Patient Treatment Date/time: Diagnosis: Treatment Regimen:

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1 Name: Address: DOB: HCRN: Consultant: Ward: Assessment: Pre Systematic Anti Cancer Therapy (SACT) Continuation *This assessment is for patients on multiday regimens Patient Treatment Date/time: Diagnosis: Treatment Regimen: Cycle number: Cycle day: Vital Signs/Early Warning Score completed NA Have all necessary bloods been completed? FBC U&E Liver profile Bone profile Coagulation Screen Iron Studies TFTs CRP Other Details: Tumour markers Details: Blood results reviewed and satisfactory to proceed with treatment? Details: Peripheral Intravenous Cannulation (PIVC) Record How many attempts to successfully cannulate: Time/date Size of PIVC Vein 1 Blood return VIPs score 1 Patient tolerance of procedure achieved 2 Initial/NMBI pin 1 See appendix 1 and indicate if the right or left arm used 2 If no or poor blood return achieved, please document action in nursing note

2 Patient Name DOB HCrN Central Venous Access Device (CVAD) Record PICC Port Hickman Vascath Other Details: Time/Date Lumen Blood return Lumens flushed and Catheter external Description of exit site colour achieved? 3 patent? 3 length (if applicable) Red Blue Yellow Brown Red Blue Yellow Brown Red Blue Yellow Brown initial/nmbi Pin Pre treatment checks CTCAE Version 4 4 Grade CTCAE Version 4 Grade Chest pain Weight loss Infection Diarrhoea Bleeding Constipation Dyspnoea Urinary disorder Confusion/cognitive disturbance Fatigue Pain Peripheral neuropathy -sensory Mood alteration Peripheral neuropathy -motor Mucositis/stomatitis Bruising Nausea Rash Vomiting Occular/Eye problems Anorexia Palmer/Planter Syndrome Other ECOG Status 5 SACT Administration Blood return present prior to commencing and throughout treatment? SACT fully infused without any adverse events If ambulatory SACT pump attached correctly? NA If ambulatory SACT pump attached, is clamp open? NA Assessment completed by: NMBI pin: Please document additional details in notes section if required 3 If No, document further actions in nurses notes section 4 See appendix 2 for CTCAE version 4 5 See appendix 3 for ECOG score

3 Patient Name DOB HCrN Does the patient require admission? Has PIVC been flushed & removed? Any PIVC complications? CVAD flushed as per hospital policy? Any CVAD complications? Has Huber needle been removed? (if applicable) Discharge Location: NA Time PIVC removed: Comments: NA Comments: NA Comments: If 5fu pump attached on discharge, has disconnection been arranged? Has spill kit been given to patient (If applicable) Safe handling and disposal of cytotoxic drug information leaflet given? Date given for CVAD flush and dressing if not for treatment before next due? NA Give details of disconnection: Time: Date: Location: Day ward CIT NA Yes No NA Is the Patient for any supportive medications at home? Did the patient receive a prescription? Details: NA Give details of flush/dressing Time: Date: Location: Day ward CIT PHN If the patient is for G-CSF, is administration arranged? NA Details: MDT referrals/community supports arranged this visit Is patient for follow up/review appointment? NA Has the appointment been arranged? NA Details: Have blood requests for next appointment been given to patient? NA Details: Next day ward appointment date: Next appointment time: Reason: Assessment completed by NMBI pin

4 Patient Name DOB HCrN Time Notes Sign/NMBI Signature Bank Name Signature Initials Role NMBI Pin

5 Appendix 1: Visual Infusion Score (VIPS) Visual Infusion Phlebitis Score (VIPS) Condition of site Score IV site appears healthy 0 One of the following is evident: 1 Slight pain near IV site Slight redness near IV site Two of the following are 2 evident: Pain at IV site Erythema Swelling Appendix 2: Common Terminology Criteria for Adverse Events- CTCAE Version 4 Grades Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Chest pain Location? When did it start? Mild Pain pain; limiting instrumental Pain at rest; Infection Has the patient taken their own temp? Any chills, shivering, shaking episodes? Any local signs? Are they neutropenic? Dyspnoea It is a new symptom? Is it worsening? Any chest pain and for how long? *consider SVCO, anemia, treatment related Confusion/cogniti ve disturbance Is this symptom new? How long have they had these symptoms? Is it getting worse? Any s to medications? Pain Is it a new symptom? How long? Is the pain constant? or no or no or no Asymptomatic or mild symptoms not requiring intervention New onset shortness of breath with moderate exertion Mild disorientation not interfering with s. Slight decrease in level of alertness Mild pain: not interfering with function Localised. Localised intervention indicated Shortness of breath with minimal exertion; limiting instrumental cognitive disability and/or disorientation limiting s pain: pain or analgesia not activities of daily living Intravenous antibiotics indicated Shortness of breath at rest; Severe cognitive disability and/or severe confusion; severely limiting s. Altered level of consciousness Severe pain: Pain or analgesia s Death consequences, loss of consciousness Disabling

