PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES

Transcription

1 PRINCESS MARGARET CANCER CENTRE CLINICAL PRACTICE GUIDELINES HEAD AND NECK ONCOLOGY NURSING FOR HEAD AND NECK CANCERS

2 Head & Neck Site Group Oncology Nursing for Head and Neck Cancers Specialized Oncology Nursing Specialized Oncology Registered Nurses and Advanced Practice Nurses are part of the core team involved in the care of patients with Head & Neck (H&N) cancers. The Specialized Oncology Nurse has specialty knowledge and skill in relation to cancer, in particular, H&N cancer. Role of the Specialized Oncology Nurse and Timing of Assessments the role of the Head & Neck specialized oncology nurse is to conduct a comprehensive health assessment, engage in a therapeutic relationship with patients and families, provide patient education, symptom management and support for patients across the trajectory of care, facilitating continuity of care and system navigation patients may be seen by the Specialized Oncology Nurse in the following settings: o New Patient clinic at time of initial consultation o Weekly treatment review clinics, for patients undergoing radiotherapy o Outpatient follow-up clinic the Specialized Oncology Nurse will review and assess: o New patients o Patients in distress as identified by healthcare professionals, patients/caregivers, or through screening tools such as the Edmonton Symptom Assessment Score (ESAS), or Distress Assessment and Response Tool (DART) o Patients undergoing procedures o Patients in transition Patients currently undergoing radiation treatment or undergoing treatment planning may be seen as required in the Radiation Nursing Clinic (RNC) for management of disease related symptoms or side effects from treatment o Registered Nurses (RNs) staff this clinic. The RN may consult the H&N Nurse Practitioner or an overseeing physician depending on the presenting issue o Patients are seen based on their health care needs and those with urgent needs will be assessed first. Advanced Practice Nurses (APNs) APNs will have a Masters degree in nursing, and knowledge and expertise in the specialized care of patients within a cancer population. They function in the domains of direct clinical practice, education, research, organizational leadership and professional development. Last Revision Date September

3 The APN may be a Nurse Practitioner (NP) or a Clinical Nurse Specialist (CNS) The APN manages the care of patients with complex problems and needs during and following treatment. The choice of NP and/or CNS within the program is based on the needs of the patient population and the program. Nursing Support and Symptom Management Protocols a) Education and counselling Provide ongoing education and reinforcement of information pertaining to the following: o Treatment course and expectations. o Management of disease-related symptoms and side effects of treatment. o Self-care practices during treatment and recovery. o Prescribed medications. o Gastro-jejunal (GJ) tube care. o Available resources both within the hospital and community. b) Oral Assessment and Care Pre Treatment: o What is the patient s usual oral care routine? During Treatment: o Anticipate timing of treatment effects. o Daily / weekly oral assessment & documentation Recommended oral care while on treatment: o Brush teeth with either a soft or baby toothbrush (post meals and Qhs). o Avoid toothpastes with sodium lauryl sulphate (SLS). o Biotene (SLS free, contains fluoride & salivary enzymes) o Continue flossing (if had done so prior to treatment). o Encourage fluoride tray usage o Oral rinses (NaHCO3, NaCl and/or FLAT club soda) as needed o NO chlorhexidine or alcohol based mouthwash. o NO lemon glycerin swabs (acidic). o Recommend saliva substitutes / lubricants as needed. o Water based gels as required (lips or mucous membranes) c) Pain Perform a pain assessment. Encourage appropriate usage of prescribed local and systemic analgesics (refer to physician guidelines). Notify a responsible physician if a prescribed pain regime is required or inadequate. d) Mucositis Assessment and Care (mucositis and thick saliva management) Last Revision Date September

4 Daily / weekly oral assessment & documentation. Pain control reinforce usage of both local anesthetics (Xylocaine Viscous or Mucositis Mouth Wash) and / or systemic analgesics. Oral care as highlighted above. Prevention cryotherapy (oral cooling) 30 minutes pre 5-FU. Nutrition and fluid management. Limitation/avoidance of EtOH and tobacco use. e) Xerostomia Daily / weekly oral assessment & documentation. Oral care as previously highlighted Water based gels Saliva substitute Cool Mist vaporizer. Nose breathing Breathe Ease f) Taste Changes Daily / weekly oral assessment & documentation. Assess for oral candidiasis (thrush) or infection. Oral care as highlighted. Suggest foods both nutritious and high in calories. Assist patients with the transition and/or combination of oral and tube nutrition g) Bowels Refer to attached documents for guidelines relating to assessment and management of opioid-induced and non-opioid induced constipation. h) Feeding tube Assessment and Care Assess for the following on a weekly basis: o Signs / symptoms of infection. o Displaced/dislodged tube. o General care practices of the patient pertaining to the tube. Required care on a weekly and/or as needed basis: o Feeding tube dressing change. Please refer to the following patient education pamphlet, How to Care for Your Feeding Tube, for specifics pertaining to GJ tube maintenance. Reinforce care practices with patient as required [APPENDIX 16]. Upon completion of radiotherapy treatment, home-care / Community Care Access Centre (CCAC) should be initiated, in collaboration with the H&N dietician, for all patients with feeding tubes. i) Hydration Assessment Obtain a record of both recent intake and output. screen for symptoms of dehydration (e.g. postural dizziness, lethargy) Take postural vital signs. Last Revision Date September

