Download HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE

HOSPITAL NAME
INSTITUTIONAL POLICY AND PROCEDURE (IPP)
Department:
Manual:
Section:
TITLE/DESCRIPTION
POLICY NUMBER
CANCER-CHEMOTHERAPY PREPARATION AND
ADMINISTRATION (ADULTS)
EFFECTIVE
REVIEW DUE
REPLACES NUMBER
NO. OF PAGES
DATE
APPROVED BY
APPLIES TO
PURPOSE
This document defines the policy and outlines the procedures used in the preparation and administration of any prescribed
chemotherapeutic agent.
DEFINITION
The following define terms used in this document:
Extravasation: The leakage of a drug into the subcutaneous tissue that is capable of causing pain, necrosis, and/or
sloughing of the tissue.
Irritant: A cancer chemotherapeutic agent capable of producing venous pain at the site or along the vein, with or without
an inflammatory reaction.
Vesicant: A cancer chemotherapeutic agent capable of causing or forming a blister and/or causing tissue destruction and
pain upon extravasation.
RESPONSIBILITY
This document is directed to licensed nurses and RNs.
CROSS REFERENCES
Intravenous Therapy policy
Preparation of IV Admixture policy
Ordering of Chemotherapeutic Agents policy
Universal Precautions policy
Medication Administration/Documentation policy
Clinical Nursing Skills, 4th edition
Pediatric Nursing Procedures
POLICY
Registered Nurses are accountable for all aspects of chemotherapy infusions (see policy Safe Handling and Spill
Management of Cytotoxic/Hazardous Agents).
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Licensed nurses who have documented training may change bags of 24 hour infusions. If the vesicant agent is being
administered as a 24-hour continuous infusion or IVPB through a central line, the RN shall be responsible for assessing
central line patency every shift by documenting blood return or when patient complains of burning, pain, or swelling at
catheter site.
Informed consent must be obtained if the patient is participating in any investigational trial.
All equipment and unused drug(s) should be treated as hazardous waste and disposed of appropriately.
Chemotherapeutic agents administered into the central nervous system (intrathecally or ommaya) will be administered by a
physician or his designee.
The patient shall be monitored according to specific drug protocol during the administration of chemotherapeutic agents.
Licensed nurses shall be knowledgeable about the appropriate dosage, precautions of chemotherapeutic administration,
reactions, contraindications, and compatibility of the drugs involved.
Nurses shall be educated about spill management and disposal of contaminated materials, including patient excreta.
The infusion must be stopped immediately if the patient displays a local or generalized anaphylactic reaction. Venous
access shall be maintained with IV fluids.
When administering a drug known to have an increased incidence of allergic response, an intradermal skin test and/or a
test dose may be ordered with the initial dosing and with subsequent dosing where indicated.
Emergency drugs, equipment, and a physician shall be readily available.
extravasation will be available in the inpatient pharmacy.
Guidelines for managing chemotherapy
The medically approved antidote for extravasation management shall be readily available on specialty unit(s) or in the
inpatient pharmacy.
PROCEDURE
PREPARATION PROCEDURE
The following delineates the procedure for preparing to administer chemotherapeutic agents:
1. Verify the drug, specific dose, appropriate route of administration with the physician's orders versus the protocol
or published literature (see policy Ordering Chemotherapeutic Agents).
2. Initiate the nursing chemotherapy administration note.
3. Verify that the appropriate consent forms have been signed prior to the administration of investigational
antineoplastic drug.
4. Read the label, package insert and other information (protocol or specific literature) for precautions suggested
and special requirements for administering the ordered medication.
5. Wash hands.
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6. Recommended personal protective equipment includes: disposable non-permeable protective clothing such as
cuffed long-sleeved non-permeable latex surgical gloves, disposable mask, and goggles.
7. Use Luer-lock universal adapters on syringes and intravenous sets wherever possible to prevent spillage.
8. To minimize exposure:
a. When expelling bubbles from a syringe, cover the tip of the needle with a sterile alcohol swab.
B. If the drug comes into contact with your skin, flush immediately and wash thoroughly with soap (NOT
HIBISTAT) and water. If an eye or mucous membranes come into contact with the drug, flush with
copious amounts of water for approximately 15 minutes.
9. Place disposable contaminated materials in a red plastic bag. Put needle and syringe in properly labeled,
puncture-resistant Sharps container. Under no circumstances should needles be recapped.
10. Wash thoroughly after removing gloves.
IV PUSH CHEMOTHERAPY ADMINISTRATION
The following delineates the procedure for IV Push Chemotherapy Administration:
Step
1
Action
Identify the patient.
2
Verify that the Chemotherapy checklist is complete(see policy ordering Chemotherapeutic
Agents).
3
Initiate the Chemotherapy Administration note.
4
Verify that the appropriate consent forms have been signed prior to the administration of an
investigational drug.
5
Read the label, package insert, and other information (protocol Or specific literature) for
precautions.
6
Suggested and special requirements for administering the ordered medication. Position patient
comfortably with arms accessible for venipuncture.
7
Choose and identify appropriate intravenous site for a peripheral IV. Proceed distally (hand) to
proximally (forearm). Place a disposable nonpermeable pad under the chosen site.
KEY POINT:
1. Avoid the side of mastectomy, phlebitis, inflamed or sclerosed areas, impaired lymphatic
drainage, impaired venous circulation, or sites distal to a new or recent venipuncture.
2. VESICANT DRUGS need peripheral IV access less than 24 hours old.
3. Avoid IVs in the wrist, hand or antecubital fossa.
`
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8
Set up desired IV administration set using a luer lock connector and a compatible IV solution to
be used as a flush.
9
Wash hands and put on latex surgical gloves.
10
Follow the procedure for insertion of a needle or intravenous catheter. (See Intravenous Therapy
policy.)
11
Verify patency and placement of peripheral IV by aspirating for blood return. Once blood return
is obtained, flush with a compatible IV fluid.
KEY POINT: CHEMOTHERAPEUTIC AGENTS should NEVER be used to test the
patency of an IV access.
12
Connect the IV tubing to the intravenous catheter.
13
Premedicate patient with medications as ordered prior to the administration of the
chemotherapeutic agent.
14
Cleanse the medication port of IV tubing closest to catheter site with alcohol or betadine pledget
and allow to dry.
15
Reconfirm patency of IV site by aspirating for blood return. Administer the IV chemotherapeutic
agent at the prescribed rate using a free-flowing compatible IV solution.
16
Observe IV site for signs of infiltration (see Chemotherapy extravasation).
KEY POINT: If any adverse side effects appear, STOP administration of chemotherapy and
notify the physician IMMEDIATELY.
17
Observe patient for signs of adverse drug reaction including pain, burning, and tingling during
and after infusion.
KEY POINT: Have chemotherapy drug antidotes and emergency drugs readily available.
18
Reconfirm patency of IV access by verifying blood return. It is recommended that 2 ml in a 10
ml syringe or 0.2 ml in a 2 ml syringe be aspirated to confirm placement.
19
Flush the IV line with a compatible sterile IV solution after the medication is given.
20
Discontinue the IV according to procedure. Elevate the extremity and apply pressure as needed.
21
Dispose of syringes and needles in a puncture resistant sharps container.
22
Wash hands.
23
Document interventions in the Patient’s Medical Record. (See policies Medication
Administration/Documentation and Preparation and Administration of Intravenous Admixture.)
KEY POINT: ALWAYS document condition of patient.
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Step
1
Action
Initiate the patient.
2
Verify that the chemotherapy checklist is complete (see policy Ordering Chemotherapeutic Agents).
3
Initiate the Chemotherapy Administration Note.
4
Verify that the appropriate consent forms have been signed prior to the Administration of an
investigational drug.
5
Read the label, package insert, and other information (protocol or specific literature) for precautions
suggested and special requirements for administering the ordered medication.
6
Position the patient comfortably, with arms accessible for venipuncture.
KEY POINT: Vesicants MUST be administered via a central line.
Choose and identify appropriate intravenous site for a peripheral IV. Proceed distally (hand) to
proximally(forearm). Place a disposable non-permeable pad under the chosen site.
KEY POINT: Avoid the side of mastectomy, phlebitis, inflamed or Sclerosed areas, impaired
lymphatic drainage, impaired venous circulation, or sites distal to a new or recent venipuncture.
7
8
9
Set up appropriate IV administration set with Luer lock extension, using compatible IV solution to
prime tubing.
KEY POINT: NEVER PRIME TUBING WITH A CHEMOTHERAPY DRUG.
Check patency of the central line by aspirating blood return and flushing with 20 cc of a compatible
IV solution. (For pediatric patients, flush with 10 cc of IV fluids.)
10
Connect the Luer-lock extension directly to the central line and secure the line connections with
tape. Set the IV infusion pump at the desired rate.
11
Premedicate the patient with medications as ordered prior to administration of the chemotherapeutic
agent.
12
Administer chemotherapeutic agent as ordered.
13
When changing bags of chemotherapy solution
- Always use latex gloves
- Cover connection with sterile 4x4 gauze sponges.
- Remove old bag of solution.
- Dispose of solution in RED BAG.
Connect new bag of solution and continue administration of chemotherapy as ordered.
14
Wash hands.
15
Document interventions in patient record. (See policies Medication Administration/Documentation
and Preparation and Administration of IV Admixtures.)
KEY POINT: ALWAYS document patient’s Condition.
PIGGYBACK INFUSION
The following delineates the procedure for Piggyback Infusion chemotherapy administration.
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KEY POINT: Vesicants must be delivered via central line.
Non-vesicants may be delivered via a peripheral IV either by IV infusion pump or by secondary administration set.
Step
1
Action
Identify Patient
2
Verify that the Chemotherapy Checklist is complete (see policy Ordering Chemotherapeutic
Agents).
3
Initiate the Chemotherapy Administration note.
4
Verify that the appropriate consent forms have been signed prior to administration of an
investigational drug.
5
Read the label, package insert and other information (protocol or specific literature) for precautions
suggestions suggested and special requirements for administering the ordered medication.
6
Choose and identify appropriate intravenous site for a peripheral IV.
7
Proceed distally (hand) to proximally (forearm). Place a disposable Place a disposable
nonpermeable pad under the chosen site.
KEY POINT: Avoid the side of mastectomy, phlebitis, inflamed or sclerosed areas, impaired
lymphatic drainage, impaired venouscirculation, or sites distal to a new or recent venipuncture.
Set up a primary IV administration set using a Luer lock connector and a compatible IV
solution. Prime the tubing.
8
a. ADULTS: Set up a secondary IV administration set and connect to primary line. Back flush
the IV fluid from the primary tubing to the secondary line until the fluid reaches the drip
chamber of the secondary administration set. Clamp the tubing of both the primary and
secondary lines and connect the chemotherapy piggyback to the secondary line.
KEY POINT: Never prime tubing with a chemotherapy drug.
b. PEDIATRICS: IV chemotherapy agents must be delivered via an IV infusion pump. Set up
the infusion pump tubing with luer lock extension tubing. Use a compatible IV solution to
prime the tubing. Connect the secondary administration set to the primary line. Clamp the
tubing of both the primary and secondary lines. Connect the chemotherapy piggyback to
the secondary line.
KEY POINT: Never prime tubing with a chemotherapy drug.
9
Connect the tubing from the primary administration set to the patient's intravenous catheter.
10
Premedicate the patient with medications as ordered prior to the administration of the
chemotherapeutic agents.
11
Administer chemotherapy as ordered.
12
When changing bags of chemotherapy solution:
- Always use latex gloves.
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- Cover connection with sterile 4x4 gauze sponges.
- Remove old bag of solution.
- Dispose of solution in RED BAG.
- Connect new bag of solution.
KEY POINT: The piggyback tubing should be flushed between medications by backflushing IV
fluid from the primary line to the piggyback bag to avoid mixture of medications
13
Wash hands.
14
Document interventions in the patient medical record. (See policies Medication Administration /
Documentation and Preparation and Administration of Intravenous Admixtures.)
KEY POINT: ALWAYS document patient's condition.
INTRAMUSCULAR ADMINISTRATION
The following delineates the procedure for intramuscular administration chemotherapeutic agents.
Step
Action
1
Identify the patient.
2
Verify that the Chemotherapy checklist is complete (see policy Ordering Chemotherapeutic Agents).
Inititate the Chemotherapy.
3
4
Administration Note.
Verify that the appropriate consent forms have been signed prior to the administration of an
investigational drug.
5
Read the label, package insert and other information.
6
Put on latex gloves.
7
Attach appropriate needle to syringe for administration (see Intramuscular injections in Adult and
Pediatric Patients – ClinicalNursing Skills, 4th edition, pages 385-390 and Pediatric Nursing
Procedures, pages 123-128).
KEY POINT: Chemotherapeutic agents for IM injection are dispensed in premixed syringes
from pharmacy.
8
Administer IM chemotherapy drug as ordered.
9
Dispose of syringes and needles in a puncture resistant sharps container.
10
Remove gloves and discard in red bag.
11
Wash hands.
12
Document interventions in the Patient's Medical Record (see policy Medication
Administration/Documentation).
KEY POINT: ALWAYS document the patient's condition.
ORAL CYTOTOXIC AGENT ADMINISTRATION
The following delineates the procedure for administering oral cytotoxic agents:
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Step
1
Action
Identify the patient.
2
Verify that the Chemotherapy checklist is complete (see policy Ordering Chemotherapeutic Agents).
3
Initiate the Chemotherapy Administration Note.
4
Verify that the appropriate consent forms have been signed prior to the administration of an
investigational drug.
5
Read the label, package insert and other information (protocol or specific Premedicate the patient
with medications as ordered prior to the administration of chemotherapeutic agents.
6
Wash hands.
7
Put on latex gloves.
8
Administer medication directly from package.
9
Remove and discard gloves into red bag.
10
11
Wash hands.
Documents interventions in patient medical record (see policy Medication
Administration/Documentation.
KEY POINT: Always document the patient’s condition.
Step
1
Action
Identify patient.
2
Wash hands.
3
Obtain sterile cotton swab or 4x4 gauze.
4
Put on double latex gloves.
5
Apply cytotoxic agent to swab or gauze.
6
Apply to lesion as ordered by physician.
7
Discard contaminated swabs or gauze into red bag.
8
Dispose contaminated linen into appropriate linen bag.
9
Instruct the patient to avoid skin contact with others.
10
Use occlusive dressings to cover areas of topical application.
11
Remove gloves and discard into red bag.
12
Wash hands.
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13
Document interventions in patient’s medical record (see policy Medication Administration /
Documentation).
KEY POINT: ALWAYS document patient’s condition.
MANAGING EXTRAVASATION OF CHEMOTHERAPEUTIC AGENTS
Step
1
Action
Stop the administration of the chemotherapeutic agent. Notify the physician.
2
Leave the needle in place.
3
Immediately aspirate and discard any residual drug and blood in the intravenous tubing, needle, and
suspected infiltration site. If applicable, instill the ordered antidote intravenously and then remove the
IV catheter/needle.
4
If unable to aspirate the residual drug from the intravenous tubing, remove the IV cathether/needle.
5
Inject the antidote subcutaneously clockwise into the infiltrated area using a 25 gauge needle. Change
and discard the needle with each new injection. The number of injections needed depends upon the
extent of the extravasated area. At least 4 injections are needed for an extravasation of 1-3 cm. These
injections should be given in a clockwise direction. Any extravasation over 3 cm may need additional
injections to cover the area.