6 Grades Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Mood alteration How long have they felt this way? What help them feel better? What supports are in place? Mild mood alteration, not function mood alteration, not s Severe mood alteration s Mucositis/Stomati tis Are there mouth ulcers? Evidence of infection? Able to eat and drink? Asymptomatic or mild symptoms pain not interfering with oral intake Severe pain, oral intake Suicidal ideation Danger to self or others Requires parentrenal/entren al support Nausea What is their oral intake like? Are they taking antiemetic? Vomiting How many days/episodes? Are they constipated or have diarhorea? Loss of appetite without alteration in eating habits 1-2 episodes in 24 hours Oral intake decrease without significant weight loss or dehydration 3-5 episodes in 24 hours Inadequate oral caloric and fluid intake >6 episodes in 24 hours consequences Anorexia What is appetite like? Has it recently d? Weight loss Are they trying to lose weight? Diarrhoea *Consider infection Constipation How many days since LBM? What s their baseline? Any nausea, vomiting or abdominal pain? Urinary frequency Fatigue Any other associated symptoms? or no Loss of appetite without to eating habits 5-10% less than baseline Increase of <4 stools per day over baseline. Mild increase in ostomy output Occasional or intermittent symptoms, occasional use of laxatives Nocturia or increase x 2 times function Mild: Increase in baseline fatigue, but not effecting daily activities Oral intake altered without significant weight loss or malnutrition 10-20% less than baseline Increase of 4-6 stools per day over baseline. increase in ostomy output Persistent symptoms with regular use of laxatives/ene mas and limited s (activities of daily living) Increase>2 times x <hourly : Decrease in performance and difficulties with s and Oral intake altered in association with significant weight loss/malnutrition >20% less than baseline Increase of >7 stools per day over baseline Severe increase in ostomy output Constipation >1 hourly urgencycatheter indicated Severe Significant decrease in performance and interferes with ALDs complications such as collapse consequences Obstruction/Life threatening consequences Disabling

7 Grades Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Peripheral Neuropathy When did it start? Is it continuous? Is it getting worse or affecting mobility or function? Any constipation or urinary incontinence? Asymptomatic parenthesis/tingl ing persistent. Not interfering with s Sensory alteration, Interferes with not s Sensory alteration, Interferes with s Disabling Permanent sensory loss *consider spinal cord compression Bruising Localized or in a dependent area Rash Macules/papule Is it localized or s covering < generalized? 10% BSA with How long has it or without been there? symptoms (e.g., Signs of infection? pruritus, Is there any itch? burning, tightness) Nail Changes When did it start? How long has it been there? or no Discolored, ridging, pitting Generalized Macules/papul es covering 10-30% BSA with or without symptoms (e.g., pruritus, burning, tightness); limiting instrumental Partial or complete nail loss Macules/papule s covering >30% BSA with or without associated symptoms; Interferes with s Palmer/planter syndrome Mild numbness, tingling swelling of hands and feet with or without pain or redness Painful redness and/or swelling of the hands and/or feet Moist desquamation, ulceration and severe pain Appendix 3: ECOG Status ECOG Status ECOG score 0 ECOG score 1 ECOG score 2 ECOG score 3 ECOG score 4 Fully active, able to carry on all predisease performance without restriction Capable of only limited self care, confined to bed or chair more than 50% of waking Completely disabled Cannot carry on any self- care. Totally confined to bed or chair hours Restricted in physically strenuous activity but ambulatory and able to carry out work of light or sedentary nature, e.g. light house work, office work Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% or waking hours Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group.Am J Clin Oncol. 1982;5: