CANCER REHABILITATION PATHWAY - HAEMATOLOGY Statement: To be used in conjunction with Brain and CNS Rehabilitation Care Pathway as appropriate Diagnosis and Care Planning: The following symptom pathways may be useful at this stage of the pathway: Fatigue Management Breathlessness Lympohoedema Mobility and Loss of Function Pain Metastatic Spinal Cord Compression D1 Information/Support a Obtain collateral information on social situation & support network b Assess information needs for patients & provide suitable verbal & written advice including local support groups c Provide family & carer support & education as required d Provide contact details for relevant AHPs e Provide relevant information prescription f Ensure key worker is allocated and contact details provided D2 Nutrition a Ensure nutritional screening is implemented using a validated tool b Assess nutritional requirements & status and factors affecting nutritional intake including patient s circumstances & ability to act on dietetic advice c Provide practical dietary advice, including written information tailored to individual s needs, prognosis,circumstances d Liaise with other health professionals in the haematology team
e Provide ongoing monitoring & support to patient, family & carers f Formulate and provide nutritional care plans to achieve optimal nutritional status g Where necessary, consider alternative methods of nutrition support & provide advice & support for health care professionals, patients & relatives h Influence organisational approach to provision of food D3 Referral/Liaison a Liaise with MDT & internal & external agencies as appropriate b Assessment of multiple myeloma patients to include the possibility of pathological fracture and spinal cord compression. D4 Respiratory Function a Identify patient with or without pre-existing respiratory disease if it is likely to impact on treatment b Assess respiratory status and impact on function c Commence chest physiotherapy to suit individual requirements d Optimise physical & respiratory fitness if it is likely to impact on treatment e Assess, advise and implement seating and postural management D5 Skin Care a Assess for & arrange provision of pressure relieving cushions/ mattresses to optimise comfort & minimise the risk of developing or exacerbating existing pressure sores b Minimise the risk of developing or exacerbating existing pressure sores c Initial complex seating and pressure management aiming to improve sitting tolerance in the initial stages D6 Work, Leisure & Activities of Daily Living a Undertake risk assessment for falls & manual handling b Undertake assessment of patients ability in all daily care including bathing & showering, providing equipment as required c Undertake baseline assessment of patients mobility, including stairs and transfers. Provide appropriate equipment to facilitate independence (refer to mobility and loss of function pathway) d Assess & advise on hand dexterity, eye sight & cognitive abilities where difficulties may be anticipated e Assess levels of fatigue & advise as necessary (refer to fatigue care pathway) f Maintain restorative exercise and health promotion as possible pre operatively g Undertake assessment of domestic care ability h Undertake assessment of work and leasure activities i Assess communication - including vocal cord dysfunction. Treatment: The following symptom pathways may be useful at this stage of the pathway: Fatigue Management Breathlessness
Lympohoedema Mobility and Loss of Function Pain Continence Anorexia and Cachexia Dysphagia Metastatic Spinal Cord Compression T1 Assessment & Support a Complete holistic initial assessment including respiratory, mobility, moving and handling risk assessment and physical condition using a recognised assessment tool b Negotiate goals with patient & allocate appropriate outcome measures c Undertake baseline assessment including physical fitness & treatment of patient and review subsequently as required d Assess respiratory function, mobility, social history f Agree & implement goal specific treatment plan g On going monitoring and support to patient, family and carers h Assess fatigue and implement management strategies i Monitor degree of immune suppression T2 Cognitive & Psychological Factors a Assess psychological needs of patients & families/ carers & refer/ advise appropriately b Complete holistic initial assessment looking at social situation, functional cognitive & perceptual areas c Assess & plan anxiety management programme in order to provide confidence for patient &/ or carers in management of condition d Help patients to explore their feelings around body image, self identity, self esteem, sexuality & relationships e Assess and advise strategies to manage role adjustment and refer on to other agencies f Assess for and arrange provision of memory aids, family support and home adaptations in relation to safety and falls management T3 Equipment Provision a Provide aids & equipment to support daily living & self management techniques to optimise management of activities of daily living b Ensure equipment to facilitate independence &/ or care is provided in a timely service according to local guidance c Ensure equipment required to enable independence in activities of daily living is delivered & fitted prior to discharge T4 Exercise & Physical Well Being a Teach patient exercises for maintenance of circulation and general muscle strength if patient is acutely unwell b Teach patient exercises for maintenance of circulation & general muscle tone if patient is unable to mobilise c Advise patient about effective exercise, lifting & general activity, with written support materials if required d Provide exercise intervention for all patients undergoing high dose chemotherapy with or without stem cell transplantation
e Advise patients on increasing levels of physical activity & the benefits there of f Refer to exercise classes to improve fitness & wellbeing g Complete risk assessment in relation to any manual handling difficulties h Provide tailored exercise intervention appropriate to all patients throughout the treatment pathway T5 Information/Support a Issue appropriate information to ensure patient is supported post discharge b offer support and information to carers T6 Mobility a Assess patient s functional ability to manage at home including stairs (refer to mobility pathway) b Supply mobility equipment required prior to discharge c Undertake & complete moving & handling risk assessment documentation d Educate & demonstrate use of equipment & techniques for safe moving & handling to patients & carers and provide written information f Assess for musculo-skeletal problems and treat as appropriate T7 Nutrition a Implement nutritional screening using validated tool b Continue to Assess and monitor nutritional requirements & status c Continue to Assess and monitor factors affecting nutritional intake including nausea and vomiting, diarrhoea and dysphagia, refer to speech and language as appropriate d Continue Assess and monitor patient s circumstances & ability to act on dietetic advice e Provide practical dietary advice, including written information tailored to individual s needs, prognosis & circumstances & neutropenic diet and mouth care f Formulate care plan and continue to review nutritional care plans to achieve optimal nutritional status g Where necessary, consider alternative methods of nutrition support & provide advice & support for health care professionals, patients & relatives liase with home enteral feeding team as appropriate h Monitor and identify biochemistry, full blood count and electrolyte disturbance, renal function and refeeding syndrome and advise/refer as appropriate i Assess and monitor for signs of graft versus host disease (GVHD) j Advise on fatigue, weight maintenance, alternative diets, vitamin, minerals and herbal supplements k Educate and apply appropriate food safety restrictions l Dietary advice for renal dysfunction (low potassium, low phosphate, sodium and fluid restrictions) as appropriate T8 Referral/Liaison a Arrange outpatient or community physiotherapy and OT if required after discharge b Give patient contact name & telephone number of physiotherapy and OT services to contact between discharge & outpatient appointment in case of problems with mobility & function c Liaise with other health professionals in the oncology/ haematology team, MDT & refer onto other agencies as appropriate d Arrange dietetic and speech and language follow up after discharge and provide appropriate contact numbers
T9 Respiratory Function a Assess respiratory status b Provide respiratory treatment as indicated T10 Skin Care a Assess for & arrange provision of pressure relieving cushions/ mattresses to optimise comfort & minimise the risk of developing or exacerbating existing pressure sores b Minimise the risk of developing or exacerbating existing pressure sores c Assess, educate and advise on daily skin care d On-going graded seating and pressure care management T11 Work, Leisure & Activities of Daily Living a Maintain awareness of wider issues of cancer prognosis & impact of treatment on self image b Provide ongoing monitoring & support to achieve patient s goals and work towards independence in all activities of daily living including return to work, leisure activities and lifestyle c Assess bathing/ showering to address possible continence issues & provision of equipment as indicated d If required, advise patient about managing continence problems through pelvic floor exercises, with written support materials (refer to continence pathway) e Conduct home assessment if indicated & implement recommendations f Conduct post-discharge & follow up if indicated g Provide advice on energy conservation & techniques in activities of daily living h Provide equipment to facilitate independence with hygiene needs i Help with access & mobility to the toilet j Assess levels of fatigue & advise as necessary (refer to fatigue care pathway) T 12 Mouth care a Assess condition of mouth including mucosa and pain b Assess impact on nutritional status c Encourage oral hygiene and use of mouth washes d Liaise with medical team for analgesia as required e Establish treatment plans & realistic goals with patient & carers including priorities for intervention Post Treatment: The following symptom pathways may be useful at this stage of the pathway: Fatigue Management Breathlessness Lympohoedema
Mobility and Loss of Function Pain Continence Anorexia and Cachexia Dysphagia Metastatic Spinal Cord Compression PT1 Assessment a Complete holistic initial assessment including respiratory, mobility, moving and handling, risk assessment and physical condition, nutrition and communication using validated assessment tools b Complete social, psychological functional cognitive perceptual assessment c Establish treatment plans and realistic goals with patient and carers including priorities for intervention d Complete outcome measures e Monitor degree of immune suppression PT2 Cognitive and Psychological Factors a Assess & plan anxiety / psychological management programme in order to provide confidence for patient &/ or carers in management of condition b Address issues concerning patients sense of body image, self esteem, self identify, confidence and sexuality d Assess and advise on strategies to manage role adjustment e Assess and implement cognitive rehabilitation f Advise on coping mechanisms using cognitive behavioural therapy techniques and anxiety management strategies PT3 Exercise & Physical Well Being a Advise general exercise and acivity tailored to patients individual requirements b Include/ invite to a fitness programme as an out-patient c Advise on home exercise programme as appropriate d Work on optimising functional mobility and physical condition e Assessment of fitness, physical, psychological & musculo-skeletal problems that would include urinary/ faecal incontinence f Provide exercises for areas affected by treatment to ensure reduction in pain, return of movement & to improve function h For patients with lymphoedema refer to the lymphoedema pathway i Assess levels of fatigue & advise as necessary PT4 Information/Support a Provide ongoing monitoring & support to patient, family & carers using available media b Repeat outcome measures PT5 Mobility
a Educate & demonstrate use of equipment & techniques for safe moving & handling to patients & carers b Ensure equipment to facilitate independence &/ or care is provided in a timely service according to local guidance PT6 Nutrition a Implement nutritional screening using a validated tool b Continue to assess and monitor factors affecting nutritional intake including patients circumstances and ability to act on dietetic advice c Provide practical dietary advice, including written information tailored to individual s needs, prognosis & circumstances d Formulate and review care plan to achieve optimal nutritional status e Where necessary, consider alternative methods of nutrition support & provide advice & support for health care professionals, patients & relatives f Liaise with home enteral feeding team for artifical feeding as appropriate g Advise on fatigue, weight maintenance, diet, and supplements as necessary h Educate and apply appropriate food safety restrictions i Dietary advice for renal dysfunction (low potassium, low phosphate, sodium and fluid restrictions) as appropriate PT7 Referral/Liaison a Liaise with other members of the team according to referral criteria and refer as necessary b Ensure that appointment is available for any intervention in a timely manner PT8 Skin Care a Assess for & arrange provision of seating/pressure relieving cushions/ mattresses to optimise comfort, support posture & minimise the risk of developing or exacerbating existing pressure sores b Minimise the risk of developing or exacerbating existing pressure sores c Assess and monitor for GVHD d Assess, educate and advise on daily skin care e Provide advice and splinting for peripheral neuropathies PT9 Work, Leisure and Activities of Daily Living a Assess home environment where appropriate in relation to treatment plan including functional mobility and stairs b Undertake bathing/ showering/ toilet assessment & provision of equipment as required c Address issues such as clothing that requires minimum effort to get on & is comfortable particularly with patients with prosthetics/stomas/ lines/ drains d Provide equipment to facilitate independence with hygiene e Provide vocational rehabilitation and advice on return to work as appropriate f Assess and advise strategies to manage role adjustment g Assess fatigue and implement management strategies PT10 Mouth care
a Assess condition of mouth including mucosa and pain b Assess impact on nutritional status c Encourage oral hygiene and use of mouth washes d Liaise with medical team for analgesia as required e Establish treatment plans & realistic goals with patient & carers including priorities for intervention Monitoring & Survivorship: The following symptom pathways may be useful at this stage of the pathway: Fatigue Management Breathlessness Lympohoedema Mobility and Loss of Function Pain Continence Anorexia and Cachexia Dysphagia Metastatic Spinal Cord Compression M1 Assessment a Complete holistic assessment using a recognised assessment tool b Undertake MDT assessment/ review & allocate key lead/ key worker c Complete outcome measures d Monitor degree of immune suppression M2 Cognitive and Psychological Factors a Assess & plan anxiety / psychological management programme in order to provide confidence for patient &/ or carers in management of condition b Help patients to explore their feelings around body image, self esteem and self identity & sexuality, realtionships and religious values c Offer up to level 2 psychological support throughout assessment and treatment d Identify psycho-social needs to establish a base line measurement & promote psychological adjustment & well being e Teach relaxation techniques as part of anxiety management f Provide ongoing physical & psychological functional assessment in relation to activities of daily living g Assess and advise strategies to manage role adjustment h Assess fatigue and implement management strategies M3 Exercise & Physical Well Being a Assess and review physical fitness and refer to exercise programme as appropriate
b Refer on to community based exercise prescription M4 Information/Support a Help improve general health and wellbeing b Provide ongoing monitoring & support to patient, family & carers c Provide appropriate information prescription M5 Mobility a Undertake & complete moving & handling and falls risk assessment documentation b Educate & demonstrate use of equipment & techniques for safe moving & handling to patients & carers c Assess mobility and access around the home environment M6 Nutrition a Implement nutritional screening using validated tool b Continue to assess and monitor nutritional requirements & factors affecting nutritional intake including patient s circumstances & ability to act on dietetic advice c Provide practical dietary advice, including written information tailored to individual s needs, prognosis & circumstances d Advise on healthy eating, fatigue, weight maintenance, alternative diets, vitamin, minerals and herbal supplements e Formulate & review nutritional care plans to achieve optimal nutritional status f Where necessary, consider alternative methods of nutrition support & provide advice & support for health care professionals, patients & relatives g Dietary advice for renal dysfunction (low potassium, low phosphate, sodium and fluid restrictions) as appropriate M7 Skin Care a Assess for & arrange provision of seating/pressure relieving cushions/ mattresses to optimise comfort, support posture & minimise the risk of developing or exacerbating existing pressure sores b Minimise the risk of developing or exacerbating existing pressure sores c Assess and monitor for GVHD d Assess, educate and advise on daily skin care M8 Referral/Liaison a Liaise with other members of the team according to referral criteria & refer onto other agencies as appropriate M9 Work, Leisure and Activities of Daily Living a Advise on adaptive techniques to enhance independence in functional tasks b Assess home environment where appropriate in relation to treatment plan c Establish treatment plans & realistic goals with patient & carers including priorities for intervention d Provide pressure relieving cushions to optimise comfort & minimise the risk of developing or exacerbating existing pressure sores e Assess patients for needs such as psychological support & other support groups f Advise on maintaining role at work or re-engaging in work place
g Support patients to re-engage in community and leisure activities h Ensure equipment to facilitate independence &/ or care is provided in a timely service according to local guidance i Assess fatigue and implement management strategies j Provide ongoing support to facilitate work activities k Assess levels of fatigue & advise as necessary J. Arends et al Espen Guidelines on enteral nutrition: non surgical oncology. Clinical Nutrition (2006) 25, 245-259 NICE Guidelines 2003 (?guidance for artificial nutritional support or enteral)