East Midlands Strategic Clinical Network
Competency Workbook
for the Administration of
Cytotoxic Chemotherapy
- NURSING
Name:
Mentor:
Clinical Area:
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 1
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Contents
Introduction ………………. ……………….
Reading List …………………………………
Accountability …………………………………
Cell Biology ………………. ……………….
Patient Assessment ……………………….
Principles of Chemotherapy ……………….
Health & Safety
………………………..
Intravenous Administration Pumps ……….
Side effects of Chemotherapy
……….
GI tract
……………………......
Bone Marrow Suppression ……….
Neurotoxicity/Skin
……………….
Urinary/Renal ………………………..
Cardiotoxicity ………………………..
Other Side Effects
……………….
Chemotherapy Administration
………
Via Peripheral Cannula ……............
Via CVAD
………………............
Oral
………………………..
Complications …………………………………
Extravasation ………………………..
Hypersensitivity/Anaphylaxis ………
Tumour Lysis ……………………….
Drug Calculations
……………………….
Formative Assessments
………………
Pre-Chemotherapy Assessments
……..
Triage Assessment ……………………….
Summative Assessment
………………
Appendix 1: Data Sheet
………………
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Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 2
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Introduction
This workbook has been produced to ensure consistency in the training and education of all
nurses working within Oncology & Clinical Haematology within the East Midlands Strategic
Clinical Network (EMSCN). This workbook can be used by any member of staff starting work
in an area where chemotherapy is administered. It can also be used to augment
chemotherapy training provided in-house or via a university accredited course.
The workbook is designed to cover all aspects of patient care relating to chemotherapy
administration. If a certain aspect covered in this workbook is not part of your job role (e.g.
pre-chemotherapy assessment) then mark the assessment as not applicable.
It is anticipated that the registrant should complete this workbook within 3 months of
receiving it.
Theory
The appropriate sections of this workbook must be correctly completed in full prior to the
final summative assessment. The assigned mentor must be a Band 6 (or above)
Chemotherapy nurse who has been assessed as fully competent to administer
chemotherapy. The assigned mentor should support & facilitate the student to complete this
workbook. A drug Data Sheet can be found in appendix 1 to facilitate learning about
individual chemotherapy drugs. Data sheets should be completed for each assessed regime,
with a variety of regimes and routes appropriate to your clinical area.
Practical
The student should be observed, supervised & assessed on at least 10 occasions with the
administration of chemotherapy. These practical competencies should cover a variety of
different regimens & include oral cytotoxic drugs if appropriate to your role. A 24 hour
telephone triage/rapid access competency must also be completed if deemed necessary.
Should patient pre-chemotherapy assessment take place in your clinical area, then you will
need to be under supervision on at least three occasions. The above can be assessed by an
assigned mentor.
The final summative assessment / competency sign-off must be undertaken by an assessor
that fulfils the criteria as described in EMSCN Chemotherapy Training & Assessment
Framework for Registered Nurses. The frame work can be accessed by using this address:
http://www.eastmidlandscancernetwork.nhs.uk/Library/EMCNDC012711ChemoNursesTraini
ngAssessmentFrameworkFinalVersionOct2011.pdf
To safely care for a patient undergoing chemotherapy treatment it is essential that clinical
competence is maintained. It is therefore vital that the individual works within a specialist
area that regularly handles chemotherapy.
Competency in the safe administration of Cytotoxic drugs MUST be assessed ANNUALLY in
line with Local, Network and National Directives. This is included as part of the Annual
Appraisal process and Cancer Peer Review.
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 3
Issue No: 1
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Reading List:
