Pre-treatment Phase. Pre-treatment Phase

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1 Pre-treatment Phase Author: Ayda G. Nambayan, DSN, RN, St. Jude Children s Research Hospital Content Reviewed by: Judith Wilimas, MD, St. Jude Children s Research Hospital Cure4Kids Release Date: 7 April 2006 Informed Consent The physician is the person who is primarily responsible for obtaining informed consent regarding treatment or participation in clinical trials; but the nurse is responsible for ensuring that informed consent has been obtained and is available on the patient s chart. In addition, the nurse has an ethical duty to ensure that the children and/or their families understand the treatment plan: its goals and expectations, its requirements, and the responsibilities of the health care team and the patients. The nurse must also ensure that the patient and family know they have the right to give or withhold consent for treatments. The person giving consent must understand the purpose, risks, and benefits associated with the proposed treatment and be aware of non-treatment alternatives. They must voluntarily give consent and demonstrate that they understand the information they are receiving and are competent to make related health care decisions. Most institutions have a policy for informed consent related to cancer treatments. The nurse should be familiar with this policy and follow the procedure accordingly. Associated Pre-treatment Care Pre-operative Care Much preparation goes into getting a child ready for a surgical procedure. For example, the surgeon often uses diagnostic imaging to plan the surgical approach he or she will take. The nurse should make sure that these imaging results as well as laboratory results (e.g., Hb, WBC, platelet count, and coagulation factors) are readily available to the surgeon before the procedure. Abnormal blood counts are corrected as much as possible with blood transfusions before the procedure. Electrolyte levels are also assessed and corrected if necessary. In addition, many hospitals have child life staff who help to prepare the child for surgery. Preparation for surgery can include allowing the child to hold medical equipment, giving the child age-appropriate explanations of procedures, and arranging a tour of the operating room. Module 5 - Document 3 Page 1 of 10

2 The nurse is responsible for ensuring that all appropriate documents (e.g., consent form) and laboratory results are in the patient s records. On the day of surgery, the nurse should prepare the patient according to hospital policies and ensure that all preoperative orders (if any) are appropriately implemented. Pre-Chemotherapy: Prior to chemotherapy treatments, the nurse is responsible for: Checking that the informed consent for treatment is signed and that patient/family have adequate understanding of the treatment modality and its requirements. Obtaining related patient history 1. allergies and experiences with prior illness, hospitalizations and medications 2. documentation of any prior chemotherapy and patient response to it; and any use of anti-emetics. 3. documentation of current medications that the patient is taking, including vitamins, allergy medications, non-prescription drugs, as well as complementary and alternative therapies. Obtaining recent height and weight measurements Height in centimeters Weight in Kilograms Check Laboratory reports Complete Blood Counts (CBC) Serum Chemistry if needed Reviewing child s treatment plan 1. verify the day and phase of treatment 2. verify drug, dose, and pretreatment studies required prior to administration 3. verify and prepare the pretreatment orders, such as anti-emetics and antihistamines 4. double check height and weight of the patient and compare with last recorded value 5. calculate drug dosages using body surface area (BSA) if applicable. (Children who weigh less than 10 Kg. [22 lbs] or who are less than 12 months old require a milligram-per-kilogram dose.) a. A 1 Nomogram (grid) b. Formula: BSA = sq. root of ht (cm) x wt (kg) 3600 Example: Height = 60 cm (23.5 inches) Weight = 20 Kg (44 lbs) 60 (20) = 1200 = Module 5 - Document 3 Page 2 of 10