5 Reinforce fluid needs as outlined by the Registered Dietician (RD). Report assessment to the H&N NP or a responsible physician. j) Psychosocial Support Provide ongoing emotional support: o Information. o Coping strategies. o Lifestyle changes o Referrals social work, POPC, community resources and/or CCAC. k) Tracheostomy (Trach) Care and Managament Refer to UHN Trach Policy [APPENDIX 17]. l) Nutritional Intake The Specialized Oncology Registered Nurse and the APNs collaborate with the Registered Dietitian (RD) and Speech Language Pathologist (SLP) to assist patients with nutritional and hydration needs during treatment, and with the transition to oral intake and resumption of eating following treatment. Last Revision Date September

6 Bowel routine for preventing constipation from pain medications For patients with cancer taking pain medications What is a bowel routine? A bowel routine is a schedule for taking medication to prevent or relieve constipation (difficulty moving your bowels). UHN Why do I need a bowel routine? A side effect of pain medication (also called opioid analgesics) can be constipation. Having a bowel routine will prevent you from getting constipation. Preventing constipation is easier than treating it. Patient Education Improving health through education The goal is to have a regular bowel movement every 2 to 3 days, or as close to your normal pattern as possible. What medications do I need for my bowel routine? This bowel routine uses 2 medications that you can get in any pharmacy or drug store. They are sold as over-the-counter (OTC), so you do not need a prescription. A few drug plans do cover the cost, so check your coverage or ask your Pharmacist for help. These medicines are: Docusate Sodium (also called Colace): a stool softener that keeps the stool soft so you do not strain to push the stool out. Senokot: a laxative that helps move the stool through the bowel. Both of these medications come in a pill or liquid form. If you want to change the form of your medication, use this table to help you figure out how much you need to take. Please visit the UHN Patient Education website for more health information: University Health Network. All rights reserved. This information is to be used for informational purposes only and is not intended as a substitute for professional medical advice, diagnosis or treatment. Please consult your health care provider for advice about a specific medical condition. A single copy of these materials may be reprinted for non-commercial personal use only. Author: Maurene McQuestion and Jennifer Deering Created: 05/2012 (11/2012) Form: D-5906 C034-D

7 Changing from Pill to Liquids (or Liquids to Pill): Medication Dose Pill Liquid Colace 100 mg 1 capsule 25 ml (5 teaspoons) Senokot 8.6 mg 1 tablet 5 ml (1 teaspoon) When do I start my bowel routine? Start your bowel routine on the same day you are starting your pain medication (such as codeine, morphine). If you are already following a bowel routine, follow the information you have been given. What is the bowel routine schedule? The bowel routine involves taking Colace and Senokot 2 times a day, in the: Morning, and Evening (bedtime) The bowel routine is done in steps to make it easy for you to change how much bowel routine medication you need. This allows you to take more if you still do not have regular bowel movements or to take less if you get loose stool. The steps will help balance the side effects of your medication, the food you eat, and other things so you can maintain a regular bowel movement. Important instructions on how to take your bowel routine medication: Do not take bowel routine medication at the same time as your other medications. Take the Colace and Senokot 1 hour before or 2 hours after other medication. Normal or regular is what was normal for you before starting treatment. If it is normal for you to have a bowel movement every day, you should still have a bowel movement at least every 2 to 3 days while taking pain medications. If you do not have a bowel movement within 3 days, call your nurse to review what you are taking and suggest changes. Tell your doctor or nurse how you are doing on the bowel routine. If you are already taking other laxatives, tell your nurse. He or she may give you different instructions to follow. 2

8 Bowel Routine Steps STEP 1 Take 1 Colace (25 ml or 5 teaspoons) and 1 Senokot (5 ml or 1 teaspoon) in the morning. Repeat at bedtime. The next steps can be used to increase your dose until you have a regular bowel movement. If needed, you can go from one step to the next every 24 hours. STEP 2 STEP 3 STEP 4 STEP 5 Take 2 Colace (50 ml or 10 teaspoons) and 2 Senokot (10 ml or 2 teaspoons) in the morning. Repeat at bedtime. Take 2 Colace (50 ml or 10 teaspoons) and 3 Senokot (15 ml or 3 teaspoons) in the morning. Repeat at bedtime. Take 2 Colace (50 ml or 10 teaspoons) and 4 Senokot (20 ml or 4 teaspoons) in the morning. Repeat at bedtime. Speak to your doctor or nurse to review what you are taking. A different kind of medication or changes may be needed. I am having loose or runny stool. Should I stop my bowel routine? If you start to have loose or runny stools, do not stop taking your bowel routine medicines. Go back to the previous step. The step approach lets you adjust your bowel routine medicines to meet your needs. Call or speak to your nurse and let him or her know what is happening. Does chemotherapy cause constipation? Some chemotherapy treatments can cause constipation. Anti-nausea medication can also cause constipation. Ask your doctor or nurse if constipation is a side effect of medications you are taking. What should I do if my chemotherapy does cause constipation? On the day of your chemotherapy, move your bowel routine up by 1 step to prevent constipation from your chemotherapy and anti-nausea medicines. For example, if you are on step 2, go to step 3 on the day you get your chemotherapy medicine. You can stay on step 3 or change it in a couple of days, if needed. 3