Bulman C & Schutz S (2013) Reflective Practice in Nursing. Oxford, Wiley-Blackwell
Corner J & Bailey C (2008) Cancer Nursing: Care in Context (2nd Ed.) Oxford, WileyBlackwell
Department of Health (2011) Improving Outcomes: A Strategy for Cancer. London, DoH
Gaze M (2003) Handbook of Community Cancer Care. London, Greenwich Medical Media
Griffith R & Tengnah C (2008) Law and Professional Nursing. Exeter, Learning Matters Ltd
Grundy M (2006) Nursing in Haematological Oncology. (2nd Ed.) London, Elsevier Health
Balliere Tindal
Hamilton H & Bodenham AR (2009) Central Venous Catheters. Chichester, Wiley-Blackwell
Hinchcliffe R & Rogers S (2008) Competencies for Advanced Nursing Practice. London,
Edward Arnold, Publishers
Hull C, Redfern L & Shuttleworth A (2005) Profiles & Portfolios. A Guide for Health & Social
Care. (2nd Ed.) Hampshire, Palgrave MacMillan
Langhorne ME, Fulton JS & Otto SE (2007) Oncology Nursing. (5th Ed.) St Louis, Missouri,
Mosby Elsevier Health Sciences
MacCready T and MacDonald J (2006) Introduction to Cancer Care. Whurr Publishers
National Chemotherapy Advisory Group (2008) Chemotherapy Services in England:
Ensuring quality and safety. London, DoH
Priestman T (2012) Cancer Chemotherapy in Clinical Practice. (2nd Ed.) London, SpringerVerlag
Skeel RT (2011) Handbook of Cancer Chemotherapy. (8th Ed.) London, Lippencott Williams
& Wilkins
Wilkes GM & Barton-Burke M (2014) Oncology Nursing Drug Handbook. (18th Ed.) London,
Jones & Bartlett Publishing Inc
Yarbro CH, Frogge MH, Goodman M (2013) Cancer Symptom Management. (4th Ed.) Oxon,
Jones & Bartlett Sudbury
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Assessment of Knowledge:
Accountability:
Who is responsible for obtaining and checking informed consent in your area?
Who is able to prescribe the first and then all subsequent chemotherapy prescriptions, and
where would you find an up-to-date record of this information?
What is ‘Duty of Care’ and how does it relate to chemotherapy administration?
.
Outline your responsibilities regarding the administration of a chemotherapy drug that you
have never encountered before:
Describe a Never Event that relates to chemotherapy:
Cell Biology:
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Label this diagram of the cell cycle:
Define each phase below and briefly explain what happens during it:
GO phase:
GI phase:.
S phase:
G2 phase:
M phase:
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Cancers are categorised by the cell or tissue that they originate from. There are 8
groups. Can you state where they originate from?
Carcinomas:
Sarcomas:
Melanomas:
Lymphomas:
Leukaemia:
Myelomas:
Nerve cell tumours:
Germ cell tumour:
What does poorly differentiated mean?
What does well differentiated mean?
Explain what is meant by the term ‘Primary’ Cancer?
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What are Tumour Markers and why do we monitor them?
Name three tumour markers relevant to your clinical area and the cancer that they relate
to:
1)
2)
3)
Patient Assessment:
Patient assessment prior to each cycle of chemotherapy is an essential part of the
chemotherapy process. Ensuring ‘fitness to treat’ and the correct management of side
effects is crucial in maintaining patient safety.
What is ‘Performance Status’ & why should it be assessed/reviewed at each cycle?
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What is Common Toxicity Criteria grading? How does this help you manage toxicities and
side effects?
Some side effects and toxicities can be so severe that a dose reduction or deferral is
needed. Sometimes treatment may be stopped altogether.
Remember - Treatment must NEVER be given without consulting a doctor first, if a
clinician has requested a medical review which hasn’t happened or outcome of review
is not known.
Why should treatment not be given without first consulting a doctor, if a patient has had a
recent hospital admission?
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Principles of Chemotherapy:
Define the term ‘cytotoxic’:
.
Complete the following table:
Classification
Give two examples of drug
Alkylating Agents


Antimetabolites


Cytotoxic Antibiotics
(anthracyclines)


Vinca Alkaloids


Topoisomerase1-11 inhibitors


Taxanes


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Chemotherapy may be used to treat cancer in different ways and with different aims.
Define the following treatment aims and give examples:
Radical / Curative:
Neo-adjuvant:
Adjuvant:
Palliative:
Concurrent:
Therapeutic:
Salvage:
Chemotherapy can be administered in combination. This is common practice in most
radical treatment protocols. What benefit is there in giving cytotoxic medication in
combination?
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Define the terms ‘course’ / ‘programme’ and ‘cycle’:
Course / Programme:
Cycle:
Explain why cytotoxic drugs are given in cycles:
Health & Safety:
Where should chemotherapy be reconstituted and why?
.
What are the contents of the spillage kit?
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Explain what action you would you take in the event of a significant liquid spill involving
staff/patient clothing and an area of floor?
.
Staff/patient clothing:
Spillage on floor:
Where is the spillage kit kept in your clinical area?
Remember – IV administration sets should always be inserted into a bag of
chemotherapy at waist level, in a tray with sides and NEVER when hanging on a drip
stand.
What considerations must be taken into account when collecting chemotherapy from
pharmacy or another area, including carrying equipment?
Cytotoxic waste must be incinerated at 1000°C by a waste disposal contractor at a licensed
site in accordance with COSHH regulations. Cytotoxic waste should be disposed of in a
designated receptacle designed for that purpose.
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How do you ensure all of your contaminated waste is disposed of safely?
Bodily fluids can also be considered as cytotoxic waste, depending on the time that the
chemotherapy was administered.
What precautions should you take when dealing with any bodily fluids from a patient who
has received chemotherapy?
W
What Personal Protective Equipment (PPE) should be worn at all times when handling and
administering chemotherapy?
Intravenous Administration Pumps:
Before you administer any chemotherapy or IV drug through a mechanical device/pump, you
MUST have received training on how to use the equipment.
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Name the types of pumps used to deliver Chemotherapy/IV drugs in your area:
Where can you find the instruction manual for this equipment?
What would you do if before or during the administration of a drug, the pump alarmed with a
fault or you were concerned that it may not be functioning correctly?
.
How would you check that you have entered the correct rate/amount etc into the pump?
Give a brief step by step explanation below:
Remember – all pump rates must be INDEPENDENTLY checked by two nurses when
administering chemotherapy
Side Effects of Chemotherapy:
Chemotherapy affects the normal, healthy cells as well as the cancer cells. Rapidly dividing
cells are most vulnerable to the effects of chemotherapy, and some drugs have specific
effects on specific organs.
The prevention, detection and management of chemotherapy side effects is a vital nursing
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role.
List four areas of the body that contain rapidly dividing cells that are commonly affected by
chemotherapy




Side effects of chemo are usually classified as Immediate, Short-term and Long-term. In the
box below, give two examples of each:

Immediate


Short-term / Delayed


Long-term

The Gastrointestinal (GI) tract
Side effects involving the GI tract are common and can range from mild to life-threatening.
They include Mucositis, Nausea and Vomiting and Diarrhoea
Name two cytotoxic drugs that can cause constipation:


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What advice would you give a patient about or if they experience any diarrhoea, particularly
if they are receiving Irinotecan, Capecitabine or 5FU chemotherapy?
.
Name a drug that you use in your clinical area that is particularly associated with diarrhoea
as a side effect. What advice would you give to the patient who you give this drug to?
Where would you find the ‘Management of Diarrhoea’ guideline in your area?
What is Mucositis?
What advice would you give a patient to try and prevent or limit oral mucositis?
Name four groups of anti-emetics, and give an example of each:
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Group
Drug
What does ‘High Risk’, in relation to anti-emetics mean?
List two chemotherapy drugs that are ‘High Risk’:


You are administering an emetically ‘Low Risk’ chemotherapy. Outline the anti-emetic
management of your patient including TTOs:
What is anticipatory nausea and how can it be managed?
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Bone Marrow Suppression:
Most, but not all chemotherapy drugs cause bone marrow suppression. It needs to managed
carefully to avoid potentially fatal complications.
Define the term Bone Marrow Suppression:
Define the term ‘Blood Nadir’:
What do the following terms mean?

Anaemia

Thrombocytopenia

Pancytopenia
Define the term Neutropenia:
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What is Neutropenic Sepsis? Give a brief explanation:
What are the signs and symptoms of Neutropenic Sepsis?
Remember…the absence of fever does not rule out the presence of infection!
What is the national standard time-frame for commencing IV antibiotics in a patient with
suspected neutropenic sepsis?
Neurotoxicity & Skin:
Name two common chemotherapy drugs that can cause peripheral neuropathy:


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Why is it so important that this side effect is monitored carefully?
What are the early symptoms of peripheral neuropathy?
What are the symptoms of Palmar – Plantar Erythrodysesthesia (PPE)?
Name three drugs that can cause significant PPE:



Urinary / Renal Side Effects:
Name three chemotherapy drugs that are considered ‘nephrotoxic’:



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What precautions / observations might you need to do when administering these drugs?
Haemorrhagic cystitis is a side effect of which drug, and what can be administered to
prevent this?
What effect does Epirubicin/Doxorubicin have on the urine?
.
Cardiac Side Effects:
Name three chemotherapy drugs that can have significant cardiotoxicity:



What diagnostic tests are performed to reduce the risk of cardiac problems?
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Other Side Effects:
Name three chemotherapy drugs that cause complete Alopecia:



Name two drugs that can cause partial alopecia:


What is Scalp-Cooling and how does it work to prevent hair loss?
Why is Scalp-Cooling only effective in some chemotherapy that cause alopecia, and not all?
.
Outline the potential risks of Scalp-Cooling:
.
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Fatigue is described by many patients as one of the worst side effects of chemotherapy. List
three things that you would advise a patient who was suffering from fatigue and lethargy:



Certain cytotoxic drugs can cause organ-specific toxicities. List the organ potentially affected
by each of the following drugs (e.g. Cisplatin can cause Kidney damage):

Bleomycin

Epirubicin

High-dose Methotrexate
Chemotherapy Administration:
Pre-Chemo Administration Checks – refer to the Cytotoxic Policy for full administration
guidelines
What are the NORMAL ranges for the following blood components?

Haemoglobin (Hb)

White blood cells (WBC)

Neutrophils

Platelets
What are the acceptable and agreed parameters for a full blood count (in your area) to
administer chemotherapy?

Haemoglobin (Hb)

White blood cells (WBC)
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
Neutrophils

Platelets
What would your actions be if your patients’ bloods were outside of these parameters?
What are the normal parameters for Liver Function Tests (LFT’s)?

Bilirubin

ALT

AST (if no ALT)

ALP
What levels indicate a normal renal function?

Serum Creatinine

Creatinine Clearance
Why is it so important to discuss any liver/renal blood results which are out of normal range
with a Doctor?
What baseline test should be carried out before commencing a course of chemotherapy with
an anthracycline?
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What would you do if a Doctor asked you to assist with Intrathecal (IT) Chemotherapy?
Name the only drugs that are to be administered via the Intrathecal route:
Chemotherapy Administration via Peripheral Cannulae & Extravasation:
Intravenous chemotherapy must be given through a recently sited cannula, preferably in the
cephalic or basilic veins, followed by the dorsal venous network, then the wrist.
Why should the anti cubital fossa NOT be used for cannulation / administration of
chemotherapy?
Explain why you would not cannulate a vein that has been recently punctured, unless it is
proximal to the puncture:
It is the responsibility of the nurse administering the chemotherapy to ensure that vein
integrity is maintained throughout. When vein integrity is compromised, there is potential for
the drugs to extravasate causing severe tissue damage and treatment delays.
Care must be taken to ensure appropriate checks are performed to assess vein and cannula
integrity before administration.
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Discuss the checking procedure that you would perform to assess cannula/vein integrity:
Choose the most appropriate answer for the following scenarios:
You are assessing a patient’s newly inserted cannula/vein for patency; however no blood
return is evident. There is no haematoma/swelling and no pain. Should you:
a) Use the cannula cautiously ☐
b) Set up a giving set of 0.9% sodium chloride and reassess for blood return after 5
mins. If still no blood return, recannulate
☐
c) Re-cannulate the patient immediately
☐
You have attached a giving set of saline/fluid prior to chemotherapy administration and you
have noticed that the drip rate on gravity is slowing. The patient has no pain and you are still
getting blood return/flashback. What should you do?
a) Re-cannulate the patient immediately
☐
b) Allow the drip to run a little longer and possibly apply a heat pad before re-assessing
the situation. The vein may be in spasm and normal function may resume ☐
c) Continue as blood return is evident ☐
Venous return alone does not provide confirmation of correct cannula placement; equally,
lack of venous return does not necessarily mean that a cannula is no longer in a vein.
Patient assessment of vein function is dependent upon:
 The presence or absence of blood return
 The amount of blood return
 Drip rate on gravity
 Patient discomfort
 Visible changes around cannula site
Always exercise caution when there is evidence of a slowing drip rate/pump occlusion alarm
or a lack of blood return. If ever in doubt – re-cannulate.
All chemotherapy drugs can be classified into one of the following categories:
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



Vesicant DNA Binding
Vesicant Non – DNA Binding
Irritant
Non – Vesicant
Which of these drug classifications have the greatest potential for tissue damage?
Which of these drug classifications have the least potential for tissue damage?
Why should the drugs with greater potential for damage be given first?
Think of a common regime in your area which incorporates multiple bolus drugs:

Name the regimen:

What are the bolus drugs in the regimen?

In relation to tissue damage, what classification are these drugs?

In what order should they be administered?
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Chemotherapy Administration via a Central Venous Access Device (CVAD):
Chemotherapy regimens often include the need to administer chemotherapy bolus drugs.
Bolus chemotherapy should be given in a standard sequence relating to the potential to
cause tissue damage. Drugs with the highest potential for damage should be given first.
Chemotherapy administration via a CVAD:
Central Venous Access Devices should only be used after a catheter has been assessed for
suitability and fitness for use. This should be done by establishing a gravity feed infusion
prior to treatment. The following signs and symptoms MUST be investigated BEFORE
treatment:
 Persistent Withdrawal Occlusion (PWO) – CVAD flushes well but there is no blood
return
 Pinch-off syndrome
 Partial/total occlusion
 Infection
 Migration
 Swelling of insertion site or skin tunnel
 Leakage from exit site
 Pain/discomfort in neck, shoulder or chest
Briefly explain what you would do if you encountered Persistent Withdrawal Occlusion
(flushes well but no blood return). What guideline would you refer to?
Oral Chemotherapy:
Oral Chemotherapy is becoming increasingly prevalent. Whilst this has its benefits, it also
has its limitations and risks. The same stringent guidelines and procedures in relation to
patient assessment and principles of administration should be the same as intravenous, or
any other chemotherapy delivery.
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List three Oral Chemotherapy drugs, and give one example of the disease it may be used to
treat:



What advice would you give a patient in the storage & handling of oral chemotherapy?
What advice would you give to a patient if they had forgotten or missed a dose?
Where would you find the guidance/work instructions/procedural documents for Oral
Chemotherapy delivery in your area?
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What is a Tyrosine Kinase Inhibitor (TKI)? Give a brief explanation of this group of drugs
and how they work:
Potential Complications:
Hypersensitivity/Anaphylaxis:
Virtually all chemotherapeutic agents have the potential to cause infusion reactions. An
infusion reaction is a type of hypersensitivity reaction that develops during or shortly after
administration of a drug. Hypersensitivity to a chemotherapeutic agent is defined as an
unforeseen reaction whose signs and symptoms cannot be explained by the known toxicity
of the drug. Anaphylaxis is a severe, life threatening, generalized or systemic
hypersensitivity reaction. It is characterized by rapidly developing life-threatening airway
and/or breathing and/or circulation problems, as well as skin and mucosal changes. In most
cases, prompt and appropriate action in response to an infusion reaction or
hypersensitivity/allergic reaction can prevent a reaction to an infusion developing into lifethreatening anaphylaxis.
Name three groups of drugs which are most likely to cause an infusion reaction:


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Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 31
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
List five signs & symptoms of a hypersensitivity infusion reaction:
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Name two life-threatening symptoms that would characterise an anaphylaxis reaction:
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Briefly describe how you would manage a patient with a hypersensitivity reaction:
What main drug (including dose) should be given in the event of anaphylaxis, and by what
route should it be administered? Where is this drug kept in your area?
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 32
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Where would you find the infusion reaction/hypersensitivity & anaphylaxis guidelines/policy
in your area?
Tumour Lysis Syndrome:
This is a relatively rare complication of chemotherapy, but can occur spontaneously in an
active tumour.
Define the term Tumour Lysis Syndrome & explain why this is a complication:
What are the symptoms & how do we treat it?
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 33
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
How can the risk of developing Tumour Lysis Syndrome be minimised?
Drug Calculations & Chemotherapy Dosing:
These are mostly measured in milligrams per body surface area (mg/m2). There are
standard doses of chemotherapy for each regime but these will vary according to each
individual patient’s size.
The dose of chemotherapy will be calculated by the prescribing doctor and checked by the
pharmacist. However as the chemotherapy nurse accountable for administering the drug you
must check that the dose is correct.
Simply multiply the standard dose required in mg, by the patient’s surface area in m2 to
check that the prescribed dose for each individual patient is correct.
e.g. Oxaliplatin 130mg / m2 regime
Standard dose is 130 mg/ m2
Patient’s surface area is 1.8 m2
130 x 1.8 = 234 mg (patient’s individual total dose)
Remember that this dose can be rounded up or down by pharmacy (dose banding).
Carboplatin Dosing:
Carboplatin doses are based on renal function rather than body surface area. The Calvert
formula is used which is based on the desired serum exposure, expressed as the area under
the serum concentration time curve (AUC).
Carboplatin dose in mg = AUC(GFR + 25)
The Doctor should specify which AUC is required e.g. 5,6 or 7
GFR means globular filtration rate (a measurement of renal function). Use the
Creatinine clearance result for this.
Example: The patient has a Creatinine clearance result of 80ml / minute. The Doctor has
specified the AUC required is 5. Calculate the dose of Carboplatin as follows:
Carboplatin dose in mg = AUC 5 (80+25)
Work out the sum in the brackets first. Then multiply this answer by the figure outside the
brackets.
This means 80+25 = 105
105 x 5 = 525 mg of Carboplatin.
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 34
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Cockcroft Formula:
This is used as an alternative to measuring a patient’s renal function with a 24 hour
urine collection. Instead the Creatinine clearance is calculated using the following
formula:
Women
Creatinine clearance = (140 – age) x weight in kg x 1.04 divided by serum creatinine
Men
Creatinine clearance = (140 – age) x weight in kg x 1.23 divided by serum creatinine
Example: For a 55 year old man who weighs 80kg and has a serum Creatinine result of 70.
Work out the sum in the brackets first
(140-55) = 85
85x80 = 6800
6800 x 1.23 = 8364
8364 divided by 70 = 119.5
Therefore the Creatinine Clearance is 119.5 ml / min
Chemotherapy Calculations Quiz:
Use a calculator but write the method used to work out the problem.
1. Calculate the following rates for an infusion pump (ml/hour):
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You need to give 1 litre of saline over 2 hours. What is the rate?
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You need to give 250ml infusion of chemotherapy over 90 minutes. What is the rate?
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 35
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
2. Calculate the dose of Carboplatin for a patient with a creatinine clearance of
68ml/min. The AUC specified is 5.
3. How would you calculate the creatinine clearance for your 52 year old female patient
whose weight is 60 kg and who has a serum creatinine result of 79?
4. Mrs.Brown is due cycle 3 of her oral chemotherapy. Her surface area is 1.5mg/m2.
She received 1800mg twice daily for the first two cycles but has been experiencing
side effects. As a result her consultant has now prescribed a dose reduction of 25%.
The tablets only come in 150mg and 500mg doses. What should her new dose be?
5.
A patient has been prescribed chemotherapy at 1000mg/m2. They have a SA of
1.68 and they need a 20% dose reduction. What should the new dose be?
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 36
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Cytotoxic Drug Administration – Formative Assessment:
This is the suggested assessment criteria for cytotoxic drug administration; however please
refer to local assessment criteria if necessary. It is anticipated that you should complete at
least 10 differing assessments (including oral chemotherapy) under the direct supervision of
your assessor. If more assessments are required please find them on the EMCN website.
Assessment Criteria:
1
2
3
Assessor Initials
4
5
6
7
8
9
Demonstrate sound knowledge of the
treatment regime & required pretreatment investigations.
Read patient’s notes, prescription &
relevant regimen protocol & identify
any special instructions,
investigations, (including abnormal
blood test results) or issues for which
you need to seek advice.
Ensure appropriate consent forms
have been completed.
Greet & accurately identify patient.
Review patient’s history since last