3 Sq. Root of 0.34 = 0.57 Pre-treatment Phase Usually, dosages are calculated using mg/square-meter formula, i.e., 10 mg per m 2 Example: Ordered dose = 10 mg/m 2 Child s BSA = 0.57 m 2 Dose to be Administered = 5.7 mg Children who weigh less than 10 Kg. (22 lbs) or who are less 12 months old require a milligram-per-kilogram dose. Example: Order: 0.5 mg per Kg Patient s Weight = 6.8 Kg (15 lbs) Dose = 3.4 mg. Review the pretreatment laboratory values and other studies (imaging, cardiac function, etc.) that might have been performed. 1. If child is neutropenic (or WBC is < 2000), calculate Absolute Neutrophil Count (ANC) by multiplying WBC count by total number of bands and segs. ANC = Segs + Bands (WBC ). ANC Calculator Cure Hodkins.com, Fullerton, CA Example: WBC = 2000 cu/mm Segs = 47 % Bands = 3 % = 50 % or (0.5) = 1000 (ANC) For succeeding treatments check for presence of treatment side-effects that could be dose limiting 1. Myelosuppression 2. Mucositis 3. Presence and degree of peripheral neuropathy 4. Vital Signs fever, hypotension, wheezing 5. Peripheral edema suggestive of congestive heart failure Check patient s veins (if IV chemo is indicated) and condition of venous access Module 5 - Document 3 Page 3 of 10

4 device Pre-treatment Phase 1. Veins should be robust and healthy 2. Veins should be easily accessible 3. Venous access device site must not be infected and there should be evidence of a brisk blood return (blood backs without hesitancy and quickly) If oral chemo will be given, determine ability of the patient/family to comply. Assess the most appropriate time for the patient to take the chemotherapy that will be least disruptive to the patient s life and would promote increased compliance. Determine how patient likes to take his oral medications Organize chemotherapy drugs according to sequence of administration; pre-medicate patient as necessary. Check and double check chemotherapy drugs and dosages; use hospital policies regarding double checking in order to avoid errors. Pre-Radiation Therapy: Determine overall goal of radiation therapy Curative Adjunctive Palliative Make sure that all data needed before initiation of therapy are readily available Goal of therapy: whether curative, adjunctive, or palliative Pertinent tumor facts: size, location and histologic grade Imaging studies containing relative volume of poorly vascularized or necrotic tissue Co-morbid conditions such as autism, Down s syndrome, etc. Age, physiologic and psychological condition of the child Previously established radiation plan Assess the need for conscious sedation, general anesthesia, or mild sedation. The use of immobilization devices (head holders, bite blocks, chin supports, etc) might overwhelm the child. Allow the child to handle the device and/or play with the device prior to therapy. Develop an age-specific plan of care. Coordinate with Child Life specialists (if available) to provide age-specific preparation and support (A 2) Make sure that radiology lines are visible and assess areas of the skin that will be exposed to radiation. In some instances, permanent tattoos replace the skin marks, and though not painful, might cause anxiety in patients and family. The nurse is instrumental in helping patients and families understand that the radiation marks are important to ensure correct and adequate tumor exposure during radiation therapy. (Recently, the radiation marks are applied to the immobilization devices instead of the patient s skin, which can help decrease patient anxiety, associated self-image difficulties and prevent accidental erasures of skin marks). Module 5 - Document 3 Page 4 of 10

5 Prepare the patient for sedation if necessary. Conscious sedation or general anesthesia might be required to ensure adequate immobilization and accuracy of radiation beam. Again, the nurse is the professional who supports and allays the fears of parents and patients regarding sedation. Inform the patient and family about side-effects of treatment, treatment outcomes, safety, and equipment, since misinformation causes distress and unnecessary fear of the unknown. One fear is the idea of the child s radioactivity while undergoing therapy and how to protect the child and others from the dangers of radiation. The nurse can also dispel myths about radiation therapy held by employees and students at the child s school. This will help the child as he/she re-enters the school, and will help school personnel anticipate the needs of the child. Module 5 - Document 3 Page 5 of 10

6 Helpful Web Links University of Washington School of Medicine Ethics in Medicine University of Virginia, Charlottesville, VA Health Sciences - Informed Consent Pediatrics Circumcision Reference Library Informed Consent, Parental Permission and Assent in Pediatric Practice Oncology Nursing Society, Pittsburgh, PA Clinical Journal of Oncology Radiation Therapy Standards of Nursing Practice ONS Virtual Congress Topics Clinical Trials Negotiating Options with your Patients Related Seminars Seminar #201: Interpreting Complete Blood Counts Belinda Mandrell, RN, MSN Seminar #227: IV Insertion - Practically Perfect Peripheral Pediatric Punctures Lunetha Britton, RN Seminar #196: Chemistry Analysis Belinda Mandrell, RN, MSN Seminar #250: Child Growth and Development Angie Koenecker, CCLS; Clare Goode-Gardner, CCLS Seminar #628: Assessments of Pediatric Oncology Patients Kelley Windsor, RN, BSN, CPON; Geraldine Robinson, RN, BSN, CPON; Evelyn Fields, RN, BSN Module 5 - Document 3 Page 6 of 10