6
Avoid applying pressure to the suspected infiltration sites.
7
Apply topical ointment as needed, if ordered.
8
Cover lightly with a sterile dressing.
9
Apply warm or cold compresses as ordered.
10
Elevate the arm.
11
Observe patient regularly for pain, erythema, induration, and /or necrosis, up to 14 days after the
incident. Erythema, induration, and/or tissue breakdown occurs.
Note: Frequency of observation depends on the drug, amount suspected to have infiltrated, extent
of suspected injury, and the patient's needs and concerns. Plastic surgery and physical therapy
consults may be considered if pain.
12
Document interventions in the patient medical record. Include the following:
- Date, time
- Physician notified
- Drug administered
- Approximate amount of drug extravasated
- Nursing management of extravasation
- Condition of patient
- Appearance of site
- Follow-up measures
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MANAGING HYPERSENSITIVITY/ANAPHYLACTIC REACTIONS
Hypersensitivity/anaphylaxis may be suspected if the following signs and/or symptoms occur (usually within the first 15
minutes of start of infusion/injection):
Symptoms
• Generalized itching
• Desire to urinate and/or defecate
• Chest tightness
• Chills
• Difficulty speaking
• Flushed appearance (angioedema of face, neck, eyelids, hands, feet)
• Agitation
• Local or Generalized urticaria
• Uneasiness
• Respiratory distress with or without wheezing
MANAGING HYPERSENSITIVITY / ANAPHYLACTIC REACTIONS
Symptoms:
• Dizziness
• Hypotension
• Dizziness
• Hypotension
• Dizziness
• Hypotension
• Crampy abdominal pain
• Anxiety
Step
1
Action
Stop the chemotherapy infusion. Notify the physician.
2
Maintain the intravenous line with normal saline or another appropriate solution.
3
If not contraindicated, ensure maximum rate of infusion if the patient is hypotensive.
4
Maintain the airway and anticipate the need for cardiopulmonary resuscitation.
5
Monitor the vital signs every (2) minutes until stable, then every (5) minutes for 30 minutes. Continue
to monitor every thereafter until reaction has resolved.
6
Continue to monitor every thereafter until reaction has resolved.
7
Monitor the vital signs every two (2) minutes until stable, then every five (5) minutes for 30 minutes.
Continue to monitor every 15 minutes thereafter until reaction has resolved.
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All medications are to be administered with a physician's order. Medications usually prescribed are:
- Epinephrine
- Aminophylline
- Diphenhydramine
- Hydrocortisone
KEY POINT: Some or all of these medications may be ordered to be kept at bedside prior to
administration of chemotherapeutic agents. It is recommended that a physician be readily available at
the time of administration.
8
Document interventions in the patient's medical record. Include the following:
- Date and time of reaction
- Condition of patient
- Vital signs
- Symptoms noted
- Physician notified
- Medication administered
- Nursing management
- Outcome of patient following interventions
- Reassure patient and family
FORMS
EQUIPMENT
Use the following supplies for Safe Handling of Chemotherapeutic Agents:
Sterile 4 X 4's Non-permeable Gowns
Sterile Needle Red Bag (should use needleless canula)
Luer-Lock Syringe Goggles
Alcohol/Betadine Nonpermeable
Masks Surgical Latex Gloves
Disposable Pad
REFERENCES
American Society of Hospital Pharmacists (1990, revised 1996). ASHP technical assistance bulletin on handling cytotoxic
and hazardous drugs. Bethesda, MD: Author.
Cancer Chemotherapy: Guidelines and Recommendations for Practice 1996 Oncology Nursing Society.
Yarbro, C.H., et al. Cancer Nursing: Principles & Practice, 5th edition. Boston: Jones
and Bartlett, 2000
APPROVAL:
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Signature
Date
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Approved By
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Latest Revision Approved
By
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