer, & Doty, 2012). When thinking of patients under the influence of alcohol or other drugs, some healthcare professionals may picture an out-of-control patient or family member in the emergency department or a family member or visitor making a scene while visiting a hospitalized loved one. However, a review of some recent studies show that just as big a problem is the need to deal with patients who are going through alcohol withdrawal while hospitalized (Elliott, Geyer, & Doty, 2012). Recent studies indicate that a significant number of hospitalized patients suffer from alcohol use disorder (AUD) such as alcohol abuse or dependence. Results of a 2008 study show that an estimated one in five patients admitted to a hospital suffer from an AUD. Additional data estimate that one in four medical-surgical hospitalized patients have some form of AUD (Elliott, Geyer, & Doty, 2012). Staff members need to be alert to alcohol withdrawal signs and symptoms, which may mimic other illnesses or disorders. These signs and symptoms are indicative of declining alcohol blood levels and usually appear within a few hours to a few days after alcohol intake stops (Elliott, Geyer, & Doty, 2012). Examples in practice Mr. Bob Forrester is a 40 year-old business executive. He is hospitalized after having developed a severe, systemic fungal infection. He has been taking the antifungal drug Nizoral (ketoconazole). Mr. Forrester is sad and withdrawn and tells the nurses that he just wants to be left alone. His wife is tearful and stops at the nursing station to tell his primary nurse, Hannah, that, I just don t understand what is happening. Bob was always so upbeat and positive. Page 100 Even simply presenting options that threaten a patient s values may lead to conflict, as in the scenario with the terminally ill infant. Physicians have an obligation to present all options and information about each option so that patients and families can make informed decisions. But presenting options must be done with compassion and respect. Patients and families should never be made to feel that there is a right and a wrong decision. of his activities. He will need to take insulin. The patient is having a difficult time accepting the diagnosis and his physician believes that psychosocial counseling may be helpful. The patient and his family adamantly refuse. The family is of Middle Eastern descent and believes that personal problems are best taken care of within the family (Gagalanit, 2016b). The physician needs to work with the family, especially the family spokesperson, to help the patient receive the care that he needs while respecting the family s cultural values. Cultural and religious beliefs should always be respected. If the healthcare team is unfamiliar with a particular culture and/or religion, they need to gather information about both and, if possible, ask for the assistance of representatives from that culture and/or religion to help provide culturally appropriate care. Failure to do so may lead to conflict and even instances of workplace violence (Brooks, 2015; Gagalanti, 2016d). These signs and symptoms may increase in severity as the time from the last drink of alcohol increases. These signs and symptoms include (Elliott, Geyer, & Doty, 2012): Tremors. Anxiety. Headache. Palpitations. Diaphoresis. Nausea and vomiting. Seizures. Hallucinations. Delirium. Tachycardia. Hypertension. Fever. Nursing consideration: Alcohol withdrawal is a stressful time for the patient s loved ones, as well as the patient. Increase in stress and anxiety may also increase the risk of verbal and/ or physical aggression. Nurses should anticipate the potential effects of alcohol withdrawal and be prepared to deal with potentially volatile situations. It is important that healthcare professionals recognize the potential for alcohol withdrawal and know what signs and symptoms to look for. They should also anticipate potentially violent behavior. Early recognition and preparation for alcohol withdrawal will help to initiate appropriate treatment measures that help patients get through the withdrawal and to be prepared for potential violent outbursts (Elliott, Geyer, & Doty, 2012). Since he got this horrible infection, he is so depressed and at times he just yells at me to leave him alone. A pharmacist, who is a friend of the Forresters, also happens to be present. At that moment, Bob is heard shouting at another nurse. As Hannah, the pharmacist, and Mrs. Forrester hurry into the room, Bob is seen throwing his water pitcher at the housekeeper and yelling, Just get out. I want everyone to leave me alone. I don t care if I live or die! The pharmacist asks Hannah what

103 medications Bob is taking and what potential side effects may occur. Using her ipad to consult her online drug reference Hannah finds that depression is a potential side effect of Nizoral (Comerford, 2016). Side effects of prescription medications Sometimes it can be easy to forget that prescription medications have a wide variety of side effects, including changes in mental status. Mood changes, outbursts, agitation, and depression are just some of the side Patient assessment The Joint Commissions sentinel event database contains data pertaining to inadequate assessment as a contributing factor to workplace violence (Joint Commission, 2010). As seen in the preceding section on prescription drugs, a thorough assessment of the medications Mr. Forrester was taking might have helped the nursing staff to more quickly identify his medication as a contributing factor to his behavior. A thorough patient assessment is critical to safe and appropriate patient care. Think not only about the patient s history and presenting clinical picture, but about his home environment as well. Is there a family history of abusive behaviors? Does the patient feel safe in his/her own home? Has there been an incident in the patient s past (e.g. experiencing a traumatic event such as rape or serving in the military in a war zone) that could affect how he/she responds to others? What pathophysiological changes have occurred that may have an adverse impact on a patient s mental status or on his/her ability to control anger? Include the patient s family in the health assessment as much as possible. They may be able to provide important information, Confused patients Examples in practice Mr. Wilson is a retired minister with a reputation as a kind, gentle man, who is a good husband and father. He recently suffered a stroke. He is confused and often verbally aggressive, cursing and shouting at staff members. His wife is heartbroken, telling nurses and therapists that her husband rarely raises his voice at home and never uses foul language. Staff members try to comfort Mrs. Wilson, explaining that these behaviors can be part of the pathophysiology of stroke. Many illnesses and injuries contribute to or cause confusion, fear, and belligerence. Persons who were polite, well-mannered, and gentle may become aggressive and physically abusive. It is important to explain to families and loved ones about the reasons for these types of behaviors. It is also important to help staff members who may not have a good understanding of the pathophysiology of conditions that contribute to such behaviors. For example, dietary aids, students, housekeepers, and maintenance personnel may all come into contact with persons who are confused and belligerent. It is important that these staff members be educated about the effects problems such as stroke, dementia, and head injury can have on behavior. In fact, education concerning workplace violence and its causes should be offered to all employees, not just direct patient care providers and security guards. Workplace violence can affect any and all employees! Change Change can be seen as either positive or negative. A promotion, buying a new house, losing weight, having surgery or treatment that cures an illness may all be viewed as positive changes. Diagnosis of a serious illness, experiencing painful and otherwise difficult treatments, and hospitalization all involve change of a less pleasant nature. Change has often been a source of conflict. Changes in policies and procedures, changes in personnel, changes in job expectations may all be greeted with distrust and even hostility. Patients, especially inpatients or those who are dealing with serious or chronic conditions, effects that can be caused by many common medications and that also can contribute to workplace violence. If a patient is displaying unusual behaviors and outbursts of anger, look up the side effects of the medications he/she is taking. There are so many varied reasons for workplace violence that sometimes busy healthcare professionals forget to consider the effects of medications. especially if the patient is confused or incompetent. The family unit may also need to be assessed. Are they anxious and fearful? Have they been acting as the patient s caregivers? If so, are they tired and under stress? Most families and other loved ones are worried about the patient. They (and the patient) feel a lack of control and may use aggression as a means to gain some control over a frightening situation. Most hospital stays involve exposure to the unknown for patient and their caregivers. Unpleasant, painful diagnostic tests and treatments, unfamiliar environment, having to deal with a serious diagnosis, and feeling that nurses, therapists, doctors, and other healthcare professionals have taken over their lives definitely do not make for a calm experience. Assess patients and families for their levels of stress, coping mechanisms, and support systems. Also, don t forget to assess for alcohol and drug use. As pointed out in the previous section, such substances can have quite an impact on the behavior of patients and families. Equally important is to check for nicotine use. Hospitalized patients have few if any opportunities to smoke. Abrupt cessation of smoking can make for very irritable and even aggressive patients (Elliott, Geyer, & Doty, 2012). are forced to deal with a multitude of changes on an almost daily basis. Compounding the problem is that patients and their families often have no control over what is happening to them. Feelings of loss of control compounded by change can be an explosive combination (Scott, 2015). Consider how healthcare employees feel when changes in routine or policy are mandated without their input. This comparison can help healthcare employees to empathize with patients and families and acquire a better understanding of how they feel when confronted by the changes that occur as the result of illness or injury. Expressions of empathy and acknowledging just how difficult change can be can help to calm a patient and defuse a potentially violent situation. Communication The Joint Commission has cited inadequate communication as a potential cause of workplace violence (Joint Commission, 2010; Joint Commission, 2013). But what exactly does inadequate communication mean? Inadequate communication can mean that (Joint Commission, 2010; Joint Commission, 2013): Patients receive incorrect or contradictory information from various members of the healthcare team. Patients receive information in terms that they do not understand, perhaps containing a great deal of technical terms that are not defined. For patients who are not native English speakers, information in their native language may be inadequate or not available. Patients are told what to do or what decision to make without being given enough information to make an informed decision or to provide informed consent. Patients are given biased information. In other words, the healthcare professional providing information allows his/her personal beliefs and values to influence how he/she communicates with the patients. Page 101

104 Patients are not given the opportunity to ask questions or to think about what they have been told. Patients overhear staff members talking about them and even ridiculing questions they ask or decisions they make. Patients get the impression that healthcare professionals are not really listening to them. Patients get the impression that healthcare professionals do not have time to discuss information with them. Patients get the impression that healthcare professionals are bored or disinterested in their health and well-being. Whether or not any or all of the preceding concerns are truly accurate, what matters is if the patients and/or their families think they are accurate. Failure to communicate effectively leads to feelings of fear, frustration, and, possibly anger. This anger can contribute to incidences of workplace violence. Lack of a safe environment All employees should ask themselves if they believe that their work environment is safe. Joint Commission findings show that 36% of reported workplace violence events in the sentinel event data base were due to a lack of safety in the work environment. Some deficiencies that contribute to workplace violence include (About.com Psychology, 2011; Joint Commission, 2010; Joint Commission, 2013; Scott, 2015). Lack of effective policies and procedures that address the issue of workplace violence. Lack of management commitment. Lack of trained security guards. Lack of sufficient numbers of security guards. Inadequate system of staff and visitor identification. Failure of staff members to wear employee identification. Lack of education and training for employees on the topic of workplace violence and how to reduce and/or prevent it. Belief that healthcare professionals don t care about them It is important that all staff members who come into contact with patients (and this includes housekeepers, volunteers, secretaries, etc.) convey the attitude that they genuinely care about all patients and their families (Bigelow, 2014; Leckey, 2011). It is easy to become complacent about interacting with patients. And there may be some patients and family members that staff members actually dislike. It is not expected that all staff members like every patient and every patient s family members and visitors. What is expected is that all staff members treat all patients, families, and visitors with respect and objectively do their best to promote the patients maximum health and wellness. It is not necessary to like someone to provide safe and appropriate care and to convey an attitude of compassion and empathy. If patients and their loved ones believe that the persons who are responsible for their very lives genuinely care about their welfare, chances are that they will be at least minimally cooperative. If these same patients and their loved ones believe that no one cares if they get well or not, aggression is a distinct and likely possibility (Brooks, 2015; Centers for Disease Control and Prevention, 2014). Violence as part of the patient s lifestyle There are patients (as well as their families and friends) whose lifestyle is violent. Violence is part of their everyday existence. Examples include persons who are victims of and/or perpetrators of domestic violence, gang members, persons who are involved in criminal activities, and those who have grown up in a family where verbal and/ or physical violence was the norm. These individuals are more likely to behave in a violent manner because this is what is normal for them (Healthyplace.com, 2016). Assessing a patient for a violent lifestyle will help to prepare staff members to deal with persons who are verbally aggressive and possibly physically aggressive. Examples in practice Jasmine is a nursing assistant who is Asian-American. She is taking care of an elderly patient who has dementia. The patient is usually confused and often verbally aggressive. When she sees Jasmine, she screams: Get away from me! I m sick of all you foreigners taking over my country. Jasmine becomes upset and begins to shout back at the patient. The situation escalates and the patient attempts to strike Jasmine. Taking patient aggression personally Most patients and families are not being deliberately aggressive. In the preceding scenario, Jasmine takes the patient s comments personally. It can be difficult to remain calm and objective when someone is making hurtful comments. However, Jasmine s patient is confused and suffering from dementia. It is unlikely that the verbal attack has any personal aim toward Jasmine herself. It is important that all staff members be taught ways to remain calm even in the midst of verbal aggression. It is important that all staff members be taught about the effects of disease and injury and how fear and other reasons for aggression are often due to feelings of loss of control and anxiety. Of course, there are instances when patients, families, and visitors are deliberately aggressive. Fortunately, this is usually the exception, not the norm. The important thing to focus on is not to take behavior personally. No matter how difficult, the first thing to do is to help healthcare workers establish an objective therapeutic relationship with patients. Understanding how and why patients behave the way they do is a foundation for establishing such a relationship (Brooks, 2015). communication as the Foundation for Reducing/Preventing Workplace Violence in Healthcare Settings Communication is critical to establishing a therapeutic nurse/patient relationship. It is an issue that can either enhance patient care and workplace safety or increase the risk for poor patient care outcomes and workplace violence. There are many aspects of communication to discuss. A good place to start is with communication among those who work in healthcare settings. Communication among staff members Examples in practice Raymond is a pharmacist making rounds with the interdisciplinary rehabilitation team on the spinal cord rehabilitation unit. He and the team are discussing concerns about one of the patients, whom they are carefully monitoring for symptoms of worsening depression. The patient has just been started on an antidepressant, and, as an 18-yearold, is at risk for an increase in suicidal thoughts when beginning antidepressant therapy. They are satisfied that he shows no evidence of such an increase. However, the housekeeper stops them in the hallway. Page 102 You had better pay more attention to that young man. His girlfriend just broke up with him last week and when no one is around I see him crying and muttering about killing himself or someone else. I told the doctor about this but she told me I was just here to clean rooms and to mind my own business! This scenario is a good example of communication failure among staff members. A housekeeper s observations can be critical to the health and well-being of patients. The willingness of physicians, nurses, pharmacists, and therapists to respectfully listen to each other cannot

105 be stressed enough. All employees need education about preventing workplace violence and the importance of communication among all who work in the organization. Discounting important observations based on the role someone fulfills can be a dangerous mistake. Communication among staff members does not have to be verbal. Consider documentation. Team members do not always have the ability to discuss a patient s status face-to-face. Patients lengths of stay are shorter and shorter and opportunities to communicate seem to decrease as well. Think about the pharmacist who fills prescriptions and sends medications to various patient units but must rely primarily on the patient s medical record as a means of communication. Or the physical therapist that sees patients in the gym but seldom has an opportunity to interact with the nurses in person. Documentation must be concise, accurate and easily accessible to all. The implementation of electronic medical records has helped with accessibility. But if documentation is not complete, timely, and accurate, accessibility means nothing. Finally, think about how healthcare professionals communicate with each other. Do they treat each other with respect? Do they actively listen to each other? Do they take the time to relay important information? If face-to-face communication is not possible, do they make time to telephone each other to relay essential information quickly? If the answer to any of these questions is no, then changes need to be made to the way communication among staff members takes place. Active listening, genuine interest in the observations of colleagues, and the willingness to treat each other with respect are the focus of good communication among staff members (Neese, 2015). Examples in practice Andy is an RN on a medical floor. He has an unusually heavy patient load today because several colleagues have called in sick. A family member wants to talk to him about her mother s medication. Andy pauses on his way down the hall to answer her questions. The conversation is conducted in the hallway, neither of them sit down, and other staff members are constantly rushing by them. As Andy answers her questions, he glances at his watch every few minutes. Finally, the family member becomes angry and says loudly, Don t bother with me anymore. It s obvious you couldn t care less. But I ll tell you that I am not leaving here tonight until someone answers my questions properly. And I don t want you taking care of my mother anymore either! Her voice carries down the hall and people stop and stare at them while overhearing their confrontation. Good communication between staff members and patients/families Andy is busy and it was not the best time for him to attempt to answer the woman s questions. However, he violated almost every principle of good communication. He conducted an important conversation in a public hallway. Neither of the persons involved was in a comfortable environment. Andy kept glancing at his watch, indicating a lack of interest and/or being anxious to finish the conversation. Failure to communicate adequately can and does increase the likelihood of workplace violence. Here are some verbal communication guidelines to help prevent patient/family anger and to defuse an angry confrontation if it does occur (Verywell, 2016; Brooks, 2015; Leckey, 2011; Scott, 2015): Listen actively. Show interest and a desire to assist the patient or family member. Maintain eye contact if culturally appropriate. Don t indicate impatience by checking a wristwatch. If it is not understood what the patient or family member is asking, ask for clarification. Check if the patient or family member understands what is being said to her/him. Listen in a timely fashion. Consider Andy s actions in the preceding scenario. It would have been better if he explained to his patient s daughter that he needed to do something urgently for another patient but would return in 15 minutes (if that time frame were realistic) to talk with her. It is better to delay a conversation and set a time limit for return rather than rush through a conversation. Show respect. All human beings deserve respect. A visitor may arrive in dirty jeans and unshaven, but he still deserves to be treated with respect. Lack of respect will almost always lead to animosity. Address patients and visitors as Mr., Mrs., Ms., etc. unless invited to use first names. Never address adult patients and visitors as honey, dear, sweetie, or other demeaning term. They are not children. Some healthcare professionals seem to feel that patients and visitors, especially elderly patients and visitors, should be addressed as though they are children. This is demeaning and will not facilitate good communication. This principle holds true for patients who have dementia or are confused. Respect is always important and always appropriate! Say please and thank you. Use a calm tone of voice. This is always appropriate and could make the difference between calming an angry patient or family member and triggering an instance of verbal or physical aggression. Don t be drawn into an argument. Don t raise your voice. Try to avoid telling someone who is upset to calm down. This may cause the situation to escalate. Instead, ask the angry person to, please speak more slowly so that I can understand what you are saying. Use repetition. For example, after listening to what a patient or family member is saying respond by saying, So what you are telling me is and repeat what was said to you. This helps clarify concerns. If a patient, family member or visitor begins to raise his/her voice or shout, speak softly. People often will stop shouting in order to hear what you are saying. People may instinctively match your tone of voice by speaking more softly as well. Avoid public confrontations. Do not have difficult conversations in a public place. Such conversations are best conducted in a private patient room, a private lounge, an office, etc. If family members or other visitors are involved in a conflict, direct them to separate waiting areas. Do not allow quarrels and other confrontations to occur in front of patients. If patients are quarreling with visitors, it may be necessary to ask the visitors to leave. Never hesitate to call for the assistance of security guards. Offer options. For example, suppose a patient is away from the nursing unit for a diagnostic test, and a family member is becoming increasingly anxious. Offer the family member the choice of having a seat in the waiting room or remaining in the patient s room. If the test will last for any length of time, it may be appropriate to suggest that the family member get a snack or cup of coffee in the coffee shop. Help patients/families to maintain or regain control. Comments such as, I understand you re upset, what can I do to help? Or Take some deep breaths or Please sit down and breathe slowly are simple instructions that will help them to focus on something other than fear or anger. Examples in practice Monica is a 36-year-old breast cancer survivor. She has arrived at her doctor s office for the results of some additional diagnostic tests that were conducted to determine if there is any evidence of metastasis. The office is crowded and Monica has been waiting for over 30 minutes past her scheduled appointment time. When the nurse finally escorts Monica to an exam room, she apologizes to Monica for the delay. Monica responds by saying that I know you are busy. I am sure that everything will be OK. Monica is clenching and unclenching her fists and breathing quickly. As the doctor enters the room she shouts, How dare you keep me waiting like this! Both the nurse and the doctor are surprised. The nurse tells the doctor, Monica wasn t upset. Page 103

106 She said she understood the delay! Monica has missed important non-verbal cues that the patient was upset. Non-verbal communication is every bit as important as verbal communication. Some sources point out that over 90% of communication is actually non-verbal. Here are some important guidelines for non-verbal communication (About.com Psychology, 2011; Brooks, 2015; Cherry, 2016; Leckey, 2011; Scott, 2015): Be alert to early warning signs of agitation. Early signs of increased anxiety and agitation are rapid breathing, sighing, and wringing of hands. Look for discrepancies between what is said and what body language indicates. For example, in the preceding scenario, Monica says that it was OK that she had to wait and that she believed that everything would be OK. But her body language indicated otherwise. She was breathing rapidly and clenching and unclenching her fists. Pay attention to any differences between what is said and non-verbal behaviors. Maintain eye contact when culturally appropriate maintain good eye contact. Do not overdo eye contact, however. This can make some people uncomfortable. Experts suggest that eye contact should be made at intervals that last about four to five seconds. Maintain open body language when talking to patients, families, and visitors. Keep hands and arms at your sides or resting on a table. Lean forward slightly to show interest. Avoid closed body language. Do not cross your arms, clench your fists, or turn away from the person you are speaking to. Cultural awareness It is important that culture be considered and respected when attempting to provide a safe environment for patients, families, visitors, and staff members. It is important to avoid assumptions. Cultural generalizations can be made but all persons are unique. Avoid assuming that all persons of a particular race, religion, or ethnicity will behave in the same way and have the same values and religious beliefs. Even some seemingly simple behaviors such as eye contact and a handshake can have cultural implications. Here are some tips for ensuring cultural sensitivity (Gagalanti, 2016d): Handshake: In Western cultures, the right hand is extended with the thumb up. The handshake is firm but should not cause discomfort. The hand is shaken two or three times and then released. Handshakes often differ in other cultures. For example, the Chinese and Japanese may grasp hands less firmly but hold the hand for a longer period of time. Muslim men generally do not shake the hand of a woman. Eye contact: In the United States, eye contact demonstrates interest and is part of active listening. It indicates honesty and confidence. However, in many Asian countries, direct eye contact may be interpreted as disrespectful. Looking away may be an indication of respect. In Mexico, direct eye contact may be interpreted as aggressive behavior, while in France eye contact may be maintained so intensely that Americans may become uncomfortable. Be objective. Do not show amusement, disdain, or disgust. Do not judge what the patient says or believes. Do not interrupt. Allow patients, family members, and visitors to finish their sentences. Avoid assuming you know what they are going to say or ask. Nursing consideration: Non-verbal communication can provide the nurse with important clues about the patient s level of comfort and emotional state. Nurses must know that non-verbal communication is every bit as important as verbal communication. Examples in practice Joseph is a 20-year old college student of Middle Eastern ancestry. He is hospitalized following a car accident during which he sustained multiple fractures. His female nurse asks him if he would prefer a male nurse and if he would like his bed turned to face east so that he can pray. The nurse assumes that a man of Middle Eastern ancestry is Muslim and prefers a member of the same sex as a care provider. Joseph looks puzzled and a little annoyed. He is a fourth generation American and a Christian. Why are you assuming what I am just because of my ethnic background? Elizabeth is a Japanese citizen who is in the United States on a work visa. She is hospitalized because of a septic infection that developed after removal of an ovarian cyst. During a patient education session her nurse, a man, uses hand gestures to explain some points of care. Elizabeth is offended since, in her culture, the use of hand gestures can be insulting (Gagalanti, 2016c). Personal space: Personal space varies among countries and cultures. For example, in the U.S., personal space is usually about three feet. In Italy and South American countries, the personal space distance is closer, but in Asian countries the distance is often greater. Be guided by the other person s body language. If they seem uncomfortable, allow a greater amount of personal space. Facial expressions: A smile in most Western countries indicates pleasure. Americans in particular smile easily. However, people in some Asian countries may actually conceal annoyance or other negative emotions with a smile. Japanese may smile less often, believing that if one is really happy, a smile is not necessary. Hand gestures: Hand gestures, a common practice in American culture, may be seen as signs of aggression in other countries. For example, in China and some other Asian countries hand gestures can be considered rude. Hand gestures in general are easily misunderstood. For example the thumbs up sign, an indication of approval or victory in the U.S., is considered crude in the Arab world. Winking at someone is considered rude in Australia and Taiwan. Standing with hands on hips can be interpreted as aggressive in many countries. The preceding generalizations help to illustrate just how varied cultural considerations can be. Facial expressions, hand gestures, eye contact, and personal space are just a few of the behaviors that can offend others or help to enhance communication. It is important to ensure personal safety when dealing with aggressive patients, families, or visitors. Violence rarely takes place without some warnings such as raising one s voice, clenching fists, and violating personal space. Part of controlling the problem of workplace violence includes ensuring your personal safety. Ensuring Personal Safety Here are some recommendations for maintaining personal safety (About.com Psychology, 2011; Brooks, 2015; Cherry, 2016; Leckey, 2011; Scott, 2015): Trust your instincts. If you feel uncomfortable, recognize early warning signs of violence, or just have a feeling that you are in danger, trust your instincts. Use good communication techniques to defuse the situation. If this does not work, take protective measures. Page 104

107 Tell someone else of potential difficult situations. If you know in advance that a meeting with a patient or family member is going to be or may become problematic, tell at least one other co-worker where you will be meeting and how long you anticipate the meeting will take. Maintain an exit pathway. Never allow a patient, family member, visitor, etc. to get between you and an exit. Always position yourself between the person you are talking to and the exit. Evaluate your environment. Remove items that could be used as weapons, such as syringes, scissors, knives from meal trays, even hot coffee, etc. from the environment. Assess the likelihood that someone could use a chair, bedpan, meal tray, or another object as a weapon. Dress appropriately. Be aware of your appearance and what, if any, articles of clothing that could be used as weapons. Avoid tight fitting clothing that accentuates breasts and/or hips. Avoid clothing that shows cleavage. Such clothing may encourage some persons to make inappropriate remarks or sexual gestures. Avoid wearing jewelry or accessories that can be used to injure you. For example, a scarf, lanyard, or necklace can be pulled tight around the throat. Keys worn around the neck can be grabbed and used as a weapon. Long earrings can be pulled off, causing injury. Avoid high heels that can prevent you from moving quickly if you need to get away from a dangerous situation. Know how to get help. Know what to do in case of an emergency. Know how to quickly contact security guards. Do not be afraid to shout for help if necessary. Suggestions for implementing a strategic plan for preventing workplace violence OSHA and the Joint Commission have made a number of suggestions for the development of a strategic plan for preventing workplace violence. Some practical suggestions include (About.com Psychology; Joint Commission, 2010; Joint Commission, 2013): All healthcare organizations should have a violence prevention program in place. The program should be based on policies and procedures that are developed with input from all levels of staff and who represent all departments. All employees should have the opportunity to review policies and procedures and support their implementation. All administrators and managers must support the implementation of policies and procedures that guide the implementation of a workplace violence prevention program. A written plan should be in place that describes the various types of workplace violence, how to prevent their occurrence, how to deal with them if they do occur, and how to document their occurrence. All employees should receive education and training concerning a violence prevention program. The written plan should make it clear that there is zero tolerance for violence, verbal and nonverbal threats, and physical violence. The written plan should clearly state that no reprisals will be taken against any employee who report or experience workplace violence. The written plan should include a plan for establishing and maintaining security, including the procedure for hiring of security guards, the requirement for all employees to wear organizationmandated identification, and instructions for reporting instances of violence. An analysis of the workplace for the potential for violence and how well each department is equipped to deal with violent behavior should be conducted. An analysis should include (Joint Commission, 2010; Joint Commission, 2013): Review of risk management and other data that document occurrences of workplace violence. No strategic plan can be implemented successfully unless all employees receive ongoing education and training concerning the incidence of workplace violence, how to prevent it, how to deal with it when it occurs, how to document it, and how to receive necessary follow-up help if they become victims of such violence. Appropriate education is ongoing. A one-time discussion of policies and procedures is not enough to ensure a culture of safety. Establishing and maintaining a workplace environment that helps employees to prevent and/or reduce the incidence of workplace violence requires Education and Training Evaluation of the physical environment for safety issues, such as security of fire and security doors, properly secured medications, employee identification, availability of objects that could be used as weapons to patients and visitors, and availability of security guards throughout the organization. The work environment should be free from clutter so that items such as books, keys, pens, etc. cannot be used as weapons. Assessment of employees knowledge of how to prevent and/or deal with workplace violence. A system that allows for additional security precautions in high risk areas, such as the emergency department, should be established. Assessment of risk factors for violence such as substance abuse, history of domestic violence, etc. should be part of a patient s admission assessment. A system of documenting instances of workplace violence should be clearly established. The workplace violence prevention program should include medical intervention, follow-up counseling, support groups, stress management, and employee assistance programs to help victims of workplace violence deal with the aftermath of violence. The workplace violence prevention program should include a mechanism to analyze trends, assess strengths and weaknesses of the program, measure improvements, and maintain current knowledge of strategies to reduce the occurrence of workplace violence. Periodic, unannounced assessments of the organization for violations of security and staff members ability to deal with aggressive or potentially aggressive patients should be conducted. Appropriate staff members, such as security guards and emergency department personnel, should receive training in responding to agitated, potentially violent persons. Such training may include ways to physically restrain agitated, violent persons without causing them injury. continuing education endeavors. The organization s professional development/staff development department and human resource department should work with administration, management, and staff members to plan, implement, and evaluate education offerings pertaining to workplace violence prevention (About.com Psychology, 2011; American Nurses Association, 2015; Joint Commission, 2010; Joint Commission, 2013). Page 105

108 Strategies for the implementation of ongoing education and training How to deal with verbally and/or physically violent persons. How to document occurrences of workplace violence. How to access employee assistance if workplace violence is experienced. As appropriate, physical restraint and crisis management techniques to subdue violent persons. Orientation Workplace violence prevention strategies should be part of the orientation of every employee. Topics to include are (About.com Psychology, 2011; Joint Commission, 2010; Joint Commission, 2013; Scott, 2015): A discussion of policies and procedures related to workplace violence. An explanation that the organization has a zero tolerance toward workplace violence. An explanation that there will be no reprisals or disciplinary action taken against employees who report workplace violence. A review of data pertaining to the occurrence of workplace violence and the organization s response to these occurrences. Conditions that can predispose patients, families, and visitors to become violent. Reasons for the occurrence of workplace violence. Warning signs of escalating anger and aggression. Techniques to calm angry and/or agitated persons. Employees should be given the opportunity to express concerns and ask questions. The purpose of addressing workplace violence during orientation is not to frighten employees but to prepare them to help prevent the problem and deal with it if they experience it. Nursing consideration: The depth and specifics of interventions will vary depending on the role of the employee in the organization. For example, a security guard or emergency department nurse may receive training in the physical restraint of violent patients. A member of the housekeeping department would most likely not receive such training. Annual mandatory training All healthcare employees are required to participate in mandatory training on an annual basis, with common topics including infection control, safety, and risk management. As part of safety training, prevention of and dealing with workplace violence should be addressed (Joint Commission, 2010; Joint Commission, 2015). Continuing education Continuing education involves offering additional information beyond what is provided during orientation and annual mandatory training. Such information might include (Avillion, 2015): Current statistics on the incidence and prevalence of workplace violence. Information regarding new techniques to help calm patients, family members, and visitors. Data pertaining to incidence and prevalence of workplace violence occurrences within the organization, including strengths and Simulation of workplace violence Simulation of clinical situations has been used as an education technique for a considerable length of time. Simulation of workplace violence can be used to prepare staff members to defuse such situations (Avillion, 2015). Simulation can also be used to help staff react if violence actually occurs. Various scenarios such as a visitor who is under the influence of alcohol, a confused patient, or a family member who is angry about the care a loved one received can be simulated. Summary In summary, violence in the workplace is a problem that must be dealt with by every organization. A zero tolerance for such violence must be clearly established and upheld by all members of the administrative and management staff. A workplace violence prevention program must be developed and implemented with the cooperation and support of all employees. Barriers to the reporting of workplace violence must be identified and eliminated, and reasons for the occurrence of such violence discussed. All employees, including administrators and managers, must receive ongoing training and continuing education about the incidence and prevalence of workplace violence, how to prevent such violence, and how to deal with it if it occurs. Competency of the ability to help prevent and deal with workplace violence should be assessed. Page 106 Time for such training is limited. Numerous topics must be addressed within a limited time frame. Case studies, role play, and computer-based training are all ways to incorporate prevention of and dealing with workplace violence as part of annual mandatory training. Competency of staff members regarding workplace violence should be assessed. Ways to assess competency include demonstrating effective communication as part of a role play demonstration and written quizzes. weaknesses of the organization s workplace violence prevention program. Current techniques (as appropriate depending on the employee s role in the organization) for the restraint of violent persons that can be implemented without harming those persons. Such training should be offered by educators who are trained in physical crisis management techniques. Simulations can be conducted in a classroom setting or spontaneously enacted in the actual work setting. The focus of simulation is to help prepare staff members to better cope with the problem of workplace violence. Simulation can also be used to assess competency of staff members to defuse potentially violent situations as well as their ability to deal with actual violence. Someone who is trained in simulation and debriefing should conduct these simulations to ensure that the most is gained from the learning experience (Billings & Halstead, 2012). Workplace violence should be part of the annual mandatory training that all employees receive. Data pertaining to the organization s specific record of incidence and prevalence of workplace violence, as well as the violence prevention program s strengths and weaknesses, should be shared with employees. Employees have the right to know just how safe their workplace is. Employees also have the responsibility to help enhance the safety of their work environment. Responsibilities include helping to write and evaluate relevant policies and procedures, participating in continuing education and training pertaining to workplace violence, and reporting unsafe conditions including documenting incidents of workplace violence. Workplace safety is the responsibility of all employees.

109 References 1. American Nurses Association. (2015). Workplace violence. Retrieved from nursingworld.org/workplaceviolence. 2. Avillion, A. E. (2015). Nursing professional development: A practical guide for evidence-based education. Danvers, MASS: HCPro. 3. Bigelow, S. M. (2014). How can I deal with difficult patients? Retrieved from medscape.com/viewarticle/ Billings, D. & Halstead, J. (2012). Teaching in nursing: A guide for faculty. St. Louis, MO: Saunders Elsevier. 5. Brooks, A. (2015). 10 terrific tips for new nurses dealing with difficult patients. Retrieved from 6. Centers for Disease Control and Prevention. (2014). Occupational violence. Retrieved from Cherry, K. (2016). Top 10 nonverbal communication tips. Retrieved from com/top-nonverbal-communication-tips Comerford, K. C. (2016). Nursing2016 drug handbook. Philadelphia, PA: Wolters Kluwer. 9. Elliott, D. Y, Geyer, C., & Doty, L. (2012). Managing alcohol withdrawal hospitalized patients. Nursing2012, 42(4), Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L, & MacLean, 11. S. (2009). Violece against nurses working in US emergency departments. Journal of Nursing Administration, 39(7-8), Gagalanti, G. A. (2016a). Cultures: Hispanic/Latino. Retrieved from profiles/hispanic.html. 13. Gagalanti, G. A. (2016b). Cultures: Middle Eastern. Retrieved from profiles/middleeastern.html. 14. Gagalanti, G. A. (2016c). Cultures: Asian. Retrieved from asian.html. 15. Gagalanti, G. A. (2016d). Cultures. Retrieved from Healthyplace.com. (2016). Cycle of violence and abuse and how to break the cycle of abuse. 17. Retrieved from Joint Commission. (2010). Preventing violence in the health care setting. Sentinel Event Alert, Issue 45, June 3, Joint Commission. (2013). Revisiting disruptive and inappropriate behavior. Retrieved July 11, 2016 from behavior/. 20. Joint Commission. (2016). Bullying has no place in health care. Retrieved fromhttps://www. jointcommission.org/assets/1/23/quick_safety_issue_24_june_2016.pdf. 21. LaGrossa, J. (2013). Confronting workplace violence in nursing: Nurses should not accept or tolerate violence as part of the job. Retrieved from Confronting-Workplace-Violence-in-Nursing.aspx. 22. Leckey, D. (2011). Ten strategies to extinguish potentially explosive behavior. Nursing2011, 41(8), Neese, B. (2015). Effective communication in nursing: Theory and best practices. Retrieved from Occupational Health Safety. (2016). Joint Commission launches workplace violence resource center. Retrieved from Occupational Safety and Health Administration (OSHA). (2016). Workplace violence. Retrieved from Occupational Safety and Health Administration (OSHA). (2015). Guideline for preventing workplace violence for healthcare and social service workers. Retrieved from Publications/osha3148.pdf. 27. Scott, V. (2015). Workplace conflict resolution essentials for dummies. Hoboken, NJ: Wiley Publishing. 28. Stevenson, K. N., Jack, S. M., O Mara, L., & LeGris, J. (2015). Registered nurses experiences of patient violence on acute care psychiatric inpatient units: An interpretive descriptive study. BMC Nursing. Retrieved from United States Department of Justice. (2011). Special report. Workplace violence, Washington, D.C: Office of Justice Programs. Bureau of Justice Statistics. 31. Verywell. (2016). Top 10 nonverbal communication tips. Retrieved from top-nonverbal-communication-tips Page 107

110 PATIENT AND FAMILY ANGER: WHAT TO DO WHEN FRUSTRATION SPILLS INTO THE WORKPLACE Self-Evaluation Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet. 1. In the hospital setting, workplace violence occurs most often in: a. Oncology units. b. Waiting rooms. c. Psychiatric units. d. b and c. 2. Which of the following statements pertaining to barriers to the reporting of workplace violence is accurate? a. Recent legislation has helped to define a standardized national definition of workplace violence. b. Employees may be embarrassed that they cannot defuse an aggressive situation. c. Fear of political consequences is no longer a barrier to reporting. d. Research now shows that nearly 100% of workplace violence incidents are reported to management. 3. A nurse who works in the emergency department is punched by a patient whose alcohol level is above the legal limit. She does not report the incident since she believes that everyone gets hurt eventually if they work in emergency departments. This nurse is exhibiting what barrier to reporting workplace violence? a. Fear of retaliation. b. Failure to understand the scope of the problem. c. It s just part of the job. d. Lack of managerial support. 4. According to an analysis of the Joint Commission s Sentinel Event Data Base concerning workplace violence: a. In 53% of reported events inadequate communication among staff, patients, and families were noted. b. Flaws in leadership had little or no impact on incidences of workplace violence. c. Inadequate assessment contributed to less than half of reported events. d. Patient education issues triggered about 40% of workplace violence events. 5. Which of the following situations indicates a violation of patient culture or values that may lead to triggering anger in patients and/ or families? a. Apologizing to a patient who is a vegetarian and received a meal containing meat. b. Supporting a patient s decision to discontinue chemotherapy. c. Trying to convince a patient who is a visitor from the Middle East that he should participate in psychosocial counseling. d. Respecting an older Hispanic female patient s decision to allow her husband to function as her decision-maker. 6. A patient is undergoing open heart surgery. The surgery is taking longer than they initially expected and her family is becoming anxious and upset. They are in the waiting area outside the cardiac critical care unit. The nurse who will be taking care of the patient approaches them. One of the family members shouts What is happening to my mother? This waiting is driving me to distraction! The best response the nurse could make is: a. This type of surgery generally lasts for at least another hour. Would you like to wait in your mother s room or would you prefer to get a cup of coffee in the coffee shop. b. Honey, just relax while I try to get more information. But this surgery usually takes a long time. c. I know you re upset but don t shout at me. d. Your mother wouldn t want you to worry so much. 7. A patient is listening to the nurse practitioner explain treatment options for a diagnosis of stage I breast cancer. The patient nods her head periodically and says I understand what you are telling me. She is wringing her hands slightly and her respiratory rate is increasing. What is the most accurate assessment of what the patient is communicating? a. The patient is understandably nervous but is under control. b. The patient is too upset to continue the teaching session. c. The patient s body language indicates early warning signs of agitation. d. The patient is about to become physically violent. 8. Cultural awareness is critical to enhancing nurse patient communication and avoiding situations that could become violent. Which of the following examples indicates good cultural awareness? a. Using hand gestures to emphasize important points when providing patient education to a Japanese patient. b. A female nurse taking the hand of a male patient who is Muslim. c. A nurse avoids eye contact with a Mexican patient who has been hospitalized while visiting family members in the United States. d. Winking at a patient from Taiwan when telling her a joke. 9. When taking action to maintain personal safety the nurse should: a. Maintain an exit pathway. b. Trust her/his instincts. c. Dress appropriately. d. All of the above. 10. Implementation of ongoing education and training for violence prevention should include: a. An explanation that the organization will tolerate only minimal occurrences of workplace violence. b. Opportunities to express concerns and ask questions. c. How to document occurrences of workplace violence. d. b and c. Answers: 1.D 2.B 3.C 4.A 5.C 6.A 7.C 8.C 9.D 10.D Page 108

111 Patient Safety: Implementation of National Safety Standards for Nurses Release Date: 2/15/2016 Expiration Date: 2/15/2019 Faculty Adrianne E. Avillion, D.Ed., RN Dr. Avillion is an accomplished nurse educator and published healthcare education author. Dr. Avillion earned her doctoral degree in adult education and her M. S. from Penn State University, along with a BSN from Bloomsburg University. Adrianne has served in various nursing roles over her career in both leadership roles and as a bedside clinical nurse. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing education and nursing professional development. She currently owns and is the CEO of Strategic Nursing 4 Contact Hours Professional Development, a business that specializes in continuing education for healthcare professionals and consulting services in nursing professional development. Additionally, she writes on safety issues in her role as editor and writer of a newsletter for The National Association of Physicians Nurses as well as incorporates safety education as part of continuing education tutorials for various continuing education companies. Content reviewer Nancy J. Denke, DNP, ACNP-BC, FNP-BC, FAEN Audience National patient safety standards are a core competency for nursing practice. This course is for all nurses who are responsible for providing patient care. Purpose statement Safety comes first in patient care and in health care environments. This course presents the latest National Patient Safety goals as well as strategies for nursing. Learning objectives Implement patient care designed to achieve National Patient Safety Goals. Describe how to prevent never-ever events. How to receive credit Read the entire course online or in print which requires a 4-hour commitment of time. Depending on your state requirements you will asked to complete either: An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through March 1, 2021); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Nursing, Provider Explain how to reduce the occurrence of non-reimbursable hospital-acquired conditions. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print your Certificate of Completion. # ; Florida Board of Nursing, Provider # ; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Page 109

112 Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent Sponsorship/Commercial Support and Non-Endorsment It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction Safety first! There is not a practicing healthcare professional who would not agree that safety first is (or should be) the guiding principle of patient care services. Given that, why are medical errors the third leading cause of death in the United States? Why, according to recent research, do nearly 440,000 Americans die annually from preventable hospital errors [1]? EBP alert! Research shows that an alarming number of healthcare consumers die from preventable medical errors. It is imperative that nurses and their healthcare colleagues comprehend safety mandates and safety research findings and then implement the recommendations into all aspects of their practice [1,2]. Clearly, it is essential for all healthcare providers to improve the safety of the environment in which patient care is delivered. Accrediting National Patient Safety Goals It is a typically hectic evening at one of the Hazelmoor Community Hospital medical units. A notice has been shared and posted that concerns the latest National Patient Safety Goals. Nurses are requested to familiarize themselves with these goals and how the hospital plans to achieve them. The nurses know that they must eventually make time to review this information, but that time is not tonight as it is just too busy, and patient care comes first. Nor is there time the next evening. Nor the next. Time goes by, and as one nurse puts it, Our patients come first. We can t stop to read a bunch of stuff when we should be taking care of patients. That s why safety is compromised. All of this paper work and theory! The people that write History of the National Patient Safety Goals The National Patient Safety Goals (NPSGs) are a set of standards which address the highest-priority patient safety issues that The Joint Commission promotes and utilizes to implement major changes in patient safety [3]. The NPSG program was established in 2002 and the first set of NPSGs was effective on January 1, The purpose of establishing such goals was to assist accredited organizations in addressing specific areas of concern regarding patient safety [4]. How are the NPSGs developed, and who develops them? According to The Joint Commission website, a panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs [4]. This panel is called the Patient Safety Advisory Group and is comprised of nurses, physicians, pharmacists, bodies and national organizations such as The Joint Commission and the Institute of Medicine have conducted research, published reports, and issued mandates regarding safety measures that should, and must, be implemented. But, how much is the average healthcare professional aware of such research and the rationale behind mandates and recommendations? The purpose of this educational program is to discuss three critical topics related to essential safety standards: National Patient Safety Goals. Never ever events. Centers for Medicare and Medicaid Services conditions that are not reimbursable if not present upon admission. The educational program will also explain how nurses can implement the recommendations and mandates of these standards to improve patient safety as well as the quality and appropriateness of their practice. these things should try being out here actually taking care of patients. Then maybe they d see what it s like in the real world! Does the preceding situation sound familiar? Have you heard colleagues make similar statements? Have you made such comments yourself? You are not alone. Many healthcare professionals do not have a clear understanding of the National Patient Safety Goals, or how achieving these goals will improve patient care. It is not enough to distribute facts about these goals and what should be done to achieve them. Leaders of healthcare organizations have an obligation to explain how these goals were identified, how each organization developed a plan for achieving these goals, and most importantly, how the goal achievement will improve patient care. risk managers, clinical engineers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of healthcare settings. The Patient Safety Advisory Group works with staff from The Joint Commission to identify emerging patient safety issues, and advises The Joint Commission on how to address those issues in NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, and/or in Center for Transforming Healthcare projects [4]. Large amounts of data are generated by the collaboration of The Joint Commission and the Patient Safety Advisory Group. How does The Joint Commission determine patient safety issue priorities for Page 110

113 NPSGs when faced with so much information? Input is solicited from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders. Based on this input, The Joint Commission identifies priority patient safety issues, and how to best address them. The Joint Commission also determines if an NPSG is applicable to a specific accreditation program. If so, the goal is adapted to be program-specific [4]. Nursing consideration: Nurses may be concerned that the people who have input into the development of safety priorities lack current experience in patient care delivery. One way to alleviate these concerns, and to encourage staff nurses to become more involved in implementing NPSG recommendations is to encourage them to become more involved with The Joint Commission Perhaps they may even become a member of the Patient Safety Advisory Group or become active in another Joint Commission process. For more information about the Patient Safety Advisory Group, contact the Executive Vice-President and Chief Medical Officer of The Joint Commission at +1 (630) , or access The Joint Commission website for more information ( NPSGs alert! What exactly are the responsibilities of the Patient Safety Advisory Group? As stated directly on the website, the group [5] : Annually recommends program-specific NPSGs for adoption by The Joint Commission Board of Commissions. Reviews draft patient safety recommendations for potential publication in The Joint Commission s periodic Sentinel Event Alert advisory, and advises Joint Commission staff as to the evidence for, and face validity of these recommendations as well as their practically and cost of implementation. Recommends potential future topics for Sentinel Event Alert. Assesses and facilitates learning initiatives about sentinel events, Sentinel Event Alerts, and the National Patient Safety Goals, including the implementation and effectiveness of the National Patient Safety Goals. Learning initiatives include: online tools such as Frequently Asked Questions and PowerPoint presentation;, tool kits to facilitate implementation of the National Patient Safety Goals; and education seminars and workshops. Current National Safety Goal priorities Samantha is a registered nurse who was recently appointed as a member of her hospital s Safety Advisory Council. She is preparing to attend her first meeting. The focus of the meeting will be a review of the newly published National Patient Safety Goals (NPSGs). Samantha is a bit uneasy about this focus as her role as a staff nurse has been to implement actions mandated by the hospital to comply with the goals. Now she is going to be in a position to help design actions that she and her colleagues must implement. This is a major responsibility, and Samantha is both excited and apprehensive about her new accountability as a leader. Samantha and other stakeholders must not only follow organizational mandates in regards to compliance with NPSGs, but must become active participants in the decision-making process of how these goals can be achieved. Since their establishment in 2002, the NPSGs have evolved to become one of the most important methods of promoting and enforcing major safety changes in healthcare organizations. Recent 2016 Hospital National Patient Safety Goals The following summaries are based on information taken from The Joint Commission web site s easy-to-read version of the goals [6]. The easy-to-read version is intended for the general public as well. For the exact language of the goals, access: Identify patients correctly. Use at least two ways to identify patients. For example, use the patient s name and date of birth. This will make sure that each patient gets the correct medications and treatments. Make sure that the correct patient gets the correct blood when receiving a blood transfusion. Nursing consideration: Nurses must always be sure to identify patients in at least two ways prior to administering medications and blood products. Nurses may be tempted to ignore this simple safety mandate, especially if they know the patient well. But, ignoring the mandate even once makes it easier to ignore it again, and then again. Nurses also serve as role models for colleagues bound by the same mandate. Nurses must always use at least two methods to identify each patient [6]. Improve staff communication. Get important test results to the right staff person on time. changes, in addition to existing goals, have concentrated on preventing hospital-acquired infections and medication errors, promoting surgical safety, ensuring correct patient identification, enhancing communication between staff, and identifying patients at risk for suicide. The most recent 2016 goal is to reduce the harm associated with clinical alarm systems [3]. Before discussing the implications of the newest goal related to the safety of hospital alarm systems, we must review the other goals highlighted in the 2016 NSPGs. Each goal was developed to evaluate the safety and the quality of care provided for patients in the different care arenas which include hospitals, home-care, ambulatory care, behavioral health, critical-access hospitals, laboratories, long-term care, nursing-care centers, and office-based surgery. To access information about each 2016 NPSGs, go to this website link: For the purpose of this educational program, we will focus on the hospital, ambulatory care, and home-care goals. Nursing consideration: Communication is essential to reduce errors. Research shows that appropriate communication enhances patient safety [7]. Research shows that poor communication can contribute to medical errors while good communication can help to reduce their occurrence [7]. However, improving staff communication is not limited to just getting test results to the right person in a timely manner. Communication involves sharing information as a team about the patient s status and progress toward desired outcomes. Use medicines safely. Before a procedure, label medicines that are not labeled, for example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medications to thin their blood. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Page 111

114 Nursing consideration: In addition to complying with the preceding directives, nurses must ensure medication lists are reconciled each time a patient is transferred from or accepted from another healthcare facility or patient care area. Educate patients and families how to safely take their medications at home. Have them demonstrate safe self-medication practices. Do not ask them simple yes and no questions such as Do you know what side effects your medication can cause? Instead, ask them Tell me what side effects your medicine can cause and what you should do if these happen. Be sure to assess their knowledge in a practical way. Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. This is a major addition to the 2016 NPSGs. It will be discussed in detail later in this program. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO). Set goals for improving hand cleaning, and use these goals to improve hand cleaning. Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent blood infection from central lines. Use proven guidelines to prevent infection after surgery. Use proven guidelines to prevent infections of the urinary tract that are caused by catheters Home Care National Patient Safety Goals This summary is taken directly from The Joint Commission s easy-toread version [10]. Identify patients correctly. Use at least two ways to identify patients. For example, use the patient s name and date of birth. This ensures that each patient gets the correct medicine and treatment. Use medicines safely. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Nursing consideration: Nurses should have patients or families demonstrate safe self-medication. It is not enough to simply give them information about their medications and ask yes or no questions such as, Do you understand how to take your medicine? Instead have them explain what side effects might occur and what to do about them, or have them actually demonstrate how to administer a specific medication. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO). Set goals for improving hand cleaning. Use these goals to improve hand washing. Nursing consideration: Nurses must teach patients and friends appropriate hand washing techniques. This includes when and how to implement the techniques. EBP alert! Research shows that proper hand washing is the most effective way to prevent the spread of infections in hospitals [8]. Nurses have an obligation to share research findings that show that this and other infection control interventions really do help to prevent infection. Adults are more likely to apply knowledge in the work setting if they have evidence that specific interventions actually work. Identify patient safety risks. Find out which patients are likely to try to commit suicide. Nursing consideration: The prevalence of mental illness makes it almost a certainty that nurses, no matter where they practice, will care for persons who are currently experiencing a mental illness. It is estimated that 25 percent of all adults in the United States will develop at least one mental illness during their lifetime [9]. Nurses must be aware of the signs and symptoms as well as information from the patient s personal and family history that indicate a patient is at risk for suicidal behavior. Prevent mistakes in surgery. Make sure that the correct surgery is conducted on the correct patient, and at the correct location on the patient s body. Mark the correct place on the patient s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. Nursing consideration: It is essential that nurses be alert to the possibility of any potential errors in the surgical setting and act swiftly to prevent their occurrence. Prevent patients from falling. Find out which patients are most likely to fall. For example, is the patient taking any medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients. Nursing consideration: Nurses must also be alert to other safety hazards or issues in the patient home that contribute to falls such as scatter rugs, highly polished floors, wet surfaces and mobility difficulties. Identify patient safety risks. Find out if there are any risks for patients who receive oxygen. For example, are there fireplaces in the patient s home? Nursing consideration: Nurses must teach patients and families how to avoid hazards associated with oxygen therapy. Increasing the awareness of contraindications when a family member is on oxygen therapy, such as smoking, must be communicated to persons visiting the home where oxygen is in use Ambulatory Care National Patient Safety Goals The following summary is taken from The Joint Commission s easyto-read version [11]. The 2016 goals for ambulatory care are similar to those of hospitals and include: Identify patients correctly. Use medicines safely. Prevent infection(s). Prevention of mistakes in surgery. Page 112

115 2016 NPSG: Clinical alarm safety Ben is an experienced cardiovascular care nurse. He is working on the step-down cardiac care unit, and has been one of the leaders on the unit for many years. A new nursing employee is touring the unit with the nursing director as part of her hospital orientation. She comments, Isn t anyone worried about all of the alarms going off? Nobody seems to be concerned. Ben explains that, Most alarms are actually false. You get to know what is real and what isn t. For instance, we have one man whose alarm goes off all the time because he s a really restless sleeper. At that moment the code for cardiac arrest is heard coming from the room of the man who is a restless sleeper. His cardiac monitor alarm had been going off for several minutes. Unfortunately, the alarm had been ignored and now the patient is in cardiac arrest. Alarm fatigue occurs when the daily number of alarm signals, such as bells, beeps, and tones from medical devices (especially physiological devices), overwhelms healthcare personnel with information. This can actually desensitize healthcare personnel to the alarms themselves. Nurses and other healthcare professionals may turn alarm volumes down in an effort to control noise levels. Turning down the volume may create an unsafe environment for the patient. After a period of time, clinicians may not respond to alarms simply because the alarms have become part of the normal background noise of a unit, and no longer trigger concern [12]. EBP alert! Research shows that 80 to 99 percent of alarms generated by devices such as ventilators, blood pressure monitors, and electrocardiograms are false and/or do not actually need any clinical intervention [13]. Clinicians are becoming desensitized to the sounds of alarms, and experiencing alarm fatigue. Nurses and other healthcare professionals must work with each other to make eliminating alarm fatigue a priority. This can be accomplished by avoiding unnecessary monitoring, and educating clinicians to the full potential of devices. The extent to which alarm fatigue has adversely affected patients is not precisely known. The United States Food and Drug Administration s Manufacturer and User Facility Device Experience Database listed 566 alarm-related deaths between January 2005 and June This number is believed to under-represent the actual cases [12]. From 2009 to 2012, The Joint Commission reported 98 alarm-related events, 80 of which resulted in death, 13 resulted in permanent loss of function, and five resulted in unexpected additional care or extended stays. Since sentinel event reporting to The Joint Commission is voluntary, some experts believe that this number represents less than ten percent of such adverse occurrences [13]. Healthcare safety experts agree that alarm fatigue is becoming worse, and the consequences of this are perilous [4,12,13]. In June 2013, The Joint Commission approved a new NPSG on clinical alarm safety for hospitals and critical access hospitals. This goal was implemented in two phases. Phase one began on January 1, 2014 when hospitals were required to establish alarm safety as an organizational priority, and to identify the most important alarms to manage based on their internal situations. Phase two began on January 1, 2016 and hospitals are expected to develop and implement specific components of policies and procedures, and to educate staff in the organization of alarm system management [4]. The Joint Commission points out that clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety [14]. The Joint Commission also notes that the problem of alarm safety is multifaceted. Alarms may be difficult to detect. There may be numerous alarm signals that tend to desensitize staff and contribute to persons missing or even ignoring alarm sounds. Some staff members may even turn off alarms to decrease the amount of noise on a particular unit [14]. Desensitization to alarms may have serious or even fatal consequences for patients. In addition to The Joint Commission, several organizations have compiled useful information about safely managing alarm systems. For example, the Advancement of Medical Instrumentation (AAMI) founded in 1967, is a nonprofit organization with a mission to develop, manage, and use safe and effective healthcare technology. On the organization s website, they are described as the primary source of national and international consensus standards for the medical device industry as well as a source of practical information, support, and guidance for healthcare technology and sterilization professionals [15]. More detailed information can be found at their website: Another source of information is the ECRI Institute, an independent nonprofit organization whose mission is to benefit patient care by promoting the highest standards of safety, quality, and costeffectiveness in healthcare [2]. The institute accomplishes its mission through research, publishing, education, and consultation. ECRI s goal is to be the world s most trusted, independent organization providing healthcare information, research, publishing, education, and consultation to organizations and individuals in healthcare [2]. The ECRI Institute compiles an annual top ten list of patient safety concerns based on its review of patient safety event reports, research requests, and root-cause analyses submitted to the ECRI Institute PSO. This is one of the first patient safety organizations (PSOs) to be federally certified under the provisions of the Patient Safety and Quality Improvement Act (PSQIA). The ECRI Institute s report is not simply a list. It recommends that healthcare organizations use the list of patient safety concerns as a starting point for their patient safety discussions and for establishing their patient safety priorities [2]. The ECRI Institute also provides some free safety resources on its website: Since the ECRI Institute began publishing its list of top health technology hazards in 2007, alarm hazards have been at or near the top of the list [2]. Although the current Joint Commission emphasis is on alarm fatigue, the ECRI Institute is encouraging healthcare organizations to look beyond alarm fatigue, and investigate the incidence of alarms that do not activate when a patient is in distress. According to the senior project officer at the institute, alarm-related adverse events, whether due to missed alarms or unrecognized alarm conditions, can often be traced to alarm systems that were not configured appropriately. The ECRI Institute recommends that organizations examine their alarm configuration policies and procedures and ensure that they address the full range of factors that can lead to alarm hazards [2]. January 4, 2016: The Safety Council is meeting today, the first regular work day of the new year. Members of the council are reviewing their compliance with The Joint Commission s alarm safety goal. Compliance was to have been achieved on January 1, The Safety Council members are confident that the policies and procedures that have been in place since October 2015 adequately meet Joint Commission standards; however, they are not going to relax. Today, council members are going to review safety data, including adverse events reports, particularly those relating to alarm safety. They have also invited several staff nurses and therapists, who work daily on units that are sometimes bombarded by the constant noise of alarms, to attend the meeting. Members want to know how these healthcare professionals have been implementing policies and procedures, and what revision suggestions they may have to further enhance patient safety. Nursing consideration: The preceding example of a fictional Safety Council demonstrates the importance of constantly reviewing actions undertaken to meet safety standards. It also emphasizes the importance of soliciting feedback from practitioners who work with these identified safety dilemmas every day. Page 113

116 Experts note, that in order to adequately address patient safety and clinical workflow, an overall plan must be developed to manage clinical interruptions. This plan must include [16] : Addressing alarms (e.g. physiological monitors). Responding to alerts (e.g. critical lab notification). Communicating with members of the healthcare team. Nursing consideration: In order to effectively address the problem of alarm safety, nurses should also know what types of adverse events have occurred that are linked to problems with alarms. What types of alarm-related adverse events have been reported? According to information from the U. S. Food and Drug Administration s Manufacturer and User Facility Device Experience database, falls, delays in treatment, ventilator use, and medication errors were causes of death or common injuries related to alarms [12]. Factors that contributed to these injuries or fatalities included [12] : Absent or inadequate alarm systems. Improper alarm settings. Alarm signals that were not audible in all areas. Nursing consideration: Key recommendations from The Joint Commission and other safety experts regarding alarm safety include [12] : Establish a cross-disciplinary team to address the potential effect of alarm fatigue in all patient care areas. Create priorities for the adoption of alarm technology. Train clinical care teams on safe alarm management and response in high-risk areas and on the safe use of the devices. Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission as of November 2015, suggests that healthcare organizations begin their alarm safety efforts by determining the baseline number of device alarms per day. They should then be able to answer the following questions [13] : How many alarms required a clinical intervention? How many alarms resulted in harm or death? What are the organization s current monitor alarm default parameters? How can we adjust alarms to indicate actionable alarms? Nursing consideration: Nurses are all too well aware that many alarms do not actually indicate an actual patient problem or emergency. Some experts recommend that clinicians work with engineers and equipment manufacturers to customize the configuration of alarms and avoid the overlapping of redundant alarms. These changes must demonstrate a means for staff to quickly recognize alarms that need immediate attention. Additionally, some experts say that unnecessary patient monitoring results in excessive nuisance alarms. Patients should be monitored only when it is clinically necessary. Alarms should be individualized for each patient to make the alarms most effective [13]. It is necessary for all healthcare organizations to have a documented and functional work plan to achieve the alarm National Patient Safety Goal [17], in addition to the specific requirements and explanations outlined in the 2016 Joint Commission National Patent Safety Goals [18]. The Joint Commission Sentinel Event Alert published on April 8, 2013 provides very helpful information to deal with the problem of alarms [19]. The Joint Commission Sentinel Event Alert of April 8, 2013 focuses on medical device alarm safety in hospitals. The Joint Commission s Sentinel Event database includes 98 alarm-related events (80 of which led to fatalities) reported from January 2009, to June The majority of events, 94 of 98, occurred in hospitals. The majority of the 94 events occurred in telemetry, intensive care, general medicine, and emergency department areas [19]. For the alarm-related events reported to The Joint Commission, major contributing factors included [19] : Absent or inadequate alarm system(s). Improper alarm settings. Page 114 Alarm signals that were not audible in all areas. Alarm signals inappropriately turned off. EBP alert! Research shows that the preceding factors have contributed to alarm-related problems. All nurses must be familiar with research findings related to this issue and be advocates for the reduction of alarm-related incidents [19]. Additional factors that contributed to alarm-related sentinel events have been identified by The Joint Commission. These include [19] : Alarm fatigue. Alarm settings that have not been customized to the individual patient or patient population. Inadequate staff training or education on the proper equipment use and functioning. Inadequate staffing to support or respond to alarm signals. Alarm conditions and settings that are not integrated with other medical devices. Equipment malfunction and failure. EBP alert! Research shows that alarm fatigue is the most common contributing factor related to alarm-related sentinel events. Thus, all clinicians must take every possible action to resolve the problem of alarm fatigue [19]. So now we know the major factors that contribute to alarm-related adverse events. What do we do about them? The Joint Commission, the Association for the Advancement of Medical Instrumentation (AAMI), and ECRI Institute have compiled a number of recommendations for the reduction of patient harm related to alarm systems [2,19] : Organizational leadership must ensure that there is a process for safe alarm management and response in high-risk areas identified by the organization. Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions. Identify the default alarm settings and the limits for such devices. Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions. Alarm alert! When establishing such guidelines, include identification of situations when alarm signals are not clinically necessary [19]. Establish guidelines for tailoring alarm settings, and limits for individual patients. These guidelines should address situations when limits can be modified to minimize alarm signals, and the extent to which alarms can be modified to minimize alarm signals. Inspect, check, and maintain alarm-equipped devices to provide accurate and appropriate alarm settings, proper operation, and detectability. Alarm alert! The frequency of inspection, checking, and maintenance activities should be based on established criteria such as manufacturers recommendations and risk levels [19]. All members of the clinical care team should receive education and training on the organization s process for safe alarm management and response in high-risk areas, and on the safe use of the alarmed medical devices on which they rely. To help in the reduction of nuisance alarm signals, it is recommended that single-use sensors be changed according to manufacturer s recommendations, unless contraindicated. Assess the acoustics in the patient environments to determine if critical alarm signals are audible. Organizational leadership must re-establish priorities for the adoption of alarm technology. Note that the priority-setting process

117 should drive technology adoption rather than allowing technology to drive priority-setting. Establish a cross (interdisciplinary) team that includes representation from clinicians, clinical engineering, information technology, and risk management to address alarm safety and the potential impact of alarm fatigue in all patient care areas. Never ever events What does the term never ever event mean? First introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), the term never ever event is used to describe especially shocking medical errors (such as wrong-site surgery) that should never occur. The list of never ever events has grown over time to include adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable [21]. The current list, revised in 2011, consists of 29 events, grouped into seven categories [21] : Surgical events. Product or device events. Patient protection events. Surgical events Carolyn is a young nurse who is about to begin her dream job as a surgical nurse in a prestigious operating theater at a major metropolitan medical center. She has had three years of experience as a staff nurse on a large post-operative surgical unit, and has recently completed her operating room orientation. Today she and her colleagues are dealing with a heavy caseload of outpatient surgeries. The next patient is scheduled to have a partial mastectomy of the right breast. Dr. Marlene Mason, the surgeon scheduled to perform the operation, has a reputation of being a bully and verbally abusive to the nurses working with her. One of Carolyn s colleagues whispers a warning to her, Be alert today. This is Mason s fourth case today and she s in a horrible mood. One of her patients went downhill during surgery this morning and died soon after the surgery was completed. Dr. Mason enters the operating room and immediately begins complaining about the way the nurses have set up the room. She spots Carolyn and groans, Don t tell me I have to deal with some new kid that doesn t know what she s doing. I need competent help in here! OK let s get this over with. It s a simple partial mastectomy of the left breast so even you should be able to deal with it. Carolyn is horrified and explains that the procedure is to be performed on the right, not the left, breast. The surgeon becomes agitated and accuses Carolyn of insubordination and orders her from the room. Get out! Don t you think I know what I m doing? It s the left breast! She shoves Carolyn towards the exit as Carolyn s supervisor arrives. The supervisor clarifies that the surgery is to be performed on the right breast and tells the operating room team to take a time out until this situation is under control. The preceding example is an example of a never ever event that is on the verge of occurring. Unfortunately, healthcare professionals are not strangers to circumstances that are out of control. The response to such circumstances is to ALWAYS act in the best interest of the patient. Carolyn acts appropriately in the best interest of the patient to avoid the tragic occurrence of a never ever event. Surgical never ever events include [21] : Surgery or other invasive procedure performed on the wrong body part. Surgery or other invasive procedure performed on the wrong patient. Wrong surgical or another invasive procedure performed on a patient. Unintended retention of a foreign object in a patient after a surgery or another procedure. Intra-operative or immediate postoperative/post-procedure death in an American Society of Anesthesiologists Class I patient. Share information about alarm-related incidents with appropriate organizations such as The Joint Commission, the Food and Drug Administration, AAMI, and the ECRI Institute. Nursing consideration: All staff nurses should be encouraged to contribute input to the development of safe alarm management. They must also be encouraged to seek membership on appropriate councils that address patient safety and quality. Care management events. Environmental events. Radiologic events. Criminal events. The never ever sentinel events most often reported to The Joint Commission are [21] : Wrong-site surgery (13.5 percent). Suicide (12 percent). Op/post-op complications (11 percent). Delay in treatment (8.3 percent). Medication error (8.2 percent). Patient fall (6.3 percent). Nursing consideration: All nurses, not just those who work in the surgical suite, must be aware of surgical never ever events. All nurses contribute, to some extent, to the prevention of surgical never ever events. Fortunately, wrong-site, wrong-procedure, and wrong-patient surgery (WSPE) events are relatively rare. Research suggests that such errors occur once out of every 112,000 surgical procedures. To put this in perspective of individual hospitals, this statistic means that an individual hospital would only experience one such error every five to ten years. However, this estimate is based on procedures performed in the operating room. If procedures performed in other settings (such as ambulatory surgery centers) were included, the rate of such occurrences may be significantly higher [22]. The Joint Commission has developed a universal protocol for the prevention of WSPEs. The following is a summary of the critical factors of this protocol taken directly from the organization s website. For the complete protocol, access The Joint Commission website: [23]. Conduct a pre-procedure verification process. Verify the correct procedure, for the correct patient, at the correct site. When possible, involve the patient in the verification process. Identify items that must be available for the procedure. Use a standardized list to verify the availability of items necessary for the procedure. Match the items that are to be available in the procedure area to the patient. Mark the procedure site. For spinal procedures, mark the general spinal region on the skin. Special intraoperative imaging techniques may be used to locate and mark the exact vertebral level. Mark the site before the procedure is performed. If possible, involve the patient in the site marking process. The site is to be marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, site marking may be delegated to some medical residents, physician assistants, or advanced practice registered nurses. Ultimately, the licensed independent practitioner is accountable for the procedure, even when delegating site marking. Page 115

118 The mark must be unambiguous and used consistently throughout the organization. The mark is to be made at or near the procedure site. The mark should be sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site. For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site, use your organization s written, alternative process to ensure that the correct site is operated on. Perform a time-out. Note that the procedure is not to start until all questions or concerns are resolved! Recall that a time-out was called in the sample scenario at the beginning of this section in order to resolve the conflicts that were occurring. Conduct a time-out immediately before starting an invasive procedure or making an incision. A designated team member starts the time-out. The time-out is to be standardized. The time-out involves the immediate members of the procedure team including the individual performing the procedure, the Product or device events A senior year nursing student is providing patient care to a woman who is on mechanical ventilation following a severe car wreck. The student notices that the safety inspection tag on the ventilator expired a few weeks ago. She also notices that her patient has developed a low-grade fever. Could there be some type of contamination of the ventilator? The student reports her findings to the staff nurse responsible for the patient who tells her, Oh, it s not the ventilator. Bio-engineering is so busy that sometimes they can t check every single piece of equipment on time. It s only a couple of weeks late. Unfortunately, the patient s condition deteriorates, and it is determined that the ventilator was harboring bacteria that led to the patient developing pneumonia. The preceding scenario is an example of a never ever that should have been prevented. According to the National Quality Forum s Health Care Never Events, product or device events include [21] : Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting. Patient protection events Mr. Burns is 92 years old and is being discharged from the hospital today following treatment for pneumonia. He has had trouble understanding his discharge instructions. He also displays problems with short-term memory and the ability to perform self-hygiene. Mr. Burns is a widower and his only child, a daughter, lives nearly 700 miles away. Should Mr. Burns be discharged to his home? What obligations do his caregivers have to protect his safety after discharge? This scenario is a good example of a potential patient protection event. Discharging Mr. Burns without further assessment of his ability to function safely at home, or an assessment of his home environment and resources would be negligent. His caregivers have an obligation to ensure his safety. Current assessment indicates Mr. Burns may be unable to make decisions and live safely in his home environment. Patient protection events are among the never ever events identified by the National Quality Forum. These include [21] : Discharge or release of a patient/resident of any age, who is unable to make decisions, to anyone other than an authorized person. Care management events The administrative team and members of the quality/risk management council are meeting under emergency circumstances. A patient has died as the result of a serious medication error. Some members of the Page 116 anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. During the time-out, the team members must agree, at a minimum, on the correct patient identity, correct site, and the correct procedure to be conducted. When the same patient has two or more procedures, if the person performing the procedure changes, another time-out needs to be performed before starting each new procedure. Document the completion of the time-out. The amount and type of documentation is to be determined by the organization. Surgical event alert! As of October 1, 2015 there were 92 wrongpatient/wrong-site/wrong-procedure errors reported to The Joint Commission for the 2015 calendar year [25]. Author s note: The remainder of the National Quality Forum s Healthcare never ever events are summarized in the following sections [21]. Because of, in part, their scope and number, generalized suggestions for achievement are provided. Patient death or serious injury associated with the use of or function of a device in patient care, in which the device is used for functions other than as intended. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting. Nursing consideration: Some suggestions for preventing the preceding never ever events include [21,24] : Remain alert to any drugs, devices, or biologics that have expired expiration or inspection dates, and take immediate action to remove/replace/check such items as appropriate. Monitor all equipment for any evidence of malfunction, and take immediate action to replace/repair such equipment. Monitor connections between catheter connections to prevent air embolism. Patient death or serious disability associated with patient elopement (disappearance). Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility. Nursing consideration: Nurses must work collaboratively with all members of the healthcare team to develop and implement policies and procedures to ensure that patient protection events do not occur. These policies and procedures should include [21,24] : Assessment of a patient s ability to make decisions, including his/her ability to return to a safe environment after discharge. Implementing safeguards to avoid patient elopement from the healthcare setting. Assessment of a patient s mental health, including assessment for suicidal ideation. Such assessment should be conducted on all patients. council want to fire the nurse who made the error and blame the entire tragic adverse event on her. Other council members point out

119 that the error was not just one person s fault, but a combination of events resulting from a flawed medication administration process. A true organizational culture of safety does not play the blame game. An error is seldom the fault of one person. Persons who are interested in improving patient safety should look to improve the processes and systems that are the foundation of any healthcare organization functions. Never ever care management events include [21] : Patient death or serious injury associated with a medication error. Patient death or serious injury associated with unsafe administration of blood products. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy. Artificial insemination with the wrong donor sperm or wrong egg. Patient death or serious injury associated with a fall while being cared for in a healthcare setting. Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a healthcare facility. Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, and/or radiology test results. Nursing consideration: The preceding care management never ever issues are broad in scope and numerous in number, and affect many aspects of patient care. Preventing these events includes following policies and procedures, improving patient/family education, assessing the effectiveness of patient/family education, ensuring excellent communication and collaboration among healthcare team members, and participating in continuing education and training to keep knowledge and skills current [2,21,24,26]. Environment events Environmental never events include [21] : Patient death or serious injury associated with an electric shock while being cared for in a facility, excluding events involving planned treatments such as electric counter-shock. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Patient death or serious injury associated with a burn incurred from any source while being cared for in a facility. Patient death or serious injury associated with the use of or lack of restraints or bedrails while being cared for in a facility. Radiologic events The specific factor identified in the radiologic event category is the introduction of a metallic object into the MRI area associated with the death or serious injury of a patient or staff member [21]. It is imperative Criminal events Criminal never ever events include [21] : Any incidence of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider. Abduction of a patient/resident of any age. Death or significant injury of a patient or staff member resulting from a physical assault that occurs in or on the grounds of a healthcare setting. Additional safety concerns identified by the ECRI Institute As mentioned earlier, the ECRI Institute compiles an annual list of the top ten safety concerns for healthcare organizations. In 2015, the number one identified concern was alarm hazards, which has been discussed in detail. But what are the remaining nine concerns? A summary of the ECRI Institute s additional nine concerns follows. It is likely that these concerns are of importance to most, if not all, healthcare organizations. 1. Data integrity: Incorrect or missing data in EHRs and other health IT systems. Information technology (IT) can help to improve communication, provide swift access to essential data, and reduce errors for all members of the healthcare team. However, in order for IT to improve safety, a system must be in place to ensure that data in the electronic healthcare records (EHRs) are accurately and appropriately transferred to the various IT systems within an organization. Nursing consideration: Prevention of environmental events involves teamwork among clinical and non-clinical staff members. If equipment is malfunctioning, it should be immediately removed from service, and the appropriate department notified for repair and/ or replacement. If a piece of equipment has outdated safety check documentation, the appropriate department must be notified for repair and/or replacement. The use of any type of restraining device must strictly adhere to legal mandates and organizational policies and procedures [2,21,24,26]. that anyone working with a patient undergoing an MRI be alert to the introduction of any metallic objects in the MRI area. A checklist must be completed to assure patient eligibility for this procedure. The leadership of all healthcare organizations must have policies and procedures in place to ensure that all persons working in or having privileges to work in a facility have the appropriate licenses and credentials to fulfill the roles for which they have been hired. Appropriate security must be in place to prevent patient/resident abduction and/or physical assault. Policies and procedures must also address what to do in the event of acts of (or threatened acts of) violence so that patients, visitors, and staff members are kept as safe as possible. Education and training should be provided regarding how to deal with violence in work settings [2,21,24,26]. According to the ECRI report, examples of data integrity failures include [2] : Appearance of one patient s data in another patient s record. Missing data or delayed data delivery. Clock synchronization errors between medical devices and systems. Default values used by mistake. Fields pre-populated with erroneous data. Inconsistencies in patient information when both paper and EMR are used. Outdated information copied and pasted into a new report. Page 117

120 Nursing consideration: Nurses and their colleagues must remember to evaluate any IT issues that may and can contribute to an adverse event. Data entry is only as accurate as the person who is entering the information. The configuration of the IT system must also be evaluated. How easy is it to have multiple patient records open on a user s screen at one time? What, if any, are the identification checks to make sure that data is entered for the correct patient? How easy is it to cut and paste information? How can old or no longer accurate information be deleted from the active portion of a patient s record? These are just some of the questions that arise when reviewing the role IT may play in errors. Nurses must be vigilant in assisting in the evaluation of the IT process in their organizations and in the effectiveness of EHRs. 2. Managing patient violence. EBP alert! Research shows that workers in healthcare and social assistance settings are five times more likely to be victims of nonfatal assaults or violent acts than average workers in all other occupations [27]. This makes managing workplace violence imperative, and a top priority in the healthcare setting. A current review of the literature indicates that violence occurs in all healthcare settings, not just in the emergency department (ED) [2]. The ECRI Institute lists Managing Patient Violence as number three in their 2015 list of top ten patient safety concerns. The report suggests the following actions to help manage/prevent patient violence [2] : Acknowledge that the problem of violence is occurring in all healthcare organizations/facilities and is not limited to specific Page 118 areas such as the ED. Provide all staff with training and education in de-escalation strategies, behavioral health, and management strategies when physical violence is threatened or actually occurring. Hire adequate security staff. Develop and implement a facility-wide safety plan that considers all levels of risk, from a single acute episode, to an active shooter, to a threat that requires evacuation of the facility. 3. Mix-up of IV lines leading to misadministration of drugs and solutions. The risk of IV line mix-ups is more likely in critical care areas where multiple lines are often in place. However, the risk exists in all healthcare settings where patients or residents (e.g. long-term care residents) may need several types of medication [2]. The ECRI Institute recommends the following actions to prevent IV infusion-line confusion [2] : Trace all lines back to their origin before making connections. Develop and implement a policy and procedure for positioning different lines on different sides of the patient. Label each infusion line with the name of the drug or solution being infused. Do not force connections. If force is required, it should probably not be connected. Nursing consideration: Since nurses are those who administer drugs or solutions via IV lines, this safety concern is especially critical to their practice. Incorporating ECRI Institute recommendations into applicable policies and procedures should help to avoid IV line mix-ups. 4. Care coordination events related to medication reconciliation. The ECRI Institute has identified medication reconciliation as its fifth top ten patient safety concerns [2]. The prevention of medication errors is an ongoing healthcare concern, and medication reconciliation is of utmost importance. The Agency for Healthcare Research and Quality has identified the following recommendations for accurate medication reconciliation [28] : Develop a single medication list that is shared by all disciplines for documenting the patient s current medications. Clearly define roles and responsibilities for each discipline involved in the medication reconciliation process. Standardize the medication reconciliation process throughout the organization. Simplify the medication reconciliation process as much as possible by eliminating unnecessary redundancies. Make the right thing to do the easiest thing to do within the parameters of normal legal practice. Develop effective prompts or reminders for consistent behaviors as they pertain to the medication reconciliation process. Educate patients, families, or other caregivers on the medication reconciliation process. Ensure that the medication reconciliation process meets all pertinent legal and regulatory requirements. Nursing consideration: Note that medication reconciliation can be problematic upon admission to acute care or outpatient facilities unless the patient and/or family have kept accurate records of the patient s medications. It should be a top nursing priority to educate patient and family about the necessity of keeping thorough and accurate medication records. This includes not only prescription medications, but over-the-counter medications, vitamins, minerals, herbal preparations, and any other supplements being taken. 5. Failure to conduct independent double checks independently. Failure to conduct truly independent double checks can, and does lead to errors. The ECRI Institute recommends the following recommendations to make sure that independent double checks are completed [2] : The second patient care provider who is performing the double check needs to look at all facets of the process including patient identity, indication and appropriateness, drug or blood type, dose, programmed infusion rate, and route. The second provider should not receive conclusions from the first provider. For example, suppose the first provider says to the second provider, I get a dose of 5,000 units of heparin. What do you calculate? The second provider already has a clue about what he or she thinks the answer should be. The second provider should calculate the dosage without hearing what the first provider calculated. Obtain staff buy-in for the independent double check process. Risk management and research findings regarding errors linked to the failure to adhere to independent double checks should be shared with clinical staff. Investigate systems processes and issues. The organization should be prudent when determining which processes require independent double checks. 6. Opioid-related events. EBP alert! The use and prescription of opiates has increased dramatically in recent years. So has opioid misuse and abuse. In fact, in 2011, the number of ED visits related to opioid misuse and abuse were over 420,000. This is double the number of visits recorded in Therefore, nurses and other patient care providers must be alert to the likelihood of encountering patients who may be misusing or abusing opioids [2]. The ECRI Institute identified two issues of major concern regarding opioid prescriptions and the potential for opioidrelated events. First, there is a concern that prescribers are ordering the same amount of hydromorphone as they would morphine, even though hydromorphone is about seven to seven and one half times as potent as morphine. This can lead to overdose and dangerous adverse effects [2].

121 The second issue is that prescribers sometimes do not differentiate between patients who are opioid-tolerant (defined as patients who have been taking an opioid of a threshold dosage for at least one week) from those who are described as opioid-naïve (meaning patients who have not been taking an opioid of a threshold dosage for at least one week). Failure of prescribers to consider these two issues of major concern can lead to serious, even fatal consequences [2]. Nursing consideration: Research shows that patients may share their opioid medications with family members or friends. Research also shows that family members and friends may help themselves to such medications without the patient s knowledge or consent. It is imperative that nurses educate patients and families regarding the dangers of opioid misuse [2]. In order to reduce/avoid opioid-related events the ECRI Institute recommends that [2] : Prescribers participate in continuing education regarding safe opioid prescribing and the potential dangers of failing to adhere to safe-prescribing standards. All healthcare professionals should participate in continuing education regarding safe opioid prescribing as well as recognition of opioid use, misuse, and abuse, and strategies to intervene. Patients and families must be educated about opioid safety including how to properly store and dispose of opioids. Healthcare organizations must monitor their adverse events for evidence of opioid-related events, and take steps to prevent their occurrence. 7. Inadequate reprocessing of endoscopes and surgical instruments. Even though endoscopes and surgical instruments are extremely difficult to clean (requiring multiple steps to ensure cleanliness), healthcare organizations reprocess thousands of reusable surgical instruments and devices on a daily basis. Failure to thoroughly clean such devices may allow organisms to remain on the devices (i.e. fomite ). Some organisms may not be affected by disinfection or even sterilization. Even if thorough cleaning is accomplished, organisms may grow if equipment is not thoroughly dried.2 In other words, reprocessing requires thorough cleaning, disinfection, sterilization (as appropriate), and drying. The Association for the Advancement of Medical Instrumentation (AAMI) suggests the following steps to improve the quality of medical device and surgical instrument reprocessing [29] : Cleaning and disinfection/sterilization of reusable devices are separate but equally important actions that must be performed before each patient use according to manufacturer s written instructions for use of the device. Follow the manufacturer s instructions for cleaning, disinfection, and/or sterilization of devices. Create a multidisciplinary committee to review priorities and establish a plan for implementing them. Representatives should be sourced from the operating room, infection control, healthcare technology management endoscopy, risk management, quality improvement, safety, education, and materials management groups and teams. Share lessons learned with other healthcare organizations and learn from other organizations as well. Establish formal written procedures for reprocessing. Know and implement the current standards, recommended practices, and manufacturer s written instructions for use. Include central sterile processing in the act of purchasing decisions for medical devices. Separate and standardize functions and locations. In other words, separate central service from reprocessing. Train and educate staff regarding appropriate reprocessing. Assess organizational compliance with standards and regulations. Examples of tools for assessment can be found at: fda.gov/medicaldevices/deviceregulationandguidance. 8. Inadequate patient handoffs related to patient transport. Research shows that when a patient is transported within the healthcare facility to another clinical setting or between units within the facility, a risk for harm exists [2]. But transport does not pose the only danger as the change of shift report (also a form of handoff ), if not performed correctly, also can endanger the patient [30]. Handoff is defined as the process of transferring responsibility for patient care. Sign-out is the act of relaying information regarding the patient [30]. The risks involved with handoff and sign-out vary with the acuity of the patient. However, even so called low-risk patients are at risk if the processes of handoff and sign-out are not executed accurately. The Joint Commission requires that each patient handoff communication include a standardized interactive approach to promote safe transfers. The ECRI Institute s report on the 2015 top ten safety hazards identifies several recommendations to build a process that enhances safety and reduces risk during handoff and sign-out [2,30]. Include transport-related incidents (including handoff and signoff information) as part of adverse event, and near-miss adverse event, reporting. Identify units and areas that are most often involved in transport and safety hazards. Establish criteria for determining the level of transport needed. Ensure that the necessary equipment is available for transport and that responsibility has been assigned for maintenance of therapies, and troubleshooting of equipment problems during transport. Determine the training, competency, and experience required of personnel performing the transport, and ensure that those personnel possess such training, competence, and experience. Develop and implement tools, forms, and checklists that facilitate handoff communication among all team members. 9. Medication errors related to pounds and kilograms. Errors involving mix-ups between pounds and kilograms often occur in emergency departments, but can occur in any setting, including the home. These kinds of errors generally involve pediatric patients, whose small bodies often react quite adversely, even fatally, to an inaccurate mediation dose [2,31]. Pediatric drug doses are weight-based, and the recommended doses are administered in relation to weight in kilograms. However, in many healthcare settings, children are weighed in pounds, and medication measurements must then be converted to kilograms. This conversion can be inaccurately calculated, thus leading to medication errors [31]. The Emergency Nurses Association s (ENA) position statement in support of weighing pediatric patients only in kilograms includes the following information [31]. Pediatric weights should be measured and documented in kilograms only. Scales used to weigh pediatric patients should be configured to only record weights in kilograms. Pediatric weights should be documented in a prominent place on the medical record. Electronic medical records (EMR) should be standardized to allow only kilograms for pediatric weight entries. The actual weight of the pediatric patient should be considered to be part of the mandatory nursing assessment unless patients need resuscitation or emergent stabilization. Page 119

122 Page 120 For the pediatric patient needing resuscitation or emergent stabilization, there should be a standard method of estimating weight in kilograms. The pediatric patient s weight in kilograms must be included in an interdisciplinary or intradisciplinary patient handoff report. Nursing consideration: Note that the weight in kilograms must be utilized as a function of all handoffs to facilitate safety, and decrease adverse effects related to handoffs and sign-outs. The ECRI Institute offers these suggestions for reducing the risk of medication errors related to pounds and kilograms [2]. Hospital-acquired conditions The phrase hospital-acquired condition (HAC) refers to conditions that patients acquire while receiving treatment for another condition in an acute care health setting [32]. On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year 2009 Final Rule, the Centers for Medicare and Medicaid Services (CMS) included ten categories of HACs that, if they occurred, were not reimbursable by Medicare [33]. These categories are, for most if not, all organizations, never ever events as well. As of 2015, the list of categories has been expanded to 14 and include the following items [33] : Foreign object retained after surgery. Air embolism. Blood incompatibility. Stage III and IV pressure ulcers. Falls and trauma. Fractures. Dislocations. Intracranial injuries. Crushing injuries. Burn(s). Other injuries. Manifestations of poor glycemic control. Diabetic ketoacidosis. Non-ketotic hyperosmolar coma. Hypoglycemic coma. Secondary diabetes with ketoacidosis. Secondary diabetes with hyperosmolarity. Catheter-associated urinary tract infection (CAUTI). Vascular catheter-associated infection. Foreign object retained after surgery The problem of surgical items accidentally left inside the body after surgery has existed since the beginning of the practice of surgery. The contemporary preferred term for this problem is Retained Surgical Items (RSI) rather than retained foreign bodies, or objects, or URFOs [35]. Nursing consideration: Retained objects are usually detected immediately after the procedure by X-ray, during routine follow-up medical visits, or from the patient s reports of pain or other forms of discomfort [34]. However, RSIs can be discovered hours to years after the initial operation [35]. Therefore, nurses must remain alert to the possibility of RSI and always ask patients about any history of surgical procedures during nursing assessment. The most frequent retained surgical items are [34] : Soft goods, such as sponges and towels. Small miscellaneous items, including un-retrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains. Nails and other sharps. Instruments, most commonly malleable retractors. Ensure that pediatric scales (calculated in kilograms) are readily available in all areas of the organization. Document and display weights only in kilograms in the electronic healthcare record (EHR). Integrate digital scales with the HER to eliminate or reduce the need for data entry. Use clinical decision support functions that compare recorded weights with expected weights. Purchase infusion pumps with dose error reduction components. Avoid storing any high-alert drugs or other medications that have the potential to cause patient harm if weight-based doses are miscalculated in clinical areas. Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG). Surgical site infection following bariatric surgery for obesity. Laparoscopic gastric bypass. Gastroenterostomy. Laparoscopic gastric restrictive surgery. Surgical site infection following certain orthopedic procedures. Spine. Neck. Shoulder. Elbow. Surgical site infection following cardiac implantable electronic device (CIED). Deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures. Total knee replacement. Hip replacement. Iatrogenic pneumothorax with venous catheterization. Nursing consideration: Beginning in fiscal year 2015, the HAC reduction program mandated by the Affordable Care Act, requires the CMS to reduce hospital payments by one percent for hospitals that rank among the lowest-performing 25 percent in regards to HACs [32]. Thus, it is essential that all nurses be especially vigilant in preventing HACs. They must also appreciate where their organizations stand in regard to HAC performance. It is important that nurses be familiar with policies and procedures established to prevent HACs in their organizations. This educational program provides information to support nurses in their efforts to reduce/prevent HAC occurrence. Research shows that the retention of surgical items has significant monetary implications. The Pennsylvania Authority estimated that the average total cost of care related to the retention of such items is about $166,000, which includes legal defense, indemnity payments, and surgical costs not reimbursed by the CMS. Other studies estimate that the medical and liability costs are $200,000 or more per incident [34]. What are the most common root causes of RSIs reported to The Joint Commission? These causes are [34] : Absence of policies and procedures. Failure to comply with existing policies and procedures. Problems with hierarchy and intimidation. Communication failure with the physicians. Failure of staff members to communicate important patient information. Inadequate or incomplete staff education. In the October 17, 2013 Sentinel Event Alert [34], The Joint Commission recommended a number of strategies to reduce RSIs and improve safety. A summary of some of the most essential information follows. For the

123 complete report, access this online pdf: assets/1/6/sea_51_urfos_10_17_13_final.pdf. Establish effective processes and procedures. Establish a reliable and standardized counting system. Develop and implement effective evidence-based, organization-wide standardized policies and procedures for the prevention of RSIs. Establish an effective counting procedure. The Joint Commission directly recommends that a counting procedure should [34] : Be performed audibly and visibly by two persons engaged in the process. The surgical team should verbally acknowledge verification of the count. Include counts of items added to the surgical field throughout the surgery or procedure. Include counts of soft goods, needles/sharps, instruments, and small miscellaneous items. The team should document unretrieved device fragments. Verify that counts printed on prepackaged sponges and instrument sets are correct. Handle any discrepancies according to the organization s policy. Be performed before the procedure begins in order to establish a baseline count; before the closure of a cavity within a cavity; before wound closure begins; at skin closure or end of procedure; and at the time of permanent relief of either the scrub person or the circulating registered nurse. Be applicable in all settings where invasive procedures are performed. Be reviewed periodically and revised as appropriate. Establish effective wound opening and closing procedures. Wound opening and closing procedures should include: Inspection of instruments for signs of breakage before and after use. Air embolism Intravascular air embolism is a preventable HAC that occurs when air enters the vascular system [36,37]. Air embolism is a serious, lifethreatening event. It occurs when there is a direct connection between a source of air and the vascular system, and the pressure gradient allows the entry of this air into the bloodstream [37]. Common causes of air embolism include [36,38] : The entry of air through open intravenous (IV) and infusion systems. Examples include disconnection and open stop-cock. EBP alert! Research shows that the amount of air that enters the vascular system is influenced by the patient s position, and the height of the vein in relation to the right side of the heart [36]. Thus, nurses must be aware of proper patient positioning at all times! Infusion lines that are not properly filled or completely vented. During parallel infusions where gravity and infusion pumps are connected together. Errors that occur during the performance of a pressure infusion. Air entering the intravascular system during surgical procedures that require the opening of the vascular system such as neurosurgical, vascular, gynecological, or orthopedic procedures. The Pennsylvania Patient Safety Authority has published the following suggestions to prevent air embolism associated with central venous access devices (CVADs) [37]. During insertion [37] : Place the patient in Trendelenburg position with a downward tilt of 10 to 30 degrees during central line placement. Avoid CVAD insertion during patient inspiration. If the patient is able, ask him/her to hold his/her breath and perform a Valsalva maneuver. After insertion [37] : Make sure that all catheters and connections are intact and secure. Adherence to the organization s established counting procedure. Methodical wound exploration. Empowerment of any member of the operative team to call a closing time-out prior to the initial closing count to allow for an uninterrupted count. Perform intra-operative radiographs. Intra-operative radiographs should be performed: When the surgical count is incorrect [34]. When the operative procedure is determined by the surgical team to be at high risk for retained surgical items. Nursing consideration: If the counts remain unreconciled after initial radiologic examination, the surgical team should consider additional imaging or further wound exploration. Effective communication. Effective communication is essential. The Joint Commission recommends that an organization should institute team briefings and debriefings as a standard part of the surgical procedure. This allows any team member to express concerns regarding patient safety. Additionally, the surgeon should verbally verify the results of the counting procedure. Appropriate documentation. Document the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Safe technology. The Joint Commission suggests that organizations research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration. Occlude the catheter and/or the needle hub. Make sure that all self-sealing valves are functioning accurately. Ensure proper care and maintenance of CVADs by: [36,37,62,63] Making sure that all lumens are capped and/or clamped. Using Luer-lock connections for needleless IV ports and selfsealing valves. Using infusion pumps with air-in-line sensors for all continuous infusions. Completely priming all infusion tubing, and expelling air from syringes before any injection or infusion. Using an air-eliminating filter on infusion tubing sets whenever necessary. Removing air from infusion bags when infusing fluids using inflatable pressure infusors. Fully priming contrast media injectors. Checking for air prior to each injection. Tracing lines and double-checking all connections. Taking all steps necessary to prevent misconnections. Inspecting the insertion site, catheter, and all connections regularly to assess for any breaks or openings that could allow air into the system. Ensuring the integrity of the central line dressing surrounding the insertion site. Using caution when moving or repositioning the patient to prevent pulling on the central line and compromising the integrity of the closed system. Teaching patients and/or families how to manage infusion therapy. During removal of CVAD [37,62,63] : Place the patient in Trendelenburg position. If this is not possible the supine position may be used. Position the catheter exit site at a height that is lower than the height of the patient s heart. Page 121

124 Cover the exit site with gauze. Apply gentle pressure while removing the catheter in a smooth, slow, and constant motion. Ask the patient to hold his/her breath and perform a Valsalva maneuver as the last portion of the catheter is removed. If the patient is unable to do this remove the CVAD during patient expiration. Place pressure on the site until hemostasis occurs. A time frame of one to five minutes is recommended. Apply a sterile occlusive dressing that remains in place for at least 24 hours. Change the dressing every 24 hours until the exit site has healed. Blood incompatibility It is 3PM, and the end of a particularly stressful eight-hour shift. Blood arrives from the blood bank for two patients: Mr. Robert Morino (who is Type A positive), and Mr. Roger Moran (who is Type A negative). Sandy, the RN responsible for the nursing care of both Mr. Morino and Mr. Moran is feeling stressed and anxious. It is snowing, and she wants to leave on time in order to be home before her young children arrive from their after-school activities. Without instituting the independent double check per hospital policy, Sandy begins administering the A positive blood to Mr. Moran, who quickly begins to have an adverse blood incompatibility reaction. The preceding scenario is truly a disaster that was waiting to happen. What are some things that contributed to this adverse event? Sandy is anxious and stressed and not focused on her work. Sandy failed to institute the independent double check required by hospital policy. The two patients had similar first and last names. The two patients had similar (yet different!) blood types. Blood incompatibility is preventable. What can nurses do to make sure that it does not occur? Let s start by reviewing what happens during an incompatibility reaction. There are four types of blood [39,40,41] : Type A (red blood cells (RBCs) have A-antigen proteins attached to them). Type B (RBCs have B-antigen proteins attached to them). Type AB (RBCs have both A-antigen and B-antigen proteins attached to them). Type O (RBCs have neither A- nor B-antigens). Blood is also classified by rhesus (Rh) factor. This is a specific RBC antigen in the blood. If this antigen is present, the blood type is Rh positive (e.g. such as in the case of Mr. Morino, who is A +). Absence of the antigen is classified as Rh negative. Most occurrences of blood incompatibility are due to human error. During an incompatibility reaction, the patient s immune system reacts Stage III and stage IV pressure ulcers In addition to the physical and emotional toll on patients, stage III and stage IV pressure ulcers carry a significant monetary burden as well. It is estimated that the cost of one stage III or stage IV pressure ulcer may be between $5,000 and $50,000 [44]. How are stage III and stage IV pressure ulcers described? Here are their determining characteristics [45] : Category/stage III: Full thickness tissue loss, although subcutaneous fat may be seen. Bone, tendon, or muscles are not exposed. Sloughing may be present, but it does not obscure the depth of tissue loss. There may be undermining and tunneling. The depth of this pressure ulcer depends on the anatomical location. For example, the bridge of the nose or the ear does not have (adipose) subcutaneous tissue and stage III ulcers in such locations can be shallow. However, in areas where there is significant adipose tissue, ulcers can be exceptionally deep. Bone and/or tendon are neither seen nor are directly palpable. Tell the patient to remain lying flat for 30 minutes after removal of the catheter. Nursing consideration: For the latest information on central line devices and other infusion issues access: The Infusion Nurses Society at index.cfm?pageid=1 The Association for Vascular Access at website/article.asp?id= against the wrong blood. The patient s immune system produces antibodies against any blood antigens not present in his/her own blood. Such a reaction can have serious, even fatal, consequences [39,40,41]. EBP alert! Research shows that the most serious transfusion complications occur within the first 15 minutes before, and the 15 minutes after initiation of each unit of blood. Thus, nurses must be particularly alert for reactions during these time periods [42]. Here are some suggestions for nurses to implement in order to avoid blood incompatibility reactions [39,42,43] : Facilitate the establishment of an interdisciplinary transfusion committee. This committee should include a transfusion safety officer. Ensure that policies and procedures relating to blood transfusion are reviewed and updated on an ongoing basis. Review the prescriber blood product ordering process. Review the patient s consent for blood product transfusion and make sure that the right for refusal appears on the consent. Ensure that there is a process for monitoring, tracking, and trending all blood samples for type and cross, type and hold, wrong blood in tube, mislabeled tubes, and issued blood components from the blood bank. Transfuse the patient within 30 minutes of blood product pick-up from the blood bank. Always confirm the identity of the patient using two identifiers. Institute independent double check per hospital policy. Double check the blood type of patients and the blood packs before each transfusion. Double check that all information (full patient name, address, blood type, etc.) on the label of the blood product matches the patient s information. Note that this means that the nurse MUST know the patient s blood type and other relevant information. Double check the blood product s label for expiration dates. Implement a bar code patient identification system as appropriate. Category/stage IV: Full thickness tissue loss where bone, tendon, and/or muscle are exposed. Sloughing or eschars may be present, often with undermining and tunneling. The depth varies according to anatomical position. Ulcers may be shallow in areas that do not have (adipose) subcutaneous tissue (e.g. nose, ear). These types of pressure ulcers can extend into muscle and/or supporting structures such as fascia, tendon, or joint capsules, thus making osteomyelitis possible. Exposed bone or muscle is visible and/or directly palpable. Which patients are at risk for the development of pressure ulcers? Here are some factors that increase such risk. These are divided into three primary areas including mobility/activity, perfusion (including diabetes), and skin/pressure ulcer status [44,46]. Advanced age: The elderly person s skin has less subcutaneous fat, which leads to decreased protection from pressure. Page 122

125 Friction/ahear: Decreases the epidermal layer, reducing protection of the skin. Hypotension: Decreases the perfusion of local tissues, making skin more vulnerable to breakdown. Immobility: Lack of mobility can lead to sustained pressure on bony prominences. Length of stay in critical care units: The longer the length of stay is indicative of critical conditions associated with decreased mobility and/or position change, and increased shear force, all of which increase the risk for skin breakdown. Length of time on mechanical ventilation: Indicates inadequate oxygenation and the need to provide ventilation mechanically. Decreased oxygen levels means decreased oxygen to body tissues, including the skin. Moisture: Moisture (e.g. incontinence, sweat, failure to dry skin after bathing) contributes to skin breakdown, and in many cases, poor wound healing. Nutrition: Inadequate nutrition and decreased protein intake alters the proper state of the skin, contributing to skin breakdown. Pressure: The longer pressure is sustained, the more likely local tissue ischemia, edema, and tissue death occurs. Pressure scale risk scores: The higher the score on a pressure scale score, the greater the risk of pressure ulcer development. Vasoactive medications: Vasoactive medications, given to improve blood pressure, increase vasoconstriction, thus decreasing the perfusion of skin tissue. Falls and trauma Patient falls with serious injury are among the top ten sentinel events reported to The Joint Commission Sentinel Even Database. Since 2009, The Joint Commission has received 465 reports of patient falls with injuries. About 65 percent of those falls caused fatalities [47]. The Joint Commission reports that from January 2009 to October 2014, the most common contributing factors contributing to reported falls included [47] : Communication failures. Deficiencies in the physical environment. Failure to adhere to protocols and safety practices. Inadequate assessment. Inadequate staff orientation, supervision, staffing levels, or skills. Lack of leadership. EBP alert! Research shows that major factors to reduce falls and other adverse events are effective communication and interdisciplinary work [48]. Thus, nurses must work with their interdisciplinary colleagues to reduce/prevent falls. Suggestions for fall prevention include the following nursing interventions [47,48] : Establish an interdisciplinary fall team with representatives from all disciplines. Manifestations of poor glycemic control Nurses are essential to managing glycemic control for hospitalized patients. They perform and act on the results of blood glucose monitoring and medication administration. They also provide much of the patient/family education pertaining to glycemic management [49]. Research indicates that there are several factors that increase the risk of poor glycemic control in hospitalized patients. These include [49] : Insufficient nurse staffing. Nursing staff with excessive workloads. Lack of effective and timely communication. Nursing measures to decrease the risk for pressure ulcer development include [44,46] : Performing skin assessment upon admission and at least once per shift thereafter. Skin inspection should be conducted more often on patients at high risk for pressure ulcer development. Document the results of all skin assessments. Identify patients at high risk for pressure ulcer development using a risk-identification scale. Incorporate results of skin assessment in change-of-shift reports and at any handoffs and sign-offs. Incorporate a schedule of turning and body repositioning, and document these actions. EBP alert! Research shows that shearing forces can be reduced by keeping the head of the bed no higher than 30 degrees [44,46]. Use appropriate positioning devices according to hospital policy and procedure. Keep skin warm and dry. Dry thoroughly after bathing. Remove skin secretions such as sweat and barrier creams. Use nonirritating, non-drying cleansing agents. Use moisturizers as appropriate. Keep bed sheets, clothing, etc., dry and wrinkle free. Take measures to avoid spasticity and contracture prevention. Ensure proper nutritional intake, especially protein. Promote mobility and self-position changes as appropriate. Remain alert to any skin changes (such as redness) that may suggest impending skin breakdown. Develop and implement policies and procedures to enhance safety and prevent falls. Implement a fall risk screening assessment. Assess patients on admission, and periodically throughout hospitalization. Determine if patient medications may cause dizziness, coordination problems, or other issues that may contribute to falls. Initiate fall prevention interventions such as providing the patients with no-slip socks, teaching them about the use of (and supervising the use of) mobility assistive devices, and making sure that the call bell is within reach, and that patients know how to use it. Create a culture of safety in which systems and process issues are evaluated as the primary causes of adverse effects, and in which open communication is supported. Initiate rounds at least hourly to evaluate the safety of the patients and their environments. Nursing consideration: If and when a fall does occur, a post-fall huddle should be conducted. This is done to evaluate: what risk factors for the fall existed: the circumstances surrounding the fall: and what measures should be taken to prevent future falls, including the review and revision of existing policies and procedures. Such a huddle is not conducted to cast blame, but to improve the culture of safety within the organization. Teaching hospitals in which inexperienced resident physicians may be providing care for complex, critically ill patients. EBP alert! Low nurse staffing undermines the culture of safety critical to the provision of safe and appropriate patient care. The organization s nurse leaders must evaluate staffing in terms of a culture of safety [49]. Suggestions for ensuring proper glycemic control include [49,50] : Establishing a system of interdisciplinary collaboration and open communication. Page 123

126 Providing continuing education for nurses and physicians regarding glycemic control. Providing adequate patient/family education regarding glycemic control. Establishing policies and procedures that effectively guide glycemic control. Catheter-associated urinary tract infections Clara is a junior nursing student. She is taking care of a patient who has had an indwelling urinary catheter for three days. Clara is concerned about the possibility of infection, and asks the staff nurse responsible for the patient when it would be removed. The staff nurse is extremely busy and tells the student not to worry about a catheter when there are more urgent matters to attend to. Clara knows that hospital policy is that the catheter should be removed as soon as possible. She decides to talk to her instructor, and the resident physician when he sees the patient that morning. Are Clara s concerns valid? Are her actions appropriate? The answer to both questions is yes. Clara knows, as should all nurses, that hospital acquired catheter-associated urinary tract infections (CAUTIs) are a serious problem. A catheter-associated urinary tract infection (CAUTI) is considered to be a preventable complication by the Centers for Medicare and Medicaid Services and thus no additional payment is provided to hospitals for costs associated with CAUTIs. Unfortunately, CAUTIs are still the most common nosocomial infection. They account for up to 40 percent of infections reported by acute care hospitals. Such infections increases hospital costs and is linked to an increase in morbidity and mortality [51]. EBP alert! Research shows that [52] : 70 to 80 percent of CAUTIs are due to the presence of an indwelling urethral catheter. 12 to 16 percent of adult hospitalized patients will have a urinary catheter at some time during hospitalization. When an indwelling urethral catheter remains in place the daily risk of acquiring bacteria in the urinary tract varies from three to seven percent. Vascular catheter-associated infection More than five million patients require central venous access every year, and infection is the main complication of intravascular catheters in patients who are critically ill [53]. Every year, an estimated 250,000 cases of central venous catheter-associated blood stream infections occur in the United States. The cost per infection is an estimated $34,508-$56,000 [54]. Nurses and their interdisciplinary colleagues must make every effort to prevent such infections. The following interventions are important to the prevention of vascular catheter-associated infections: Hand hygiene. Proper hand hygiene is the most important infection control measure and the most effective way to prevent the transmission of healthcare associated infections [54,55]. Nursing consideration: Patients and families should be taught to observe if healthcare workers are washing their hands before and after providing patient care. They should be told to ask their healthcare providers to wash their hands if they have not done so. The Centers for Disease Control and Prevention (CDC) and the Institute for Healthcare Improvement (IHI) both advocate that hand hygiene be performed before and after palpating the catheter insertion Page 124 Monitoring blood glucose levels according to hospital policies and procedures, and intervening appropriately. Establishing an adequate system of nurse staffing to ensure adequate patient coverage. Ensuring that equipment used for blood glucose monitoring is in good working order and that all nurses know how to use such equipment. Nurses must do everything possible to find alternatives to insertion of indwelling catheters., If such catheterizations cannot be avoided, removal of indwelling catheters must be performed as soon as possible. Additional research findings show that [51] : The major risk factor for CAUTIs is prolonged catheterization. 25 percent of hospital in-patients, and up to 90 percent of patients in a critical care unit have a urinary catheter at some point during hospitalization. Unfortunately, such catheters are often inserted without an appropriate indication or remain in place after the need is no longer present. Most hospitals do not have effective strategies for preventing CAUTIs. Experts recommend the following actions to prevent CAUTIs [51,52] : Establish policies and procedures which include: indications for indwelling urinary catheterization, insertion guidelines, and limitation of insertion to those patients who meet criteria for use. All healthcare team members must document the indication for indwelling catheter placement upon admission, and daily. If the patient is admitted with a CAUTI, this must also be documented. Be sure that only trained, competent personnel insert urinary catheters. Provide education and training as needed. Ensure that supplies and equipment necessary for aseptic catheterization technique are readily available. Review the necessity of continuing indwelling catheters on a daily basis. Such catheters should be removed as soon as possible. Implement infection control surveillance programs which include the: development of any CAUTIs; and the development of appropriate action plans to reduce/prevent CAUTI occurrence. Nursing consideration: Nurses should ensure that indwelling catheters are properly secured to prevent movement and urethral traction. They must also ensure that a sterile, continuously closed drainage system is maintained [52]. site; before and after inserting, replacing, accessing, repairing or dressing a venous access device; before donning and after removing gloves; when hands are visibly soiled or contaminated; before and after invasive procedures; and after using the bathroom. Palpation of the insertion site should not be performed after the application of skin antiseptics, unless aseptic technique is maintained [54]. Maximum sterile barrier precautions. Maximum sterile barrier precautions must be taken when inserting the venous catheter. These precautions include not only the person inserting the catheter, but anyone assisting with the procedure, and the patient as well [53,54]. Skin antisepsis. The IHI advocates the use of chlorhexidine skin antisepsis. The CDC prefers the use of a two percent chlorhexidine solution but a tincture of iodine or 70 percent alcohol can be used [54]. Skin antisepsis should be performed at the time of insertion and with every dressing change [54,55]. Selection of catheter site. The site of insertion is important to optimal outcomes. The use of the subclavian site is preferred to the jugular or femoral sites in adults to minimize infection risk [54,55].

127 Dressing change. Dressings for insertion sites must be impermeable to water vapor. Use of sterile gauze, a sterile transparent, semipermeable dressing, or a chlorhexidine-impregnated sponge dressing that covers the catheter insertion site should be initiated. Topical antibiotic ointments or creams should not be applied to the insertion site because of the possibility of promoting fungal infections or pathogen resistance. Dressings are changed when they become wet, loose, or soiled. CVAD dressing are generally changed weekly for a transparent semipermeable dressing, and every 48 hours for a gauze dressing [54]. Surgical site infections The prevention of surgical site infections is imperative. In the operating room setting, breaks in sterility, and a failure to follow established protocols for infection control put the patients at risk for surgical site infections [56]. Some strategies to prevent surgical site infections include the following interventions [56,57] : Healthcare providers must cleanse their hands and arms up to their elbows with an antiseptic agent just prior to surgery. Healthcare providers must cleanse their hands with soap and water or an alcohol-based hand cleanser before and after caring for each patient. Deep vein thrombosis Deep vein thrombosis (DVT) affects about 350,000 Americans every year [59]. In the hospital setting DVT is listed as a preventable HAC. Nurses and other healthcare providers must first be aware of factors that place patients at higher risk for the development of DVT. These include [58] : Using birth control pills or hormone therapy. Having blood clotting disorders. Some malignancies. Increasing age. Being overweight or obese. Immobility. Personal or family history of DVT or pulmonary embolism. Pregnancy. Smoking. Having vein disease(s). Assessment and removal. The catheter should be removed as soon as it is no longer indicated. The risk for infection increases with the length of time the device is left in place, and decreases when the catheter is removed [54]. EBP alert! The risk for infection has declined with the standardization of aseptic care and the requirement that insertion and maintenance of catheters be performed by experienced staff members. Education of staff in the insertion and maintenance of intravascular catheters is required, and staff competency must be periodically evaluated. Nurses must demonstrate competency in the care of patients with vascular catheters [54,55]. If hair needs to be removed from the surgical site, an electric clipper must be used. A razor should NOT be used. Patients and families should be educated to not touch the surgical wound or dressings. Healthcare providers caring for patients after surgery should adhere to strict hand hygiene standards. They should also change dressings according established policies and procedures. Nursing consideration: As stated earlier in this education program hand hygiene is the most effective way to prevent infections. Nurses must help to ensure that all colleagues and visitors adhere to hand hygiene protocol. Strategies for the prevention of DVT include [58,59] : Administrating anticoagulant therapy as indicated. Promoting early movement and mobilization. Facilitating position change in patients who have difficulty moving themselves. Applying compression stockings or pneumatic compression devices as ordered and indicated. Teaching patients and families about the importance of early movement and position change. Nursing consideration: Most of the interventions to prevent DVT are easily implemented. However, busy nurses and other healthcare professionals may forget to implement tasks as simple as position change or teaching patients the importance of early movement and position changes. They must remain alert to the possibility of DVT development and how to prevent it! Iatrogenic pneumothorax with venous catheterization A pneumothorax is a collapsed lung, and the result of air leaking into the space between the lungs and the chest wall. In most cases of pneumothorax, only a portion of the lung collapses [60]. Pneumothorax can be due to [60,61] : Chest injuries. Underlying lung diseases. Ruptured lung air blisters. Mechanical ventilation. Certain invasive procedures, such as venous catheterization. Certain risk factors for pneumothorax include [60] : Age: Pneumothorax due to ruptured air blisters is most likely to occur in patients between 20 and 40 years of age. Gender: Men are more likely to have a pneumothorax than women. Genetics: Some types of pneumothorax seem to run in families. History of pneumothorax: A previous pneumothorax event predisposes an individual to experience another pneumothorax. Lung disease: Patients with underlying lung disease, particularly chronic obstructive pulmonary disease (COPD) are more likely to suffer a pneumothorax. Mechanical ventilation: Patients requiring mechanical ventilation are at higher risk for pneumothorax. Smoking: The risk increases with the number of cigarettes smoked as well as the length of time the patient has been smoking. Iatrogenic pneumothorax (iatrogenic means something that is accidentally caused during medical treatment or procedure) has been identified as a preventable HAC. Thus, it is important to be able to identify appropriate steps to take to prevent such occurrence during venous catheterization. Such steps include [61] : Identifying patients at higher risk for pneumothorax during catheterization and being especially alert for problems. Ensuring the use of a standardized method of venous catheter insertion according to established policies and procedures. Ensuring that insertion is performed by physicians who have adequate experience in catheter insertion. Page 125

128 Using ultrasound during catheterization to guide catheterization. Using ultrasound, chest radiography, and CT scanning for early recognition of pneumothorax. In summary Nurses must be familiar with HACs identified as preventable by the CMS and by organizations that emphasize safety and appropriateness of care. There are currently (as of this writing) 14 categories of HACs identified by the CMS. However, there may be additional categories identified in the future. There may also be additions to other never-ever events and these will most likely be revisions and additions to The Joint Commission National Patient Safety Goals. Nurses have a professional responsibility and moral obligation to keep themselves informed about current and future safety issues such as National Patient Safety Goals, never-ever events, and CMS identified preventable HACs. Thanks to modern technology, nurses References 1. Hospital Safety Score. (2013). 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Centers Diseases Control and Prevention (CDC). (2011). CDC report: Mental illness surveillance among adults in the United States. Retrieved December 30, 2011 from mental1healthsurveillance/fact_sheet.html. 10. The Joint Commission (2015). Home care National Patient Safety Goals. Retrieved November 7, 2015 from The Joint Commission (2015). Ambulatory Care National Patient Safety Goals. Retrieved November 6, 2015 from Pevtzow, L. (2013). New guidelines to reduce alarm fatigue. Retrieved November 11, 2015 from Appold, K. (2015). Noise complaint. The Hospitalist, 19(6), Retrieved November 11, 2015 from The Joint Commission (2015) Hospital National Patient Safety Goals. Retrieved November 14, 2015 from Advancement of Medical Instrumentation (AAMI). (2015). About AAMI. Retrieved November 14, 2015 from &navItemNumber= Extension Health Care. (2015). The countdown is on: Complying with The Joint Commission alarm safety goal. Retrieved October 28, 2015 from Hyman, W. A. (2014). A work plan for The Joint Commission Alarm National Patient Safety Goal. Journal of Clinical Engineering, 39(1), The Joint Commission (2015) National Patient Safety Goals. Retrieved November 15, 2015 from The Joint Commission (2015). The Joint Commission Sentinel Event Alert. Issue 50, April 8, Retrieved November 14, 2015 from alarms_4_5_13_final1.pdf. 20. Patient Safety Network. (PSNET). (2014). Never events. Retrieved October 28, 2015 from ahrq.gov/primers/primer/ Patient Safety network (PSNET). (2015). Wrong-site, wrong-procedure, and wrong-patient surgery. Retrieved November 15, 2015 from The Joint Commission (no date given). The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Retrieved November 16, 2015 from org/assets/1/18/up_poster1.pdf. 23. Minnesota Department of Health. (2013). Minnesota s 29 reportable adverse health events. Retrieved November 17, 2015 from HCPro. (2015). Joint Commission: Procedure errors, retention of foreign body, suicide top sentinel event list. Accrditation Insider, November 16, 2015 Retrieved November 17, 2015 from com/acc /joint-commission-procedure-errors-retention-of-foreign-body-suicide-topsentinel-event-list.html. 25. McKeon, L. (2011). Preventing never events: What frontline nurses need to know. Nursing made Incredibly Easy, 9(1), Retrieved November 18, 2015 from nursingmadeincrediblyeasy/fulltext/2011/01000/preventing_never_events What_frontline_nurses.10. aspx. 26. Hospitals & Health Networks. (2015). Addressing violence in the health care workplace. Retrieved November 18, 2015 from Nursing consideration: In the event of a pneumothorax during the procedure, a standardized treatment algorithm for management of pneumothorax has been shown to improve outcomes and decrease the length of hospitalization. Nurses must work with the healthcare team to develop such an algorithm and be familiar with the interventions identified in the algorithm [61]. can access such information on relevant internet websites such as the CMS and The Joint Commission websites. Nurses also have a professional obligation to become involved in how their employing organizations address safety issues. They should volunteer for committees and task forces and act as patient advocates at all times. Nurses must support their organization s efforts to enhance safety and well-being of patients, visitors, and employees. In addition to adhering to safety mandates, they should help teach their colleagues how to establish and maintain a culture of safety. All employees are responsible for patient safety. Nurses are on the front-line of all safety initiatives and should act as leaders in the safety process. 27. Agency for Healthcare Research and Quality (AHRQ). (2012). Medications and clinical handoffs (MATCH) toolkit for medication reconciliation. Retrieved November 18, 2015 from gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match3.html. 28. Pyrek, K. M. (2013). Improper reprocessing targeted as one of healthcare s most dangerous hazards. Retrieved November 19, 2015 from Patient Safety Network (PSNet). Handoffs and signouts. Retrieved November 27, 2015 from psnet.ahrq.gov/primers/primer/9/handoffs-and-signouts. 30. Sitko, E. R. (2013). Leading medication safety groups endorse position on weighing pediatric patients in kilograms. Retrieved November 30, 2015 from advanceweb.com/features/articles/avoiding-medication-errors.aspx. 31. Lake Superior Quality Innovation Network. (2015). Understanding the hospital-acquired condition reduction program. Retrieved November 30, 2015 from HAC_fact_sheet.pdf. 32. CMS.gov. (2015). Hospital-acquired conditions. Retrieved November 1, 2015 from medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html. 33. The Joint Commission Sentinel Event Alert. (2013). Preventing unintended retained foreign objects. Retrieved November 30, 2015 from URFOs_10_17_13_FINAL.pdf. 34. Nothing Left Behind. (2015). Retained surgical items. Retrieved November 30, 2015 from nothingleftbehind.org/. 35. [36] Safeinfustiontherapy.com. (2015). Causes of air embolism. Retrieved December 2, 2015 from int/hs.xsl/7701. html 36. [37] Pennsylvania Patient Safety Authority. (2012). Reducing risk of air embolism associated with central venous access devices. Retrieved December 2, 2015 from ADVISORIES/AdvisoryLibrary/2012/Jun;9(2)/Pages/58. aspx. 37. IV Infusion Home. (2015). Air embolisms and IV therapy. Retrieved December 2, 2015 from ivinfusion.wordpress.com/2015/03/23/air-embolisms-and-iv-therapy/. 38. Colledge, H., & Boskey, E. (2015). ABO incompatibility reaction. Retrieved December 3, 2015 from Chen, Y.B. (2014). ABO incompatibility. Retrieved December 3, 2015 from medlineplus/ency/article/ htm. 40. Mesa, R. A. (2013). Blood transfusion: Is there a universal blood donor type? Retrieved December 3, 2015 from American Society of Registered Nurses. (2008). Blood transfusion error prevention: Nurses role. Retrieved December 3, 2015 from Pennsylvania Patient Safety Authority. (2010). Improving the safety of the blood transfusion process. Retrieved December 3, 2015 from Jun7(2)/documents/33.pdf. 43. Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit. Critical Care Nurse, 33(6), National Pressure Ulcer Advisory Panel (NPUAP). (2015). NPUAP pressure ulcer stages/categories. Retrieved November 4, 2015 from npuap-pressure-ulcer-stagescategories/. 45. Kirman, C. N., et al. (2015). Pressure ulcers and wound care treatment & management. Retrieved December 4, 2015 from The Joint Commission (2015). New sentinel event alert focuses on preventing falls. Retrieved November 7, 2015 from patient_falls/. 47. Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and improvement in high reliability organizations. OJIN: The Online Journal of Issues in Nursing, 18,(2). Retrieved November 6, 2015 from TableofContents/Vol /No2-May-2013/Fall-Program-Measurement.html?css=print. 48. McHugh, M. D., Shang, J., Sloan, Dm. M., & Aiken, L. H. (2010). Risk factors for hospital-acquired poor glycemic control : A case-control study. Retrieved December 7, 2015 from nih.gov/pmc/articles/pmc /. 49. Durkin, M. T. (Ed.). (2013). Professional guide to diseases (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. 50. American Association of Critical Care Nurses (AACN). (2011). Catheter-associated urinary tract infections. Retrieved November 7, 2015 from cathassocuti-nov11.pcms?menu=practice. 51. Evelyn, L. et al. (2014). Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Retrieved November 8, 2015 from Page 126

129 52. Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related infection in the intensive care unit. Retrieved November 8, 2015 from content/14/2/ Siegel, M., & Kramer-Cain, J. (2013). Vascular catheter-associated infections. Retrieved November 8, 2015 from Busby, S. R. et al. (2015). Assessing patient awareness of proper hand hygiene. Nursing2015, May, 2015, Safety Monitor. (2014). Infection prevention practices in ambulatory surgery centers. AJN, 114(7), CDC et al. (no date given). FAQs: Surgical site infections. Retrieved December 9, 2015 from cdc.gov/hai/pdfs/ssi/ssi_tagged.pdf. 57. American Academy of Orthopaedic Surgeons. (2015). Deep vein thrombosis. Retrieved December 9, 2015 from WebMD. (no date given). How to prevent deep vein thrombosis (DVT). Retrieved December 10, 2015 from Mayo clinic. Pneumothorax. Retrieved December 10, 2015 from Zarogoulidis, P. et al. (2015). Pneumothorax as a complication of a central venous catheter insertion. Retrieved December 10, 2015 from Agency for Healthcare Research and Quality (AHRQ). (2014). Appendix 3. Guidelines to prevent central line-associated blood stream infections. Retrieved February 15, 2016 from professionals/education/curriculum-tools/clabsitools/clabsitoolsap3.html. 62. Agency for Healthcare Research and Quality (AHRQ). (2015). Why focus on central line-related bloodstream infections (CLASBSIs) Retrieved February 15, 2016 from default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4a-crbsi-bestpractice.pdf. Patient safety: IMPLEMENTATION OF NATIONAL SAFETY STANDARDS FOR NURSES Self-Evaluation Exercises Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your participant sheet. 1. The ECRI Institute has identified a number of safety concerns. Based on the Institute s report, which of the following statements accurately represents an identified safety concern? a. Research shows that patients may share their opioid medications with family members and friends. b. Cleaning and disinfection/sterilization of reusable devices represent the same action. c. Medication errors related to pounds and kilograms generally involve elderly patients. d. The nursing department should develop a patient medication list that is separate from the list shared by all disciplines. 2. In order to avoid air embolism associated with CVADs: a. Ask the patient to take a deep breath during CVAD insertion. b. Avoid clamping CVAD lumens. c. Avoid applying pressure while removing the catheter. d. Place the patient in Trendelenburg position during catheter placement. 3. To prevent surgical site infections healthcare providers: a. Must cleanse hands up to their wrists with antiseptic agents just prior to surgery. b. Should use a razor to remove hair from the surgical site. c. Teach patients not to touch surgical wound dressings. d. Avoid using alcohol-based hand cleansers since these dry the skin and promote skin breakdown. 4. A patient with type B negative blood: a. Has B antigen proteins and positive Rh factor. b. Has both B antigens and the Rh factor. c. Has neither A nor B proteins. d. Has both A and B proteins but no Rh factor. 5. The risk of poor glycemic control is increased by: a. Insufficient nurse staffing. b. Lack of timely communication. c. Lack of glycemic control experience by resident physicians. d. All of the above. 7. Actions that should be taken to avoid hospital acquired conditions include: a. Having the surgical team document unretrieved device fragments. b. Asking a patient to take deep breaths during the insertion of a CVAD. c. Knowing that the most serious transfusion complications occur within the first hour before and after initiation of each unit of blood. d. Recognizing that the femoral site is the preferred site in adults for venous catheter insertion. 8. Which of the following actions adheres to The Joint Commission recommendations for operating room counting procedure? a. One person performs an audible and visible counting procedure. b. A counting procedure is first performed at the time the surgical incision is made. c. Surgical team members include counts of items added to the surgical field throughout the surgery. d. The surgical team does not include soft goods in the count. 9. Which of these actions shows an accurately performed double check when blood product administration is required? a. The first nurse says to the second nurse This blood is labeled Type A positive. That s right isn t it? b. The first nurse asks a nursing assistant to verify the patient s identity. c. The first nurse asks a blood bank technician to verify the blood type while commenting that this getting a second check is a waste of time. d. The first nurse asks the second nurse to double check the accuracy of all of her preparations to administer a blood product. 10. The most effective way to prevent transfer of hospital acquired infections, including vascular catheter-associated infections, is: a. Skin antisepsis. b. Hand hygiene. c. Maximum sterile barrier precautions. d. Proper dressing changes. 6. Which of the following statements pertaining to iatrogenic pneumothorax is accurate? a. Ultrasound should be used during catheterization to guide catheterization. b. Iatrogenic refers to a pneumothorax that is deliberately induced. c. Women are more likely to have a pneumothorax than men. d. Pneumothorax due to ruptured air blisters is most likely to occur in patients over the age of 65. Answers: 1.A 2.D 3.C 4.A 5.D 6.A 7.A 8.C 9.D 10.B Page 127

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