attendance & use the Common
Toxicity Criteria to assess &
document the patient’s physical
condition and their fitness for
treatment. Seek advice from
appropriate team member if required.
Assess the patient’s psychological /
emotional state & respond
appropriately, including referrals to
appropriate agencies and personnel.
Give opportunity for, and
subsequently answer both patient &
carers questions appropriately.
Check the patient and / or carer
understands the treatment to be
given & any potential or immediate /
delayed side effects together with
their management (including
awareness of reactions & how to call
for help).
Demonstrate the correct checking
procedure including drug
calculations, blood results & infusion
pump checks
Ensure the administration of any premeds and/or supportive medications
Assemble all venous access
equipment, confirming that IV route is
appropriate & that venous access
device is suitable for use. Cannulate
following protocol if necessary.
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 37
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
10
Assessment Criteria:
1
2
3
Assessor Initials
4
5
6
7
8
9
Infection control, ANTT, PPE &
effective hand washing adhered to at
all times.
Undertake final check of treatment
drugs against prescription & patient’s
identity before administration. Give
required drugs via prescribed route,
at prescribed rate, in appropriate
order.
Correctly observe vein patency on
cannulation and at suitable periods
throughout administration. The
patient must never be left
unattended whilst bolus vesicant
drugs / vinca alkaloids are being
administered.
Monitor patient for indications of
extravasation, discomfort or any
allergic / hypersensitivity reactions &
act appropriately.
When chemotherapy administered,
dispose of cytotoxic waste and
sharps as per policy.
Confirm details of the next
appointment and any prior
investigations or tests with the
patient and/or carer including blood
test forms.
Ensure patient has all medication to
take home & understands how to
handle, take & store them. Re-iterate
24 hour helpline numbers.
Record details of treatment in
patient’s notes, prescription chart /
ePrescribing & chemotherapy care
plan.
Communicate with appropriate
colleagues as required.
Signature of Assessor:
Name of Assessor:
Date:
NB Shaded boxes are not applicable for Oral chemotheray
Patient Pre-Chemotherapy Formative Assessment:
Complete at least 3 assessments under the direct supervision of your assessor.
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 38
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
10
Assessment Criteria:
Assessors Initials:
1
2
Arrange for an independent translator /
interpreter if you have reason to believe this will
assist the patient’s understanding.
Demonstrate an understanding of the referral
process and ensure that the assessment is
undertaken within an appropriate timescale after
admission/referral.
Read the patient’s notes, prescription - if
previously prepared - and protocol, and identify
any special instructions. Review the results of
all relevant investigations (including blood test
results) and identify any issues on which you
need to seek advice.
Ensure the environment provides for maximum
possible privacy, dignity and comfort throughout
the assessment and determine whether the
patient wishes to have any other person
present.
Take action to pre-empt and prevent
interruptions from communication devices and
visitors to the room.
Greet, accurately identify the patient and
introduce yourself and any colleagues present
to the patient and/or carer.
If a carer is present, ensure that the patient
consents to their presence throughout the
assessment and is willing for them to receive
the same information as that given to the
patient.
Undertake the assessment within your own
sphere of competence and involve the patient
and/or carer in the assessment as appropriate.
Determine the patient’s and/or carer’s
understanding of their current circumstance in a
manner which reassures the patient that you are
familiar with their history.
Review the patient’s history since their last
attendance.
Assess the patient’s physical condition and their
fitness for treatment and seek advice from an
appropriate professional colleague if required.
Use visual clues to add to your understanding of
the patient’s care needs, circumstances,
choices and preferences.
Explain the treatment and their risks and
benefits to the patient and/or carer together with
any potential side effects and their management
and accurately answer any questions at a pace
& level which is appropriate to the patients:
 Emotional state
 Level of understanding
 Culture and background
 Preferred ways of communicating
 Needs
Explain in terms that the patient and/or carer
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 39
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
3
can understand how the treatment works:
 Basic cell cycle
 Why there are different regimes
 Effects on healthy cells – cause of side
effects, cells recover
Emphasise the seriousness of neutropenia,
reporting it and taking precautions to prevent
infection:
 Potentially life-threatening
 Thermometer
 Use of paracetamol
Explain actions to take if any side effects occur
i.e. how and when to contact the unit.
Emphasise the specific side effects that MUST
be reported.
Explains the importance and timing of blood
tests prior to a course of chemotherapy.
Explanations of waiting times (Pharmacy
system, chemo tailor made etc).
Makes appropriate referrals to minimise the
impact of side effects e.g. wig referral.
Check that the patient and/or carer understands
the treatment choices being offered, the
implications of this choice and any potential side
effects together with their management.
Determine whether or not the patient is willing to
proceed.
Confirm the details of the appointment for their
first course and any prior investigations or tests
with the patient and/or carer, if appropriate.