7 Appendix: A 1 Nomogram (Grid) Aschenbrenner DS, Cleveland LW, Venable SJ. Drug Therapy in Nursing, Lippincott Williams & Wilkins, Philadelphia, PA Module 5 - Document 3 Page 7 of 10

8 To determine body surface area using the nomogram: A straight edge (or ruler) is placed so that it connects the patient s height in the left column with his/her weight in the right column. Where the line intersects in the center (middle) column is the patient s body surface area (m 2 ) In the example below, the patient s height in cm is 37 cm and the patient s weight is 22 Kg. By using a straight line, the height and the weight measures intersects at 0.37 (which is the BSA in m 2 Aschenbrenner DS, Cleveland LW, Venable SJ. Drug Therapy in Nursing, Lippincott Williams & Wilkins, Philadelphia, PA Go Back Module 5 - Document 3 Page 8 of 10

9 A 2 Age-specific Preparation and Support Pre-treatment Phase Younger than 3 years Child might require pharmaceutical assistance in order to ensure accurate delivery of therapy. A mild sedative may be used. The issue of separation anxiety (in both the child and the parent) can be addressed by assigning the same health care provider to care for the child every time and by allowing the parents to be present. Preschool (4-6 years) Use behavioral interventions strategies that focus on sensory information, i.e., play therapy, exploration and rewards, plus simple and concrete explanations immediately prior to therapy. Allow the children to wear their own clothes during treatments and bring with them a favorite toy or their security blanket. Use games and stories specifically designed to gain cooperation of preschool children and eliminate the need for sedation. School Age (7-12 years) Children in this age group can process information, are task-oriented, and are eager to please. These children respond well to simple, direct explanations of the procedure and what they should do and what is expected of them. Such children are often intrigued by how the equipment works. Therefore, it is helpful to show them the radiation area and allow them to manipulate and play with the equipments that will be used in order to familiarize them with the environment and lessen their fear. The nurse can also teach parents to help by teaching them activities that they can do with their child at home in order to cope with the requirements of radiation therapy. For example, parents can integrate immobilization activities into games they do at home and also appropriately use rewards to reinforce desired behaviors. Adolescents Adolescents can effectively participate and comply with the immobilization requirements of radiation therapy. Because of the concern adolescents have with body image, the issues of skin marking and/or tattooing should be approached very sensitively. Go Back Module 5 - Document 3 Page 9 of 10

10 Acknowledgements: Author: Ayda G. Nambayan, DSN, RN, St. Jude Children s Research Hospital Content Reviewed by: Judy Wilimas, MD, St. Jude Children's Research Hospital Edited by: Marc Kusinitz, PhD, St. Jude Children s Research Hospital Cure4Kids Release Date: 7 April 2006 Cure4Kids.org International Outreach Program St. Jude Children's Research Hospital 332 N. Lauderdale St. Memphis, TN You may duplicate and redistribute this content in its entirety for educational purposes provided that the content is made available free of charge. This content may not be modified or sold. You can assist us in the development of additional free educational materials by sending us information about how and when you show this content and how many people view it. Send all comments and questions to nursing@cure4kids.org. St. Jude Children's Research Hospital, 2006 Last printed 4/26/2006 4:21 PM Last Updated; 6 April 2006; AS X:\HO\IO Edu Grp\Projects\NURSING COURSE\NCEnglish\Edited\Module 5\M5 Final Revisions\NEM05D03V08.doc Module 5 - Document 3 Page 10 of 10

APEx Program Standards

APEx Program Standards The following standards are the basis of the APEx program. Level 1 standards are indicated in bold. Standard 1: Patient Evaluation, Care Coordination and Follow-up The radiation