APPENDIX 11
Section-A
Demographic Data
Patient Code :
Case No.:
Please encircle the appropriate options for each question given below
A. Age (yrs) :
i.
18 - 30
ii.
31 - 45
iii.
46 - 60
iv.
> 61
B. Gender :
i.
Male
ii.
Female
C. Educational status :
i.
No formal education
ii.
Primary
iii.
Secondary
iv.
Graduate & Above
D. Marital Status :
i.
Unmarried
ii.
Married
iii.
Widow/ Widower
iv.
Separated
v.
Divorced
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E. Occupation
i.
Employed
ii.
Unemployed
iii.
Self-employed
F. Family Income :
i.
< Rs.5,000/-
ii.
Rs.5,001/- to Rs.10,000/-
iii.
Rs.10,001/- to 15,000/-
iv.
Rs.15,001/- & above
G. Type of Occupation :
i.
Labour work
ii.
Office work
iii.
Others, if others , specify___________________________
H. Diagnosis : __________________________________
I. Treatment Related Information :
i.
Name of the Protocol :
a. CAPOX :________________
b. CAPIRI:________________
c. CAPE+AVASTIN :________________
d. If others, specify :___________
ii.
Dose of Capacetabine ( per cycle in mg/m2 ):
iii.
Specify Cycle of chemotherapy protocol : _________
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Section – B
Knowledge on Self Identification of Hand Foot Syndrome:
Note :
1.
1.
2.
There are eight questions.
2.
There is only one right answer
2.
Choose the right alternative and encircle it.
3.
All questions are compulsory.
Hand Foot Syndrome is
1.1
Infection of hands and feet
1.2
A Skin Reaction involving Hands and Feet.
1.3
Due to injury of hands and feet.
Hand Foot Syndrome can occur on
2.1
Inner surface of hands and feet.
2.2
Outer Surface of hands and feet.
2.3
All surfaces of hands and feet.
3. Occurrence of Hand Foot Syndrome should be observed
3.1
Within 24hrs after initiation of treatment.
3.2
Within 2-4 weeks of treatment.
3.3
Within 4-8 weeks of treatment.
4. The development of Hand Foot syndrome could be best attributed to which of
following causes
4.1
Overdose of drugs.
4.2
Leakage of drugs into sweat glands of palms and soles.
4.3
Allergic reactions to the drugs by the body.
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5. Which of the following signs is evident first in a patient who begins to develop
Hand Foot Syndrome
5.1
Severe Skin changes limiting self care activities of Daily Living.
5.2
Skin changes without pain.
5.3
Skin changes with pain limiting routine activities.
6. Hand and Foot Syndrome is a common side effect of drug
6.1
Cyclophosphamide
6.2
Methotrexate
6.3
Capecitabine.
7. It is important to understand the signs and symptoms of early Hand Foot
Syndrome because
7.1
It can lead to deterioration in quality of life and/or treatment
interruption.
8.
7.2
It has potential to spread and affect various organs of body.
7.3
It may cause permanent disability in hands and feet.
What is an effective way to treat a patient who develops severe Hand
Foot syndrome
8.1
Applying dressings with antibacterial ointments on advice by the
doctor.
8.2
Application of medicated skin ointments on advice of doctor
8.3
Dose reduction and treatment interruption on advice of doctor
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Section – C
Knowledge on Self Management of Hand Foot Syndrome
Note :
1. There are eight questions.
2. There is only one right answer
3. Choose the right alternative and encircle it.
4. All questions are compulsory.
9. Discomfort due to Hand Foot Syndrome can be prevented by
9.1
Performing regular exercises such as walking, jogging, etc.,
9.2
Limiting activities involving Hands and Feet.
9.3
Massaging hands and feet with pain balm.
10. Reddness of Hands and Feet can be managed by
10.1
Wearing tight gloves or socks.
10.2
Applying Self Medicated skin creams.
10.3
Cooling of Hands and Feet with Ice packs.
11. Pain and peeling of skin in hands and feet can be managed by
11.1
Immersion of affected part in hot water.
11.2
Cleaning hands, feet and skin fold areas in luke warm water and drying
gently.
11.3
Immersion of affected part in cold water.
12. Application of emollients is recommended to patient with
Hand Foot Syndrome to keep skin
12.1
Soft
12.2
Dry
12.3
Moist
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13. Long distance walking is discouraged in patients with Hand Foot Syndrome
because it causes
13.1
Pressure on soles of feet leading to ulcers or blister formation.
13.2
Fatigue.
13.3
Bleeding .
14. Hand and feet skin integrity can be promoted in patients who are on oral
capecitabine by which of the following measures
14.1
Cleaning of affected part in soap water repeatedly.
14.2
Avoiding contact with extreme hot water and cold water
14.3
Doing repeated jumping or gripping exercises.
15. Swelling of hands and feet can be managed by
15.1
Massaging the affected part with oil.
15.2
Avoiding wearing tight clothes and elevating hands and feet using soft
cushions.
15.3
Taking Rest.
16. Which of the following is any alternative measure or treatment for severe form
of Hand Foot Syndrome
16.1
Medicines, self care, emollients and dose interruption are sufficient
16.2
Surgery of hands and feet is required.
16.3
Not aware of any treatment available.
THANK YOU FOR YOUR VALUABLE PARTICIPATION
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Knowledge score will be evaluated in terms of following grades
Score Obtained
Grade
(Maximum obtainable score=16)
Greater than 14
Excellent
11-14
V.Good
7-10
Good
4-6
Fair
Less than 3
Poor
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