Provide information on how to obtain help at any
time.
Provides appropriate written information to
support verbal information.
Completes all documentation following
consultation.
Correctly calculates and orders the regimen for
the patient’s first course if applicable.
Signature of Assessor
Name of Assessor
Date:
NB Shaded boxes are not applicable in Paediatrics
Document Code:
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number: 40
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
24 Hour Triage & Access Competency Assessment:
Following completion of triage training and assessment process, complete at least 3 triage
assessments under the direct supervision of your assessor.
Assessment Criteria:
Assessors Initials:
1
2
3
Explain your own role and its scope, responsibilities &
accountability in relation to the provision of interim clinical
advice
Ask appropriate questions to understand the reasons why the
patient is contacting the unit for advice
Explain clearly:
 Any clinical advice to be followed and its intended
outcome
 Anything they should be monitoring and how to react to
any changes
 Any expected side effects of the advice
 Any actions to be taken if these occur
Confirm that the individual understands the advice being given
& has the capacity to follow required actions
Provide information that:
 Is current best practice
 Can be safely put into practice by people who have no
clinical knowledge or experience
 Acknowledges the complexity of any decisions that the
individual has to make
 Is in accordance with patient consent & rights
Communicate with the individual, in a manner that is
appropriate to their level of understanding, culture or
background, preferred ways of communicating and which meets
their needs. Communicate in a caring and compassionate
manner
Communicate with the individual in a manner that is mindful of:
 How well they know the patient
 The accuracy and detail that they give you regarding the
situation and the patient medical history, medication etc.
 Patient confidentiality, rights and consent
Manage any obstacles to effective communication and check
that your advice has been understood
Provide reassurance and support to the individual or third party
who will be implementing your advice pending further
assistance
Ensure that you are kept up to date regarding the patient’s
condition so that you can modify the advice you give if required
Ensure that full details of the situation and the actions already
taken are provided to the person or team who take over the
responsibility for the patients care.
Recognise the boundary of your role and responsibility and the
Document Code:
Written By: Andrew Feltham C Penn
Issue No: 1
Date of Issue: Aug 2014
Review Date: Aug 2016
Authorised by: EMCN Chemotherapy Group
Page Number: 43
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Assessment Criteria:
Assessors Initials:
1
2
3
situations that are beyond your competence and authority
Seek advice and support from an appropriate source when the
needs of the patient and the complexity of the case are beyond
your competence and capability
Ensure you have sufficient time to complete the assessment
Provide information on how to obtain help at anytime
Record any modifications which are made to the agreed
assessment process and documentation and the reasons for
the variance
Record and report your findings, recommendations, patients
response and issues to be addressed according to local
guidelines
Inform the patients’ medical team on the outcome of the
assessment
Demonstrate competent use of the assessment tool and
completion of assessment pathway
If the patient is part of a clinical trial inform the trials team as
soon as possible
Signature of Assessor
Name of Assessor
Date:
Oncology / Haematology 24 Hour Triage (Rapid Assessment & Access Tool Kit)
UKONS Central West Chemotherapy Nurses Group
Document Code:
Written By: Andrew Feltham C Penn
Issue No: 1
Date of Issue: Aug 2014
Review Date: Aug 2016
Authorised by: EMCN Chemotherapy Group
Page Number: 44
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Summative Assessment of Chemotherapy Competency
If not applicable to your clinical area, please mark N/A.
Date:
Mentor Signature:
Chemotherapy course / programme
completed:
Electronic prescribing training completed:
ANTT training completed:
IV Cannulation completed:
Central Venous Access Device training
completed:
Infusional Pump training completed:
Minimum of 10 Chemotherapy
Administrations:
Minimum of 3 Pre-Chemotherapy
Assessments:
Minimum of 3 Triage Assessments if
appropriate:
Completed all aspects of the workbook
I have the knowledge and skills to competently administer chemotherapy
and triage emergency chemotherapy related calls.
Name: ……………………………………………………….
Signature: …………………………………………………..
Date: ………………………………………………………...
Sign-Off Assessor Name: …………………………………
Signature: …………………………………………………..
Document Code: EMCN-DC-0007-14
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Appendix 1: Data Sheet (photocopy as required)
Record of Drug Knowledge:
Regime/protocol administered …………………
Assessment no
Type of cancer treated …………………………..
Drug
Type of Drug (e.g. Alkylating Agent) & How It Works
Investigations Required Prior to Each Course
Indication for Dose Reduction
Document Code: EMCN-DC-0007-14
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number:
Issue No: 1
Circle appropriate description
Vesicant
Bolus
Peripheral
Non-vesicant
Infusion
Central
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version
Drug
Emetogenicity
(Grade 1-5 And Description
e.g. Low)
Drug Specific Short Term
Side Effects
Potential Long Term Effects
Evidence to Support the Use of These Agents In This Type Of Cancer (e.g. NICE, Trust Guidelines / Protocols etc.)
Document Code: EMCN-DC-0007-14
Date of Issue: Aug 2014
Review Date: Aug 2016
Written By: Andrew Feltham C Penn
Authorised by: EMCN Chemotherapy Group
Page Number:
Issue No: 1
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest version