Telephone Triage for Oncology Nurses [3 ed.] 9781635930276, 9781635930269

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Telephone Triage for Oncology Nurses Third Edition Edited by Margaret Hickey, RN, MSN, MS, and Susan Newton, APRN, MS, AOCN®, AOCNS®

Oncology Nursing Society Pittsburgh, Pennsylvania

ONS Publications Department Publisher and Director of Publications: William A. Tony, BA, CQIA Senior Editorial Manager: Lisa M. George, BA Assistant Editorial Manager: Amy Nicoletti, BA, JD Acquisitions Editor: John Zaphyr, BA, MEd Associate Staff Editors: Casey S. Kennedy, BA, Andrew Petyak, BA Design and Production Administrator: Dany Sjoen Editorial Assistant: Judy Holmes Copyright © 2019 by the Oncology Nursing Society. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by an information storage and retrieval system, without written permission from the copyright owner. For information, visit www.ons.org/sites/default/files/Publication%20Permissions. pdf, or send an email to [email protected]. Library of Congress Cataloging-in-Publication Data Names: Hickey, Margaret (Margaret M.), editor. | Newton, Susan, 1967- editor. | Oncology Nursing Society, issuing body. Title: Telephone triage for oncology nurses / edited by Margaret Hickey and Susan Newton. Description: Third edition. | Pittsburgh, PA : Oncology Nursing Society, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2018033800 (print) | LCCN 2018034959 (ebook) | ISBN 9781635930276 (ebook) | ISBN 9781635930269 Subjects: | MESH: Neoplasms--nursing | Nursing Assessment--methods | Telephone | Triage--methods | Remote Consultation--methods | Handbooks Classification: LCC RT48 (ebook) | LCC RT48 (print) | NLM WY 49 | DDC 616.99/40231--dc23 LC record available at https://lccn.loc.gov/2018033800 Publisher’s Note This book is published by the Oncology Nursing Society (ONS). ONS neither represents nor guarantees that the practices described herein will, if followed, ensure safe and effective patient care. The recommendations contained in this book reflect ONS’s judgment regarding the state of general knowledge and practice in the field as of the date of publication. The recommendations may not be appropriate for use in all circumstances. Those who use this book should make their own determinations regarding specific safe and appropriate patient care practices, taking into account the personnel, equipment, and practices available at the hospital or other facility at which they are located. The editors and publisher cannot be held responsible for any liability incurred as a consequence from the use or application of any of the contents of this book. Figures and tables are used as examples only. They are not meant to be all-inclusive, nor do they represent endorsement of any particular institution by ONS. Mention of specific products and opinions related to those products do not indicate or imply endorsement by ONS. Websites mentioned are provided for information only; the hosts are responsible for their own content and availability. Unless otherwise indicated, dollar amounts reflect U.S. dollars. ONS publications are originally published in English. Publishers wishing to translate ONS publications must contact ONS about licensing arrangements. ONS publications cannot be translated without obtaining written permission from ONS. (Individual tables and figures that are reprinted or adapted require additional permission from the original source.) Because translations from English may not always be accurate or precise, ONS disclaims any responsibility for inaccuracies in words or meaning that may occur as a result of the translation. Readers relying on precise information should check the original English version. Printed in the United States of America

Innovation • Excellence • Advocacy

Contributors EDITORS Margaret Hickey, RN, MSN, MS President MMH Communications Gulf Breeze, Florida Overview; Legal Concerns of Telephone Triage

Susan Newton, APRN, MS, AOCN®, AOCNS® Oncology Advanced Practice Nurse Senior Director TMAC/The Medical Affairs Company Dayton, Ohio Lymphedema

AUTHORS Elizabeth Abernathy, RN, MSN, AOCNS® Director, Clinical Practice, Nursing Education and Research Duke Cancer Network Durham, North Carolina Constipation

Jeannine M. Brant, PhD, APRN, AOCN®, FAAN Oncology Clinical Nurse Specialist/Nurse Scientist Billings Clinic Billings, Montana Pain

Andrea Bales, MS, RN, CNL, OCN® Assistant Nurse Manager The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Sleep–Wake Disturbances

Lynne Brophy, MSN, RN-BC, APRN-CNS, AOCN® Adult Breast Oncology Clinical Nurse Specialist Stefanie Spielman Comprehensive Breast Center The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Venous Access Device Problems

Sharon Baumler, MSN, RN, CORLN, OCN® Staff Nurse University of Iowa Health Care Iowa City, Iowa Oral Mucositis Madelaine Binner, MBA, FNP-BC, DNP Oncology Nurse Practitioner Anne Arundel Medical Center Annapolis, Maryland Models of Telephone Triage and Use of Guidelines Lisa Blackburn, MS, APRN-CNS, AOCNS® Clinical Nurse Specialist The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Sleep–Wake Disturbances

Darcy Burbage, RN, MSN, AOCN®, CBCN® Supportive and Palliative Care Nurse Navigator Helen F. Graham Cancer Center and Research Institute Newark, Delaware Alopecia Pamela H. Carney, MSN, RN, OCN® Patient Care Coordinator Vanderbilt-Ingram Cancer Center Nashville, Tennessee Dysgeusia (Taste Dysfunction); Fatigue

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . iii

CONTRIBUTORS Jane Clark, PhD, RN, AOCN®, GNP-C Oncology Nursing Consultant Decatur, Georgia Malignant Ascites Rebecca Collins, MS, RN, OCN®, CHPN, NE-BC, CENP Director of Care Transitions Innovative Care Solutions/Pure Health Care Dayton, Ohio Antibiotic Therapy Problems Kerri A. Dalton, MSN, RN, AOCNS® Director, Clinical Practice and Education Duke Cancer Network, Duke Network Services Duke University Health System Durham, North Carolina Diarrhea Beth Eaby-Sandy, MSN, CRNP Nurse Practitioner in Thoracic Oncology Abramson Cancer Center University of Pennsylvania Philadelphia, Pennsylvania Rash Michele Farrington, BSN, RN, CPHON® Clinical Health Care Research Associate University of Iowa Health Care Iowa City, Iowa Oral Mucositis Karen Feldmeyer, MSA, RDN, LD Registered Licensed Dietitian, Nutritionist, and Department Manager Atrium Medical Center Middletown, Ohio Dysphagia; Esophagitis; Xerostomia (Dry Mouth) Terri Gross, RN, BS, CHPN Senior Director of Mission Excellence Ohio’s Hospice of Dayton Dayton, Ohio Anxiety; Deep Vein Thrombosis Laura B. Houchin, MSN, RN, AOCNS® Oncology Clinical Nurse Specialist Duke University Health System Durham, North Carolina Dizziness

Mary K. Hughes, MS, RN, CNS, CT Psychiatric Clinical Nurse Specialist Department of Psychiatry University of Texas MD Anderson Cancer Center Houston, Texas Depressed Mood Joyce Jackowski, MS, FNP-BC, AOCNP® Nurse Practitioner Florida Cancer Specialists Venice, Florida Alterations in Sexuality Nicole Korak, MSN, FNP-C Senior Director of Operations IQVIA Dallas, Texas Confusion/Change in Level of Consciousness; Paresthesia (Peripheral Neuropathy) Misty Lamprecht, MS, APRN-CNS, AOCN®, BMTCN® Clinical Nurse Specialist, Blood and Marrow Transplant Program The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Venous Access Device Problems Lori Lindsey, RN, MSN, FNP-BC, CCRC, OCN® Senior Manager, Clinical Services McKesson Specialty Health—The US Oncology Network Dallas, Texas Myalgia and Arthralgia Victoria Wochna Loerzel, PhD, RN, OCN® Associate Professor and Beat M. and Jill L. Kahli Endowed Professor in Oncology Nursing University of Central Florida Orlando, Florida Bleeding; Fever With Neutropenia; Fever Without Neutropenia Heather Thompson Mackey, MSN, RN, ANPBC, AOCN® Nurse Practitioner, Cancer Prevention and Wellness Novant Health Derrick L. Davis Regional Cancer Center Winston-Salem, North Carolina Cough; Dyspnea

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CONTRIBUTORS Jackie Matthews, RN, MS, APRN-CNS, AOCN®, ACHPN Oncology and Palliative Clinical Nurse Specialist Vice President, Palliative and Supportive Care Innovative Care Solutions Dayton, Ohio Dysphagia; Esophagitis; Xerostomia (Dry Mouth) Deborah Metzkes, RN, BSN, OCN®, MBA Clinical Educator IQVIA Boca Raton, Florida Anorexia; Menopausal Symptoms Cynthia Muller, MJ, BSN, RN Clinical Support Specialist and Educator Bayer Oncology TKI Division Whippany, New Jersey Legal Concerns of Telephone Triage Mary Murphy, RN, MS, AOCN®, ACHPN President and Chief Nursing and Care Officer Ohio’s Hospice of Dayton Dayton, Ohio Anxiety; Deep Vein Thrombosis Tayreez Mushani, BScN, MHS, CON(C), CHPCN(C) Assistant Professor Aga Khan University School of Nursing and Midwifery Nairobi, Kenya Flu-Like Symptoms Pamela J. Pearson, RN Immunotherapy Infusion Registered Nurse Seattle Cancer Care Alliance Seattle, Washington Bone Loss; Nausea and Vomiting Jody Pelusi, PhD, FNP, AOCNP® Oncology Nurse Practitioner/Investigator Phase I Clinical Trials Honor Health Research Institute Scottsdale, Arizona Oral Therapies and Telephone Triage Mary Ann Plambeck, RN, MSN, NEA-BC, OCN® Clinical Operations Director Duke Cancer Center Durham, North Carolina Setting Up a Telephone Triage Call Center

Jeanene “Gigi” Robison, MSN, APRN-CNS, AOCN® Oncology Clinical Nurse Specialist The Christ Hospital Health Network Cincinnati, Ohio Hand-Foot Syndrome; Phlebitis Sharon Rockwell, BSN, RN, OCN®, CRNI Immunotherapy Infusion Registered Nurse Seattle Cancer Care Alliance Seattle, Washington Bone Loss Erin J. Ross, DNP, MS, ANP-BC, CORLN Nurse Practitioner Head and Neck Institute Cleveland Clinic Cleveland, Ohio Hemoptysis Marlon Garzo Saria, PhD, RN, AOCNS®, FAAN Tarble Foundation Oncology Clinical Nurse Specialist and Nurse Scientist Assistant Professor of Translational Neuro­ sciences and Neurotherapeutics Director, Center for Quality and Outcomes Research Pacific Neuroscience Institute and John Wayne Cancer Institute at Providence Saint John’s Health Center Santa Monica, California Seizures Gary Shelton, DNP, NP, ANP-BC, AOCNP®, ACHPN Clinical Program Manager, Hematology and Oncology Mount Sinai Hospital New York, New York Difficulty or Pain With Urination; Hematuria; Pruritus (Itch) Sharon Steingass, RN, MSN, AOCN® Nursing Director The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, Ohio Models of Telephone Triage and Use of Guidelines

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CONTRIBUTORS Heather Vanderploeg, RN, BSN, OCN®, CBCN® Medical Science Liaison Director AstraZeneca Norfolk, Virginia Immune-Related Adverse Events

Laura S. Wood, RN, MSN, OCN® Research Nurse Cleveland Clinic Cancer Center Cleveland, Ohio Immune-Related Adverse Events

Rita Wickham, PhD, RN Adjunct Faculty Rush University College of Nursing Rapid River, Michigan Headache; Hiccups (Singultus)

DISCLOSURE Editors and authors of books and guidelines provided by the Oncology Nursing Society are expected to disclose to the readers any significant financial interest or other relationships with the manufacturer(s) of any commercial products. A vested interest may be considered to exist if a contributor is affiliated with or has a financial interest in commercial organizations that may have a direct or indirect interest in the subject matter. A “financial interest” may include, but is not limited to, being a shareholder in the organization; being an employee of the commercial organization; serving on an organization’s speakers bureau; or receiving research funding from the organization. An “affiliation” may be holding a position on an advisory board or some other role of benefit to the commercial organization. Vested interest statements appear in the front matter for each publication. Contributors are expected to disclose any unlabeled or investigational use of products discussed in their content. This information is acknowledged solely for the information of the readers. The contributors provided the following disclosure and vested interest information: Margaret Hickey, RN, MSN, MS: Publication Practice Counsel, Stone Communications, consultant or advisory role Susan Newton, APRN, MS, AOCN®, AOCNS®: Elsevier, other remuneration Jeannine M. Brant, PhD, APRN, AOCN®, FAAN: Genentech, Inc., Insys Therapeutics, honoraria Beth Eaby-Sandy, MSN, CRNP: AbbVie Inc., consultant or advisory role; AstraZeneca, Helsinn Healthcare SA, Merck and Co., Inc., Takeda Pharmaceutical Company, honoraria Joyce Jackowski, MS, FNP-BC, AOCNP®: Elsevier, other remuneration Nicole Korak, MSN, FNP-C: IQVIA, consultant or advisory role Heather Thompson Mackey, MSN, RN, ANP-BC, AOCN®: Elsevier, other remuneration Deborah Metzkes, RN, BSN, OCN®, MBA: IQVIA, Novartis Pharmaceuticals Corp., consultant or advisory role Marlon Garzo Saria, PhD, RN, AOCNS®, FAAN: Brain Cancer Research Institute, John Wayne Cancer Institute, San Diego Brain Tumor Foundation, employment or leadership position; Cancer Life, consultant or advisory role; ICU Medical, Inc., honoraria Heather Vanderploeg, RN, BSN, OCN®, CBCN®: AstraZeneca, employment or leadership position Laura S. Wood, RN, MSN, OCN®: Merck and Co., Inc., consultant or advisory role; Bristol-Myers Squibb Co., Pfizer Inc., honoraria

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Table of Contents PREFACE........................................................................................................................................ix ACKNOWLEDGMENTS.............................................................................................................xi INTRODUCTION...........................................................................................................................1 OVERVIEW.....................................................................................................................................5 MODELS OF TELEPHONE TRIAGE AND USE OF GUIDELINES.................................... 11 SETTING UP A TELEPHONE TRIAGE CALL CENTER....................................................... 33 ORAL THERAPIES AND TELEPHONE TRIAGE................................................................... 43 LEGAL CONCERNS OF TELEPHONE TRIAGE.................................................................... 49 TELEPHONE TRIAGE PROTOCOLS...................................................................................... 71 Alopecia............................................................................................................................. 73 Alterations in Sexuality................................................................................................ 77 Anorexia............................................................................................................................ 81 Antibiotic Therapy Problems..................................................................................... 85 Anxiety............................................................................................................................... 89 Bleeding............................................................................................................................ 93 Bone Loss.......................................................................................................................... 97 Confusion/Change in Level of Consciousness...................................................101 Constipation..................................................................................................................105 Cough...............................................................................................................................109 Deep Vein Thrombosis...............................................................................................113 Depressed Mood..........................................................................................................117 Diarrhea...........................................................................................................................123 Difficulty or Pain With Urination.............................................................................129 Dizziness..........................................................................................................................133 Dysgeusia (Taste Dysfunction)................................................................................137 Dysphagia.......................................................................................................................143

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TA B L E O F CO N T E N T S Dyspnea...........................................................................................................................147 Esophagitis.....................................................................................................................151 Fatigue.............................................................................................................................155 Fever With Neutropenia.............................................................................................161 Fever Without Neutropenia......................................................................................165 Flu-Like Symptoms......................................................................................................169 Hand-Foot Syndrome.................................................................................................173 Headache........................................................................................................................179 Hematuria.......................................................................................................................185 Hemoptysis....................................................................................................................189 Hiccups (Singultus)......................................................................................................193 Immune-Related Adverse Events...........................................................................199 Lymphedema.................................................................................................................205 Malignant Ascites.........................................................................................................209 Menopausal Symptoms.............................................................................................213 Myalgia and Arthralgia...............................................................................................219 Nausea and Vomiting.................................................................................................225 Oral Mucositis................................................................................................................231 Pain....................................................................................................................................239 Paresthesia (Peripheral Neuropathy)....................................................................243 Phlebitis...........................................................................................................................247 Pruritus (Itch).................................................................................................................253 Rash...................................................................................................................................261 Seizures............................................................................................................................267 Sleep–Wake Disturbances........................................................................................273 Venous Access Device Problems............................................................................279 Xerostomia (Dry Mouth)............................................................................................287 APPENDICES............................................................................................................................291 INDEX.........................................................................................................................................299

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Preface Improved understanding of molecular carcinogenesis and immune therapy has led to considerable strides forward in cancer treatments. Although these new agents bring great promise, they also produce a number of adverse events requiring close monitoring to provide maximal patient benefit. Oncology nurses are challenged to keep abreast of changes in patient management to ensure quality care. Continued nursing research and evidence-based practice guidelines are necessary to enhance patient outcomes related to nursing care. Additionally, technologic improvements, such as video telecommunication via smartphones and online communication platforms such as Skype™, have introduced a new dimension to telephone triage. The ability to view a patient during a telephone call can enhance the nurse’s ability to assess the patient’s problem. This combination of video and voice is being used more frequently in the nurse’s triage of patients, so much so that the term telephone triage nursing has evolved into telenursing. A number of updates have been included in this text to address these technologic advances. This third edition of Telephone Triage for Oncology Nurses has been expanded to address patient needs that may result from the newer cancer treatments— targeted therapies and immunotherapy. Targeted therapies for cancer are commonly small molecules that can be taken orally and managed by the patient and family at home. Although oral therapy supports patient independence, self-management of side effects may be challenging. A section has been added to this edition to address improving nursing management of oral therapies. Immunotherapy may result in adverse effects very different from those with traditional cancer treatments. These effects are addressed throughout the protocols, which discuss some common complaints, as well as in a stand-alone protocol in this text. This book is a result of efforts by professional nurses from diverse settings and geographic locations who synthesized the most current scientific information related to triaging patient problems. The authors of each protocol have carefully reviewed the literature and updated the content from the second edition. Importantly, both chapters and protocols have been updated to incorporate available evidence-based nursing practice and the latest in nursing policy regarding telenursing and multistate licensure. The information in this text will provide the professional oncology nurse with updated tools to improve patient care through quality telenursing practice. Margaret Hickey, RN, MSN, MS Susan Newton, APRN, MS, AOCN®, AOCNS®

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . ix

Acknowledgments Thank you to all the nurses who contributed to the development of the third edition of this book. The time, energy, and expertise given by each contributing author and reviewer exemplifies their dedication to ensuring quality patient care, collegiality, and willingness to advance oncology nursing practice. A special thank you to my colleague, friend, and coeditor, Susie Newton, for her ongoing dedication to the profession of oncology nursing and her drive to mentor and educate other nurses. This edition of Telephone Triage for Oncology Nurses would never have become a reality without the support and mentorship of Barbara Sigler, a pioneer and leader in nursing publications. Thank you to the Oncology Nursing Society Publications Department for their assistance and support during the development of this edition. And, at home, a loving thank you to Kenny, my husband and best friend, for his support and patience while I spent hour upon hour staring at the computer screen to help pull this edition together. Lessons learned in life, at home and professionally, have inspired me to tackle the writing and editing of this book and others. It is my hope that this one small step in bringing the voice of expert nurses forward will help to enhance nursing care for patients with cancer and their families. —Margaret “Margie” Hickey

I am blessed to have a family who encourages me in my professional endeavors, including three terrific boys, Alex, Casey, and Jackson. Also, to my biggest fan, my mother, Dolores “Tootie” Maloney. Without the loving support of my family, I wouldn’t be able to dedicate the time and energy to projects like this book. Having Margie Hickey as a coeditor makes the writing and editing process fun. I am lucky to have her as a friend, a sounding board, and an editing buddy. The Oncology Nursing Society Publications Department staff are superb to work with and keep us on track. The best part of continuing the telephone triage series is networking with the many talented oncology nursing authors. I learn so much through the process and have met colleagues who are now part of my close network. Oncology nurses are a special group of caregivers, and it is by learning from each other that we can take better care of our patients. —Susan “Susie” Newton

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . xi

Introduction Margaret Hickey, RN, MSN, MS Over the past few decades, trends in health care have shifted cancer care delivery from inpatient to outpatient settings. In 2012, the American Academy of Ambulatory Care Nursing reported that more than three million nurses, or 25% of RNs in the United States, cared for patients in ambulatory care settings (Mastal & Levine, 2012). In addition to the large number of nurses working in outpatient settings shown in this survey, a growing number of nurses are also caring for patients using telehealth. A 2015 workforce survey by the National Council of State Boards of Nursing (NCSBN) and the National Forum received responses from 78,700 nurses, or 30% of the U.S. nursing workforce. Nearly half of the respondents said they provided patient care using telehealth (NCSBN, 2016). The results of both surveys made it clear that nursing care is no longer defined within the brick-and-mortar walls of a healthcare setting, further reflecting the demand for nontraditional expertise in professional nursing practice in the ambulatory care setting. This change to the patient care delivery setting can be a challenge to professional nurses educated in the traditional inpatient model. The inpatient setting continues to be the primary location of basic nursing education, yet many nurses at some point will find themselves practicing outside the inpatient hospital. Nurses transitioning to ambulatory care and other settings often expect to use the same knowledge and skills learned in their acute care practices. Although some competencies may be transferable, the expertise and skills needed in the outpatient setting are unique. An ambulatory nurse is often a coordinator of care rather than a hands-on, direct care provider. A transition to ambulatory nursing requires clinical expertise, leadership, and autonomous critical-thinking skills. Nursing practice can include face-to-face care but also indirect care, such as over the telephone or via computer. Unique assessment and communication skills are required when direct sensory input is not available (Stokowski, 2011). Since its invention in 1876, the telephone has been used as a tool to seek healthcare assistance. Some accounts of Alexander Graham Bell’s first recorded telephone call claim it was for medical help after he spilled sulfuric acid on himself (WGBH Educational Foundation, n.d.). The telephone, complemented by video or pictures, is an essential and effective means of information sharing and communication, and therefore, it is a vital tool for the ambulatory care nurse. Telephone triage is defined as “an interactive process between the nurse and client that occurs over the telephone and involves identifying the nature and urgency of client health care needs and determining the appropriate disposition” (Rutenberg & Greenberg, 2012, p. 5). Providing telephone triage and telephone advice are essential skills for the ambulatory nurse. Regardless of the nursing specialty (e.g., pediatrics, otolaryngology, oncology), nurses in outpatient clinics often find themselves performing assessTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 1

Introduction ments and providing triage and advice over the telephone. In cancer centers, telephone calls from patients are an important component of everyday nursing practice. Telephone triage assessment allows for the oncology nurse to discuss signs and symptoms experienced by the patient and to direct the patient accordingly. Triage assessments may be used to provide homecare instructions for the patient or home­ care provider. Or, if a telephone triage assessment results in the need for immediate patient evaluation, it is the responsibility of the triage nurse to relay information to the patient’s care team or direct the patient to the closest emergency department. The triage nurse also determines if the patient needs assistance with calling for emergency medical transportation (G. Shelton, personal communication, October 27, 2017). The work of responding to telephone calls of patients and families must be considered when establishing nursing roles and responsibilities, as well as when developing a budget for the outpatient/ambulatory center. Telephone assessments and triage have become integral in providing ambulatory care delivery, improving appropriate access to care, and controlling healthcare costs. The American Hospital Association (2016) published a brief documenting the growing integration of telehealth in healthcare organizations as a cost-effective care delivery method. The care provided needs to be individualized for the patient and his or her unique problem. Mastery of telephone triage is a difficult yet necessary skill for the outpatient nurse. Ambulatory triage nurses must quickly collect information and knowledge on the patient, including current and past medical history and social situation. Telephone assessments require an experienced nurse with expert knowledge of usual disease states or conditions and treatment regimens. The nurse must possess excellent communication skills that allow for quick establishment of rapport and completion of an accurate patient assessment limited to auditory clues (Derkx, Rethans, Knottnerus, & Ram, 2007). Oncology nurses are especially challenged in meeting patient needs over the telephone. A nursing assessment of a patient with a cancer diagnosis can be quite complicated. The primary diagnosis, as well as side effects from treatment, can result in a variety of symptoms. The nurse may be taken off guard by the patient’s telephone call, as it can occur at any time. The patient’s medical record, with complete medical and cancer history and treatment plan, may not be available when the nurse first responds to the call. The complex patient assessment is made even more difficult when performed over the telephone because the nurse is unable to visually observe or examine the patient. This is a significant challenge, as visual messages and nonverbal communication account for up to 55% of the impact in a face-to-face patient assessment (Car & Sheikh, 2003). Nurses are direct care providers. They are educated and practice in settings where they use their senses when assessing and caring for patients. As nurses gain more experience, they assimilate and process information through their senses so rapidly that they often are unaware of individual thought processes. This is commonly described as intuition or a gut feeling. Regardless of how the nurse defines this ability, the thorough nursing assessment, including sensory observations, allows the expert nurse to make prompt and accurate decisions. This intuition often is lost when the assessment is performed on the telephone because of the lack of sensory 2 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Introduction input. The nurse cannot directly see, touch, or smell, and must rely solely on verbal and listening skills. Furthermore, the nurse may be communicating with a family member or friend attempting to describe the patient’s complaint. It is not surprising that telephone triage can be a daunting task for an oncology nurse if not well prepared. A systematic process, including written protocols or guidelines, complete and concise documentation, and processes within the busy practice setting, allows the nurse to give the required time and attention to the patient’s call. Preparedness requires an in-depth understanding of oncology diagnoses; treatments, their side effects, and management; and excellent assessment and telephone communication skills. Nurses with years of experience and skill in telephone assessment and communication may develop a “telephone intuition” that allows them to ask a few pointed questions to quickly get to the root of the problem. They are able to hone their assessment with both their knowledge of the specialty and of the patient. These nurses will listen “between the lines,” focusing not only on the patient’s words but also the tone of voice. This expert nurse listens to “hear” body language in the tone of voice. Lockwood (n.d.) reported that tone accounts for 86% of verbal communication, with actual spoken words accounting for the remaining 14%. The expert telephone nurse can quickly identify the patient’s anxiety, pain, or other symptoms, such as shortness of breath. However, for nurses who have not yet gained these skills, few resources are available. The goal of this book is to provide useful tips for oncology nurses as they develop telephone triage or telephone nursing practices in their clinical settings. To date, no other text has addressed the special needs of patients with oncology problems or the special skills required by the oncology telephone triage nurse. The authors hope this book will help both expert and less-experienced nurses. The purpose of this text is to provide “how-to” tips for telephone assessment, communication, and documentation, as well as for the telephone triage process, including a discussion of legal concerns and sample models of practice. The telephone guidelines and protocols are symptom based and were selected to address the common complaints of patients with cancer. These protocols offer a basic structure for handling telephone calls in an outpatient setting while providing continuity of care for the patient with cancer. This text is designed to assist oncology nurses at all experience levels. It can be used as a resource for oncology nurses learning the telephone nursing role. The expert nurse will find this text a valuable augment to the education of newer nurses and a guide on how to develop a formalized telephone nursing practice in the clinic. The symptom-related protocols will assist any nurse with calls and complaints not experienced previously. Symptom-focused telephone protocols are included to direct oncology nurses in the development of guidelines in their practice settings. It is essential that these protocols are not implemented without the review and approval of the physician or physicians who manage the patients in the practice. These telephone protocols are written to serve as a guide to nurses to meet the specific needs of their oncology patient population. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 3

Introduction Oncology nurses from across the United States and as far away as Kenya have contributed these protocols to help other nurses and improve patient care. This text could not have been accomplished without the sharing spirit and collegiality of oncology nurses dedicated to improving the care of patients with cancer.

REFERENCES American Hospital Association. (2016). Telehealth: Helping hospitals deliver cost-effective care. Retrieved from http://www.aha.org/content/16/16telehealthissuebrief.pdf Car, J., & Sheikh, A. (2003). Telephone consultations. BMJ, 326, 966–969. https://doi.org/10.1136/bmj​ .326.7396.966 Derkx, H.P., Rethans, J.-J.E., Knottnerus, J.A., & Ram, P.M. (2007). Assessing communication skills of clinical call handlers working at an out-of-hours centre: Development of the RICE rating scale. British Journal of General Practice, 57, 383–387. Lockwood, T. (n.d.). Voice and language. Retrieved from http://www.fenman.co.uk/traineractive/training​ -activity/voice-and-language.html Mastal, M., & Levine, J. (2012). Perspectives in ambulatory care: A survey. Nursing Economics, 30, 295–304. National Council of State Boards of Nursing. (2016). Executive summary: The 2015 National Nursing Workforce Survey. Journal of Nursing Regulation, 7(Suppl.), S4–S6. Rutenberg, C., & Greenberg, M.E. (2012). The art and science of telephone triage: How to practice nursing over the phone. Hot Springs, AR: Telephone Triage Consulting. Stokowski, L.A. (2011). Ambulatory care nursing: Yes, it’s a specialty. Retrieved from https://www​ .medscape.com/viewarticle/749906_2 WGBH Educational Foundation. (n.d.). The world’s first phone call happened in Boston. Retrieved from https://www​.wgbh.org/news/2016/03/11/science-and-technology/worlds-first-phone-call -happened-boston

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Overview Margaret Hickey, RN, MSN, MS Telemedicine describes the provision of medical care across distance using electronic means. Historically, telemedicine centered on consultation or other situations in which a licensed physician is in direct contact with another licensed physician. Telenursing describes nursing services provided via telecommunication channels and is a subset of telemedicine. In 1997, the National Council of State Boards of Nursing (NCSBN) first determined that nursing practice does in fact occur when nurses provide care via telecommunication channels. In 2014, this definition was expanded to include advances in communication technologies: high-speed Internet, wireless, and satellite and televideo communications (NCSBN, 2014). The College of Registered Nurses of Nova Scotia (2017) further defined telenursing as a nursing practice in which nurses “meet the health needs of clients using information, communication, and web-based systems” (p. 1) to deliver, manage, and coordinate care through information and telecommunication technologies. The most typical example of telenursing is the nurse in direct telephone contact with the patient or caregiver; however, use of video and photographs can augment these calls with additional visual context. Telephone nursing care involves the establishment of a nurse–patient relationship and is facilitated by the nursing process. The nursing process is an interactive problem-solving process used to give organized and individualized patient care. It involves assessment with data collection, identification of the problem, planning, implementation, and evaluation. Nauright, Moneyham, and Williamson (1999) held two focus groups of nurses involved in telephone triage and consultation. The goals of these focus groups were to examine the evolving role of nurses in telephone triage and consultation, identify and describe issues that affect their practice, and discuss the implications of this emerging role on nursing practice, education, and research. The focus groups included nurses who staffed health maintenance organization (HMO) and hospital call-in advice lines from two states. They were asked to describe what they did in their role as telephone triage nurses. These nurses described the three major activities of telephone triage as educating patients, advocating for patients, and connecting patients with needed resources. These main activities continue yet today. The nurses surveyed did not describe their role in the true sense of triage (i.e., sorting patients into urgency categories based on their injuries or symptoms) but rather as nursing care provided through a new venue—the telephone. The nurses included in these focus groups did not come from oncology offices; however, oncology nurses would most likely describe their role in much the same way. Telenursing has evolved over the decades. It first came onto the healthcare scene during the 1960s. During that decade and the next, telephone nurses became gateTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 5

Overview keepers for several HMOs. Nurses screened calls hoping to eliminate unnecessary office visits and to encourage self-care at home. In the 1980s, fierce competition arose among hospitals, forcing public relations with the community to become a major marketing strategy. Healthcare marketers saw the potential for “Call a Nurse” initiatives to provide a community service while enhancing the hospital’s image. These nurse call lines usually had toll-free numbers that were extensively marketed. Telenursing in these call centers provided health information rather than triage and advice. The call centers also served as a means of increasing referrals to in-house programs, services, and physicians. The nurses provided health information and assisted patients with referrals and maneuvering through the healthcare system. The era of managed care arrived in the 1990s. The concepts of care management, telephone triage, and “Call a Nurse” programs continued to proliferate during this decade. The efforts of health plans to balance service quality with cost control spurred rapid growth in telephone nursing advice services. It was during this era of managed care that the term telephone triage began to appear in MEDLINE® indexes, giving credence to this new subspecialty. In 2010, the Patient Protection and Affordable Care Act encouraged implementation of alternate care models, allowing ambulatory care personnel to function in newly expanded roles, including advancing the use of communication technology in health care. The American Academy of Ambulatory Care Nursing (AAACN, 2018) has formalized the scope and standards of practice for professional telehealth nursing. Telenursing has become a common practice for ambulatory care nurses in today’s healthcare delivery system, so much so that the 2016 AAACN position statement clearly outlines the importance of the professional nurse in the ambulatory setting through three specific areas: ••Professional nurses are essential to the provision of safe, high-quality care. ••Professional nurses are the team members best positioned to coordinate interprofessional care across the care continuum to lessen the complexity for patients and families. ••The role of ambulatory professional nurses is critical to the provision of telehealth and virtual care. Telephone triage is one component of telenursing. The term triage is derived from the French verb trier, which means “to sort.” Medical triage refers to the act of “sorting” patients into urgency categories based on their injuries or symptoms. The concept of medical triage began during World War I in France. It was designed to save the wounded and to not waste resources on soldiers with fatal injuries. The NATO Standardization Office (2017) defined triage as the evaluation and classification of wounded for purposes of treatment and evacuation. It consists of the immediate sorting of patients according to type and seriousness of injury, and likelihood of survival, and the establishment of priority for treatment and evacuation to assure medical care of the greatest benefit to the largest number. (p. 116) More commonly today, face-to-face triage is performed in emergency departments (EDs). Triage skills and the term triage extend to the telephone in EDs and ambulatory clinics across the country. 6 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Overview The ED provides an excellent example of the similarities and differences that exist between the triage process in a face-to-face visit and via the telephone. While the nursing process is used during both, the face-to-face triage nursing assessment is aided by the ability to interview the patient and/or family member and direct examination of the patient. The nurse is able to see, touch, listen, and smell during the examination. Additionally, in the ED setting, the nurse is able to record key physical parameters, such as temperature, pulse, respirations, and blood pressure. On the telephone, the ED nurse is challenged with making decisions regarding patient acuity and disposition based only on spoken word. Telephone triage is a systematic process designed to screen the patient’s symptoms for urgency and to guide the patient to the appropriate level of care in the appropriate time frame based on a verbal telephone interview alone—listening to and talking with the patient or patient surrogate. The nurse must form an estimate of the problem and identify a working diagnosis or impression. He or she then provides the patient or surrogate with direction regarding the appropriate time and location to seek care or remain at home. If the patient is advised that he or she does not need urgent care, clear instructions are given on how to treat and continue to monitor the problem at home, as well as when to call again or seek immediate care. The nurse may find it necessary to make referrals to other services and community resources. The term telephone triage has come to encompass the broader concepts of telephone health advice. The key component of telephone triage is to triage the call. However, the nurse also provides advice, information, and patient education. The advice given may include recommendations for care to be provided at home, instructions regarding when to seek medical help, and referral to the appropriate healthcare facility. Much of the literature and research to date has focused on triage nursing as it is practiced in freestanding call centers or EDs. This explains the continued use of the term telephone triage to describe telenursing. However, we believe the term telenursing more accurately describes the nursing care provided by oncology nurses to patients, including advice, homecare instructions, psychosocial support, and making referrals and appointments. All of these tasks facilitate continuity of care and the nurse–patient relationship. Systematic patient assessment is critical to the nurse performing telephone triage. An experienced nurse skilled in assessing patients and managing patient care may find the assessment process alien once the telephone is the only vehicle for patient management. The nurse continues to apply the nursing process to telenursing; however, the approach to employing the process may differ from face-to-face care. The nursing process consists of assessment, nursing diagnosis, identification of expected outcomes or goals, planning, implementation, and evaluation (AAACN, 2017). ••Assessment: The assessment is based on the telephone interview. The nurse must identify relevant information and recognize problems even when the patient is being evasive. Information available in the medical record, such as allergies, medications, and medical history, is integral in data collection. This information needs to be verified in the interview, as changes may have occurred since the Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 7

Overview last visit. The caller can be the patient or a caregiver. Although both can provide important information, it is recommended that the nurse speak directly with the patient regardless of who initiated the call. This gives the nurse an opportunity to listen to breathing and voice cues, such as slurred speech or signs of confusion. ••Nursing diagnosis: The nurse’s identification of the problem, working diagnosis, or conclusion is derived from the history, telephone interview, and any objective symptoms. ••Identification of expected outcomes or goals: The nurse needs to determine what needs to occur in order to resolve the problem. The goal of care should be realistic and attainable. ••Planning: Once the problem is identified, the urgency of the problem and the appropriate disposition are determined. The most effective decision makers consider the whole situation and not just the symptoms. Other factors such as age, gender, illness, recent treatment, and distance from care must be considered. The process needs to be interactive so that the nurse can determine the patient’s willingness and ability to comply with advice. For example, a nurse identifies a 32-year-old woman’s complaint of severe abdominal pain as requiring urgent care and recommends that the patient go to the nearest ED. The nurse failed to elicit that the woman has a three-year-old child at home, and no one is available to care for the child. Subsequently, the patient disregards the advice. ••Implementation: Once the urgency is determined and a referral is made, the nurse needs to work with the patient to set an appointment and arrange appropriate transportation, if necessary, for medical evaluation. The nurse must provide instructions to the patient, regardless of whether the problem requires the patient to be seen today or to monitor symptoms at home. ••Evaluation: Before the call has ended, the nurse should review the plan with the patient and evaluate the caller’s understanding of the instructions and the patient’s intended compliance with the advice. For example, the nurse should ask the patient to repeat back the plan and also ask the patient if there is any reason that he or she cannot or will not follow through with it. If it is deemed necessary, the nurse should schedule a follow-up call to evaluate the patient’s status. Multiple authors, nursing organizations such as the American Nurses Association, and state boards of nursing repeatedly emphasize the importance of using guidelines or protocols for telephone triage. Standard protocols provide written guidance of questions that best elicit information from patients, as well as advice and disposition instructions for the patients. This text provides examples of protocols designed to address common complaints of patients with oncologic conditions. Protocols do not stand alone; rather, they complement and support established policies and procedures. These protocols are designed to be a guide and should be closely reviewed by the experts in the department, including the RNs, nurse practitioners, and medical team responsible for the practice, and edited as needed to meet the needs of the patients seen in the oncology ambulatory center. Required policies include telephone call processing and instruction in directing patients’ calls. Appropriate documentation of the calls needs to be outlined, 8 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Overview and documentation forms or electronic medical record templates should be developed to streamline the process and ensure that the needed information is captured. Policies and procedures need to be written to outline the actions to be taken by the nurse and physician and should include the communication process between the two. Finally, policies must ensure that patient confidentiality is maintained. See Appendix A for an example of a policy guideline. Protocols and policies improve the telephone nursing process. However, they do not guarantee quality telephone triage and improved patient outcomes. Telephone protocols are only as good as the nurses who use them. These protocols will never replace sound clinical judgment and critical-thinking skills. It is essential that while assessing a patient and the patient’s situation, nurses gather adequate information from the patient’s medical record, the patient, and other resources as needed. Telephone protocols serve as guidelines for nurses, especially less-experienced oncology nurses, to aid them in the nursing process and decision making. Telenursing has evolved over the years, and it will continue to change with the explosion of communication technology. The scope of telenursing is multifaceted, addressing triage, health advice, and information. The number of nurses practicing telenursing is increasing annually, as is the number of patients using the services available.

REFERENCES American Academy of Ambulatory Care Nursing. (2016). The role of the registered nurse in ambulatory care: Position statement. Retrieved from https://www.aaacn.org/sites/default/files/documents​ /PositionStatementRN.pdf American Academy of Ambulatory Care Nursing. (2017). Scope and standards of practice for professional ambulatory care nursing (9th ed.). Pitman, NJ: Author. American Academy of Ambulatory Care Nursing. (2018). Scope and standards of practice for professional telehealth nursing (6th ed.). Pitman, NJ: Author. College of Registered Nurses of Nova Scotia. (2017). Practice guidelines: Telenursing. Retrieved from https://crnns.ca/wp-content/uploads/2017/09/Telenursing.pdf National Council of State Boards of Nursing. (2014, April). The National Council of State Boards (NCSBN®) position paper on telehealth nursing practice. Retrieved from https://www.ncsbn.org​ /14_Telehealth.pdf NATO Standardization Office. (2017). NATO glossary of terms and definitions (English and French). Retrieved from https://nso.nato.int/nso/terminology_Public.html Nauright, L.P., Moneyham, L., & Williamson, J. (1999). Telephone triage and consultation: An emerging role for nurses. Nursing Outlook, 47, 219–226. https://doi.org/10.1016/S0029-6554(99)90054-4

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Models of Telephone Triage and Use of Guidelines Sharon Steingass, RN, MSN, AOCN® Madelaine Binner, MBA, FNP-BC, DNP

INTRODUCTION The work of RNs can be organized around disease-specific populations as well as by clinical setting, such as in inpatient, ambulatory, or home care. An episode of care in the ambulatory environment may occur as an in-person, telehealth, or electronic message encounter. Telehealth encounters involve delivery, management, and coordination of care that integrates electronic information and telecommunication technology to increase access, improve outcomes, and contain or reduce healthcare costs (American Academy of Ambulatory Care Nursing [AAACN], 2017). Nurses involved in telehealth are responsible for triage, education, disease coordination, management of referrals, communication of diagnostic testing, and medication management (AAACN, 2017). Telephone nursing has grown into its own unique specialty and is especially important to support care transitions and ensure that patients receive timely and consistent evidence-based care. Telephone nursing practice has been defined as the delivery, management, and coordination of care provided via telecommunication technology within the domains of ambulatory care nursing (AAACN, 2018; Espensen, 2009). This chapter will provide a review of telephone nursing models, discuss factors that influence the management of a telephone encounter, describe assessment methods that can be used during a telephone nursing encounter, discuss the use of clinical decision support (CDS) tools, and outline essential elements for documentation of a telephone encounter. Each of these components provides a framework for comprehensive telephone encounter management to ensure that caller expectations are met and that key nursing competencies are defined for nurses providing care via the telephone.

CARE DELIVERY MODELS OF TELEPHONE NURSING Models of nursing care have been designed to provide a framework that guides and directs practice and defines the clinical competencies needed to provide care within a setting. As the role and scope of telephone nursing and telehealth nursing continue to evolve, various models of telephone nursing have emerged to help Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 11

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s provide a context to support training, develop competencies, define scope of practice, and measure and improve outcomes. The nursing process is a systematic method commonly used by nurses to plan, provide, and evaluate nursing care. AAACN (2017) defines the nursing process through six steps: assessment, nursing diagnosis, identification of expected outcomes or goals, planning, implementation, and evaluation. This same framework can be seen in the earliest model of telephone nursing, the Data to Wisdom Continuum, first described by Englebardt and Nelson in 2002. The authors defined telephone nursing as the study of how health data, information, and knowledge are collected, stored, processed, communicated, and used to support the process of healthcare delivery to clients, providers, administrations, and organizations involved in healthcare delivery. The Data to Wisdom Continuum describes the elements of telephone nursing performed daily: nurses collect and organize data and draw conclusions; use their knowledge, expertise, and wisdom; and act on and communicate the data and conclusions across the continuum of care. Although this model describes some of the major steps that a nurse takes during the telephone interaction, it does not completely describe how the work is accomplished. In 2004, with the evolution of evidence-based practice, a new model of telephone nursing emerged, the Decision-Making Triad (Greenberg & Pyle, 2004). In this model, Greenberg and Pyle illustrated how telephone nurses use three primary sources of information to make decisions: knowledge, clinical context, and patient preference. The Decision-Making Triad expands on the data collected in the Data to Wisdom Continuum, acknowledging the clinical context that influences collected data. The patient’s current health or disease issues, treatment plans, and settings are important aspects of the data and thus may influence the judgment or decision making of the telephone nurse (Greenberg & Pyle, 2004). For example, fever in a postchemotherapy neutropenic patient may be treated very differently than a transient fever as the result of an upper respiratory condition in a patient with cancer no longer undergoing active treatment. Although the fever symptom is consistent in these examples, the clinical context will drive the telephone nurse to think differently as data are collected and interpreted. The addition of evidence-based knowledge and practice is also critical to this model. As oncology nurses continue to learn about new treatments, the management of side effects may again require different interventions and actions. Consider the various types of skin reactions that patients may report via the telephone. Understanding the treatment plan and the potential cause of a skin reaction is critical when conducting an assessment over the phone, as it will allow the patient to receive the correct plan of care and the most appropriate advice. The Decision-Making Triad also takes into consideration patient preferences, ensuring that patients/callers receive information consistent with their current learning and communication styles. Nurses must continually learn and adapt to the diverse ethnic and generational communication and care needs of an ever-changing patient population. As telephone nursing continued to evolve through the early 2000s, the need for a more formal model of nursing care delivery emerged to provide a comprehensive description of the process of care used by telephone nurses. Building on the Data to Wisdom Continuum and the Decision-Making Triad, Rutenberg and Greenberg 12 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s (2012) created a telephone nursing model that describes and defines the processes used in a telephone nursing encounter, as well as the structure of a call. The Greenberg Model of Care Delivery in Telephone Nursing Practice (see Figure 1) has four distinct components: interpreting, information gathering, cognitive processing, and output. Interpreting occurs throughout the telephone encounter, as the nurse continuously listens and translates the information conveyed by the caller. During phase 1, or the information gathering phase, the nurse does most of the data gathering by connecting with the caller, seeking information on the nature and urgency of the call, and putting the call into context. This is when the telephone nurse uses his or her knowledge to gather information about the call and begins to establish a viable plan of care for the caller. Questioning and redirecting are strategies that elicit the caller’s story and allow the nurse to manage the call to ensure all pertinent information is collected. The information gathering phase will be more comprehensively described in the assessment section of this chapter. In phase 2, or the cognitive processing phase, the nurse verifies the information obtained and begins the decisionmaking process. Based on the urgency of the call, some cognitive planning may begin early in the information gathering phase. In the output phase, the nurse recommends a disposition for the call and gives specific advice or information that will be important for the caller based on the established plan of care. It is important for the nurse to validate that the caller has understood all instructions and the plan of care during Figure 1. Greenberg Model of Care Delivery in Telephone Nursing Practice

Note. Copyright 2005 by M. Elizabeth Greenberg, RNC, PhD. Used with permission.

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M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s this phase. This validation can be accomplished by asking the caller to repeat the plan of care back to the nurse in his or her own words. In some instances, the output of the call may require that the telephone nurse escalate the plan to another care provider. This may happen if elements of the plan are outside the scope of practice of the telephone nurse. In the output phase, the nurse should reassure callers that they can call back should additional information or clarification of the plan be needed, or if the plan of care does not have the expected outcomes.

FACTORS THAT INFLUENCE TELEPHONE NURSING CARE MODELS AND PROCESSES Although a model of telephone nursing care may provide a framework for care delivery, it can vary based on how each organization defines the structure of telephone nursing practice. Some influencing factors include the types of calls, routing of calls, staffing models, hours of operation, and qualifications and competencies needed for the telephone nurse.

Call Type, Reason, and Timing

Understanding and defining the types of calls received is a critical first step in developing a telephone nursing care framework and will further define other structural elements for telephone nursing practice. Patients are accustomed to connecting with their caregivers for symptom, medication, and nonsymptom-based calls. Some calls are proactive and initiated by the office. An example of proactive calls is follow-up calls after chemotherapy. See Appendix B for an example. Nonsymptom calls are appointment requests or cancellations, requests for return-to-work notices, Family and Medical Leave Act paperwork, and authorizations for diagnostic tests or prescriptions. The volume of each call type, the reason for the call, and the time of day that calls are received will help decide optimal staffing needs. Determining which role will handle which telephone call type in an ambulatory setting will avoid role confusion and ensure that scope of practice is maintained.

Call Routing

Once the various call types are determined and assigned to a role, the next influencing factor is how calls are received and routed. Various options are available for call routing, including use of a phone tree, voice mail, or answering service. All symptom management or clinical calls should be routed to a registered professional, meaning a nurse, nurse practitioner, physician assistant, pharmacist, or physician. The knowledge and skills of a licensed medical professional ensure that the interpretation, information gathering, cognitive processing, and output phases of a telephone call are comprehensive and timely. Clinical and symptom management calls may come directly to the nurse, or a message can be left via voice mail or taken by a nonlicensed staff member and transferred to a telephone nurse for management. If a message is left or taken, it is important to establish guidelines to escalate life-threatening or emergent calls immediately to a licensed care professional. 14 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s

Staffing Models

Staffing models for call management are another critical and influencing factor. In some organizations, a dedicated telephone nursing role has been defined, while other organizations assign and rotate the task among a variety of individuals. The size of the organization, volume of calls, and resources available will influence the staffing model. The staffing model can be centralized within a large call center or decentralized within each subspecialty clinical setting. One of the critical elements in determining a staffing model is the expectation of how quickly calls will be managed. If all calls are to be answered on the same day, dedicated resources (staff and time) must be established based on call volumes and type. The time frame for responding to calls may vary based on the reason for the call. For example, symptom management calls may require a response on the same day, while a one- to five-day response time is reasonable for prescription refills and paperwork calls. The ambulatory staff role and staffing model used to manage calls may differ between office and nonoffice hours based on call volume, patient population, and available resources. Different staffing and call routing processes may have to be established for nonbusiness hours. It is important for patients and caregivers to understand who will be managing their calls and issues during this time. For both business and nonbusiness hours, an escalation process must be established to ensure that the right care provider is determining the plan of care based on the nature of the call and the scope of practice of the individual managing the call.

Qualifications and Competencies

Clearly articulating expectations for the telephone nurse influences the staffing model and helps define needed qualifications. Qualifications for a telephone nurse who only takes information are very different from those needed for a telephone nurse charged to triage a call, determine the plan of care, provide information, and identify the patient’s disposition while on the call. For either role, it is critical for the nurse to have excellent listening skills and the ability to ask open-ended questions to obtain comprehensive and complete information. AAACN (2018) has developed and published standards for telehealth nursing that define the qualifications needed by telephone nurses. The standards of telehealth nursing practice have the following framework elements: assessment, nursing diagnosis, identification of expected outcomes/goals, planning, implementation, and evaluation. For each standard, specific competencies for telephone nurses and nurse leaders in telehealth are defined. Telehealth competencies are defined as “the behavior and outcomes specific and necessary to provide efficient, effective, and evidence-based care” (AAACN, 2018, p. 42). These competencies also serve as measurements for annual performance evaluations.

ASSESSMENT METHODS USED DURING TELEPHONE TRIAGE Eliciting a patient history and performing a patient assessment are difficult enough in face-to-face patient encounters. Performing an assessment without essential visual, Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 15

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s olfactory, and tactile (sensory) input adds another level of challenge. This is, in effect, what occurs with telephone triage. Despite sensory limitations, telephone triage offers the option of convenient access to a healthcare professional for advice, education, and support in self-management, as well as monitoring for potential toxicities and treatment effects (Black & Caufield, 2007; Kondo et al., 2015). The literature supports that effective telephone triage may reduce emergency department or office visits, prevent escalation of patients’ symptoms to a critical level that requires hospitalization, result in improved patient satisfaction and outcomes, and lower healthcare costs (Flannery, Phillips, & Lyons, 2009; Kondo et al., 2015). As previously discussed, it is essential to determine the reason for the call, as this will aid in guiding the assessment strategy. Regardless of the nature of the call, if not speaking directly with the patient, keep in mind the legal responsibility for ensuring patient confidentiality of personal health information (PHI). In keeping with requirements of Health Insurance Portability and Accountability Act (HIPAA) regulations, patients must identify and authorize recipients of this information and discussion of PHI. Once a triage call is received, the nurse’s skills in hearing and listening replace all other senses. As such, the telephone triage nurse must possess clinical knowledge and experience, effective communication and critical-thinking skills, and the ability to frame questions to extract the pertinent information required to formulate a nursing diagnosis. Assessment skills used in face-to-face patient interviews are not necessarily transferable to telephone interviews, indicating that explicit training in telephone triage, assessment, and decision-making skills is essential (PurcStephenson & Thrasher, 2010). Experienced telephone triage nurses guide but do not lead patients through the assessment process. On the other hand, experienced telephone triage nurses also do not allow patients or caregivers to lead them to an inaccurate diagnosis. It is important to note that as more oral oncologic agents become available, the management of patients with cancer is moving more and more into the patients’ homes and increasingly relies on family members to provide care that was once provided by nurses. Family members’ and caregivers’ perceptions of their loved one’s symptoms, especially the more subjective symptoms or emotional state of the patient, become much more difficult to assess within the context of telephone triage. In a study, McMillan and Moody (2003) evaluated congruence in patient and caregiver reporting of intensity of symptoms for pain, dyspnea, and constipation. The results indicated that caregivers significantly overestimated symptom intensity. This is a key reason why the nurse should speak directly to the patient whenever possible. Telephone triage nurses must also understand that patients underestimate symptoms because of the fear of delaying or discontinuing therapies or the possibility that their disease is progressing. The use of standardized assessment processes and tools can provide consistency in triage practices, minimize risk for potential liability, and augment accountability for advice given. A well-designed assessment drives the decision-making process and considers legal and best practice implications; however, the use of valid assessment instruments needs to be considered, along with the intuitive knowledge, 16 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s comfort level, and experience of the triaging nurse. Gleason, O’Neill, Goldschmitt, Horigan, and Moriarty (2013) assessed educational needs of oncology triage nurses and found that nurses must possess a reasonable comfort level without feeling compelled to refer all patients to the emergency department or for an office visit. The nursing process (assessment, nursing diagnosis, identification of expected outcomes or goals, planning, implementation, and evaluation) is a systematic approach to problem solving and addressing patient needs (AAACN, 2017). It is important to note that although the nursing process is sequential in theory, it usually is not linear in clinical practice. Many times, patients call with a presenting symptom, but as more information is gathered, it may become apparent to the triage nurse that other elicited symptoms are higher priority than the initial complaint. As such, the triage nurse must be flexible and modify the assessment as more data are garnered.

COMPREHENSIVE ASSESSMENT The first step in the nursing process, comprehensive assessment, is critical in formulating an accurate nursing diagnosis, an appropriate plan, and an intervention to address the patient’s concerns. Liability risks typically increase with inaccurate or incomplete assessment, deficient telephone processes and procedures, and inadequate documentation (Black & Caufield, 2007). The key assumption in effective telephone triage is that the nursing assessment and diagnosis are accurate, as these steps drive the rest of the process. Data collection sources for the assessment phase of telephone triage include information from the patient or caregiver, user-friendly access to the electronic health record or paper chart, current testing and imaging results, drug references, and accessible, yet nonrestrictive, evidence-based symptom management protocols, guidelines, and resources (Black & Caufield, 2007; Macartney, Stacey, Carley, & Harrison, 2012). Advantages for oncology nurses in the triage setting include knowledge of the disease process, treatments, and the oncology patient population. A review of current medications and self-care strategies is part of the assessment. Determine if the patient is taking the prescribed medications for supportive care correctly and if relief of symptoms is achieved. Investigate any exacerbating or alleviating factors associated with the patient’s symptoms. Emphasis should be placed on key aspects of active listening, including verbal and nonverbal auditory cues, such as respiratory changes, breathlessness, clarity of speech, the ability to stay focused and concentrate, emotional state or level of distress, background noise, and presence (or lack) of support persons.

Prioritization of Issues

Anticipated Side Effects and Toxicities

Triage nurses must be able to assign a degree of urgency or priority to patient concerns or issues to maximize positive outcome. For many patients, side effects and toxicities associated with common antineoplastic regimens and treatments can Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 17

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s be anticipated. The astute triage nurse is familiar with cancer site–specific antineoplastic regimens and common drug side effects and toxicities. Familiarity with toxicity grading scales, such as the Common Terminology Criteria for Adverse Events (National Cancer Institute Cancer Therapy Evaluation Program, 2017), may be helpful in determining the severity of treatment toxicities, keeping in mind that assessment information is based on what the patient or caregiver is conveying during the call; grading may not be as accurate as a visual examination of the patient.

Atypical Presentations

The nurse’s skill and knowledge become the greatest tools in the triage process, as not every patient follows the usual or typical pattern of response or reactions to treatments. In the triage setting, not all patients fit neatly into a symptom management protocol or guideline. With or without the aid of protocols or guidelines, the effective triage nurse does not base advice on anecdotal information (Black & Caufield, 2007). Most calls result in triage to one of three priority levels: review and reinforce self-care strategies (nonurgent); obtain medical orders as indicated with instructions for 8–24 hours or sooner for follow-up (urgent); and refer for emergent medical intervention (Rutenberg, 2000; Stacey, 2016). This priority level will drive the action plan and the disposition of the patient at the end of the telephone encounter. Processes for management of the various priority levels should be in place. For example, if it is determined that the patient may implement self-care strategies, then instructions should include what to do if symptoms do not resolve or if they recur. Also, if an office visit is indicated, triage must determine the time frame in which the patient should be evaluated (i.e., same day or next day) and facilitate scheduling the appointment. Counseling, consultation, and patient education are often provided in addition to triaging the patient’s issue.

Multiple Issues

Often, patients may present with multiple concerns; therefore, symptom management should be prioritized based on highest severity using sound nursing judgment and clinical knowledge. This priority rating may represent the clinical acuity of the patient’s concern; however, the nurse must also consider the patient’s or caregiver’s perception of the urgency of the need. The patient’s or caregiver’s emotional state, coping skills, and cultural background have an impact on his or her reactions and responses to the situation. The nurse must also recognize that personal bias, stereotyping, and prejudicial attitudes may affect the accuracy of the assessment and nursing diagnosis. This is especially pertinent to patients who are frequent callers to the triage line. Although most callers are dealing with a straightforward issue, some may be presenting multiple concerns, as well as very complex, less-apparent issues.

Complex Psychosocial Issues

Depression, anxiety, emotional upset, suicidal ideation, and demoralization are common conditions experienced by a patient with a cancer diagnosis. Macartney 18 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s et al. (2012) identified the most frequently reported symptoms for remote symptom management as fatigue, pain, nausea, constipation, and anxiety. Most nurses felt least confident managing (in order of increasing confidence) depression, dysuria/hematuria, anorexia, breathlessness, and neuropathy (see Figure 2). The triage nurse’s lower comfort level in managing complex psychosocial oncology issues clearly can pose a barrier in detecting and referring patients with cancer for appropriate psychological intervention. Up to one-third of people affected by cancer experience some form of ongoing psychological distress. Unfortunately, clinicians may not explore this issue because of lack of time and self-confidence or limited experience in evaluating patients’ emotional status (Hawkes, Hughes, Hutchison, & Chambers, 2010; Maguire, 1999). In a study by Marcus et al. (2002), only 12% of callers indicated that emotional distress was their main reason for calling the Cancer Information and Counseling Line. The majority (77%) called initially to seek medical information; however, by the end of the telephone encounter, 67% required some level of psychosocial counseling. Therefore, despite the initial physiologic concern conveyed by the patient or caregiver, the perceptive triage nurse should not overlook the possibility that a psychosocial issue may also exist. Hawkes et al. (2010) indicated the National Figure 2. Nursing Confidence and Frequency of Cancer Symptoms

Note. From “Priorities, Barriers and Facilitators for Remote Support of Cancer Symptoms: A Survey of Canadian Oncology Nurses,” by G. Macartney, D. Stacey, M. Carley, and M.B. Harrison, 2012, Canadian Oncology Nursing Journal, 22, p. 237. Copyright 2012 by Canadian Oncology Nursing Journal. Reprinted with permission.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 19

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s Comprehensive Cancer Network® Distress Thermometer as an effective screening tool for detecting general psychosocial morbidity. This tool is a quick and noninvasive option for triaging callers to an appropriate level of care. Desrochers, Donivan, Mehta, and Laizner (2016) demonstrated that psychosocial oncology support can be provided during a telephone triage encounter. Results of this qualitative descriptive study identified three emerging themes: telephone triage provided callers with the opportunity to experience a supportive presence; telephone triage can be a means to link patients with appropriate psychosocial intervention; and individualized strategies can be implemented to target a patient’s unique issues. Interestingly, in this study, listening had the dual role of data collection for the assessment as well as a therapeutic psychosocial intervention.

Assessment Methods

A clear distinction exists between nursing assessment methods and clinical decision support (CDS) tools. Espensen (2009) described CDS tools as guidelines, protocols, and algorithms. Assessment tools, by contrast, are methods to assist the triage nurse in the data collection phase of the nursing process. These assessment tools are used in conjunction with nursing knowledge and judgment to formulate the nursing diagnosis. CDS tools may help guide the triage nurse in determining a course of action that addresses the identified nursing diagnosis. Although several CDS tools are available, the nurse must adequately assess the patient prior to deciding which tool is most appropriate. Regardless of the method employed, it is imperative that a consistent, comprehensive, systematic approach is used. Several memory aids or mnemonics are used in clinical care to prompt an efficient review when assessing a patient. Triage nurses must keep in mind that medical language and terminology are often confusing or misunderstood by nonmedical people. In the process of asking questions for data collection, the nurse must try to determine the patient’s level of health literacy. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (Centers for Disease Control and Prevention, 2015). The effective triage nurse can formulate and articulate questions that the patient understands; this is the art of telephone triage. However, a limitation for many mnemonics used by telephone triage nurses is that most are focused on the physiologic symptoms and often overlook the psychological or emotional status of the patient. The ABCD (Airway, Breathing, Circulation, and Deficit/Disability) mnemonic is often used in emergent situations to determine potentially life-threatening conditions and vital signs of the patient. In this situation, the assessment is performed by the caller under the direction of the triage nurse. This is often used in 911 telephone triage centers; oncology triage nurses need to be familiar with this assessment tool in the event they receive a call of this nature. The OPQRST (Onset, Provoking/Palliating factors, Quality, Radiation/Region, Severity, Time/Treatment) method is usually geared toward evaluating pain; however, with slight modification, it may be used to evaluate other symptoms, such as vomiting, diarrhea, or fatigue. 20 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s ••Onset: When did it begin? How long does it last (duration)? How often does it occur (time)? What were you doing when the problem started? Is it constant or does it come and go? ••Provoking/Palliating factors: What brings it on? What makes it better? What makes it worse? ••Quality: What does it feel like? Can you describe it (e.g., throbbing, stabbing, dull)? Does it increase with movement? ••Radiation/Region: Where does your pain spread? Does the pain travel anywhere else? ••Severity: What is the intensity of the symptom on a 0–10 pain scale (0 = no pain; 10 = worst pain you have ever felt)? Where are you on the pain scale right now? At worst? Are there any other symptoms that accompany the pain? ••Time/Treatment: When did the symptoms first begin? What medications are you currently taking for symptoms? Do these medications relieve or decrease your symptoms? What are their side effects? What else have you tried to deal with the symptoms? Rutenberg (2000) suggested the POSHPATE method for assessment of the chief complaint. ••Problem: Chief complaint or problem is identified in detail. ••Onset: How long has the problem existed? Did it have a sudden or gradual onset? ••Symptoms: Ask open-ended questions or provide prompt comments (e.g., “Go on.” “Can you be more specific?”). Follow up with pertinent negatives or positives to fill the voids in information. ••History: Is this a new problem or has it previously occurred? ••Precipitating factors: What brings on the symptom? Does the symptom get worse with certain food or drink? Is there a specific activity that brings on or exacerbates the symptom? ••Alleviating/Aggravating factors: What makes the condition worse or better (e.g., position changes, exposure to bright light, medications)? ••Timing: When is the symptom experienced (e.g., time of day or night, monthly, seasonally, before or after treatment, sporadically)? ••Etiology: Consider possible causative or contributing factors to determine the nursing or “working” diagnosis prior to selecting a protocol, algorithm, or guideline. As previously mentioned, determining possible causes or factors contributing to a patient’s symptoms or problems is a critical step, as the nursing diagnosis drives the rest of the nursing process. The nursing diagnosis then guides the acuity of the situation. The TICOSMO method is often used to detect possible factors that may be overlooked during the initial assessment interview (Rutenberg, 2000). ••Trauma: Investigate possible injuries, even minor, recently sustained by the patient. ••Infection: Explore the presence of signs of swelling, pain, warmth, redness, drainage, or fever. ••Chemical: Consider environmental chemical exposures, drugs, medications, inhalants, herbal remedies, etc. ••Organ: Determine if specific organ or system involvement is evident (e.g., chest pain associated with cardiovascular, respiratory, or gastrointestinal systems). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 21

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s ••Stress: Evaluate somatic complaints related to physiologic and psychological distress. ••Musculoskeletal: Consider the possibility of bone metastases, pathologic fractures, side effects of antineoplastics, radiation treatments, or medications. Medications often used in the oncologic setting, such as bisphosphonates or granulocyte– colony-stimulating factors such as pegfilgrastim, or recent activities, especially those repetitive in nature, may result in musculoskeletal complaints. ••Other: Consider the patient’s age, comorbidities, transportation issues, childcare concerns, and cultural, social, and economic situations. OLD CARTS is another mnemonic oriented to the physiologic assessment of patient complaints. ••Onset of symptoms: When did the symptom first occur? ••Location: Where on the body is the symptom located? ••Duration: Is the symptom constant or does it come and go? ••Characteristics: Can you provide a qualitative description of the symptom (e.g., How does the pain feel? What word can you use to describe it? What is the consistency of the stool? Is it watery or formed? What is the color of the urine [e.g., light yellow, amber, orange, red, another color])? ••Associated factors: Do any other signs, symptoms, or events precede the occurrence of the problem? ••Relieving factors: Does anything make the problem worse or better? ••Treatments: What have you already tried to manage the symptom? Did it help? If so, how did it help? ••Severity: How bothersome is the problem for you? Can you rate your pain (0 = no pain; 10 = worst pain ever felt)? Are diarrhea episodes disrupting your daily routine or sleep pattern? If an indication exists that the patient is experiencing anxiety or depression, the triage nurse must first establish trust with the patient when discussing sensitive topics such as emotional state. However, a study screening for depression in terminally ill patients found that the straightforward question “Are you depressed?” provided a reliable and accurate screen to identify depressive mood and outperformed the questionnaire and visual analog measures (Chochinov, Wilson, Enns, & Lander, 1997). The authors in this study compared four brief screening measures for depression in a group of terminally ill patients: a single-item interview (Are you depressed?), a two-item interview assessing depressed mood and loss of interest or pleasure in activities, a visual analog scale (linear scale indicating worst possible mood and best possible mood), and the short-form, 13-item Beck Depression Inventory. The SIGE CAPS mnemonic, developed by Dr. Carey Gross and used by psychiatry residents at Massachusetts General Hospital, refers to a prescription one might write for a depressed patient—SIG: Energy CAPSules (Carlat, 1998). This mnemonic may be used to determine if symptoms of major depression or dysthymia are present. To meet the diagnosis of major depression, a patient must have four of the symptoms, plus depressed mood or anhedonia, for at least two weeks. To meet the diagnosis of dysthymic disorder, a patient must have two of the six symptoms 22 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s marked with an asterisk (*), plus depression, for at least two years. Although the triage nurse is not making a psychological diagnosis, this method can be used as a convenient screening tool. ••Sleep disorder (increased or decreased)* ••Interest, loss of (anhedonia) ••Guilt (worthlessness*, hopelessness*, regret) ••Energy deficit* ••Concentration difficulties* ••Appetite (increased or decreased)* ••Psychomotor symptoms (slowed or agitation) ••Suicidality

Assessment Validation

Source of Information

It is essential to confirm that the nursing triage assessment is valid and that the source of the data collected is reliable. At the onset of the telephone encounter, the nurse must confirm the caller’s name, relationship to the patient (if not the patient), and authorization to discuss the patient’s PHI. It is also a good practice to obtain a callback telephone number in the event the call gets disconnected. A review of the information previously documented in the paper or electronic records is necessary to adjust for any changes that may have occurred since the last entries were made.

Subjective and Objective Data

Information obtained during the telephone interview contains mostly subjective data. It is essential to document actual descriptors used by patients to convey their concerns. The nurse should not hesitate to clarify words or phrases used during subjective data collection. Although the patient is not visualized during the encounter, some quantifiable data can be gathered to “paint a virtual picture” of the patient’s situation. For example, the nurse may ask if it is possible to take the patient’s temperature, how many watery stools the patient has had over a specific period, any changes in the patient’s weight (if the patient is able to stand), or the amount of oral fluids the patient consumed in specific period. It is often difficult for patients to convey descriptions of amount, color, or odor typically used by medical professionals. The triage nurse may offer descriptive words to articulate such signs and symptoms. For example, they may ask “What is the color of your urine? Is it the color of apple juice or lemonade? How much blood is present on the pad (e.g., dime or quarter size)? Is the lump about the size of an egg? Is it smaller or larger than that?” In this age of smartphone cameras and other advanced technologies, legal implications must be considered before asking or allowing patients to text a photo of their condition to the triage nurse. Texting to personal or work phones must be encrypted to protect PHI, and even with encryption, written permission to use or share a patient’s picture with others is often required. A review of both the subjective and objective information collected is also necessary to avoid misunderstandings or confusion about certain questions and to ensure responses can be clarified and correct information confirmed. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 23

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s

DIAGNOSIS/GOAL Determining an accurate nursing diagnosis is crucial, as this will drive the plan and course of action in managing the patient’s problems or concerns. Although it is not within the triage nurse’s scope of practice to formulate a medical diagnosis, the experienced nurse has a sense of the causative or contributing factors resulting in the patient’s problems. At this point, selecting a symptom-oriented protocol or guideline, referencing other resources, and collaborating with other health professionals may be helpful in considering options for symptom management. Acuity level is also determined (nonurgent, urgent, emergent), as this directly influences the professional advice given to the caller.

PLAN/INTERVENTION Recommendations based on acuity level, nursing judgment, and evidencebased interventions are reviewed with the caller. The patient or caregiver must be included in the decision-making process for implementation of the recommended plan. This is essential, as feasibility of implementation from the patient’s perspective will be the greatest factor if the patient is to follow the provided advice. Barriers to implementing the plan should be identified, and problem-solving methods for addressing the barriers must be discussed. The triage nurse can effectively facilitate the removal of many of the obstacles identified and coordinate the necessary care. It is vital that knowledge of community resources, contact information, hotlines, crisis centers, and other support services are readily available to the triage nurse. This is also an opportunity to provide patient education to promote self-management instructions, emotional support and reassurance, coordination of resources, and a follow-up plan. If a patient informs the triage nurse of his or her decision not to comply with the recommendations made during the telephone encounter, the nurse is obligated to share the potential harm or danger that could result from noncompliance. If this were indeed the case, an additional item to consider in the action plan would be to escalate this concern to the next level of healthcare professional. Lawsuits have resulted from a nurse’s failure to provide such warnings (Frank-Stromborg, Christensen, & Elmhurst, 2001). A good way to assess compliance is to ask the patient “Is there any reason that you would not do what we just agreed you will do?” Often, this will elicit reasons for noncompliance, and the patient and nurse can work through any barriers.

EVALUATION In a 2002 study by Mayo, Chang, and Omery, the triage nurse’s evaluation of the telephone encounter was identified as the weakest category of the nursing process. Nurses often failed to ask patients to reiterate the directives or advice provided or if patients had additional questions or required any clarification of the recommen24 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s dations. Keep in mind, health professionals often toss medical jargon into conversations without even realizing it. This type of communication is often confusing and misleading for patients and caregivers. An effective evaluation determines that the caller understands the advice provided and that the individual’s health literacy level is taken into consideration. Asking the caller to repeat instructions is practical and lends itself to clearing up any miscommunications or misunderstandings. Once the caller’s comprehension of recommendations is verified, it is reasonable to confirm whether the patient can comply with the advised action plan. A straightforward question of “What do you plan to do with the advice given?” is also a reasonable inquiry. Asking the patient to call back with any changes in the situation or initiating a follow-up call is extremely beneficial in determining patient outcomes and the effectiveness of the triage encounter. A helpful practice is to always end the encounter by determining the patient’s satisfaction level with the experience and understanding of the agreed-upon disposition and follow-up strategy.

CLINICAL DECISION SUPPORT TOOLS FOR TELEPHONE NURSING As telephone nursing has continued to evolve, the need to create CDS tools has emerged. References to the use of protocols, guidelines, and algorithms to guide telephone nursing practice are prominent in the literature. Many times, these terms are used interchangeably; however, each is unique and different. All are essential components to defining and establishing a telephone nursing practice and will differ based on the needs of the organization and patient population. Merriam-Webster defines a guideline as “an indication or outline of policy or conduct” (“Guideline,” n.d.). Guidelines are commonly developed for telephone nursing to outline key requirements when managing a call. Examples of guidelines include limiting the use of jargon by speaking in lay language and ensuring that the telephone nurse does not talk over the caller. Establishing expectations for the practice to manage and return phone calls is another example of a guideline and one that is critical to meeting patient expectations and providing a good patient experience. Protocol and algorithm are sometimes used interchangeably when discussing decision-making tools for telephone nursing practice. A protocol is a detailed plan, policy statement, or set of rules to govern how a system operates, whereas an algorithm provides step-by-step instructions for solving a problem or accomplishing a task. Within the telephone nursing context, protocols will define the structure: which role manages the call, issues for managing out-of-state calls, time frames for completing telephone call requests, and the process and expectation for documentation of telephone calls. Algorithms are decision-making tools developed to support the nurse once the reason for the call has been established. Algorithms provide the nurse with suggested questions to ask to ensure that complete and comprehensive information is gathered and allows the nurse to suggest dispositions and care advice based on the information obtained from the caller. Algorithms help to Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 25

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s set a standard of consistency in gathered data and ensure that the disposition and care advice are consistent and evidence based. Many CDS tools were developed in the early 1980s and can be found in a variety of formats. AAACN defines a decision support tool as “a plan or guide for the assessment and management of a clinical problem to reduce the risk of omission and increase the predictability of desired clinical outcomes” (AAACN, 2018, p. 48). The use of CDS tools represents the standard of care that should be used with every telephone call. CDS tools are commonly developed around a symptom and serve as a supplement to clinical nursing practice. They should never be used to replace or supersede nursing judgment. These tools guide the nurse through the data-gathering phase and can help redirect when the caller is providing information. Based on reported symptoms, the nurse may discover that more than one issue is present or that additional questions are required to ensure that a symptom is fully assessed. For example, if a caller reports itching as a symptom, the nurse must assess if it is related to a medication side effect, medication interaction, exposure to poison ivy, or the beginning stages of shingles. Based on the information gathered, the nurse will develop a plan of care, including the care advice and disposition. Some organizations choose to develop their own CDS tools, while others purchase CDS tools from a publisher or software developer. CDS tools are described as having two major decision-making strategies: rigid, abstract, and linear yes/no decision trees; or contextual, flexible, case-based reasoning based on classic pictures or pattern recognition approaches (Wheeler, 2013). Regardless of the source or strategy, CDS tools should be science or evidence based and meet the needs of the patient population. Elements within this textbook represent one example of a printed CDS tool. Another example of a print-based, oncology-specific decision support tool is the COSTaRS Remote Symptom Practice Guides for Adults on Cancer Treatments (Stacey, 2016). Examples of proprietary CDS tools are Nurse Line (Mayo Clinic, n.d.) and Schmitt-Thompson triage protocols (Schmitt-Thompson Clinical Content, n.d.). Some proprietary CDS tools have two versions, one based on office hour call management and one on after-hours call management. Both homegrown and purchased CDS tools can be used in either paper or electronic formats. Integration of the CDS tool into the electronic medical record (EMR) helps to pull contact information (e.g., caller name, phone number, date of birth, date/time of the call) into the telephone call documentation and prevent omissions or errors. In some EMR systems, other pertinent data, such as recent laboratory values or current medications, can also be pulled into the telephone encounter, which can provide additional data to the CDS tool and additional information to the documentation of the telephone call and pertinent clinical history. The value of CDS tools is to provide rules for handling calls and giving advice, guide the decision-making process of the nurse, and provide structure to ensure that important elements have not been overlooked. CDS tools are not decision-making tools. They are used to complement and prompt the nurse’s existing knowledge and critical-thinking skills to substantiate the rationale for call disposition and advice. Although the use of CDS tools is widely supported by telephone nursing standards, overreliance can lead to consequences and risk management issues. Some CDS tools 26 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s have a structured documentation format, which can interfere with the course of the telephone interview, data-gathering phase, and stability of nurse–patient connection. Premature selection of a CDS tool based on the patient’s self-report of a symptom may also result in a focus on the wrong issue or omission of another key symptom or issue. Critical thinking is still required when using CDS tools. Rutenberg and Greenberg (2012) have provided additional recommendations for the effective use of CDS tools: ••Wait to open the CDS tool until the assessment has been completed. Selecting the wrong tool may interfere with the ability of the telephone nurse to carefully listen to the issues and approach the call with an open mind. ••Apply the knowledge acquired during the assessment and information gathering to determine which questions within the CDS tool or algorithm need to be asked. ••Paraphrase questions in such a way that the question is individualized to the patient. Do not read the question verbatim; think about the information that is needed. Use open-ended questions to elicit comprehensive information. ••If the patient has more than one complaint, such as nausea, diarrhea, and fever, assess the patient once, and then quickly scan all three CDS tools, selecting the highest-level disposition among the three symptoms. ••If the nurse deviates from the recommended disposition, he or she must document the justification for the deviation. In most settings, telephone nurses are permitted to deviate from the decision if it results in the upgrade of a disposition or takes a more aggressive approach than dictated by the protocol. An example would be to send a patient with low-grade fever to the emergency department rather than advising waiting to be seen in clinic on the next business day. ••If no CDS tool is present, use clinical judgment supported by general nursing knowledge or authoritative references. When an organization is selecting a telephone triage CDS tool, the following should be taken into consideration (Rutenberg & Greenberg, 2012): ••Does the CDS tool fit the needs of the organization and the patient population? ••Is the content of the CDS tool evidence based and current? ••If the organization chooses to develop its own tool, does the organization have the resources to develop and maintain the tool? ••For a purchased or proprietary CDS tool, is the organization willing to allow for adjustments or customization of the tool? Remember, if the proprietary tool is customized, the organization must be able to support the ongoing customization, upgrades, and maintenance required if it is embedded into the EMR. ••Does the tool have some features that can be edited based on the needs of the caller and the data collected? Typically, the care advice and disposition sections of a CDS tool allow for the nurse to choose the most appropriate care advice and disposition based on assessment of the situation. ••What will be the process to review and obtain feedback on the content of the CDS tool prior to implementation and when edits or changes occur? CDS tools have been shown to be effective in improving medical safety and quality. Much of the current literature has demonstrated the benefits of these tools in medication prescribing, preventive services, and prophylaxis (Osheroff et al., 2012); however, the amount of literature is insufficient on the impact of these tools Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 27

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s on telephone nursing and triage. Murdoch et al. (2015) conducted research on the impact of computer decision support software and telephone triage in a primary care setting. In this study, 22 audio and video recordings of telephone conversations were reviewed to evaluate the nurse/caller interaction using a computer CDS tool. Findings suggested that patients present with diverse symptoms; therefore, nurses using computerized CDS tools must have sophisticated communication and technologic and clinical skills to ensure that patients’ presenting problems are accurately captured and safely triaged. Additional research is needed to determine the impact of these tools in both the quality and outcomes of the telephone nursing process.

DOCUMENTATION OF THE TELEPHONE ENCOUNTER The medical record has multiple purposes, including facilitating patient care, establishing communication with the healthcare team for continuity of care, evaluating the quality of patient care, examining quality assurance/improvement, providing billing by health insurers, complying with accreditation and licensing agencies, and determining a basis of standards of care in the legal setting (Black & Caufield, 2007; Frank-Stromborg et al., 2001; Rutenberg, 2000). The diverse functioning of the medical record makes documentation of the telephone triage interaction extremely important in clinical practice.

Formats

Whether documenting the triage encounter in a paper chart or an EMR, it is imperative that the format be designed for real-time data entry and notes. The format should include prompts with pertinent questions to guide the nurse to a comprehensive assessment; it is critical that this information is not overlooked. North et al. (2014) evaluated the quality of telephone triage documentation with the use of CDS tools. Triage documents from three cohorts (pre-CDS, post-CDS, and without CDS [control group]) were evaluated using AAACN documentation standards. In the triage notes, the post-CDS group had a mean of 36.7 symptom features documented, while the pre-CDS group had 10.7 symptom features and the control group had 10.2 (p < 0.0001). CDS tool use significantly improved the quality of documentation. This supports the notion that a streamlined documentation method will allow for a thorough application of the nursing process, as well as an efficient method for timeliness in meeting the caller’s needs and attending to those waiting on incoming call lines. Technologic advances for EMRs in telehealth encounters are emerging. Encrypted emails and text messages, video telehealth conferencing, and web-based patient portals are now at the forefront of triaging patient concerns and symptom management.

Method

Electronic triage programs with checklists, data fields, and computerized dropdowns will enhance speed and minimize writing and illegibility when document28 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s ing the telephone encounter. An advantage to using data fields and drop-downs within EMRs is the ability to generate reports or the potential to track data (e.g., types of calls, frequency of calls for specific symptoms, patient outcomes when entered for follow-ups); however, reliance on computer data entry fields may hinder the nurse’s ability to document a specific piece of information if that particular “data field” is not included in the documentation template. Space for free text or narrative entries must also be available so that subjective data can be entered in the patient’s own words or from the nurse’s assessment of the patient situation. If recording information within a paper chart, a template that supports the nursing process, a systematic assessment method, evidence-based guidelines that guide the nurse’s action plan and recommendations, and evaluation of the exchange remain critical elements of the documentation. Appendix C shows an example of a sample telephone triage intake form. The flow of the document needs to support a logical, systematic approach to problem solving, with entries made in an orderly fashion rather than the disorganized way callers often provide information. The more standardized the documentation format, the less chance of omitting critical patient information that could affect the formulation of the nursing diagnosis and care plan.

Timeliness

In a busy oncology triage setting, nurses may forget details that accurately reflect the patient–nurse telephone exchange; therefore, real-time data entry for documenting the telephone encounter is the preferred method for telephone triage. EMRs must be easily accessible and user-friendly. Cumbersome software or restrictive templates will discourage real-time use and hinder the ability to tailor encounters and care plans to individual patients. In the oncologic setting, it is important that telephone triage software programs are designed to meet the needs of this specific patient population. Oncology triage nurses need to be proactive in the development of this software and the support tools that use the nursing process as the basis for providing oncology telephone triage and symptom management services.

Routing

Continuity of care is critical in the telephone triage process to track the possible escalation of a patient’s symptoms. A process for viewing historical information, including previous calls made by a patient or caregiver, is necessary to alert subsequent triage nurses, physicians, and healthcare team members to the potentially increasing acuity of a patient’s problem. As such, routing information to appropriate team members is as important as documenting the encounter in the patient’s record. In the electronic record, routing the encounter to healthcare team members is usually part of the communication process for those with access to the internal documentation system. If communicating the encounter in paper format, a reliable procedure should be established to notify healthcare team members of the patient’s status, condition, symptoms or concerns, interventions, and disposition. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 29

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s To reiterate, content of the telephone encounter needs to be accessible to healthcare team members for subsequent calls from the patient so that early identification of a potentially escalating situation can be detected. Regardless of the documentation method used, additional research is needed to determine the impact of documentation quality on patient outcomes (North et al., 2014).

SUMMARY As technology for healthcare delivery advances, the role of the telephone triage nurse evolves too. Various emerging terms, such as telehealth, telenursing, and telephone triage, will have to be defined or redefined. With the push for highquality, low-cost health care, constraints on overutilization of healthcare resources, patient expectations for convenient access to health professionals, and the current focus on patient satisfaction and improved outcomes, telephone triage offers an effective option in meeting all these requirements. Virtual assessment is beginning to replace face-to-face healthcare encounters for patient concerns, resulting in the need to modify models of care. As the field of telephone triage becomes more specialized, CDS tools will need to be created and refined to support patient needs as care moves beyond the walls of hospitals, clinics, and medical offices. Processes that enhance personalized care (despite an impersonal interaction via telephone, texts, or computer) and provide for current patient information, timely interventions, effective communication, streamlined real-time documentation accessible to healthcare team members, and follow-up care for patient outcomes are essential components for a successful nurse–patient telephone encounter. The nursing process is an effective, systematic approach that provides a structure for the triage telephone interaction. The Greenberg Model of Care Delivery in Telephone Nursing Practice (interpreting, information gathering, cognitive processing, and output) operationalizes the nursing process specific to telephone triage nursing. Explicit training for nurses providing telephone triage services is essential, as the assessment and decision-making skills used in face-to-face patient interactions are not necessarily transferable to telephone interviews and interactions. The effective triage nurse can articulate and frame questions that extract pertinent information required to formulate an accurate nursing diagnosis, which subsequently drives the acuity level, action plan, and disposition of the patient by the end of the telephone encounter. Multiple assessment aids and CDS tools are available for enhancing the assessment process; however, many aids focus on physical assessment, and the psychosocial aspect of a patient’s situation is often secondary. Lack of time, low self-confidence, or limited experience in evaluating a patient’s emotional status are cited as reasons for clinicians not exploring a patient’s distress level. Aids such as the Distress Thermometer or the mnemonic SIGE CAPS may be used as rapid, convenient psychosocial screening tools during the telephone interview. Reviewing the information gleaned during the assessment phase of the telephone encounter is essential to minimize misunderstandings or miscommunica30 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s tions and to validate that the information is accurate. The patient’s health literacy must be considered throughout the entire process. Evaluation of the telephone encounter is essential. CDS tools, which include guidelines, protocols, and algorithms, are used to guide the telephone triage nurse in structuring the interview and in decision-making efforts. These tools are commonly symptom-specific and serve as a supplement to clinical nursing practice. They may be purchased as commercial software, published in paper format, or developed by the organization. Asking patients if they can comply with the action plan is crucial, as the nurse is obligated to share potential harm that could result from noncompliance and to determine if barriers exist to plan implementation. Timely documentation of the interaction serves multiple purposes, including monitoring and detecting a patient’s potentially increasing level of acuity. Telephone triage nurses must take a proactive role in participating in ongoing research to determine the impact of CDS tools and documenting the quality of patient outcomes.

REFERENCES American Academy of Ambulatory Care Nursing. (2017). Scope and standards of practice for professional ambulatory care nursing (9th ed.). Pitman, NJ: Author. American Academy of Ambulatory Care Nursing. (2018). Scope and standards of practice for professional telehealth nursing (6th ed.). Pitman, NJ: Author. Black, K.L., & Caufield, C. (2007). Standardization of telephone triage in pediatric oncology. Journal of Pediatric Oncology Nursing, 24, 190–199. https://doi.org/10.1177/1043454207299407 Carlat, D.J. (1998). The psychiatric review of symptoms: A screening tool for family physicians. American Family Physician, 58, 1617–1624. Centers for Disease Control and Prevention. (2015). Healthy People 2010. Retrieved from https://www​ .cdc.gov/nchs/healthy_people/hp2010.htm Chochinov, H.M., Wilson, K.G., Enns, M., & Lander, S. (1997). “Are you depressed?” Screening for depression in the terminally ill. American Journal of Psychiatry, 154, 674–676. https://doi.org/10​ .1176/ajp.154.5.674 Desrochers, F., Donivan, E., Mehta, A., & Laizner, A.M. (2016). A psychosocial oncology program: Perceptions of the telephone-triage assessment. Supportive Care in Cancer, 24, 2937–2944. https://​ doi.org/10.1007/s00520-016-3091-8 Englebardt, S., & Nelson, R. (2002). Health care informatics: An interdisciplinary approach. St. Louis, MO: Mosby. Espensen, M. (Ed.). (2009). Telehealth nursing practice essentials. Pitman, NJ: American Academy of Ambulatory Care Nursing. Flannery, M., Phillips, S.M., & Lyons, C.A. (2009). Examining telephone calls in ambulatory oncology. Journal of Oncology Practice, 5, 57–60. https://doi.org/10.1200/JOP.0922002 Frank-Stromborg, M., Christensen, A., & Elmhurst, D. (2001). Nurse documentation: Not done or worse, done the wrong way—Part I. Oncology Nursing Forum, 28, 697–702. Gleason, K., O’Neill, E.B., Goldschmitt, J., Horigan, J., & Moriarty, L. (2013). Ambulatory oncology nurses making the right call: Assessment and education in telephone triage practices. Clinical Journal of Oncology Nursing, 17, 335–336. https://doi.org/10.1188/13.CJON.335-336 Greenberg, M.E., & Pyle, B. (2004). Achieving evidence-based nursing practice in ambulatory care. AAACN Viewpoint, 26, 1–5. Retrieved from https://www.aaacn.org/sites/default/files/members​ /viewpoint/novdec04.pdf Guideline. (n.d.). In Merriam-Webster online dictionary. Retrieved from https://www.merriam-webster​ .com/dictionary/guideline Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 31

M o d e l s o f T e l e p h o n e T r i a g e a n d U s e o f Gu i d e l i n e s Hawkes, A.L., Hughes, K.L., Hutchison, S.D., & Chambers, S.K. (2010). Feasibility of brief psychological distress screening by a community-based telephone helpline for cancer patients and carers. BMC Cancer, 12, 10–14. https://doi.org/10.1186/1471-2407-10-14 Kondo, S., Shiba, S., Udagawa, R., Ryushima, Y., Yano, M., Uehara, T., … Hashimoto, J. (2015). Assessment of adverse events via a telephone consultation service for cancer patients receiving ambulatory chemotherapy. BMC Research Notes, 8, 315. https://doi.org/10.1186/s13104-015-1292-8 Macartney, G., Stacey, D., Carley, M., & Harrison, M.B. (2012). Priorities, barriers and facilitators for remote support of cancer symptoms: A survey of Canadian oncology nurses. Canadian Oncology Nursing Journal, 22, 235–247. https://doi.org/10.5737/1181912x224235240 Maguire, P. (1999). Improving communication with cancer patients. European Journal of Cancer, 35, 2058–2065. https://doi.org/10.1016/S0959-8049(99)00301-9 Marcus, A.C., Garrett, K.M., Kulchak-Rahm, A., Barnes, D., Dortch, W., & Juno, S. (2002). Telephone counseling in psychosocial oncology: A report from the Cancer Information and Counseling Line. Patient Education and Counseling, 46, 267–275. https://doi.org/10.1016/S0738-3991(01)00163-X Mayo, A.M., Chang, B.L., & Omery, A. (2002). Use of protocols and guidelines by telephone nurses. Clinical Nursing Research, 11, 204–219. https://doi.org/10.1177/105477380201100208 Mayo Clinic. (n.d.). Nurse Line. Retrieved from https://mayoclinichealthsystem.org/nurse-line McMillan, S.C., & Moody, L.E. (2003). Hospice patient and caregiver congruence in reporting patients’ symptom intensity. Cancer Nursing, 26, 113–118. https://doi.org/10.1097/00002820-200304000​ -00004 Murdoch, J., Barnes, R., Pooler, J., Lattimer, V., Fletcher, E., & Campbell, J. (2015). The impact of using computer decision-support software in primary care nurse-led telephone triage: Interactional dilemmas and conversational consequences. Social Science and Medicine, 126, 36–47. https:// doi.org/10.1016/j.socscimed.2014.12.013 National Cancer Institute Cancer Therapy Evaluation Program. (2017). Common terminology criteria for adverse events [v.5.0]. Retrieved from https://ctep.cancer.gov/protocolDevelopment/electronic​ _applications/ctc.htm North, F., Richards, D.D., Bremseth, K.A., Lee, M.R., Cox, D.L., Varkey, P., & Stroebel, R.J. (2014). Clinical decision support improves quality of telephone triage documentation: An analysis of triage documentation before and after computerized clinical decision support. BMC Medical Informatics and Decision Making, 14, 20. https://doi.org/10.1186/1472-6947-14-20 Osheroff, J.A., Teich, J.M., Levick, D., Saldana, L., Velasco, F.T., Sittig, D.F., … Jenders, R.A. (2012). Improving outcomes with clinical decision support: An implementer’s guide (2nd ed.). Chicago, IL: Healthcare Information and Management Systems Society. Purc-Stephenson, R.J., & Thrasher, C. (2010). Nurses’ experiences with telephone triage and advice: A meta-ethnography. Journal of Advanced Nursing, 66, 482–494. https://doi.org/10.1111/j.1365​ -2648.2010.05275.x Rutenberg, C.D. (2000). Telephone triage. American Journal of Nursing, 100(3), 77–81. https://doi.org​ /10.2307/3522072 Rutenberg, C.D., & Greenberg, M.E. (2012). The art and science of telephone triage: How to practice nursing over the phone. Hot Springs, AR: Telephone Triage Consulting. Schmitt-Thompson Clinical Content. (n.d.). Home. Retrieved from https://www.stcc-triage.com Stacey, D. (2016). Remote symptom practice guides for adults on cancer treatments. Retrieved from https://ktcanada.ohri.ca/costars/Research/docs/COSTaRS_Pocket_Guide_March2016.pdf Wheeler, S. (2013). Is current telephone research disconnected? Retrieved from http://teletriage.com​ /articles/telephone-triage-research-real-world-practice

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Setting Up a Telephone Triage Call Center Mary Ann Plambeck, RN, MSN, NEA-BC, OCN®

Several critical elements to setting up a telephone triage call center exist, including knowing the current state of the business, what is anticipated for the future, where employees will work, the physical work environment, technology, and the skill mix of employees. Each of these elements will be addressed in this chapter.

SCOPE OF THE BUSINESS Assessing the scope of business includes understanding incoming and outgoing call volume. This can be a challenge because of the high amount of phone numbers given to customers throughout their care journey. It is also important to capture the number of telephone calls coming into clinic and provider offices. Understanding the true volume of calls is crucial in determining the number of employees and workspace needed. The scope of business includes not only call volume but also who, what, when, and why a call is being placed. 1. Who are your callers? a. When do the calls come in? Most incoming calls occur between the hours of 9 am and 5 pm, Monday through Friday. This is important knowledge when considering staffing and hours of operation. b. What are the callers’ expectations? Do they want to speak to a live person? If they leave a message, when will the call be returned? c. What phone numbers are patients calling? Often, patients have numerous saved numbers; however, their calls to providers may not be managed in a timely manner, or they may be calling multiple numbers with the same request. Having a comprehensive list of phone numbers that are frequently called by patients will ensure that call volume is accurate for planning and can be incorporated in the education plan to direct callers to the correct triage number. 2. What is the purpose of the call? a. Advice/symptom management b. Test results c. Prescription refills d. Appointments Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 33

Setting Up a Telephone Triage Call Center e. Billing/financial f. Paperwork (e.g., Family and Medical Leave Act [FMLA], prior authorization) 3. What is the provider’s level of support? It is crucial that provider expectations of triage are congruent with caller expectations. For example, if the caller is expecting a call back within the same business day but the provider feels the call can be returned within two to three days, the triage staff is often put in an awkward position. Or, if the provider requires three business days for a prescription refill, the patient calling for a same-day refill may have difficulty getting it filled in a timely manner (see Figures 3 and 4).

WORKSPACE AND ENVIRONMENT Nurses in general are at a higher risk of developing work-related musculoskeletal disorders. Triage nurses on average spend eight hours a day in a seated position, continually performing repetitive tasks such as talking on the phone, looking at a computer monitor, and typing. These repetitive actions are contributing factors to cumulative trauma disorders (Nielsen & Trinkoff, 2003). Therefore, careful attention should be considered to prevent injuries when designing a triage workstation. 1. Ergonomics: It is the responsibility of the employer to provide a safe and healthy workplace for its employees (Occupational Safety and Health Administration, n.d.). Involving employees in workplace design allows them to test and select equipment optimal to their work style (see Figure 5). a. Type of chair b. Keyboard/monitor height c. Workstation (adjustable or fixed) 2. Noise level: Background noise is a problem in any area where two or more employees share a common workspace. Noise can be generated from various sources, such as furniture movement, equipment (fax machines/copiers), or the surrounding environment, but most noise originates from several employees speaking at the same time. A noisy environment is not only disruptive to the employee but may also be heard by the customer on the phone. Some headsets are designed with noise-minimizing options. Background noise machines produce a constant sound. As employees become accustomed to this sound, they learn to tune out other background distractions. The various sounds are described in colors such as white, pink, etc. 3. Equipment: Besides a phone and computer chair, other software and accessories should be considered. a. The automatic call distributor system distributes incoming calls to a set of agents based on the customer’s selection. The routing strategy is typically an algorithm that determines the best available employee/department to respond to a given call (Leamon, n.d.). The system is also able to generate metrics that employers can use to determine call volume and productivity levels. The ability to listen to calls live is a useful tool to help staff improve 34 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Setting Up a Telephone Triage Call Center

Figure 3. Telephone Triage Patient Survey

At the Duke Cancer Institute we are interested in understanding your needs regarding telephone triage or telehealth services. We are currently evaluating our services and your feedback will help us further align our triage efforts with our patient care efforts. If you are a patient new to us today or a patient who has been seen here before, we value your input and would ask that you answer those questions that you can. Thank you for your time in completing this survey. For the following questions, please check your response or write in your answer. 1. First time being seen here?  Yes  No 2. Has our staff (physician, nurse, nurse practitioner, physician assistant) told you about our triage line?  Yes  No 3. Who told you about the phone triage line, if yes to the question above?  Physician  Nurse  Nurse Practitioner  Physician Assistant  Other______________________ 4. Have you had to call the triage line?  Yes  No If yes, how frequently have you called?_____________________________ 5. How long after you leave a message should your call be returned?  < 30 minutes  30-60 minutes  1-2 hours  3-4 hours  4-6 hours  >6 hours 6. What do you or would you call the triage line for? (circle all that apply)  Appointments  Symptoms  Prescription refills  Lab results  Disability paperwork  FMLA  Other______________________ (Continued on next page)

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 35

Setting Up a Telephone Triage Call Center (Continued)

Figure 3. Telephone Triage Patient Survey 7. If you are calling for a prescription refill, how long should it take for the prescription to be called in?  Same day  1 day  2 days  3 days  Other 8. Are you kept up to date on the status of your issue after receiving a call back?  Yes  No  NA  Other______________________ 9. Have you called the page operator after hours or on the weekend to reach your physician?  Yes  No 10. Would you find it helpful to have a triage system that is 7 days a week vs. Monday to Friday?  Yes  No 11. Would you find it helpful to have a triage system that is covered 24 hours a day?  Yes  No 12. How satisfied have you been with the triage assistance?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 13. How satisfied were you with the staff member’s medical knowledge when you called?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 14. How satisfied were you with the staff member’s understanding of your condition when you called?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 15. What is more important to you:  Having someone who knows you and can call you back later (6–8 hours) in the day  Having someone call you back within the hour who may not know you, but can review your medical record 16. If your phone or computer had live video feed (FaceTime, etc.), would you be interested in having your triage call done via video?  Yes  No 17. Other thoughts you would like to share about telephone triage:______________ ________________________________________________________________ ________________________________________________________________ Thank you for taking the time to complete this. Once you are done, please return to clinic staff when they meet you to take you to see your health care provider. Note. Figure courtesy of Duke Cancer Center. Used with permission.

36 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Setting Up a Telephone Triage Call Center Figure 4. Provider Survey 1. Who currently performs telephone triage for your patients?  Secretary  MD/NP/PA  Nurse clinician  Clinic-based screener and RN  Other__________________________________ 2. Please rank the following functions from 1 to 6 with 1 being most important to you as a provider and 6 being least important. ____Appointments ____Symptom management ____Prescription refills ____Paperwork (FMLA, disability, hospice, etc.) ____Test (lab, path, radiology) results ____Prior authorizations for prescriptions and procedures ____Other triage functions not listed above 3. How long after a patient leaves a message should their call be returned?  < 30 minutes  30–59 minutes  1–2 hours  3–4 hours  4–6 hours  > 6 hours 4. For a prescription refill, how long should it take for the prescription to be called in or electronically sent?  Same day  1 day  2 days  3 days 5. Do you think the Duke web portal should be the primary mechanism for patients to access test results?  Yes  No 6. What time should triage start taking calls each day?  7a

 8a

 9a

 Other__________________________________

7. What time should triage stop taking calls each day?  3p

 4p

 5p

 6p

 7p

8. Do you think it would be beneficial for patients to have a triage system that is 7 days a week vs. Monday to Friday?  Yes  No 9. Do you think it would be beneficial for patients to have a triage system that is covered 24 hours a day?  Yes  No (Continued on next page)

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 37

Setting Up a Telephone Triage Call Center (Continued)

Figure 4. Provider Survey 10. What do you think is more beneficial for patients?  Having someone who knows you and can call you back later (6–8 hours) in the day  Having someone call you back within the hour who may not know you, but can review your medical record and address your concerns 11. Do you understand the Scope of Practice of different staff (medical secretary, LPN, RN, etc.) in a triage role and the associated medical-legal risks?  Yes  No 12. Do you think a centralized oncology triage model with centralized resources (staffing, protocols, cross coverage, etc.) would be beneficial to patients and providers?  Yes  No  Unsure  If no, why__________________________________ 13. Would you support a structured escalation protocol for triage calls?  Yes  No  Unsure 14. How satisfied are you with your current triage model?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 15. How satisfied are you with the staff knowledge and training regarding managing triage calls?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 16. How satisfied are you with the communication of triage messages?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied 17. How satisfied are you with the documentation of triage messages?  Very dissatisfied  Dissatisfied  Indifferent  Satisfied  Very satisfied Note. Copyright 2017 by Tracy Gosselin, PhD, RN, AOCN®, NEA-BC. All rights reserved. Used with permission.

interactions with customers. The algorithm for call distribution should be created based on the scope of business. i. Prescription refills ii. Billing questions iii. Appointments iv. Test results v. Paperwork (FMLA, prior authorizations, letters) vi. Symptom management b. The call recording system allows calls to be recorded and stored. Listening to calls and reviewing them with staff offers opportunities to improve staff performance and customer service. This tool is also useful when responding to customer complaints. 38 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Setting Up a Telephone Triage Call Center c. Headset: When selecting a headset, the work environment should be considered. Is the employee in a room with other employees? i. A noise-canceling microphone ensures that the user’s voice is heard clearly. It is recommended for noisy, open office spaces. ii. Wireless headsets allow employees to move about and complete tasks, including triaging calls away from the desk. iii. Stereo headsets are generally softer on the ears and cancel background noises, making it easier for the user to hear the caller. These are recommended for noisy, open office spaces. 4. Staffing skill mix: Based on the scope of business, one can determine the type of employees that need to be hired. For example, nonlicensed staff and licensed practical/vocational nurses may be limited because of their scope of practice; therefore, they should be assigned to help with prescription refills, appointments, and paperwork requests, such as FMLA and prior authorizations. RNs can assess and advise as long as protocols and guidelines are available. 5. Workflow: Determining the severity of the call will determine the workflow. Figure 5. Ergonomics of a Workstation Monitor at arm’s length away Wrists straight, hands at or below elbow level

Adjust chair height so knees are about level with hips

Note. Image courtesy of Mayo Foundation for Medical Education and Research. All rights reserved. Used with permission.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 39

Setting Up a Telephone Triage Call Center a. Emergent calls need to be addressed immediately, and callers should be instructed to call emergency services to their location or go to an emergency department. b. Urgent calls should be handled and completed within the business day if possible. c. Routine calls are generally not about symptom management. They usually regard appointments, paperwork, and refills and do not need to be completed on the same day (see Figure 6). 6. Staff training: Once the scope of business has been decided, it is important to have triage staff educated on the patient population and the types of calls they will likely be supporting. Having triage staff spend time in the clinic with providers not only allows them to learn about the plan of care but also helps to build the relationship between the provider and triage staff. Ongoing education should be established as new treatments are being introduced or as the staff identifies areas for improvement. These educational sessions can also include review of challenging calls. Performing telephone triage in an oncology setting requires astute nursing assessment skills. Nurses working in these roles should have clinical experience managing this patient population. Nurse training for telephone triage should be ongoing, structured, and comprehensive and include observation and coaching by experienced staff.

REFERENCES Leamon, P. (n.d.). Skills based routing: A challenge for call centers. Retrieved from http://www.stern .nyu.edu/om/faculty/pinedo/ofs/download/paulskill.htm Nielsen, K., & Trinkoff, A. (2003). Applying ergonomics to nursing computer workstations: Review and recommendations. Computers, Informatics, Nursing, 21, 150–157. https://doi.org/10.1097/00024665 -200305000-00012 Occupational Safety and Health Administration. (n.d.). Ergonomics. Retrieved from https://www.osha .gov/SLTC/ergonomics

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No - Open telephone encounter, document pertinent information, and send OPEN encounter to provider.

•• Do not repeat the documentation in the routing sections. •• If you page a provider and they do not respond, submit an RLS. •• Do Not Send encounters if they have an “Out of Office” message.

Yes - Document telephone encounter; close and route to APP and/or physician.

Call handled per scope and protocol. Issue resolved?

•• Nurse collects vital information. •• Nurse reads last clinic note. All patients are called to confirm message received and estimated time of next call back.

Nurse advice call comes in to triage line.

Nonurgent Examples: Appointment change, medication refill, updates, treatment plan questions, dietary or other referrals ACTION: •• Send to provider via InBasket message. GOAL: Resolution within 48 hours

APP/MD ACTION: •• Completes with 2 hours of being sent. •• APP/MD handles message and closes encounter. •• APP/MD responds to message and routes back to triage staff. Telephone encounter is left open.

Triage Staff ACTION: •• Day 2: Resend message to APP. •• Day 3: Page APP asking to check InBasket. •• Day 4: Escalate to MD by sending the encounter and paging the MD attending. •• Day 5: Escalate to disease group lead and get COD and AD involved to resolve encounter.

Triage Staff ACTION: •• Next day: Check open encounter and send 2nd message to provider or page.

URGENT Examples: Low-grade fever, wound that is red, feverish, pus-like drainage, any of the following not controlled with current prescribed medication: nausea, pain, diarrhea, and constipation ACTION: •• Document call, route provider, leave encounter open. •• Page provider stating there is an InBasket message. •• If no response by APP within two hours, repeat page. •• If no response by APP from 2nd page within 30 minutes, page the MD. GOAL: Same Day Resolution/Time Sensitive

EMERGENT Examples: Sending patient to ER, Yervoy pt with diarrhea, acute onset of chest pain, shortness of breath, active bleeding, fever greater than 101°F, altered mental status less than 24 hours, new onset of seizures ACTION: •• Page provider and communicate information in person. •• Repeat page after 15 minutes if no response. •• Page MD if no response after 15 minutes from 2nd page. •• Write “Emergent Triage” in text page. •• Send patient to ER if no response. •• Document and close encounter. GOAL: Same Day Resolution

Figure 6. Example of Workflow

Triage Staff ACTION: •• Complete within 2 hours or by close of business day (whichever is sooner). •• Document and close encounter. •• Route back to APP to close communication.

Setting Up a Telephone Triage Call Center

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 41

Oral Therapies and Telephone Triage Jody Pelusi, PhD, FNP, AOCNP®

INTRODUCTION Currently, many cancer therapy agents come in oral formulations. One-third of all new oncologic agents being developed will also be in oral form, which means oncology nurses and practices will be further challenged to provide a safe, efficient, and consistent approach to care for all patients on oral therapies (Pelusi, 2017). Because each oral drug is unique in its dosing, administration, side effects/adverse events, monitoring, and side effect management, nurses must be ready for any call or question related to such therapies. Having a formalized oral drug management process within a practice or facility will help triage nurses address the needs of patients on oral cancer therapies. This process may comprise ongoing oral drug educational programs for staff, treatment and monitoring plans for each patient on an oral oncolytic medication, and an upto-date oral oncolytic drug reference.

RESOURCES Triage nurses should have a drug resource reference at hand for quick access to information about each oral oncolytic medication (e.g., drug, indications, dosing/ timing, potential adverse events and timing of specific adverse events, monitoring needs, symptom management strategies, potential drug–drug and food–drug interactions). Many specialty pharmacies have such references available, as well as current IV chemotherapy references, which also include oral oncolytic medications. Having access to the current version of the Common Terminology Criteria for Adverse Events (CTCAE) reference document is also important to grade patients’ symptoms. Accurate grading will guide symptom management and dosing of the oral oncolytic agent (National Cancer Institute Cancer Therapy Evaluation Program, 2017).

ASSESSMENT CRITERIA Key questions to ask patients on an oral oncolytic medication include the following: 1. What is the current symptom you are experiencing? a. When did the symptom start? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 43

Oral Therapies and Telephone Triage b. What have you tried so far? c. Is this the first time this symptom has occurred? d. If you have experienced this symptom before, how was it managed? e. What makes it better? f. What makes it worse? Nurse evaluation: Assess the patient carefully to clearly understand the symptom and its severity. Determining the grade of the symptom based on CTCAE criteria is critical to report to the oncology provider. Any dose or schedule changes, such as holding the dose or dose adjustments, are based on the grade of the adverse events experienced. For most oral oncolytic medications, the dose is held for a grade 3 or higher adverse event, and a dose adjustment is often made once the symptoms improve. Keep in mind, some agents may be held with grade 2 toxicities and subsequent dosing may or may not be adjusted. Each drug is different. Try to evaluate the symptom or issue bothering the patient. Is the symptom a result of the oral medication or treatment, the disease process, or another cause? 2. What is the name of the oral drug you are taking, and what is your cancer diagnosis? Nurse evaluation: Many oral agents are used for multiple indications and have multiple dosing regimens. It is important to establish if the patient is taking drugs at the appropriate dose and timing schedules. 3. What is the current dose and timing of your oral cancer treatment? a. Dose and frequency (e.g., daily, twice daily) b. Timing (e.g., daily for 7 days, then off for 7; 21 days out of every 28 days) c. With or without food Nurse evaluation: Evaluate whether the patient is taking the treatment correctly. If not, could misuse of the treatment be the cause of the symptom? 4. Have you ever had to hold a dose or have your dose reduced (decrease the amount you were taking)? If so, why? Nurse evaluation: Many patients may experience symptoms, have abnormal laboratory values, or have potential drug–drug interactions that may require anticancer therapy to be held or dose reduced. Patients may be reluctant to dose reduce or hold, so it is important to understand if they are truly being adherent to their treatment plan. Appropriate dosage is critical in terms of managing potential side effects/adverse reactions. Even if patients have had their dose reduced, they may have extra pills on hand at home and think it is all right to continue at a higher dose while not understanding that the adverse event could be related to their dose. 5. Where are you in your treatment cycle (e.g., cycle 4, day 1 vs. cycle 1, day 3)? a. How long have you been on this medication? b. Do you know what cycle you are currently on? Nurse evaluation: Understanding where a patient is in treatment is important, as different side effects can occur at different times in the treatment trajectory. Often, patients do not realize that different symptoms can occur after being on an 44 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Oral Therapies and Telephone Triage oral oncolytic for a period of time; therefore, the patient does not relate the drug to the symptoms. 6. Have you started any new medications, over-the-counter products, new supplements (e.g., herbs, vitamins and minerals), new foods/diets, or exercise practices? This can also include alcohol or other social/recreational medications or drugs (i.e., medical cannabis). Nurse evaluation: The potential for drug–drug or drug–food interaction is possible. Often, patients obtain new medications, such as antibiotics, from their primary care physician or other healthcare professional, not realizing that there could be an interaction or reaction. 7. How is your current medication being supplied? Do you receive it from a specialty pharmacy or a community pharmacy? Nurse evaluation: It is important to know the pharmacy that the patient is using, as questions may arise about the name, dosing, and timing of the oral oncolytic agent. 8. When was the last time you had your blood work tested or met with your oncology provider? Nurse evaluation: Determining when the last laboratory tests were done to monitor the patient and when the patient saw his or her medical oncology team is critical to evaluating if the patient needs to undergo additional laboratory testing or should be more emergently evaluated by a healthcare provider.

REPORT TO HEALTHCARE PROVIDER Once the patient has been assessed, the nurse will need to document the information obtained. In many instances, the nurse will need to share the information with the patient’s medical oncology provider. To be concise, consider adopting the report template shown in Figure 7, which includes the key elements identified in this section. Appendix D provides another example of a documentation form.

HOMECARE INSTRUCTIONS ••Keep oral oncolytic agents in their original packaging. ••Store in a safe place and out of the reach of children and animals. ••Keep a list of all medications, including the oral oncolytic (drug, indication, dose, who prescribed it). ••If your medication is vomited, do not retake unless told to do so by the medical oncology team. ••Alert the medical oncology team prior to starting any new medication, supplements, or foods. ••Do not crush oral oncolytic medication unless directed to do so by your oncology provider. ••Discuss with your oncology provider issues related to fertility, sexuality, safe handling, and spills (Olsen, LeFebvre, & Brassil, in press). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 45

Oral Therapies and Telephone Triage

Figure 7. Sample Template of Report Ms. Jones is a _____-year-old female with a history of _____. She was started on _____ (drug name) at _____ mg daily for 21 days on, then off for 7 days (28-day cycle). She is currently on cycle _____, day _____. She began to experience _____ (symptom) on _____ (date). It appears to be a grade _____ adverse event. Characteristics of the symptoms include __________________ _____________________________________________________________________. She is currently using _____ to address these symptoms but this is not working for her. She has _____ (other symptom management medication) at home but has not tried it yet. She denies starting any new medications or supplements. Her last laboratory tests were on __________________________. She reports them as having been normal. Her last office visit was on _____. She states she has never had to hold her dose or reduce her dose of medication. She has not noticed anything that makes this symptom better or worse. She gets her oral oncolytic drug from ______ (specialty pharmacy) and her local pharmacy is ________________. She has no known drug allergies.

ONCOLOGY NURSING SOCIETY RESOURCES ON MANAGING ORAL THERAPIES ••The Oral Chemotherapy Guide is a web-based video program for patients and families that provides important information and tips on oral chemotherapy (www​ .onsoralchemoguide.com/#/LRQ/oct005). ••The Oral Adherence Toolkit provides strategies for nurses to help patients receiving oral therapies to improve their adherence to prescribed therapy (www.ons.org​ /sites/default/files/ONS_Toolkit_ONLINE.pdf). ••A Putting Evidence Into Practice study by Spoelstra and Sansoucie (2015) reviewed evidence-based practice to identify effective interventions to improve patient adherence with oral anticancer agents. ••ONS Voice (https://voice.ons.org) provides tips for nurses to help manage patients receiving oral anticancer agents, and a subspecialty community is available to enhance networking via the Oncology Nursing Society Oral Adherence Community (http://communities​.ons.org/communities/community-home ?CommunityKey=62dd0485-da1c-4d41​-97f2-740c43301eb4).

REFERENCES National Cancer Institute Cancer Therapy Evaluation Program. (2017). Common terminology criteria for adverse events [v.5.0]. Retrieved from https://ctep.cancer.gov/protocoldevelopment/electronic​ _applications/ctc.htm#ctc_50 46 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Oral Therapies and Telephone Triage Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Pelusi, J. (2017). Adherence and persistence with oral therapies. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 253–256). St. Louis, MO: Elsevier. Spoelstra, S.L., & Sansoucie, H. (2015). Putting evidence into practice: Evidence-based interventions for oral agents for cancer. Clinical Journal of Oncology Nursing, 19(Suppl. 3), 60–72. https://doi​ .org/10.1188/15.S1.CJON.60-72

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Legal Concerns of Telephone Triage Margaret Hickey, RN, MSN, MS Cynthia Muller, MJ, BSN, RN

INTRODUCTION Telenursing can be described as the practice of providing nursing care via a communications system instead of face-to-face contact. This may include faxing medical information, obtaining patient issues and complaints to assess an acute situation, or teaching via Skype™ or other technologies. Telenursing and telehealth have often been used interchangeably, and although the medium of delivery has changed, the nursing process remains the same (Schlachta-Fairchild, Elfrink, & Deickman, 2008). As with any growing field in nursing, standards are being adopted to overcome barriers from legal, ethical, and regulatory concerns. Regulations vary from state to state, and this chapter does not attempt to (nor can it) address all questions regarding the legalities of telephone nursing practice. Nurses must consult with state boards of nursing and the legal counsel at their institution or practice for answers to specific questions.

STANDARDS OF CARE The American Nurses Association (2015) defines nursing standards as “authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently” (p. 3). Nursing standards set the expectations for competent nursing performance. The legal system uses standards of care as a “yardstick” to measure a nurse’s action should an allegation of malpractice arise. By averaging the specific skill, action, and care of professionals in the same situation, given the same circumstances, a standard of care is assessed. Following standards of care is important to avoid potential lawsuits against the nurse and institution (Rutenberg & Greenberg, 2014). By developing telephone nursing practice standards, the responsibilities and accountabilities of the clinical practitioners and administrators responsible for providing telephone care are clearly defined. Standards should be reflected in every telephone delivery model. Standards can be found in a variety of formats, including policies, job descriptions, performance standards, procedures, protocols, guidelines, and written standards of care developed specifically for each center. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 49

Legal Concerns of Telephone Triage Standards related to telephone triage and telenursing can fall into one of six areas (Espensen, 2009). ••Personal standards include the actions and decisions of a reasonable ordinary person based on community beliefs, morality, and ethics. ••Legal standards include applicable state and federal laws. Each state has a board of nursing that defines the nurse’s scope of practice. The telephone can provide an avenue to easily cross state lines. The nurse may not only be required to hold a nursing license from the state where he or she is physically located but also may need a license from the state in which the patient resides. Nurses must be aware of current and any new state or federal laws that address emerging concerns regarding telemedicine. ••Professional standards from professional organizations address telephone triage, telenursing, and telemedicine. The American Academy of Ambulatory Care Nursing (AAACN, 2018) published the sixth edition of Scope and Standards of Practice for Professional Telehealth Nursing to help refine and enhance telehealth nursing practice. ••Regulatory standards are developed by agencies and organizations charged with reviewing and maintaining the accreditation of healthcare systems. These standards are created by local and state health departments, the Joint Commission, the Occupational Safety and Health Administration, the Americans With Disabilities Act, and the National Committee for Quality Assurance, among others. Many of these standards affect telenursing, even when it is not directly stated. ••Structural standards reflect the conditions, equipment, and materials needed to reliably operate a call center. Written policies should be developed to outline the management of wait times, follow-up calls, and calls in a queue. ••Process standards define how the nurse will provide care and specify the type or quality of care. Process standards can be reflected in policies and procedures that outline the requirements for the nurse’s knowledge, skills, behavior, and actions. Written protocols or guidelines serve to outline the process a nurse should take in response to a caller’s symptom or complaint.

NURSING PRACTICE ISSUES The scope of healthcare professional practice within the United States is determined by state nurse practice acts, state medical boards, and other professional organizations that provide guidelines for appropriate roles of physicians and nurses. The first step in addressing nursing practice concerns about telephone nursing and telephone triage is to address if this practice constitutes nursing care. The National Council of State Boards of Nursing (NCSBN) answered this with a resounding “yes” in the 1990s. The delivery of nursing services, whether via the telephone or other electronic and broadband channels, constitutes the practice of nursing (NCSBN, 2014). In NCSBN’s 2014 update to its position statement, telehealth nursing is defined as “the practice of nursing delivered through telecommunication technologies, including high-speed Internet, wireless, satellite and televideo communications” (NCSBN, 50 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage 2014, p. 1). Nursing practice extends beyond hands-on care. It also extends to remote engagement with patients and caregivers to provide information about a patient’s health, to provide therapeutic interventions, and to monitor and record a patient’s responses and outcomes. NCSBN recognizes telephone triage as nursing practice; therefore, boards of nursing regulate telephone nursing practice (NCSBN, 2014). Likewise, the challenges and regulations related to this practice are likely to continue to emerge and evolve. One of the many challenges that NCSBN and individual state boards of nursing are addressing is that the reach of the telephone and other electronic communications easily breaches distance and can link a nurse in one state with a patient in another state. The 10th Amendment to the U.S. Constitution gives states the power to enact laws to protect their citizens. This public protection mandate gives each state the responsibility for establishing laws for governing healthcare providers within their borders. State legislation determines the regulations that healthcare professionals must follow to protect the public from incompetent or impaired providers. States do not have the ability to grant a nurse authority to practice in other states (Lawson & Shapiro, n.d.). With telenursing, it is unclear whether the care occurs at the location of the patient or the location of the healthcare provider (Hutcherson, 2001). When the nurse provides telephone triage and advice to out-of-state patients, the question remains as to where the nurse is required to have a license: the state in which the nurse is employed or the state in which the patient resides. NCSBN has a stated goal to work with Congress and telehealth advocates to resolve concerns about licensure as a barrier to the expansion of telehealth services. NCSBN’s (2014) position statement concerning telehealth nursing includes the following: 1. NCSBN understands and supports efforts to expand telehealth as a model of care delivery. We recognize that technologic advances can both reduce the cost of care and increase patient access to care across the country. 2. NCSBN recognizes the growing need for providers to be able to practice across state lines; however, a policy of one single interstate license that bases licensure on the location of the provider prohibits this practice. 3. NCSBN believes that licensure should be based on the location of the patient as directed by current law. The complete statement can be found at www.ncsbn.org. NCSBN has identified a potential resolution for this problem related to telephone nursing and other nursing practices that are blurring the state boundaries through technology. NCSBN established the Nurse Licensure Compact (NLC), which allows nurses with a multistate license to practice in their home state and within all NLC states. This interstate compact provides mutual recognition of the nursing license among the states signed onto the compact, allowing the nurse to practice in his or her home state and other states included within the compact. The nurse must meet the home state qualifications for licensure and comply with all current laws within that state, as well as adhere to each state’s practice laws and regulations. The original NLC is currently being transitioned to the Enhanced Nurse Licensure Compact (eNLC), which allows RNs, licensed practical nurses (LPNs), and Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 51

Legal Concerns of Telephone Triage licensed vocational nurses (LVNs) to have one multistate licensure that enables them to provide care to patients in other eNLC states. The eNLC was launched by a special delegate assembly of the NCSBN in 2015; this enhanced compact will replace the original NLC and provide additional protections. The eNLC became effective on July 20, 2017, and was implemented on January 19, 2018. Although subject to change, as of the time of this publication, 30 states have enacted the eNLC legislation, with several others pending legislation (see Figure 8). NCSBN keeps an updated list of states at www.ncsbn.org. Nurses with an original NLC multistate license will be grandfathered into eNLC. New applicants residing in compact states will need to meet 11 uniform licensure requirements, which can be found on the NCSBN website (www.ncsbn .org). If a nurse resides in an eNLC state and provides telephone nursing services to patients living outside of their home state, it is recommended that they seek multistate licensure. The Advanced Practice Registered Nurse (APRN) Compact allows one multistate license and the authority to practice across state lines into other compact states. One distinct difference with the APRN Compact is the requirement that states implement procedures to check criminal background records of those applying for initial APRN licensure (NCSBN, 2015). According to former American Telemedicine Association CEO Jonathan Linkous, “Passage of the NLC and APRN Compacts will empower nurses to participate in and benefit from a variety of innovative service delivery models featuring a multidisciplinary team approach to provide and coordinate a patient’s care. Patients will reap the ultimate rewards of these efforts” (Wicklund, 2016, para. 10). Figure 8. States That Have Enacted the Enhanced Nurse Licensure Compact Legislation* •• Arizona •• Arkansas •• Colorado •• Delaware •• Florida •• Georgia •• Idaho •• Iowa •• Kansas •• Kentucky •• Maine •• Maryland •• Mississippi •• Missouri •• Montana •• Nebraska

•• New Hampshire •• New Mexico •• North Carolina •• North Dakota •• Oklahoma •• South Carolina •• South Dakota •• Tennessee •• Texas •• Utah •• Virginia •• West Virginia •• Wisconsin •• Wyoming

Pending States •• Louisiana •• Michigan •• New Jersey

* Listing is subject to change but reflects status as of September 26, 2018. Note. Based on information from National Council of State Boards of Nursing, 2018.

52 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage Enhanced patient safety standards and regulations across nursing boards requiring background checks and licensure have contributed to the changes to the NLC. Legal cases have been brought forth from employees who alleged improper inquiry, wrongful termination, and retaliation upon employers’ requests for multistate licensing for all employees (Clemons v. WellPoint Companies, 2013). The importance of consistent standards and licensure in all states became apparent in these cases. Despite this effort, until all 50 states join the compact, variations in state nurse practice acts continue to carry challenges. For the sake of example, the position statements of three state boards of nursing are addressed in this section: California and Nevada, which have not enacted eNLC legislation, and North Carolina, which has enacted eNLC legislation. The California telenursing statement followed enactment of a state law in January 2000 titled Telephone Medical Advice Services. The definition provided by the statement is that “telephone medical advice means a telephonic communication between a patient and a healthcare professional, wherein the healthcare professional’s primary function is to provide the patient a telephonic response to the patient’s questions regarding his or her or a family member’s medical care or treatment” (California Board of Registered Nursing, 2011, “Definition” section). The California Board of Registered Nursing requires a California RN license for instate or out-of-state RNs to provide telephone medical advice services to residents with California addresses. The Nevada State Board of Nursing (2014) updated its telenursing practice guidelines to include the following requirements: 1. Only RNs currently licensed in the state of Nevada may practice telenursing in relation to patients in Nevada. 2. The nurse practicing telenursing must identify himself or herself by name and title and state of licensure. 3. After completion of a nursing assessment of the patient, the nurse practicing telenursing may provide advice based on the use of written medical protocols (which may include over-the-counter medications), published reference guides, or software protocols approved by the medical staff. 4. All telenursing interactions, including but not limited to the collection of demographic data, health history, assessment of chief complaint, protocols followed, referrals, and follow-ups, must be documented in a written or electronic medical record. The North Carolina Board of Nursing (NCBON), a member of the eNLC, has a position statement that echoes the practice guidelines set forth by the Nevada State Board of Nursing. NCBON (2016) determined that licensed nurses (RNs and LPNs) practice nursing when using telehealth/telenursing modalities and that the nursing practice occurs at the location of the client at the time services are provided. Nurses must be licensed in the state where the patient is located and practice in compliance with the laws, rules, and standards of practice of that state. The role of the RN and LPN is clearly outlined in the position statement, as well as specific criteria. These criteria further outline the roles of nursing practice, including Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 53

Legal Concerns of Telephone Triage the reporting and recording of nursing care, nurse education, and competence; the ability to accept medical orders; any standing orders/protocols meeting the requirements set forth by the board; and policies and procedures by the employing agency to address telenursing services (NCBON, 2016). Although many state boards of nursing are setting forth practice guidelines or position statements regarding telenursing, not all have specifically addressed this expanding role for nurses. For example, the Louisiana Telehealth Access Act, La. R.S. 40:1300.401 et seq., cited telehealth as being extremely valuable and an enhancement to access of care, potentially promoting cost-effective care delivery and improving health outcomes (Boutwell, 2015). The act provides a generous list of providers that fall under the definition of healthcare provider, including a person, partnership, limited liability partnership, limited liability corporation, hospital, dentist, RN, APRN, licensed midwife, chiropractor, certified athletic trainer, and licensed clinical laboratory scientist. It was determined that state agencies or professional licensing boards will produce rules to promote and regulate the delivery of this service. As illustrated in the practice decisions by these states, the issue of telephone nursing is being addressed on a state-by-state basis. Not only are some boards of nursing defining the scope of practice on the state basis to include state licensure when the caller and nurse reside in different states, but they also are defining what constitutes appropriate telenursing interactions. It is imperative that all nurses practicing telephone triage or telephone nursing review the decisions and regulations outlined by their state board of nursing and stay abreast of the continued changes to regulations in this ever-evolving nursing practice.

SCOPE OF PRACTICE Defining the scope of nursing practice is the role of individual state boards of nursing, and as described, many states have addressed telenursing. It is important for nurses to be familiar with their home state’s nurse practice act. The nurse practice act in each state is dynamic, as the boards of nursing address issues in the changing healthcare environment, including the evolution of telephone nursing or triage. It is imperative that nurses, regardless of the state in which they are licensed, avoid practicing medicine by diagnosing patients or prescribing treatment. As an example, the difference between a medical and nursing diagnosis is a point of law in the state of Pennsylvania. The Pennsylvania Professional and Vocational Standards for Professional Nurses define nursing diagnosis as “identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen” (West Pennsylvania Administrative Code, 2016). The statute does not define a medical diagnosis, but Mosby’s Medical Dictionary (“Medical Diagnosis,” 2012) defines it as “the determination of the cause of a patient’s illness or suffering by the combined use of physical examination, patient interview, laboratory tests, review of the patient’s medical records, knowledge of the cause of observed signs and 54 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage symptoms, and differential elimination of similar possible causes.” It is within the nursing scope of practice for professional nurses to independently perform telephone assessments, apply clinical judgment, and use decision-making skills in establishing nursing diagnoses and performing telephone triage. Additionally, they can educate patients, analyze outcomes, and coordinate patient care. Telephone triage must be limited to assessing symptoms and offering information related to the symptoms. The nurse needs to use care and follow policies, procedures, and professional standards. These standards should outline when the physician or another provider must be consulted to assist in handling the call or responding to the caller’s concerns. The nurse may deviate from the provided guidelines only when acting directly under the supervision of a physician. If the physician is not directly overseeing the interaction, the nurse is limited to employing the nursing process. The nursing process used during telephone triage is the same nursing process the nurse applies when providing direct patient care. The steps include assessment: appropriate assessing, prioritizing, and initiating the triage process, including an often complex telephone interview; planning: choosing appropriate guidelines, following them correctly, and collaborating with the patient and other healthcare providers while referencing resources used; implementation: effectively solving problems and intervening, which includes appropriate disposition of care, teaching, counseling, coordinating resources, and facilitating follow-up care; and evaluating: documenting the interaction thoroughly, communicating with others, and analyzing outcomes. Telephone nursing is a function of professional nurses (RNs). RNs must be aware that their license may enable them to supervise LPNs/LVNs or assistive personnel (AP). In informal call practices, such as in a physician’s office, AP may have years of experience in obtaining medical information from patients or dispensing advice on a physician’s behalf under the supervision and direction of the physician. In some circumstances, and where state regulations allow, an RN can supervise an LPN/LVN in telenursing. However, in these cases, the LPN/LVN is acting under the nurse’s license. The RN would be violating the nurse practice act if telephone advice were delegated to AP or LPNs/ LVNs, particularly in states that identify telephone triage solely as a function of the professional nurse. AP, such as medical assistants and receptionists, can gather basic information only; they cannot assess, triage, or make independent decisions on care or disposition. LPNs/LVNs cannot independently assess and triage; however, they can collect general information about the patient and present those data to the RN or physician for analysis or triaging. They also cannot independently educate patients, but they can provide general information as directed by the professional nurse or physician. Professional nurses should be wary of situations in which physicians ask them to exceed the limits of a state nurse practice act by asking them to independently provide treatment information. The nurse should provide treatment information only under specific direction of the physician and approved guidelines. It is helpful to develop job descriptions that clearly outline the roles of RNs, LPNs/LVNs, and AP in relation to managing patient calls. Job descriptions should accurately reflect the scope of practice, including minimum qualifications to perform telephone triage (such as professional nurse with three Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 55

Legal Concerns of Telephone Triage years of experience), required education and competency, accountability for outcomes, and how the outcomes will be measured.

TELEPHONE TRIAGE LIABILITY The term triage comes from the French verb trier, which means “to sort.” It is defined as “sorting of and allocation of treatment to patients” within a “system of priorities designed to maximize the number of survivors” (“Triage,” n.d.). Triage and telephone consulting are not synonymous. The assumption from patients and nurses that all concerns or requests for advice can be handled over the phone may lead to a missed acute situation that requires further intervention. This part of a consultation then becomes triage (Dinwoodie, n.d.). Telephone triage improves the relationship and satisfaction between patients and healthcare providers, resulting in increased care (Medical Mutual, n.d.). Every time a nurse picks up the telephone or responds to a communication from the patient or family member, a relationship is established. This relationship holds risks for three reasons. The first reason is that nurses are expected to maintain the same level of care provided in face-to-face nursing. This requires knowledgeable and accurate assessment without face-to-face interaction. This presents particular challenges, as nurses must assess symptoms and offer advice without ever physically examining the patient. Listening becomes a critical component of telenursing. Although this can be done effectively over the phone, it does not replace a provider’s physical examination and independent professional judgment. Nurses may have limited information available in the medical record and must rely on the caller’s cooperation and available technology to monitor compliance and follow-up care. Second, nurses operate in a work setting under different working conditions and with varied levels of awareness of professional standards among employers. The third reason is that nurses are responsible to stay informed and potentially to educate their employer about current standards, legal risks, and new information regarding laws and licensure. Expectations must be clear and enforced at all times; nurses must ensure patients understand instructions by asking them to repeat back to avoid misunderstandings. Patients and nurses must understand what can and cannot be done over the telephone. Strict follow-up guidelines must be established and followed.

WHAT CONSTITUTES LIABILITY? Law can be defined as the rules and regulations set by a community that govern individual conduct within that community (“Law,” 2018). The four types of law within the United States are administrative, constitutional, statutory, and common law. Medicare and Medicaid fall within statutory law. Nurse practice acts also fall under the same type of law, although many areas of state board decisions and regulations of professional practice will fall under the administrative area of law. Laws change when necessary to provide continual protection for society. Regulations of professional practice, including nursing practice, are promulgated 56 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage to protect the health, safety, and welfare of a state’s individuals. As the practice of nursing defines its regulations and licensure requirements, it is done for the protection and well-being of not only members of society but of professionals from unintentional torts, such as negligence and malpractice (Aiken, 2004). Liability is used to describe responsibility for duties that an individual or organization is legally bound to fulfill. Nurses or healthcare organizations can be found negligent in performing duties and held responsible, or liable, for their actions. A case for negligence can be based on an unreasonable or careless act that causes injury to another. Improper medication or injury during a procedure can be a basis for negligence (Aiken, 2004). Malpractice is a “dereliction of a professional duty or failure to exercise an accepted degree of professional skill or learning by a physician rendering professional services which results in injury, loss, or damage” (“Malpractice,” n.d.). Although accusations are frequent, the act of malpractice must have four elements to prove liability. The plaintiff’s lawyer is charged with proving the accusation by preponderance of evidence, demonstrating that each of following occurred (Garner, 2009): 1. Duty to the plaintiff: The nurse had a duty to provide care to the patient following an accepted standard of care. 2. Breach of that duty: The nurse failed to adhere to this standard of care. 3. Proximate cause between breach of duty and the harm: The nurse’s failure to adhere to the standard of care was the cause of the patient’s injuries. 4. Harm: The patient suffered some type of hurt or injury that resulted from the nurse’s negligent actions.

CASE LAW Many malpractice cases have been filed against nurses practicing telehealth. The professional risk is the same as when working in an office or hospital setting. Duty to provide care legally begins the minute the patient seeks advice (College of Registered Nurses of Nova Scotia, 2017). The following malpractice cases illustrate the seriousness of telenursing liability. These examples are not specific to oncology, yet they speak volumes to the importance of proper documentation, thorough questioning, and protocol procedures.

Pringle v. Nestor Prime Care Services

Chantelle Pringle, a two-year-old, became sick with a high fever and vomiting. Her mother called and spoke to the triage nurse of a large health system for 15 minutes. The triage nurse diagnosed Chantelle as “lethargic,” with a possible upper respiratory infection. She did not refer for a face-to-face visit or hospital admission. The next morning, Chantelle woke with a nonblanching rash on her body and was admitted to the hospital. Unfortunately, gangrene developed, requiring the amputation of both her feet. The court found that when the triage nurse diagnosed Chantelle as lethargic, the action should have been to contact the doctor and have her admitted. Had a physician been alerted to her condition, protoTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 57

Legal Concerns of Telephone Triage col states that she would have been admitted. It was determined that the timing of the events, if handled appropriately, would have prevented Chantelle from losing her feet, although medical experts could not unequivocally determine the exact point in time that hospitalization would have been necessary to avoid gangrene and amputation. Although liability was denied for the large healthcare system, the court determined that the delay in treatment occurred because of significant negligence by the triage nurse (Gold, 2014).

Harvard et al. v. The Children’s Clinic of Southwest Louisiana

Kasie, a 13-year-old girl, vomited early in the morning on August 28, 1991. She was a twice-daily insulin-dependent diabetic. The child’s grandmother withheld Kasie’s insulin dose after early morning vomiting. This was based on a previous episode when Kasie became hypoglycemic after receiving insulin while vomiting. Kasie continued to have episodes of vomiting and had not eaten by midday. The grandmother then called the Children’s Clinic of Southwest Louisiana. The call was received by an LPN at 1:15 pm. The grandmother testified that she asked for Dr. Calhoun and was advised he was not in; she continued to relay to the nurse that Kasie was a diabetic who was vomiting and had not had her insulin that morning. However, the triage nurse testified that the caller did not tell her that Kasie was diabetic or had not had her insulin. Promethazine was prescribed upon the grandmother’s request and administered. Kasie became lethargic during the day, and when her condition did not improve and she vomited a dark brown material, Kasie was taken to the hospital. The emergency department record reflects the registration time as midnight. Notations on the record reflect that mother and grandmother reported the episodes of vomiting and that the insulin dose was administered at 5 pm that day. Kasie was evaluated, diagnosed, and treated in the emergency department until 3 am and then transferred to the intensive care unit. Kasie died at 9:20 pm on August 29, 1991, from diabetic ketoacidosis. In court years later, the grandmother testified that she asked for Dr. Calhoun and told the nurse about Kasie’s vomiting and that she was a diabetic. The nurse only recalled the phone call as documented in the call record and no further details. The court found 80% of wrongful death fault to the triage nurse and the clinic. The rationale for the judgment was that while the nurse captured the call on the call record, she did not document any details of the telephone conversation (Martin, 2009). The standard of care that the nurse must adhere to is the level of care that would be given by a reasonable, prudent nurse under the same or similar circumstances. It is important that nurses stay abreast of standards in the nursing literature. In addition to published standards, unpublished standards based on the testimony of an expert witness also may be used against the nurse (Martin, 2009). The following are five areas that potentially can increase liability for nurses (Espensen, 2009): ••Failure to ensure patient safety: Examples include inappropriate assessment and triage, not following guidelines as written, and lack of follow-up as needed. ••Failure to communicate: The nurse always must listen to the patient and avoid jumping to conclusions or leading the caller. The nurse should convey information in a manner that the caller can understand, clarify information, and verify 58 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage the information is understood. Documentation of the interaction and any followup calls is essential. ••Failure to follow policies and procedures: The nurse must be familiar with and understand the policies and procedures. These should be updated regularly to match current practice and standards. ••Failure to act on professional judgment: Abandoning professional judgment just to follow a guideline or protocol is not appropriate. The nurse must be able to show that professional judgment was used in every call. ••Failure to document: Careful, clear documentation is required that would allow the nurse to recreate the call if needed for medical or legal reasons. The best way for nurses to protect themselves from legal risk is to carefully follow their facility’s policies and procedures, which should be based on current standards of practice, including clinical practice guidelines, nurse practice acts, and any state laws related to telephone triage. Even if the facility does not have a formal telephone triage program, patients will continue to call looking for advice and information, and nurses often will find themselves giving advice over the telephone. It is not practical for nurses to believe they can deny this service to their patients. Buppert (2009), a nurse and attorney, recommended that clinicians not provide telephone care unless the patient has been seen by the practice and the patient’s medical record is at hand with a recorded medical history, baseline examination, and current contact information. It is important to realize that this does not deny the nurse’s duty to respond to the patient once the call is answered but rather that telephone advice should not be provided. It would not be reasonable to do so without any knowledge of the patient. The patient should be referred to a local emergency department or family physician, or a clinic appointment should be made. Buppert (2009) emphasized that the advice given should be documented along with the patient’s complaint and history. This should be completed before the end of the day. Finally, the patient should be given an appointment for follow-up. It is imperative that the nurse direct the patient immediately to call 911 for emergency situations, such as chest pain or dyspnea. Figure 9 provides a summary of recommendations to help provide safe telephone triage practice in the ambulatory setting.

STRATEGIES TO MINIMIZE LIABILITY Nurses can reduce their legal risk even before they answer a call. These measures involve development of appropriate policies, procedures, and guidelines. There should be a clear statement of the purpose and goals of telephone triage. This should include the limits of services, as well as the goals the telephone triage nurse is expected to meet. The job description should accurately explain the role of the nurse in telephone triage, describe the scope of practice, and include minimum qualifications; the telephone triage industry standard is a minimum of three years of RN experience in an applicable clinical area prior to telehealth nursing (Espensen, 2009). It should detail accountability for outcomes and should be reviewed annually to ensure it reflects the current responsibilities and evolving standards of telephone nursing. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 59

Legal Concerns of Telephone Triage

Figure 9. Recommendations for Safe Telephone Triage Care •• Perform an adequate assessment that is comprehensive and focused to the situation. •• Always speak directly with the patient, if at all possible. •• Beware when the caller is not the patient. There may be confidentiality issues or translation issues, both of which increase the risk level of the triage. •• Do not accept the patient’s self-diagnosis. Information obtained from the Internet and previous diagnoses might influence the patient. •• Honor the patient’s concern or request. Listen to the person’s words and emotions. Use video or have the patient send pictures if possible and appropriate. Never provide unwarranted reassurance. •• Err on the side of caution. This is your best defense. Always. Trust your judgment. •• Know the “red flag” complaints: For example, if a patient describes a new onset of severe pain, the patient should be evaluated face to face. •• Ask open-ended questions and obtain enough information to give informed advice. Augment the phone call as appropriate and available with photos and video. •• Look for the worst-case scenario. Nurses performing triage should be experienced and aware of the worst-case scenarios in oncology. Be sure to ask open-ended questions such as, “Is there anything else you would like to tell me?” •• If the call is about a previous problem or unresolved problem, revisit the problem and schedule an appointment for a face-to-face evaluation rather than repeatedly telling the patient to call back in a few days. •• Adopt policies and practices for addressing telephone calls, including who may give advice to a patient, what credentials or education the telephone triage nurse must hold, protocols for specific complaints, and when, why, and who can vary from the protocol. Review and update the policies and protocols every year. Circulate the policies and protocols and have staff sign and date, acknowledging that they have reviewed them. •• Complete thorough documentation using a standardized electronic or paper form to include the following: –– Name of patient, date and time of call –– Name of caller and relationship to the patient –– Patient telephone number –– Chief complaint and history of present illness –– Current medications –– Allergies –– Disposition, including advice given –– Patient’s response –– Name and title of who handled the call •• Set conditions for telephone advice, including the following: –– Caller is/has been seen at the office/center in the past. –– Medical record is available to the nurse giving the advice. If the chart is unavailable, a full history should be completed. –– Do not give advice without the opportunity for follow-up. •• Understand that you maintain accountability for your actions. Take seriously the responsibility of taking telephone calls. When you accept a call, you are liable for the advice given, as well as advice not given (based on the patient complaint).

Note. Based on information from Buppert, 2009; Rutenberg & Greenberg, 2014.

60 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage Policies and procedures are guidelines that direct the nurse’s practice. These should be developed and regularly reviewed to ensure they reflect current standards. It is important that policies and procedures are not written with unattainable expectations, such as that all telephone calls will be answered within three rings or that every patient is seen within 24 hours. Good communication and documentation are key elements to telephone triage and telenursing and should improve patient care and minimize risk. Ensure that sufficient open-ended questions are asked and answered and that instructions are well understood and acceptable to the caller. Approximately 70% of errors in primary health care are related to communication problems (Fernald et al., 2004). In a study of 33 telenursing-related malpractice claims in Sweden (Ernesäter, Winblad, Engström, & Holmström, 2012), a root-cause analysis found that most claims were caused by failure to listen to the caller (n = 12), communication failures (n = 11), and telenurses asking too few questions (n = 10). In seven of the cases, telenurses failed to follow the guidelines of their computerized decision support system, although five of the cases fell to a deficiency in the system itself. Another Swedish study by Ernesäter, Ernesäter, Engström, Winblad, and Holmström (2014) compared actual malpractice telenursing calls with matched control calls. Results showed that telenurses in the malpractice calls used fewer open-ended questions and back-channel responses (e.g., mmm-huh, yes, go on) compared with the control calls and subsequently gathered less information from callers. These findings suggest that communication techniques help obtain richer descriptions and more information from patients (Ernesäter et al., 2014). Calls should be documented in a manner that makes it possible to recreate the call. Documentation should include but not be limited to any protocols used; the patient’s complaint in the patient’s own words; the information the nurse gleaned from the assessment interview; a detailed description of the information given to the patient, including when and how to seek care; resources used; referrals made and reasons for the referrals; confirmation that the patient demonstrated understanding of the information and instructions; and that the patient found the advice acceptable. Brief narrative notes may not be adequate. The use of consistent tools, including standardized forms, may assist the nurse by providing cues to ensure complete and thorough documentation. Checking boxes for specific phrases can strengthen the documentation. The nurse should make notes throughout the call and complete the documentation record immediately following the conclusion of the call. To further reduce liability risk, policies should be developed to manage anticipated problem situations, and these should outline the procedures to be used. Depending on the setting, policies should be developed to cover the following (list is not all inclusive): ••Communication with minors ••Noncompliant callers ••Angry or obscene callers ••Inability to contact patient or caller Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 61

Legal Concerns of Telephone Triage ••Anonymous callers ••Third-party callers—neighbors or others calling on behalf of the patient with or without the patient’s permission ••Conversations with the caller instead of with the patient ••Calls from caregivers ••The patient’s refusal to provide medical history ••Language barriers, including how to manage hearing-impaired patients ••Backup technology (computer and telephone lines) ••Access to emergency medical services ••Referrals to providers and services ••Confidentiality of the call and documentation ••Out-of-state calls ••Out-of-country calls ••Prioritizing calls by type and severity ••Types of calls to accept (e.g., triage, prescription) ••Patients who call who are not your patients ••Multiple-symptom calls and which clinical guidelines to use ••Overriding guidelines ••Symptoms that do not fit any of the institution’s written protocols ••Providing over-the-counter medication dosages ••New prescriptions and refills ••Laboratory test ordering and disclosure of results ••Older adult abuse/neglect ••Child abuse/neglect ••Ingestions and poisoning ••Suicide or psychiatric calls ••Chronic callers Other measures can be taken to minimize risk in developing telephone triage within a practice. A number of strategies are discussed further in this section. Select, maintain, and rely on evidence-based protocols or guidelines; these guidelines can be hard copy or protocol-driven software or data to facilitate telenursing. Guidelines are not “cookbook” medicine but rather a guide to manage the telephone call in a manner that is safe and congruent with nursing and physician practice. AAACN established standards in 2007 that outline the use of written guidelines. A court of law may find informal telephone triage to be unacceptable when the nurse provides information “off the top of his or her head.” Guidelines should be developed and/or adopted from another source. The appropriate physician should approve and regularly review all guidelines and changes. The physician has the ultimate responsibility for the care of patients, and his or her input should be sought and valued. Remember, although the physician oversees the guidelines, these are developed for the professional nurse and are not to be used as diagnostic tools. These guidelines should include when a caller should be referred for immediate services, such as a call to 911 or instructions to the patient to proceed immediately to a local emergency department or emergent services so that a physician sees the patient the same day the call is received. 62 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage When a nurse applies a guideline, it is extremely important to document the guideline used as a source and to read the information during the call rather than relying on memory. This enhances the quality of the communication by improving adherence to the established guidelines. It also decreases liability because if the information were challenged in court, it would be easy to recreate the response and defend the action that was taken. Managing telephone calls can consume hours of each working day, yet call volume can fluctuate from hour to hour and day to day. The call volumes should be monitored to ensure that appropriate staff is available to respond in a timely fashion. The practice should define adequate staffing levels for peak and off-peak calling times. Symptom-based calls should never be left until the next day, as this could be considered abandonment of care. The telephone triage nurse must be knowledgeable in the specialty and have additional resources necessary, such as reference materials, published standards of practice, and facility policies, procedures, and guidelines. If the office is paperless and the medical record and/or guidelines are available in a computer, a backup plan should be developed for times when the computer is not available. Risk may be reduced when the patient is satisfied with the telephone call; a satisfied patient is less likely to sue. A common complaint is the length of time it takes a caller to connect with a nurse. Notifying callers immediately that they may have to wait to speak to a nurse enhances caller satisfaction and may reduce the risk of a lawsuit. If the triage nurse needs to return the call, it is best to provide the caller with an estimate of when the call will be returned. This estimated time should be accurate based on the limits of the staff in the practice, and the caller should find it acceptable. If the caller states it is an emergency, he or she should be instructed to hang up and call 911. Always inform the patient that you are a nurse and cannot diagnose or prescribe. If the patient insists on speaking to a physician, this should not be denied. Avoid empty promises such as “everything will be all right” because this will only worsen the situation in the event of a negative outcome. A follow-up telephone call may be necessary to check on patient status, compliance, or understanding of instructions. Clear, written policies should be in place to identify who should receive follow-up phone calls. A nurse may be inclined to make follow-up phone calls on a favorite patient. This favoritism raises legal risk because it can be interpreted as providing a different level of service to certain patients. Quality assurance programs should be implemented to monitor interactions with patients and improve performance. Skill validations may include evaluation of the nurse’s ability to complete a thorough assessment, triage a call, communicate, and document. If the quality assurance program includes taping of calls, the caller must be informed and permission granted before the recording begins.

PATIENT CONFIDENTIALITY Patient confidentiality must be protected at all times. The patient has the same rights to protection of privacy and confidentiality over the telephone as he or Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 63

Legal Concerns of Telephone Triage she does when seen in the office or clinic. All policies and procedures designed to meet privacy standards, including Health Insurance Portability and Accountability Act (HIPAA) requirements, used in the office/clinic need to extend to telephone services. The HIPAA Privacy Rule (U.S. Department of Health and Human Services, 2003) has created national standards to protect individuals’ medical records and other personal health information. It allows patients to have more control over their health information; it sets boundaries on the use and release of health records; it establishes appropriate safeguards that healthcare providers and others must follow to protect the privacy of health information; and it holds violators accountable with civil and criminal penalties. The HIPAA rule permits healthcare providers to communicate with patients regarding their health care. Many practices have written policies and procedures to address these HIPAA requirements. These policies and procedures should outline with whom, if anyone, in addition to the patient, the nurse may discuss the patient’s care. Some oncology practices require the patient to sign a form designating, if desired, any other specific individual to which the patient’s medical information may be provided. If the patient has not provided permission, no information would be shared with anyone but the patient. Some practices take additional measures to ensure the identity of a caller. The patient and anyone else with permission to discuss the patient’s care are provided with a password. This helps to verify the caller’s identity over the phone. Follow-up calls from the nurse to check on the status of the patient, to monitor patient compliance, or to provide the patient with information raise new issues with caller ID systems and answering machines/voice mail. The HIPAA rule does not prohibit leaving messages for the patients on their answering machines or voice mail or with family members. However, it does require that reasonable safeguards are taken to protect the individual’s privacy, and the information left should be limited, for example, to only the name and number of the physician or nurse calling and the information necessary to confirm an appointment or a return call. Policies should be written to address appropriate use of caller ID displays, answering machines, voice mail, email, and fax. In some clinics, patients are asked to sign an authorization allowing healthcare providers to leave information on a work or home answering machine or to correspond via fax or email. It is important that others do not overhear the conversation the nurse has with the patient. An appropriate workspace or office should be available for the telephone triage nurse. This is to ensure that patients and others do not overhear confidential information. The HIPAA rule does not require soundproof walls or structural changes to facilities; however, it requires that appropriate administrative, technical, and physical safeguards be taken to protect the privacy of patients’ health information. The record of the telephone call and interaction is confidential, whether it is on paper or computerized, and should be protected in the same manner as the medical record. It is ideal to place all documentation on the call in the patient’s medical record immediately and not to leave it lying about for others to see. 64 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage Medical data are some of the most sensitive and private information. Protection against hackers is an ongoing battle for government and medical institutions. Data breaches are prohibited under federal and state laws. Aside from intentional misconduct, the most common cause of privacy breach is simple human error. This breach remains actionable under common law. Those responsible for risk management of institutions should be aware of all potential breaks in the system and prepare as needed to avoid any unnecessary legal consequences (Greve, 2015).

COMMUNICATING WITH SPECIAL POPULATIONS Some populations have inherent barriers that nurses must overcome to communicate effectively. It is the nurse’s responsibility to overcome barriers by communicating in a manner that the patient can understand regardless of age, mental ability, language barriers, domestic disturbances, or lack of access to an adult.

Minors

Minor callers pose a challenge because they have special needs related to communication and consent. Legal definitions of minors vary from state to state. Nurses should verify policies and practices with their state’s laws. Minors may call for several reasons. They could call with their own symptoms, on behalf of a peer or family member, or as a spokesperson for a family member who does not speak English. Policies should be developed to define what types of calls are accepted from minors and the information that can be provided.

Language Barriers

Nurses should be prepared to manage calls from patients with language barriers, including those who do not speak English, have limited English, or are hearing impaired. If a practice does not have access to a translator for the non–Englishspeaking or a telecommunications device for the deaf (TDD), the office should inform patients with this special need on their first visit. Attempting to provide telephone services to these patients may be inappropriate without the proper support. For example, it may not be appropriate to provide a follow-up telephone assessment of a patient who is hearing impaired if a TDD is not available, or to email patient instructions if the patient does not have ready access to and competency with a computer and the Internet. The hearing-impaired patient will need an appointment to be seen in the office, or the patient instructions will need to be faxed or mailed rather than emailed. To reduce legal risks of misinterpretation, a translator service that understands medical terms should be used. When a family member or employee from down the hall is used to interpret, the information shared may need to be restricted, and there is no assurance that the information was conveyed accurately. When an informed consent is required, a translator service should be used to avoid legal risk. This holds true not only in translation of a foreign language but also for a sign translaTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 65

Legal Concerns of Telephone Triage tor if the patient is hearing impaired. If the office is equipped with a TDD, the staff should be instructed on and competent in its use.

Cultural and Socioeconomic Differences

Social taboos may prevent discussion of certain health problems or bar direct communication with certain family members. Some cultures restrict discussion directly with the patient and require that the husband speak for the wife. Strategies need to be developed to address these and other challenges, including ones to help patients who have poor vocabulary skills, cultural taboos that may make it difficult to talk about bodily functions, and how to manage patients with limited access to telephones, transportation, and healthcare support.

Friends or Family Members

If a patient’s friends or family members call seeking advice for themselves, nurses should adhere to the policies addressing to whom they can provide telephone advice. Remember, a friendly neighbor today may not be so friendly in court if given the wrong information. Advise the family member or friend to contact his or her family healthcare provider or call 911 if it is an emergency.

Parents

Parents of ill children often are anxious over even the smallest of maladies and, in contrast, are sometimes unconcerned by potentially dangerous conditions. These attitudes can lead to misinformation. Parents of a child with cancer are more likely to experience these feelings. They may call over every ache and pain or ignore a potentially life-threatening event, such as a temperature elevation. It is important to provide straightforward instructions without being judgmental.

Older Adults

Older adults are more susceptible to comorbidities complicating their cancer care. A thorough, updated medical history verified by the patient is essential to properly managing this call. Often, older adults are reluctant to share information or seek help. They do not want to “bother” the physician or nurse, or they may feel their illness or complaint is a threat to their continued independence. When an older adult patient calls, it is imperative that the nurse provides time and attention to the caller, communicating an unhurried attitude to encourage the patient to share important information. Also, as many older adults experience some hearing loss, it is important that the nurse ensures these patients are heard and understood. Asking open-ended questions and being alert for the appropriateness of the answer can aid this.

Frequent or Chronic Callers

Triage nurses may find themselves lacking patience with the frequent, chronic, or repeat caller. They must be aware of this inclination because a patient who calls often may call one day with a serious malady, and it may be missed. The nurse should listen to each call intently prior to making any conclusions. If a patient calls 66 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage repeatedly in one day with the same complaint, it is a good practice to bring that patient in to see the physician. If the symptom is not so acute as to warrant a sameday appointment, certainly the anxiety it is causing the patient is.

Lengthy or Short Calls

If the assessment portion of the triage call is too short or too long, a red flag should go up in the nurse’s mind. If the assessment portion of the call goes on for more than 10 minutes, this should be a warning that this patient should be seen. If the assessment is less than three minutes, the nurse and caller have not shared enough information for the nurse to adequately assess the situation and triage appropriately (Espensen, 2009).

CLINICAL COMPETENCY Overall, the competencies required to provide safe and effective telephone triage are similar to the competencies required of all professional nurses, such as clinical competence, assessment skills in the specialty area of practice, and a complete understanding of the scope of services. RNs must have in-depth and up-to-date knowledge of their clinical area. Specific skills to telenursing include competency in the technologies being used and the ability to determine if the technologies are appropriate for the individual patient. In addition to technical knowledge, key competencies include refined communication skills, critical thinking, knowledge on how to apply evidence-based information, and expertise in patient education (College of Registered Nurses of Nova Scotia, 2017). Formal education of nurses, including adequate orientation, continuing education, and quality assurance programs, will strengthen their telehealth/telephone triage skills. As an emerging specialty, telenursing requires additional education to support competent practice. Telephone nursing practice certification was offered by the National Certification Corporation from 2001 to 2007. AAACN has recognized this educational void to support a key role in telehealth nursing and has developed the publication Scope and Standards of Practice for Professional Telehealth Nursing, most recently updated in 2018. The Ambulatory Certification Review Course and the Ambulatory Care Nurse Certification Exam include a telehealth component, and a number of materials are designed to meet the needs of nurses practicing telephone nursing in telephone triage centers. Although this information is general, much of it can be applied to the oncology nurse. More information regarding the standards, course, and textbook is available on the AAACN website (www.aaacn.org).

SUMMARY In the 1800s, two individuals changed the world of nursing care when they introduced their innovations. In England Florence Nightingale brought reform to the nursing profession, infusing it with dignity and science. Across the sea, AlexTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 67

Legal Concerns of Telephone Triage ander Graham Bell made his first call on his new invention—the telephone. Neither could have likely foreseen that the telephone would someday become a tool for nurses, one that permits increased access to patients and allows nurses to apply the nursing process from a distance. Triage, a process first employed on the battlefield to allocate limited resources, is now employed in emergency departments and clinics everywhere. Oncology nurses use telephone triage and telehealth technologies not only to evaluate the critical nature of a patient’s complaint and provide appropriate disposition advice but also to listen to and assess patient complaints and provide emotional support and homecare education. Telephone nursing has created new challenges in oncology nursing. Nurses have been educated in clinical settings, allowing full use of their five senses, whereas telephonic communication limits sensory input. Communication challenges include how to elicit the most information in a clear and concise manner without leading the caller. Process challenges exist within the busy clinic setting. The volume and nature of telephone calls are unpredictable. It is important to provide time and attention to the caller, but how is that best balanced with the time and attention needed for patients who are physically present? Models of telephone triage vary significantly depending on the size of the clinic and staffing patterns. Legal challenges include those related to state licensure issues. When the call is initiated beyond state boundaries, in which state should the nurse hold licensure? A number of processes and tips can help in limiting legal liabilities, including the appropriate use of telephone triage policies, guidelines or protocols, and documentation. The opening chapters of this textbook provided an overview of telephone triage or telephone nursing as it exists today in cancer clinics across this nation. They addressed communication tips and suggestions for triage processes, discussed legal concerns and dynamic issues that will require nurses’ ongoing vigilance of state and national regulations, and provided suggestions on ways to limit liability. The next portion of this textbook contains sample telephone protocols focusing on common complaints of patients with cancer. These protocols are the result of review of the current nursing literature and from contributions of protocols used by nurses across the United States. It is imperative that all telephone protocols used in each unique clinic setting be reviewed and approved by the supervising physician in the practice. The appendices provide some examples of different types of documentation forms for telephone calls with patients and caregivers, including the following: ••Appendix B. After Chemotherapy Follow-Up: Call Guidelines ••Appendix C. St. Luke’s Telephone Triage Form ••Appendix D. Sample Oral Chemotherapy Adherence/Adverse Event Telephone Encounter Form Also available is an example of a nursing practice guideline outlining the steps taken in one practice to provide guidance to the nursing staff on telenursing practice (see Appendix A, Telephone Nursing Practice Guideline). Oncology nursing is a dynamic process focused on providing care to patients with cancer and their families. We hope that this text will assist our nursing col68 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Legal Concerns of Telephone Triage leagues in their quest to provide quality care in today’s fast-moving, technologically advanced world.

REFERENCES Aiken, T.D. (2004). Legal, ethical, and political issues in nursing (2nd ed.). Philadelphia, PA: F.A. Davis. American Academy of Ambulatory Care Nursing. (2018). Scope and standards of practice for professional telehealth nursing (6th ed.). Pitman, NJ: Author. American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author. Boutwell, S. (2015). The state of telehealth law in Louisiana. Retrieved from https://www​ .louisianalawblog.com/health-law/the-state-of-telehealth-law-in-louisiana Buppert, C. (2009). Guidelines for telephone triage. Dermatology Nursing, 21, 40–41. California Board of Registered Nursing. (2011, January). RN tele-nursing and telephone triage. Retrieved from http://www.rn.ca.gov/pdfs/regulations/npr-b-35.pdf Clemons v. WellPoint Companies, 2013 WL 1092101 (N.D.N.Y. 2013). Retrieved from https://www. gpo.gov/fdsys/pkg/USCOURTS-nynd-1_11-cv-00084/pdf/USCOURTS-nynd-1_11-cv-00084-0.pdf College of Registered Nurses of Nova Scotia. (2017). Telenursing practice guidelines. Retrieved from https://crnns.ca/publication/telenursing-practice-guidelines Dinwoodie, M. (n.d.). Triage in general practice. Retrieved from http://www.medicalprotection.org/uk​ /practice-matters-issue-3/triage-in-general-practice Ernesäter, A., Engström, M., Winblad, U., & Holmström, I.K. (2014). A comparison of calls subjected to a malpractice claim versus ‘normal calls’ within the Swedish Healthcare Direct: A case–control study. BMJ Open, 4, e005961. https://doi.org/10.1136/bmjopen-2014-005961 Ernesäter, A., Winblad, U., Engström, M., & Holmström, I.K. (2012). Malpractice claims regarding calls to Swedish telephone advice nursing: What went wrong and why? Journal of Telemedicine and Telecare, 18, 379–383. https://doi.org/10.1258/jtt.2012.120416 Espensen, M. (2009). Telehealth nursing practice essentials. Pitman, NJ: American Academy of Ambulatory Care Nursing. Fernald, D.H., Pace, W.D., Harris, D.M., West, D.R., Main, D.S., & Westfall, J.M. (2004). Event reporting to a primary care patient safety reporting system: A report from the ASIPS collaborative. Annals of Family Medicine, 2, 327–332. Retrieved from http://www.annfammed.org/content/2/4/327 .full.pdf Garner, B. (Ed.). (2009). Preponderance. In Black’s law dictionary (9th ed., p. 1301). St. Paul, MN: Thomson West. Gold, A. (2014). Clinical negligence update. Retrieved from https://www.lexology.com/library/detail​ .aspx?g=344e9291-ce80-4649-8abc-c87cf385c1a8 Greve, P. (2015). Telemedicine law and liability. Retrieved from https://blog.willis.com/2015/10​ /telemedicine-law-and-liability-2015 Hutcherson, C.M. (2001). Legal considerations for nurses practicing in a telehealth setting. Online Journal of Issues in Nursing, 6. Retrieved from http://ojin.nursingworld.org​/MainMenuCategories /ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume62001​/ No3Sept01/Legal Considerations.html Law. (2018). In Encyclopaedia Britannica. Retrieved from https://www.britannica.com/topic/law Lawson, G., & Shapiro, R. (n.d.). The Tenth Amendment. Retrieved from https://constitutioncenter.org​ /interactive-constitution/amendments/amendment-x Malpractice. (n.d.). In Merriam-Webster medical dictionary. Retrieved from http://www.merriam​ -webster.com/medlineplus/malpractice Martin, G.A. (2009). Telehealth: Are you at risk? Retrieved from https://www.nursing.umn.edu/sites​ /nursing.umn.edu/files/martingeorgia_telehealthareyouatrisk.pdf Medical diagnosis. (2012). In Mosby’s medical dictionary (9th ed.). St. Louis, MO: Elsevier. Medical Mutual. (n.d.). Telephone triage systems. Retrieved from https://www.medicalmutual.com/risk​ /practice-tips/tip/telephone-triage-systems/103 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 69

Legal Concerns of Telephone Triage National Council of State Boards of Nursing. (n.d.). Original Nurse Licensure Compact. Retrieved from https://www.ncsbn.org/nurse-licensure-compact.htm National Council of State Boards of Nursing. (2014). The National Council of State Boards of Nursing (NCSBN®) position paper on telehealth nursing practice. Retrieved from https://www.ncsbn​ .org/14_Telehealth.pdf National Council of State Boards of Nursing. (2015). Advanced Practice Registered Nurse Compact. Retrieved from https://www.ncsbn.org/APRN_Compact_Final_050415.pdf National Council of State Boards of Nursing. (2018, January 25). Enhanced Nurse Licensure Compact (eNLC) implementation. Retrieved from https://www.ncsbn.org/enhanced-nlc-implementation .htm Nevada State Board of Nursing. (2014). Practice decision: Practice guidelines for telenursing. Retrieved from http://nevadanursingboard.org/wp-content/uploads/2014/03/Telenursing-Practice-Decision​ -Revised-3.14.pdf North Carolina Board of Nursing. (2016). Telehealth/telenursing position statement for RN and LPN practice. Retrieved from https://www.ncbon.com/vdownloads/position-statements-decision-trees​ /telehealth-telenursing.pdf Rutenberg, C., & Greenberg, M.E. (2014). Telephone nursing in radiology: Managing the risks. Journal of Radiology Nursing, 33, 63–66. https://doi.org/10.1016/j.jradnu.2013.12.004 Schlachta-Fairchild, L., Elfrink, V., & Deickman, A. (2008). Patient safety, telenursing, and telehealth. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Triage. (n.d.). In Merriam-Webster online dictionary. Retrieved from https://www.merriam-webster​ .com/dictionary/triage U.S. Department of Health and Human Services. (2003, May). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/sites/default/files/privacysummary.pdf West Pennsylvania Administrative Code. (2016). Title 49, Section 21.11. Code of Professional and Vocational Standards. Retrieved from https://www.westlaw.com/Browse/Home/Regulations​/Penn sylvaniaRegulations?guid=N643DB3208DD111DEA1A9CF3F7A575F80&contextData=(sc​.Defa ult)&transitionType=Default&VR=3.0&RS=cblt1.0 Wicklund, E. (2016). Nurses’ group lobbies for telemedicine licensure. Retrieved from https://​ mhealthintelligence.com/news/nurses-group-lobbies-for-telemedicine-licensure

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Telephone Triage

Protocols

Telephone Triage . . . . . . . . .71

72 . . . . . . . . Telephone Triage

Alopecia PROBLEM Alopecia is the partial or complete absence of hair from areas of the body where it normally grows. Distress resulting from cancer-related alopecia is very well documented in the literature (Kadakia, Rozell, Butala, & Loprinzi, 2014). For most patients, it is a constant visual reminder to themselves and to others that they have cancer. Hair growth has three phases: anagen (the active growth phase), catagen (hair is no longer growing, and the hair follicle moves closer to the surface of the skin), and telogen (the resting phase). Scalp hair is in the anagen growth phase for two to six years. Approximately 85%–90% of scalp hairs are in the anagen phase at any one time (Nail & Lee-Lin, 2015). Because the scalp has the highest percentage of hair in the anagen phase, the effects of systemic therapy on hair loss will occur in scalp hair sooner than any other place on the body.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Alopecia (hair loss) is a transient but often psychologically devastating consequence of cancer chemotherapy. In addition to the scalp, pubic, and axillary hair, eyebrows and eyelashes may also be lost. Alopecia is a hallmark sign that someone has cancer. For some patients, the emotional trauma may be so severe that it leads to discontinuing or refusing treatment (Kadakia et al., 2014). b. Many cancer treatments work by targeting rapidly growing cancer cells. This action is responsible for most of the side effects of cancer treatment. Hair follicles are among the many fast-growing healthy cells in the body. c. Certain chemotherapy drugs and some radiation therapies attack rapidly dividing cells in the body, including the hair cells. This can result in the loss of hair by either of two mechanisms: thinning of the hair shaft occurs at the time of maximal chemotherapy effect, and as a result, the hair may break at the follicular orifice (upper portion); or, if the matrix is severely inhibited, the hair may become separated at the bulb (lower portion) and begin to shed (American Cancer Society, 2017; Cancer.Net, 2016; National Cancer Institute, 2017). 2. What medications is the patient taking? Obtain medication history. Chronic use of medications such as steroids causes thinning of hair. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 73

Alopecia

HOMECARE INSTRUCTIONS When Will Hair Loss Occur? Chemotherapy

The ability of individual agents to cause hair loss depends on the route, dose, and schedule of drug administration. ••High-dose, intermittent IV chemotherapy regimens are associated with a high incidence of complete alopecia. ••Low-dose therapy, targeted therapy, oral administration, and weekly regimens are less likely to induce total or complete alopecia (Cancer.Net, 2016). The scalp may hurt at first, and then hair loss may occur, either a little at a time or in clumps. It takes about one week for all hair to fall out (National Cancer Institute, 2017). Hair may not begin to regrow until between three and six months after therapy is completed, or the hair may start to grow back while the patient is still receiving chemotherapy. The “new” hair may have a slightly different color, texture, or curl (American Cancer Society, 2017).

Radiation Therapy

Radiation therapy uses high-energy radiation to kill cancer cells by damaging their DNA. Radiation can damage normal cells as well as cancer cells. A patient may receive radiation therapy before, during, or after surgery. Some patients may receive radiation therapy alone, without surgery or other treatments, while others may undergo radiation and chemotherapy treatments simultaneously. The timing of radiation therapy depends on the type of cancer being treated and the goal of treatment (cure or palliation). Radiation may be delivered by a machine outside the body (external beam), or it may come from radioactive material placed inside the body near cancer cells (brachytherapy). Radiation side effects are caused by damage to rapidly dividing normal cells in the area being treated. These effects include skin irritation or damage at regions exposed to the radiation beams. An example would be hair loss when the head or neck area is treated.

Tips When Anticipating or During Hair Loss

(National Cancer Institute, 2017) ••Visit a hair stylist prior to treatment. Hair loss often is better managed by cutting the hair short prior to treatment. ••If the head is shaved, use an electric shaver rather than a razor to prevent cutting the scalp. ••Shop for a wig in advance of hair loss to match hair color, style, and texture. It is important to have some sort of head covering to protect the skin from sun and wind. ••Use sunscreen on exposed scalp or cover completely to protect skin from the sun’s harmful rays. ••Sleep on a soft, satiny pillowcase or try wearing a soft scarf or turban to minimize friction. 74 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Alopecia ••Treat hair gently. Keep hair clean by shampooing with a gentle, pH-balanced shampoo. Avoid vigorous toweling and blow-drying of any remaining hair. ••Use a soft-bristle brush or a wide-toothed comb. ••Avoid hair treatments such as bleaching, permanent waves, hair dye, and hairspray that can cause dry or brittle hair. ••Try not to braid hair or put it in a ponytail. ••It may be helpful to join a support group to talk with others who have lost their hair during cancer treatment.

Cold Caps A practice becoming more common is the use of scalp cooling systems as a mechanism to reduce or eliminate alopecia during chemotherapy. DigniCap® is the first U.S. Food and Drug Administration–cleared scalp cooling system on the market (www.dignicap.com). The near-freezing temperatures of the product are intended to constrict the blood vessels in the scalp, making it difficult for toxic chemotherapy agents to reach and harm the hair follicles. The cold also decreases the activity of the hair roots, which slows cell division and makes the roots less affected by chemotherapy (DigniCap, n.d.). Currently, this practice is expensive and not routinely covered or reimbursed by insurance companies. Although this intervention has been used more routinely outside of the United States, a literature review conducted by Ross and Fischer-Cartlidge (2017) found that scalp cooling may demonstrate better hair preservation than not cooling, and no increase in scalp metastasis occurred. The authors also found that few patients discontinued cooling early because of adverse effects. It has been used mostly by individuals undergoing treatment for breast cancer. Additional clinical trials are needed to evaluate the efficacy of this practice in multiple tumor sites, as well as to increase universal access to scalp cooling devices.

Report the Following Problems

(American Cancer Society, 2017; National Cancer Institute, 2017) ••Irritation in scalp ••Prolonged sun exposure ••Red, itchy, or swollen scalp

REFERENCES American Cancer Society. (2017). Hair loss. Retrieved from https://www.cancer.org/treatment/treatments​ -and-side-effects/physical-side-effects/hair-loss Cancer.Net. (2016). Hair loss or alopecia. Retrieved from http://www.cancer.net/navigating-cancer -care​/side-effects/hair-loss-or-alopecia DigniCap. (n.d.). DigniCap®—The intelligent scalp cooling system. Retrieved from https://dignicap​ .com/how-it-works Kadakia, K.C., Rozell, S.A., Butala, A.A., & Loprinzi, C.L. (2014). Supportive chemotherapy: A review from head to toe. Journal of Pain and Symptom Management, 47, 1100–1115. https://doi.org/10​ .1016/j.jpainsymman.2013.07.014 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 75

Alopecia Nail, L.M., & Lee-Lin, F. (2015). Alopecia. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 21–33). Pittsburgh, PA: Oncology Nursing Society. National Cancer Institute. (2017). Hair loss (alopecia) and cancer treatment. Retrieved from http://www​ .cancer.gov/about-cancer/treatment/side-effects/hair-loss Ross, M., & Fischer-Cartlidge, E. (2017). Scalp cooling: A literature review of efficacy, safety, and tolerability for chemotherapy-induced alopecia. Clinical Journal of Oncology Nursing, 21, 226–233. https://doi.org/10.1188/17.CJON.226-233

Darcy Burbage, RN, MSN, AOCN®, CBCN® The author would like to acknowledge Linda Bracks-Madison, MS, RN, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Alterations in Sexuality PROBLEM Alterations in sexuality encompass the inability to enjoy sexual activity (Baron, 2016). All aspects of cancer and cancer treatment may affect human sexuality. Changes in body image, reproductive function, and sexual function can affect patients before, during, and after treatment. Sexual dysfunction can persist for a long time. Alterations in sexuality are reported to occur in 67%–85% of patients (Benoot, Saelaert, Hannes, & Bilsen, 2017). Cancer survivors list return to sexual activity at a prediagnosis level as a goal after treatment is completed, and unlike other physical effects of treatments, sexual dysfunction is not as likely to return to baseline over time (Dunn, 2015; Hunter, Gibson, Arbesman, & D’Amico, 2017). Patients with cancer report loss of desire, erectile dysfunction, and dyspareunia as the most common sexual problems (National Cancer Institute, 2011).

ASSESSMENT CRITERIA Assessment of sexual health is the first part of problem identification (Julien, Thom, & Kline, 2010). Sexual health is not routinely assessed or addressed with patients (Gleeson & Hazell, 2017). Oncology nurses need to be aware of their own attitudes and knowledge about sexuality to avoid missing opportunities to discuss concerns (Dunn, 2015). Initially, start with less sensitive questions and move toward more sensitive ones. Do not assume that the patient is in a heterosexual relationship. Ask open-ended questions. Provide the patient with a confidentiality statement concerning the conversation. Advise the patient that he or she may choose not to answer sensitive questions (Kelvin, Steed, & Jarrett, 2014). 1. What is the cancer diagnosis, and what treatment is the patient receiving? 2. What are the coexisting variables? a. Gender b. Age c. Educational background d. Socioeconomic status e. Cultural or ethnic background f. Concurrent medical or psychiatric disorders g. Current prescription and over-the-counter medication use 3. How has the diagnosis or cancer treatment changed the patient’s sexual function and feelings about his or her body? 4. Has the patient’s role with his or her partner changed since the patient was diagnosed with or treated for cancer? If yes, how has the role changed? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 77

A lt e r at i o n s i n S e x u a l i t y 5. Use the ALARM or PLEASURE model to assess sexual function (Kelvin et al., 2014; Mick, 2007; see Figure 10). Figure 10. ALARM and PLEASURE Models for Sexual Function Assessment ALARM Model •• Activity •• Libido/desire •• Arousal and orgasm •• Resolution •• Medical history

PLEASURE Model •• Partner •• Lovemaking •• Emotions •• Attitude •• Symptoms •• Understanding •• Reproduction •• Energy

Note. Based on information from Kelvin et al., 2014; Mick, 2007.

The following items are examples of questions used to assist in the assessment process: a. How frequent are the current sexual activities? b. Are other forms of physical affection, such as hugging or kissing, being communicated? c. How has your desire and interest for sexual activity changed, either in initiating or responding to your partner? d. When sexually excited, does the penis become erect or the vagina lubricated, followed by ejaculation or vaginal contractions? e. Following sexual activity, is there a release of sexual tension and a satisfaction with sexual life? f. Are there any acute or chronic disorders that may interfere with sexual activity, such as diabetes, hypertension, substance abuse, or psychiatric disorders?

HOMECARE INSTRUCTIONS Action and approach are dependent on patient response to assessment questions. Several models are available for nurses to use in providing sexual information (Kaplan & Pacelli, 2011). The PLISSIT model uses a four-step approach to deal with sexual concerns: permission, limited information, specific suggestions, and intensive therapy. Most sexual problems related to cancer can be managed without referral for intensive therapy. The BETTER model was designed for oncology nurses and uses a six-step method to discuss with and educate patients about sexual function (Dunn, 2015; Kelvin et al., 2014; Mick, Hughes, & Cohen, 2004). ••Bring up the topic. ••Explain that concern for quality-of-life issues includes sexual health. ••Tell the patient you will find resources to address concerns. ••Timing should be when the patient is ready to discuss concerns. 78 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

A lt e r at i o n s i n S e x u a l i t y ••Educate the patient about how side effects of treatment may affect sexual function. ••Record the results of the assessment and interventions in the medical record. The nurse can suggest interventions for the specific problems identified through the assessment process. The methods for dealing with altered sexual health include suggesting new ways of sexual expression, new sexual positions, optimal timing for sexual expressions, and new communication patterns. To enhance the education provided, the nurse should refer the patient to informational sources (Chellayadhas, Achrekar, Bakshi, Shetty, & Carvalho, 2016). The American Cancer Society (www .cancer.org) offers various resources to facilitate coping with sexual changes related to cancer and its treatment.

Report the Following Problems

Notify the healthcare provider if no improvement has occurred. A referral for more intensive therapy may be indicated, and the nurse may facilitate referral to the appropriate provider (Dunn, 2015). Providers for more intensive therapy may include a surgeon, gynecologist, urologist, social worker, psychologist, psychiatrist, or sex therapist.

REFERENCES Baron, R.H. (2016). Psychosocial management. In B.H. Gobel, S. Triest-Robertson, & W.H. Vogel (Eds.), Advanced oncology nursing certification review and resource manual (2nd ed., pp. 737–774). Pittsburgh, PA: Oncology Nursing Society. Benoot, C., Saelaert, M., Hannes, K., & Bilsen, J. (2017). The sexual adjustment process of cancer patients and their partners: A qualitative evidence synthesis. Archives of Sexual Behavior, 46, 2059– 2083. https://doi.org/10.1007/s10508-016-0868-2 Chellayadhas, J.Y., Achrekar, M.S., Bakshi, G., Shetty, R., & Carvalho, M. (2016). Development of booklet on male sexual dysfunction, its measures and assessing its impact on knowledge of patients with urological cancers. Asia-Pacific Journal of Oncology Nursing, 3, 382–389. https://doi.org/10​ .4103/2347-5625.196495 Dunn, M.W. (2015). Bladder cancer: A focus on sexuality. Clinical Journal of Oncology Nursing, 19, 68–73. https://doi.org/10.1188/15.CJON.68-73 Gleeson, A., & Hazell, E. (2017). Sexual well-being in cancer and palliative care: An assessment of healthcare professionals’ current practice and training needs. BMJ Supportive and Palliative Care, 7, 51–54. https://doi.org/10.1136/bmjspcare-2016-001305 Hunter, E.G., Gibson, R.W., Arbesman, M., & D’Amico, M. (2017). Systematic review of occupational therapy and adult cancer rehabilitation: Part 2. Impact of multidisciplinary rehabilitation and psychosocial, sexuality, and return-to-work interventions. American Journal of Occupational Therapy, 71, 7102100040p1–7102100040p8. https://doi.org/10.5014/ajot.2017.023572 Julien, J.O., Thom, B., & Kline, N.E. (2010). Identification of barriers to sexual health assessment in oncology nursing practice [Online exclusive]. Oncology Nursing Forum, 37, E186–E190. https://​ doi.org/10.1188/10.ONF.E186-E190 Kaplan, M., & Pacelli, R. (2011). The sexuality discussion: Tools for the oncology nurse. Clinical Journal of Oncology Nursing, 15, 15–17. https://doi.org/10.1188/11.CJON.15-17 Kelvin, J.F., Steed, R., & Jarrett, J. (2014). Discussing safe sexual practices during cancer treatment. Clinical Journal of Oncology Nursing, 18, 449–453. https://doi.org/10.1188/14.CJON.449-453 Mick, J.M. (2007). Sexuality assessment: 10 strategies for improvement. Clinical Journal of Oncology Nursing, 11, 671–675. https://doi.org/10.1188/07.CJON.671-675 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 79

A lt e r at i o n s i n S e x u a l i t y Mick, J.M., Hughes, M., & Cohen, M.Z. (2004). Using the BETTER model to assess sexuality. Clinical Journal of Oncology Nursing, 8, 84–86. https://doi.org/10.1188/04.CJON.84-86 National Cancer Institute. (2011). Sexuality and reproductive issues (PDQ®) [Health professional version]. Retrieved from https://​secure.ce-credit.com/articles/100845/100845.pdf

Joyce Jackowski, MS, FNP-BC, AOCNP®

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Anorexia PROBLEM Anorexia is an abnormal loss of the appetite for food often associated with medical treatment (radiation therapy or chemotherapy), pain, nausea, depression, smell or taste changes, and the disease process. Cancer cells can alter the release of hormones (e.g., ghrelin) and hormone-like substances and modify the production of the neurotransmitters (e.g., dopamine, serotonin), neuropeptides, and prostaglandins that influence food consumption. Additionally, tumors can directly produce substances that reduce food intake, such as lactate, cytokines, and tryptophan (Ezeoke & Morley, 2015). The incidence of anorexia can be as high as 80% in patients with advanced disease (Thorpe et al., 2017) and is the fourth most common symptom of patients with cancer, after pain, fatigue, and weakness (BlauwhoffBuskermolen et al., 2016). Anorexia is closely linked to cachexia, which is a profound muscle-wasting syndrome usually seen in patients with chronic illnesses, including cancer. Patients with cachexia have involuntary loss of total body weight or skeletal muscle mass (Petruzzelli & Wagner, 2016). Typically, it cannot be reversed with standard nutritional therapy. Weight loss during cancer treatment is a significant problem and is associated with decreased survival rates (Millar, Reid, & Porter, 2013).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? 2. Is the patient in an advanced stage of the disease or receiving chemotherapy, radiation, or immunotherapy? Has the patient had recent surgical interventions? 3. What medications is the patient taking? Obtain medication history (Underhill & Ward, 2015). 4. Ask the patient to describe symptoms in detail (e.g., total amount of weight loss, weight loss over time). 5. Assess the quantity of the patient’s weight loss, as well as the patient’s current weight as it compares to ideal body weight. Ideal body weight should take into consideration height, weight, and age of the person being measured. 6. Obtain history of the problem. a. Precipitating factors (e.g., weight patterns, gain and loss cycles, nutritional intake patterns, whether weighed on a single scale or on several different scales) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 81

Anorexia b. Onset and duration c. Relieving factors d. Any associated symptoms (e.g., nausea and vomiting, weakness, xerostomia, taste changes, fatigue, amenorrhea, polyuria, cold intolerance) e. Social and cultural beliefs toward food 7. Review past medical history (e.g., eating disorders). 8. Assess for changes in activities of daily living and function (Underhill & Ward, 2015). Signs and Symptoms

Action

•• Lack of nutritional intake for several days •• Orthostatic hypotension (dizziness when standing) •• Signs of dehydration •• Collapse

Seek urgent care within two to four hours.

•• Weight loss more than 5% of baseline in a month •• Minimal nutritional intake for several days •• Continued weight loss despite adherence to instructions and ingestion of supplements and prescribed appetite stimulants

Obtain appointment to see healthcare provider within 48–72 hours.

•• Weight loss more than 10% of baseline in six months

Yes—Obtain appointment with a healthcare provider within a week. No—Continue with nutritional program, supplements, appetite stimulants, and other homecare instructions.

Cross-references: Dysphagia, Nausea and Vomiting, Xerostomia (Dry Mouth)

HOMECARE INSTRUCTIONS ••Avoid strong food odors or foods that are not appetizing. ••Try cold foods (e.g., vitamin-enhanced smoothies, sandwiches, yogurt). ••Eat several small meals per day (Underhill & Ward, 2015). ••Fortify milk by adding powdered milk. ••Add protein supplements or powdered milk to casseroles, smoothies, etc. ••Sip on nutritious drinks, such as fruit juices, when thirsty, as opposed to just water (for extra calories). ••Eat the most when you feel the hungriest, regardless of the time of day. ••Eat nutritious high-protein foods (e.g., fish, lean meat, eggs, nuts). ••Add supplements (e.g., Ensure®, ProSure®), two cans per day. ••Consult a dietitian for evaluation. This is recommended in the Oncology Nursing Society Putting Evidence Into Practice (ONS PEP) guidelines for managing anorexia (Thorpe et al., 2017). ••Follow a homecare instruction sheet for recipes and suggestions. 82 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Anorexia ••Take an appetite stimulant (e.g., Marinol®, Megace®) or corticosteroids, if prescribed (Ezeoke & Morley, 2015; Suzuki, Asakawa, Amitani, Nakamura, & Inui, 2013). Use of progestins to manage anorexia is recommended for practice in current ONS PEP guidelines (Thorpe et al., 2017). ••Take antiemetics for nausea, if prescribed. ••Consider alternative therapies such as acupuncture, which has been shown to possibly reduce the risk of developing anorexia with no reported side effects (Yoon, Grundmann, Williams, & Carriere, 2015). ••Remain as active as possible, using mild exercise such as walking or swimming to increase muscle mass, muscle strength, and level of physical functioning (Underhill & Ward, 2015). ••Practice relaxation exercises 30 minutes before meals to decrease stress. ••Establish a system of eating. Often, caregivers focus too much on getting patients to eat or trying to find new ways to make patients eat. A system of eating should be worked out between the patient and the caregiver. Both parties should be educated on the variety of causes of anorexia, some of which are beyond the control of the patient.

Report the Following Problems

••Continued lack of appetite with little or no food ingestion ••Continued weight loss ••Uncontrolled nausea or mouth sores that interfere with the ability to eat

Seek Emergency Care Immediately if Any of the Following Occurs

••Fainting when changing from a sitting to a standing position ••Dizziness

REFERENCES Blauwhoff-Buskermolen, S., Ruijgrok, C., Ostelo, R.W., de Vet, H.C.W., Verheul, H.M.W., de van der Schueren, M.A.E., & Langius, J.A.E. (2016). The assessment of anorexia in patients with cancer: Cut-off values for the FAACT–A/CS and the VAS for appetite. Supportive Care in Cancer, 24, 661– 666. https://doi.org/10.1007/s00520-015-2826-2 Ezeoke, C.C., & Morley, J.E. (2015). Pathophysiology of anorexia in the cancer cachexia syndrome. Journal of Cachexia, Sarcopenia and Muscle, 6, 287–302. https://doi.org/10.1002/jcsm.12059 Millar, C., Reid, J., & Porter, S. (2013). Healthcare professionals’ response to cachexia in advanced cancer: A qualitative study [Online exclusive]. Oncology Nursing Forum, 40, E393–E402. https://​ doi.org/10.1188/13.ONF.E393-E402 Petruzzelli, M., & Wagner, E.F. (2016). Mechanisms of metabolic dysfunction in cancer-associated cachexia. Genes and Development, 30, 489–501. https://doi.org/10.1101/gad.276733.115 Suzuki, H., Asakawa, A., Amitani, H., Nakamura, N., & Inui, A. (2013). Cancer cachexia—Pathophysiology and management. Journal of Gastroenterology, 48, 574–594. https://doi.org/10.1007/s00535​ -013-0787-0 Thorpe, D.M., Conley, S.B., Drapek, L., Held-Warmkessel, J., Ramsdell, M.J., Rogers, B., & Wolles, B. (2017). Anorexia. Retrieved from https://www.ons.org/pep/anorexia Underhill, M.L., & Ward, V.A. (2015). Cancer anorexia-cachexia syndrome. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 119–141). Pittsburgh, PA: Oncology Nursing Society. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 83

Anorexia Yoon, S.L., Grundmann, O., Williams, J.J., & Carriere, G. (2015). Novel intervention with acupuncture for anorexia and cachexia in patients with gastrointestinal tract cancers: A feasibility study [Online exclusive]. Oncology Nursing Forum, 42, E102–E109. https://doi.org/10.1188/15.ONF.E102-E109

Deborah Metzkes, RN, BSN, OCN®, MBA The author would like to acknowledge Susan Newton, RN, MS, AOCN®, AOCNS®, and Kathy White, RN, OCN®, for their contributions to this protocol that remain unchanged from the previous edition of this book.

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Antibiotic Therapy Problems PROBLEM Patients with cancer are more susceptible to infections due to the disease process and treatment (Mohammed et al., 2014). If patients experience side effects that cause an interruption in antibiotic therapy, delayed resolution of infection and interruption in oncology treatments may occur. Disruption of antibiotic therapy can lead to other issues, such as extended hospitalizations, emergency department visits, treatment delays, mortality, and morbidity (Cross, Tolfree, & Kipping, 2017). It is very important to provide support and education to a patient having difficulty taking an antibiotic or experiencing side effects with use.

ASSESSMENT CRITERIA 1. Is the patient allergic to any medications? Ask prior to conducting further assessment. 2. Is the patient experiencing an adverse allergic reaction with respiratory compromise? If so, have the patient seek emergency care as soon as possible.

Antibiotic Details

(Centers for Disease Control and Prevention, 2017; Chen, Leu, Wu, Wu, & Wang, 2015; Cross et al., 2017; Oliver, 2016; Rosenberg et al., 2013) Compare this information with the patient medical record for accuracy: 1. Name of antibiotic 2. Route of administration a. Topical b. Oral c. IV/injection i. If IV, is the antibiotic administered at a medical facility or is the patient involved in home care? ii. If the issue is IV pump related, the outside agency involved in administration may need to be contacted (Oliver, 2016). 3. Schedule and dose a. When started and last taken b. If the patient has interrupted or stopped taking the antibiotic, note the reason why.

Symptom Details

(Centers for Disease Control and Prevention, 2017; Chen et al., 2015; Cross et al., 2017; Rosenberg et al., 2013; Wierema, Konecny, & Links, 2013) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 85

Antibiotic Therapy Problems 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. A high risk of sepsis and an interruption of antibiotic in the leukemic population are of great concern. b. Is the patient currently receiving chemotherapy, radiation therapy, targeted therapy, or immunotherapy? i. Chemotherapy: A patient is at high risk for neutropenia 10–14 days after treatment. Interruption of antibiotic is of highest concern during this time. ii. Radiation: A patient receiving radiation involving areas of the upper or lower gastrointestinal tract is also susceptible to diarrhea and swallowing problems. These side effects can mimic those of an antibiotic. iii. Targeted therapy or immunotherapy: A patient on either targeted therapy or immunotherapy can be susceptible to skin rashes. These side effects can mimic those of an antibiotic. 2. What medications is the patient taking? 3. Ask the patient to describe symptoms in detail. If the patient is experiencing an adverse allergic reaction with respiratory compromise, have the patient seek emergency care as soon as possible. 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors 5. Does the patient have a central venous access device (e.g., peripherally inserted central catheter line, implanted port) (Schiffer et al., 2013)? 6. Review past medical history. 7. Does the patient have any other comorbidities or illnesses (e.g., diabetes, hypertension, HIV infection, kidney or liver disease)?

HOMECARE INSTRUCTIONS (Chen et al., 2015; Cross et al., 2017; Oliver, 2016; Wierema et al., 2013) ••Complete antibiotic therapy as prescribed, including finishing the full course, even when feeling better. ••Take antibiotic with an eight-ounce glass of water. Antibiotics may need to be taken with either food or on an empty stomach. Ask the pharmacist to provide specific dietary instructions for an antibiotic. ••If a dose is missed, take the medication as soon as possible once a missed dose is realized—unless it is almost time for the next dose. In that case, skip the missed dose. Do not double up or double dose medication. ••Do not take another person’s antibiotics. ••Avoid sunlight and use sunscreen protection while on antibiotics. ••Eat yogurt with active cultures to prevent yeast infections. ••Eat bread after taking medication to alleviate a bitter or metallic taste in the mouth caused by some antibiotics. 86 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Antibiotic Therapy Problems

Signs and Symptoms

Action

•• Severe symptoms of anaphylaxis –– Chest pain and difficulty breathing –– Acute skin changes and associated systemic symptoms (e.g., itching, hives, throat swelling, wheezing, nausea, vomiting, racing heart, chest pain, eye involvement) –– Sense of overwhelming anxiety or impending doom •• Severe gastrointestinal symptoms –– Persistent nausea, vomiting, and dehydration (e.g., decreased urination; sunken eyes; loose, dry skin; excessive thirst; dry mouth) –– Clostridium difficile: More than three stools in a 24-hour period that may be foul smelling or grossly bloody with abdominal tenderness •• Severe symptoms of epidermis/skin –– Stevens-Johnson syndrome ** Rare side effect more common in patients with cancer and those using a sulfonamide antibiotic ** Patient can report malaise, leading to itching and watering of eyes, photosensitivity, crusting of the lips and oral mucosa, pain or difficulty with urination, difficulty breathing with cough. –– Toxic epidermal necrolysis: Patient reports more severe form of rash and skin detachment with blistering and sloughing of skin. •• Nonbloody diarrhea for longer than three days; lower abdominal cramping •• Sore mouth or tongue, loss of taste, pain on eating and swallowing, white coating on tongue or in mouth •• Vaginal itching, discharge, or erythema •• Unable to swallow the pill •• Bitter taste in mouth when taking antibiotic •• Headache •• Hearing loss •• Dizziness

Seek emergency care.

Seek emergency care.

Seek emergency care.

Seek care within 24 hours.

Follow homecare instructions. Nurses should provide education. Notify physician if no improvement.

Cross-references: Dyspnea, Pain Note. Based on information from Goldberg et al., 2015; High & Roujeau, 2017; Kao et al., 2015; Rosenberg et al., 2013; Wright & Paauw, 2013.

Report the Following Problems

••Worsening or continuing stomach pain ••Generalized body rash with or without wheals or hives ••Cramps or tenderness in the abdomen ••Diarrhea, nausea, or vomiting ••Hearing loss or tinnitus ••Unusual bleeding or bruising ••Yellow eyes or skin Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 87

Antibiotic Therapy Problems

Seek Emergency Care Immediately if Any of the Following Occurs

••Chest pain or difficulty breathing ••Severe abdominal pain, profuse watery diarrhea, or bloody stool ••Severe rash or blistering of skin ••Rigors

REFERENCES Centers for Disease Control and Prevention. (2017). Core elements of hospital antibiotic stewardship programs. Retrieved from https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html Chen, Y.-C., Leu, H.-S., Wu, S.-F., Wu, Y.-M., & Wang, T.J. (2015). Factors influencing adherence to antibiotic therapy in patients with acute infections. Journal of Nursing, 62, 58–67. https://doi. org/10​.6224/JN.62.1.58 Cross, E.L.A., Tolfree, R., & Kipping, R. (2017). Systematic review of public-targeted communication interventions to improve antibiotic use. Journal of Antimicrobial Chemotherapy, 72, 975–987. https://doi.org/10.1093/jac/dkw520 Goldberg, E.J., Bhalodia, S., Jacob, S., Patel, H., Trinh, K.V., Varghese, B., … Raffa, R.B. (2015). Clostridium difficile infection: A brief update on emerging therapies. American Journal of HealthSystem Pharmacy, 72, 1007–1012. https://doi.org/10.2146/ajhp140645 High, W.A., & Roujeau, J.-C. (2017). Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae. In R. Corona (Ed.), UpToDate. Retrieved April 24, 2018, from https://www.uptodate.com/contents/stevens-johnson-syndrome-and-toxic-epidermal​ -necrolysis-management-prognosis-and-long-term-sequelae Kao, P.-H., Chen, J.-S., Chung, W.-H., Hui, R.C.-H., & Yang, C.-H. (2015). Cutaneous adverse events of targeted anticancer therapy: A review of common clinical manifestations and management. Journal of Cancer Research and Practice, 2, 271–284. https://doi.org/10.6323/JCRP.2015.2.4.1 Mohammed, A.A., Al-Zahrani, A.S., Sherisher, M.A., Alnagar, A.A., El-Shentenawy, A., & El-Kashif, A.T. (2014). The pattern of infection and antibiotics use in terminal cancer patients. Journal of the Egyptian National Cancer Institute, 26, 147–152. https://doi.org/10.1016/j.jnci.2014.05.002 Oliver, G. (2016). Optimizing patient safety when using elastomeric pumps to administer outpatient parenteral antibiotic therapy. British Journal of Nursing, 25, S22–S27. https://doi.org/10.12968​ /bjon.2016.25.19.S22 Rosenberg, J.H., Albrecht, J.S., Fromme, E.K., Noble, B.N., McGregor, J.C., Comer, A.C., & Furuno, J.P. (2013). Antimicrobial use for symptom management in patients receiving hospice and palliative care: A systematic review. Journal of Palliative Medicine, 16, 1568–1574. https://doi.org/10.1089/jpm.2013.0276 Schiffer, C.A., Mangu, P.B., Wade, J.C., Camp-Sorrell, D., Cope, D.G., El-Rayes, B.F., … Levine, M. (2013). Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 31, 1357–1370. https://doi.org​ /10.1200/JCO.2012.45.5733 Wierema, J., Konecny, P., & Links, M. (2013). Implementation of risk stratified antibiotic therapy for neutropenic fever: What are the risks? Internal Medicine Journal, 43, 1116–1124. https://doi.org​ /10.1111/imj.12251 Wright, J., & Paauw, D.S. (2013). Complications of antibiotic therapy. Medical Clinics of North America, 97, 667–679. https://doi.org/10.1016/j.mcna.2013.02.006

Rebecca Collins, MS, RN, OCN®, CHPN, NE-BC, CENP The author would like to acknowledge Maggie Chesnutt, MSN, RN, FNP, BC, CORLN, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Anxiety PROBLEM Anxiety is a “subjective feeling of distress, apprehension, tension, insecurity, or uneasiness, usually without a known stimulus or cause, and a fear of real or perceived threat to oneself” (Economou, 2017, p. 282).

ASSESSMENT CRITERIA (Acker, 2017; Pasacreta, Minarik, Nield-Anderson, & Paice, 2015) 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Anxiety related to a cancer diagnosis is a normal response to a life-threatening illness. b. Women are twice as likely as men to have an anxiety diagnosis. c. Men with anxiety will have an increased history of comorbid substance abuse. d. Anxiety increases in older adults and in those with prolonged or failed treatment regimens, surgery, or treatments that cause disfigurement, disability, and pain. e. Anxiety increases with loss of income and financial burden. f. Anxiety manifests with lack of family support and family conflicts related to the illness. g. Anxiety is linked to a history of psychiatric disorders, post-traumatic stress disorder, and poor coping skills. 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications. Medications that increase anxiety include stimulants, caffeine, thyroid medications, corticosteroids, antihistamines, anticholinergics, analgesics, anesthetics, bronchodilators, decongestants, epinephrine, and antihypertensives. 3. Ask the patient to describe symptoms in detail. a. Physical symptom examples include shortness of breath, palpitations, dry mouth, sweating, restlessness, flushing of face, tingling, trembling, sleep disturbances, headache, nausea or abdominal discomfort, chest pain, anorexia, urinary frequency, and diarrhea. b. Psychological symptom examples include feelings of apprehension, panic, excessive worries, fear of loss of control, fear of dying, inability to think clearly, irritability, and repetitive behaviors (e.g., pacing, rubbing hands, inability to relax). 4. Obtain history of the problem (Andersen et al., 2014; National Cancer Institute, n.d.; National Comprehensive Cancer Network®, 2013, 2018; Rucker & Gobel, 2014). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 89

Anxiety a. b. c. d.

Precipitating factors Onset and duration Treatment compliance Current support system

Signs and Symptoms

Action

•• Onset of anxiety (score of 0–4 on National Comprehensive Cancer Network Distress Thermometer)

Review current symptoms, both physical and psychological. Evaluate precipitating factors, duration, and severity. Rate distress using Distress Thermometer (0 = no distress; 4 = ongoing evaluation; 10 = severe distress). Offer support, active listening, and discussion of feelings. Encourage use of past coping skills, use of current antianxiety medications, or need for new medications or adjustment. Seek follow-up with physician and/or need for ongoing counseling.

•• Anxiety (score of 4 or more)

Identify if the patient is having a panic attack. What support is present with the patient? Has medication helped to decrease symptoms? If the patient feels as though symptoms cannot be controlled, encourage emergency department admission; call 911 and notify physician. Offer support, active listening, and discussion of feelings. Does the patient feel unmanaged physical or psychological symptoms that can also be interpreted as panic? Encourage use of past coping skills, use of current antianxiety medications, or need for new medications or adjustment. Seek follow-up with physician and/or need for ongoing counseling.

•• Physical and psychosocial symptoms (e.g., not in control) •• Severe panic

If the patient feels as though symptoms cannot be controlled, encourage emergency department admission; call 911 and notify physician.

Cross-references: Confusion/Change in Level of Consciousness, Dizziness Note. Based on information from National Comprehensive Cancer Network, 2013.

HOMECARE INSTRUCTIONS ••Continue any current medications, especially medications prescribed for anxiety. ••Seek available support systems. ••Find methods to deal with increased anxiety (e.g., music or art therapy, exercise, relaxation breathing). ••Identify what may trigger feelings of anxiety. ••Keep a written journal or calendar, noting the times of anxiety, onset, duration, and aggravating and alleviating factors. Share with the healthcare provider (Economou, 2017; Smith, Cope, Sherner, & Walker, 2014). 90 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Anxiety

Report the Following Problems

••Continued symptoms of anxiety despite use of medications and relaxation techniques ••Feelings of overwhelming sadness

Seek Emergency Care Immediately if Any of the Following Occurs

••Severe physical symptoms uncontrolled with standard medication ••Feelings of loss of control with thoughts of suicide

REFERENCES Acker, K.A. (2017). Anxiety. In K. Kuebler (Ed.), Integration of palliative care in chronic conditions: An interdisciplinary approach (pp. 211–223). Pittsburgh, PA: Oncology Nursing Society. Andersen, B.L., DeRubeis, R.J., Berman, B.S., Gruman, J., Champion, M.J., Massie, M.J., … Rowland, J.H. (2014). Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: An American Society of Clinical Oncology guideline adaptation. Journal of Clinical Oncology, 32, 1605–1619. https://doi.org/10.1200/JCO.2013.52.4611 Economou, D. (2017). Anxiety. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 282–284). St. Louis, MO: Elsevier. National Cancer Institute. (n.d.). NCI Contact Center—Cancer Information Service. Retrieved from https://www.cancer.gov/contact/contact-center National Comprehensive Cancer Network. (2013). NCCN Distress Thermometer for patients. Retrieved from https://radonc.ucsf.edu/sites/radonc.ucsf.edu/files/Patient%20Screening%20%20Forms_1.pdf National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Distress management [v.2.2018]. Retrieved from https://www.nccn.org​ /professionals/physician_gls/pdf/distress.pdf Pasacreta, J.V., Minarik, P.A., Nield-Anderson, L., & Paice, J.A. (2015). Anxiety and depression. In B.R. Ferrell, N. Coyle, & J. Paice (Eds.), Oxford textbook of palliative nursing (4th ed., pp. 366– 384). New York, NY: Oxford University Press. Rucker, Y., & Gobel, B.H. (2014). Anxiety. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 619–635). Burlington, MA: Jones & Bartlett Learning. Smith, P.R., Cope, D., Sherner, T.L., & Walker, D.K. (2014). Update on research-based interventions for anxiety in patients with cancer. Clinical Journal of Oncology Nursing, 18(Suppl.), 5–16. https://​ doi.org/10.1188/14.CJON.S3.5-16

Mary Murphy, RN, MS, AOCN®, ACHPN Terri Gross, RN, BS, CHPN

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92 . . . . . . . . Telephone Triage

Bleeding PROBLEM Bleeding can occur secondary to injury or disease- and treatment-related factors. Problems with coagulation (coagulopathies) resulting from the use of anticoagulants or thrombocytopenia can also play a role. Bleeding can be a life-threatening event if massive blood loss (hemorrhage) occurs or if bleeding occurs in vital organs, such as the intracranial, pericardial, or pulmonary spaces (Kurtin, 2016).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Bleeding can be caused by tumor invading surrounding structures or blood vessels, or the cancer may cause disseminated intravascular coagulation. Bleeding can also be secondary to thrombocytopenia. Thrombocytopenia, or decreased circulating platelets, can result from certain cancer types (e.g., leukemia), cancer treatments (e.g., radiation therapy, chemotherapy), underlying platelet disorders (e.g., idiopathic thrombocytopenia purpura, thrombotic thrombocytopenic purpura), coagulation abnormalities, splenomegaly, and invasion of tumor cells into the bone marrow (Kurtin, 2016). 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications and herbal remedies. Platelet function can be affected by many drugs, agents, and regimens. a. Common drugs (e.g., aspirin, nonsteroidal anti-inflammatory drugs, thiazide diuretics, tricyclic antidepressants, antibiotics, heparin) (Kurtin, 2016) b. Herbal agents (e.g., garlic, feverfew, ginkgo, ginger, green tea, turmeric) (McEwen, 2015) c. Chemotherapy regimens that include carboplatin, cisplatin, gemcitabine, or temozolomide (Kuter, 2015) d. Biologic agents (e.g., monoclonal antibodies, cytokines) (National Cancer Institute, 2013) 3. Ask the patient to describe symptoms in detail. a. If evident bleeding, is it slow and steady or spurting? b. If evident bleeding from a wound, describe the wound. c. Petechiae, usually seen when platelet count drops below 20,000/mm3 in dependent regions and over bony prominences d. Bruising e. Hemorrhagic vesicles inside the mouth or other mucous membranes Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 93

Bleeding f. Hematuria g. Gastrointestinal bleeding (e.g., melena, hematemesis) h. Mental status changes or headaches 4. Obtain history of the problem. a. Location of bleeding b. Precipitating factors (e.g., injury related, spontaneous) c. Onset and duration: When did bleeding start, and how long has it persisted? d. Estimated amount of blood loss: How many bandages have been used in an hour? If vaginal bleeding, what is the number of feminine pads used per hour? e. Relieving factors: Is bleeding stopped or slowed with direct pressure or other homecare measures? f. Any associated symptoms (e.g., light-headedness, pale skin color, cool or moist skin, thirst, rapid pulse) 5. Review past medical history. a. Use of anticoagulants b. Bleeding disorders c. New drugs used or exposure to toxic chemicals d. Recent invasive procedures e. Recent fall or other injury 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Penetrating wound with difficulty controlling bleeding •• Unconsciousness •• Signs of shock –– Light-headedness –– Pale, cold, or moist skin –– Thirst –– Rapid pulse •• Blood spurting from wound and cannot be controlled with direct pressure •• Exposed bone or deformity at injury site

Seek emergency care. Call an ambulance immediately.

•• Persistent bleeding longer than 10 minutes following direct pressure to wound •• Use of one or more feminine pads per hour •• Gaping, bleeding wound •• History of bleeding disorder or taking anticoagulant with bleeding •• Suspected thrombocytopenia with bleeding

Seek emergency care.

•• New bruises without significant trauma •• Petechial-appearing rash; little red or purple spots on the skin

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Hematuria, Hemoptysis

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Bleeding

HOMECARE INSTRUCTIONS (Damron et al., 2009; National Cancer Institute, 2010) ••To control active bleeding –– Stay calm. –– If possible, apply direct pressure for at least 10–15 minutes. Maintain pressure until bleeding stops. If bandage is saturated, do not remove; apply additional bandages on top. Try not to dislodge a clot. –– Lie down and elevate injured part above head (or above heart level). –– Apply an ice pack, which helps to control bleeding. ••For epistaxis –– Sit upright. –– Apply gentle pressure to nares. –– Apply cold compress. ••To reduce the risk of bleeding due to thrombocytopenia –– Avoid trauma, contact sports, and falls. –– Avoid sharp objects and tools. –– Avoid lifting heavy objects. –– Avoid intramuscular injections. –– Avoid medications that contain aspirin or ibuprofen. –– Avoid dental work, floss, toothpicks, and water picks. –– Avoid alcoholic beverages. –– Avoid forceful coughing, sneezing, vomiting, and nose blowing. –– Avoid constipation and enemas; follow bowel regimen as prescribed by provider to prevent straining. –– Avoid sex, vaginal douches, or tampons if platelet count is less than 50,000/mm3. –– Use an electric shaver instead of a razor blade. –– Use a nail file instead of nail clippers. –– Use a soft toothbrush. –– Use moisturizer on skin.

Report the Following Problems

(National Cancer Institute, 2010) ••Blood in urine, vomit, or stool ••Prolonged bleeding or bleeding that does not stop ••Excessive pad count during menstruation ••Swelling or bleeding occurring more than 24 hours after bleeding is under control ••Signs of infection, increased pain, drainage, fever, swelling, pus, streaks, or redness

Seek Emergency Care Immediately if Any of the Following Occurs ••Signs of shock ••Light-headedness ••Visual changes ••Pale, cold, or moist skin ••Excessive thirst

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 95

Bleeding ••Rapid pulse ••Uncontrolled bleeding with suspected thrombocytopenia ••Sudden severe headache, mental confusion, or changes in mood

REFERENCES Damron, B.H., Brant, J.M., Belansky, H.B., Friend, P.J., Samsonow, S., & Schaal, A. (2009). Putting evidence into practice: Prevention and management of bleeding in patients with cancer. Clinical Journal of Oncology Nursing, 13, 573–583. https://doi.org/10.1188/09.CJON.573-583 Kurtin, S. (2016). Alterations in hematologic and immune function. In J.K. Itano (Ed.), Core curriculum for oncology nursing (5th ed., pp. 322–339). St. Louis, MO: Elsevier. Kuter, D.J. (2015). Managing thrombocytopenia associated with cancer chemotherapy. Oncology, 29, 282–294. Retrieved from http://www.cancernetwork.com/oncology-journal/managing-thrombocyto penia-associated-cancer-chemotherapy McEwen, B.J. (2015). The influence of herbal medicine on platelet function and coagulation: A narrative review. Seminars in Thrombosis and Hemostasis, 41, 300–314. https://doi .org/10.1055/s-0035-1549089 National Cancer Institute. (2010). Bleeding problems. Retrieved from https://www.cancer.gov/ publications/patient-education/bleeding.pdf National Cancer Institute. (2013). Biological therapies for cancer. Retrieved from https://www.cancer. gov/about-cancer/treatment/types/immunotherapy/bio-therapies-fact-sheet#q10

Victoria Wochna Loerzel, PhD, RN, OCN®

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Bone Loss PROBLEM Nearly all cancers can have clinically significant negative effects on the skeleton. Cancer is a major risk factor for both generalized and local bone loss, with bone loss in patients with cancer substantially greater than in the general population. Cancer-associated bone loss is due to the direct effects of cancer cells and therapies, including chemotherapeutics, corticosteroids, aromatase inhibitors, and androgen deprivation therapy. The skeleton is the most common site of metastatic disease because cancer cells growing within bone induce osteoblasts and osteoclasts to produce factors that stimulate further cancer growth. Accordingly, skeletal effects have become increasingly important because of improved oncologic treatments that have enhanced both patient survival and longevity (Mayo Clinic, 2018). Osteopenia is a reduction in bone mass or bone mineral density. It is a less severe form of bone loss than osteoporosis (Drake, 2013). Multiple variables must be assessed when fielding problems relative to bone loss in a patient with cancer. Identifying the specific oncologic diagnosis and all concurrent medical diagnoses, as well as the individual’s medications, will give a comprehensive view of the risk factors due to bone loss. Osteoporosis is a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall, causing a pathologic fracture, or in serious cases, from sneezing or minor bumps. The term osteoporosis means “porous bone” (National Osteoporosis Foundation, n.d.-b, para. 2). Viewed under a microscope, healthy bone looks like a honeycomb. When osteoporosis occurs, the holes and spaces in the honeycomb become much larger. Osteoporotic bones have lost density or mass and contain abnormal tissue structure. As bones become less dense, they weaken and are more likely to break. People aged 50 or older who have broken a bone should ask a healthcare provider about a bone mineral density test (National Osteoporosis Foundation, n.d.-a). This test measures the amount of bone mineral in certain areas of bone. It is safe and painless and provides important information about bone health. Healthcare providers can use this information to make recommendations for promoting safety and best outcomes for patients with bone loss (National Osteoporosis Foundation, n.d.-b; see Table 1).

ASSESSMENT CRITERIA (National Osteoporosis Foundation, n.d.-a, n.d.-b) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 97

Bone Loss

Table 1. World Health Organization Definitions Based on Bone Density Levels Level

Definition

Normal

Bone density is within 1 SD (+1 or −1) of the young adult mean.

Low bone mass

Bone density is between 1 and 2.5 SD below the young adult mean (−1 to −2.5 SD).

Osteoporosis

Bone density is 2.5 SD or more below the young adult mean (−2.5 SD or lower).

Severe (established) osteoporosis

Bone density is more than 2.5 SD below the young adult mean, and there have been one or more osteoporotic fractures.

SD—standard deviation Note. Based on information from World Health Organization, 1994.

a. Breast and prostate cancer, lymphoma, and Hodgkin lymphoma prior to menopause b. Surgical removal of gonads c. Hormone therapy d. Certain chemotherapy e. Radiation therapy to bones f. Bone marrow or peripheral blood stem cell transplant 2. What medications is the patient taking? The following can lead to bone loss. This list may not include all medicines that may cause bone loss. a. Aluminum-containing antacids b. Select antiseizure medicines (e.g., phenytoin, phenobarbital) c. Aromatase inhibitors (e.g., anastrozole, exemestane, letrozole) d. Cancer chemotherapeutic drugs e. Cyclosporine A and FK506 (tacrolimus) f. Gonadotropin-releasing hormone (e.g., leuprolide, goserelin) g. Heparin h. Lithium i. Medroxyprogesterone acetate for contraception j. Methotrexate k. Proton pump inhibitors (e.g., esomeprazole, lansoprazole, omeprazole) l. Selective serotonin reuptake inhibitors (e.g., escitalopram, fluoxetine, sertraline) m. Steroids (glucocorticoids) (e.g., cortisone, prednisone) n. Tamoxifen (premenopausal use) o. Thiazolidinediones (e.g., pioglitazone, rosiglitazone) p. Thyroid hormones in excess 98 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Bone Loss 3. Review past medical history. a. Cushing syndrome b. Depression c. Eating disorders d. Hyperthyroidism e. Hyperparathyroidism f. Irregular periods g. Low levels of testosterone and estrogen in men h. Poor diet and malnutrition i. Premature menopause j. Sickle cell disease k. Weight loss 4. Assess for changes in activities of daily living and function.

HOMECARE INSTRUCTIONS ••Consume calcium and vitamin D for strong bones and for heart, muscles, and nerves to function properly. –– An inadequate supply of calcium over a lifetime contributes to the development of osteoporosis. Food sources of calcium include low-fat dairy products (e.g., milk, yogurt, cheese, ice cream); dark green, leafy vegetables (e.g., broccoli, collard greens, bok choy, spinach); sardines and salmon with bones; tofu; almonds; and foods fortified with calcium (e.g., orange juice, cereals, breads). –– Vitamin D plays an important role in calcium absorption and bone health. Food sources of vitamin D include egg yolks, saltwater fish, and liver. Adults should have vitamin D intakes of 600 IU daily up to age 70. Men and women aged 70 and older should increase their uptake to 800 IU daily. ••Smoking is harmful for the bones, heart, and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers and often go through menopause earlier. Smokers also may absorb less calcium from their diets. ••Avoid alcohol. Regular consumption of two to three ounces a day of alcohol may be damaging to the skeleton, even in young women and men. Those who drink heavily are more prone to bone loss and fracture from both poor nutrition and the increased risk of falling. ••Exercise regularly. Like muscle, bone is living tissue that responds to exercise by becoming stronger. –– Weight-bearing exercise is best for bone health because it forces the bones to work against gravity. –– Exercise should not put any sudden or excessive strain on bones. –– As extra insurance against fractures, healthcare professional recommendations for specific exercises should be followed (Kim et al., 2018). ••Preventing falls is important for individuals with bone loss (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2017). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 99

Bone Loss –– Falls can increase the likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. –– In addition to environmental factors, falls can also be caused by impaired vision or balance, chronic diseases that affect mental or physical functioning, and certain medications (e.g., sedatives, antidepressants). –– Individuals with bone loss should be aware of any physical changes that affect their balance or gait. These changes should be discussed with a healthcare provider. ••Consider treatment with therapeutic medications. Medications available for the prevention or treatment of osteoporosis include bisphosphonates, estrogen agonists and antagonists (selective estrogen receptor modulators), calcitonin, parathyroid hormone, estrogen therapy, hormone therapy, and RANK ligand inhibitor.

REFERENCES Drake, M.T. (2013). Osteoporosis and cancer. Current Osteoporosis Reports, 11, 163–170. https://doi​ .org/10.1007/s11914-013-0154-3 Kim, S.H., Seong, D.H., Yoon, S.M., Choi, Y.D., Choi, E., Song, Y., & Song, H. (2018). The effect on bone outcomes of home-based exercise intervention for prostate cancer survivors receiving androgen deprivation therapy: A pilot randomized controlled trial. Cancer Nursing, 41, 379–388. https:// doi.org/10.1097/NCC.0000000000000530 Mayo Clinic. (2018). Bone cancer. Retrieved from https://www.mayoclinic.org/diseases-conditions​ /bone-cancer/symptoms-causes/syc-20350217 National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2017). Osteoporosis overview. Retrieved from https://www.bones.nih.gov/health-info/bone/osteoporosis/overview#Prevention National Osteoporosis Foundation. (n.d.-a). Diagnosis information. Retrieved from https://www.nof​ .org/patients/diagnosis-information National Osteoporosis Foundation. (n.d.-b). What is osteoporosis and what causes it? Retrieved from https://www.nof.org/patients/what-is-osteoporosis World Health Organization. (1994). Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Geneva, Switzerland: Author.

Pamela J. Pearson, RN Sharon Rockwell, BSN, RN, OCN®, CRNI The authors would like to thank their institutional mentor, Kathleen Shannon Dorcy, PhD, RN, FAAN, Director of Clinical/Nursing Research, Education and Practice at Seattle Cancer Care Alliance, and Staff Scientist at Fred Hutchinson Cancer Research Center, for her help in reviewing this content. The authors would like to acknowledge Rae M. Norrod, MS, RN, AOCN®, CNS, and Carol Pilgrim, MSN, FNP-BC, AOCN®, for their contributions to this protocol that remain unchanged from the previous edition of this book.

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Confusion/Change in Level of Consciousness PROBLEM Confusion, or cognitive dysfunction, is a symptom or description of a person’s mental state with many subjective symptoms and objective behaviors. The patient may not be oriented to person, place, or time, or the patient’s behaviors or responses may be inappropriate. A change in level of consciousness can be described as agitation, restlessness, sleepiness, or somnolence, or the patient may be difficult or unable to arouse (Cancer.Net, 2016; Walker, 2016).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Confusion or a change in level of consciousness can result from multiple causes. These are not limited to primary neural cancers (e.g., glioma, astrocytoma), cerebral involvement from other cancers (e.g., lymphoma, acute lymphocytic leukemia), cerebral hemorrhage secondary to thrombocytopenia, metabolic disorder (e.g., abnormal ammonia level), systemic or local cancer therapies, electrolyte disorder (e.g., hypo- or hypernatremia, hypercalcemia, hypomagnesemia, hypo- or hyperglycemia, dehydration), and infection (e.g., urinary tract infection in older adults without symptoms, sepsis in neutropenic patients) (Cancer.Net, 2016; Walker, 2016). 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications and complementary or “natural” therapies. Ask about antinausea medications, steroids, and other medications used to treat allergies (Cancer.Net, 2016). 3. Ask the patient (or caregiver) to describe symptoms in detail (Walker, 2016). a. When did the patient start exhibiting symptoms? b. Are the symptoms constant or intermittent? Do they occur at a certain time of day/night? c. Is the patient as awake as usual? If not, describe. d. Is the patient restless or agitated? Is he or she paranoid or delusional? e. Is the patient confused about time, place, and person, or just one or two of these variables? f. Is the patient oriented, yet inappropriate? 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration: Has this ever happened before? c. Relieving factors d. Any associated symptoms (e.g., headache, recent fall, seizure) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 101

Confusion/Change in Level of Consciousness 5. Review past medical history. a. Diabetes mellitus b. Cardiac history c. Psychiatric history d. Any recent new diagnosis (e.g., liver metastasis) 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Unconsciousness •• Unable to arouse •• Seizure •• Altered level of consciousness and any of the following: –– Severe headache –– Chest pain or discomfort –– Rapid heartbeat –– Diabetic; unresponsive to homecare measures –– Severe abdominal pain –– Pain worsens on sitting or standing –– Temperature higher than 100°F

Seek emergency care. Call an ambulance immediately.

•• Altered level of consciousness, aroused, with any of the following: –– Headache, fever, or stiff and painful neck –– Recent head injury or trauma –– Persistent fever –– Diarrhea/vomiting; unable to take in fluids –– Suspected thrombocytopenia

Seek emergency care.

•• New or increased confusion •• Change in level of alertness •• Diarrhea/vomiting •• Mood changes, irritable, tearful, agitated •• Change in vision •• Loss of movement in limbs •• Dizziness •• Lethargy •• Tremors/shakiness •• Not able to ambulate •• Difficulty swallowing

Seek urgent care within 24 hours.

•• Sleeplessness •• Numbness and tingling •• Change in energy level

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Depressed Mood, Dizziness, Fatigue, Headache, Paresthesia (Peripheral Neuropathy) Note. Based on information from Gerstein, 2017.

HOMECARE INSTRUCTIONS •• Follow homecare instructions for sleep disturbance, fatigue, or paresthesia as appropriate. ••Employ comfort measures, such as a quiet, well-lit room, with familiar people and things. 102 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Confusion/Change in Level of Consciousness ••Post a calendar and a clock in clear sight to review. ••Create safety measures to reduce the risk of falls or self-injury. ••Refer to hospice if appropriate.

Seek Emergency Care Immediately if Any of the Following Occurs ••Unconsciousness ••Inability to arouse ••Seizure ••Altered level of consciousness

REFERENCES Cancer.Net. (2016). Mental confusion or delirium. Retrieved from http://www.cancer.net/navigating​ -cancer-care/side-effects/mental-confusion-or-delirium Gerstein, P.S. (2017). Delirium, dementia and amnesia in emergency medicine. Retrieved from https://​ emedicine.medscape.com/article/793247-overview Walker, J. (2016). Introduction to neurologic complications. In D. Camp-Sorrell & R. Hawkins (Eds.), inPractice. Retrieved from https://www.inpractice.com/textbooks/oncology-nursing/symptom​ -management/neurologic-toxicity/chapter-pages/page-1.aspx

Nicole Korak, MSN, FNP-C

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Constipation PROBLEM Constipation is defined as a decreased frequency in defecation, difficulty passing hard stools, straining with bowel movements, discomfort with bloating or cramping, or a sensation of incomplete evacuation. It occurs most frequently in older adults and is more common in women. Constipation is a common problem in patients with cancer caused secondary to pressure or blockage by a tumor mass or from the complications of cancer treatment (Thorpe, Byar, Conley, Held-Warmkessel, & Ramsdell, 2017). Constipation in patients with cancer is a common complaint, yet actual incidence frequency is not well documented. The prevalence of constipation in the palliative care population is 40%–64% and can be as high as 70%–100% in hospitalized patients with cancer (Thorpe et al., 2017).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Surgical anastomosis may lead to narrowing of the colon lumen from scar tissue or tumor obstruction. b. Recent treatments affecting diet, fluid intake, or mobility can result in constipation. Dietary changes, including a decrease in fluid and fiber or a decrease in mobility and exercise, can contribute to the development of constipation. c. Metabolic changes causing constipation include dehydration, hypokalemia, and hypocalcemia (McMillan, Tofthagen, Small, Karver, & Craig, 2013). 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications and complementary therapies. a. Constipation is the most common side effect of opioid therapy (Siemens, Gaertner, & Becker, 2015). Opioid-induced constipation results from both organ and cellular effects. Inhibition of propulsion through the gastrointestinal tract, an increase of fluid absorption in the large and small intestines, and an increase in anal sphincter and pyloric tone are all organ effects that can lead to constipation caused by opioids. At a cellular level, opioids bind with receptors in the enteric nervous system, decreasing peristalsis (Nelson & Camilleri, 2016). b. Constipation is a gastrointestinal adverse effect of a number of chemotherapy agents, most commonly alkylating agents (e.g., cisplatin, cyclophosphamide, oxaliplatin), antimetabolites (e.g., 5-fluorouracil, capecitabine, gemcitabine, methotrexate), anthracyclines (e.g., doxorubicin), immunoTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 105

C o n s t i pat i o n modulating agents (e.g., thalidomide), mitotic inhibitors (e.g., cabazitaxel, docetaxel, paclitaxel, vincristine), and topoisomerase inhibitors (e.g., irinotecan) (McQuade, Stojanovska, Abalo, Bornstein, & Nurgali, 2016). c. Anticholinergic preparations (e.g., gastrointestinal antispasmodics, antiparkinsonian agents, antidepressants) may cause decreased sensitivity to the defecation reflexes and decreased gut motility. d. Antiemetics, such as 5-HT3 receptor antagonists (e.g., ondansetron, granisetron, palonosetron) e. Phenothiazines f. Calcium- and aluminum-based antacids g. Diuretics h. Tricyclic antidepressants i. Antihypertensive agents j. Nonsteroidal anti-inflammatory drugs k. Vitamin supplements (e.g., iron, calcium) l. Tranquilizers and sleeping medications m. General anesthesia 3. Ask the patient to describe a typical bowel movement. a. Frequency b. Amount and characteristics of stool c. Timing 4. Ask the patient to describe symptoms in detail. a. Date of last bowel movement b. How does stool differ from normal in size, color, and consistency? c. Was there a distinct odor change? d. Was blood present in the stool? e. Have you had diarrhea? f. Was the stool difficult to pass? g. Were there any associated symptoms (e.g., abdominal or rectal fullness, bloating, nausea, vomiting, excessive gas, pain, cramping)? h. Has there been any perineal or rectal discomfort? 5. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors i. What have you tried, and what have been the results? ii. What have you done in the past if you experienced constipation, including use of stool softeners, fiber agents, laxatives, enemas, or suppositories? What was the effect? 6. Assess laboratory values to assist in metabolic evaluation and risk of injury, specifically platelet count. 7. Review past medical history (e.g., diagnoses, surgeries, treatments). 8. Assess for changes in activities of daily living and function. 9. Obtain dietary history. a. Patient diet 106 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

C o n s t i pat i o n b. Decrease in food or fluid consumption c. Decrease in dietary fiber Signs and Symptoms

Action

•• Severe abdominal pain, swelling, or vomiting •• Vomiting brown, yellow, or green bitter-tasting emesis •• Significant rectal bleeding with no history of hemorrhoids or bleeding with constipation

Seek emergency care.

•• No bowel movement in five to seven days, unresponsive to homecare measures •• Recent surgery or injury •• History of diverticulitis and fever •• Fever for 24–48 hours with unknown cause •• Inability to pass gas

Seek urgent care within 24 hours.

•• Dry, hard stools •• Pain with bowel movements •• Recent change in stools or bowel habits •• Recent change in medications •• Recent decrease in activity •• Recent decrease in dietary intake (fiber) and fluids

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Anorexia, Diarrhea

HOMECARE INSTRUCTIONS ••Assist the patient in finding acute constipation relief, providing guidance for the use of stool softeners and laxatives as recommended by the physician. ••Ongoing prevention of constipation is the goal for homecare instructions to avoid chronic or recurring constipation episodes (Engelking, 2008). –– Record bowel movements daily, including time of day, description, and amount. –– Establish a daily exercise routine, including diaphragmatic breathing and abdominal exercises to increase muscle tone. –– Drink 8–10 glasses of clear liquid daily if not contraindicated; carry a water bottle throughout the day. –– Include high-fiber foods in the daily diet (e.g., wheat bran, whole grain breads, oatmeal, peanut butter, beans, fruits, vegetables). An increased fiber intake must be accompanied with an increased fluid intake. Be cautious if taking opioids or if a structural blockage is suspected. –– Establish a regular time for a daily bowel movement. After breakfast is ideal, as this is when contractions in the intestines are the strongest. –– Drink hot beverages 30 minutes before defecation. Limit caffeinated drinks, as they can act as diuretics. –– Initiate a prophylactic bowel regimen per provider with chronic opioid use or in chemotherapy regimens with a high incidence of constipation. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 107

C o n s t i pat i o n ••Rectal agents should be avoided in patients with cancer at risk of thrombocytopenia, leukopenia, or mucositis from the cancer or its treatment (National Cancer Institute, 2018; Woolery et al., 2008).

Report the Following Problems

(Engelking, 2008) ••Persistent or worsening constipation ••Ineffective homecare measures ••Abdominal pain or cramping ••Vomiting ••Fever

Seek Emergency Care Immediately if Any of the Following Occurs ••Rectal bleeding ••Passing black-tarry stool ••Severe abdominal pain and swelling ••Vomiting brown, yellow, or green bitter-tasting emesis

REFERENCES Engelking, C. (2008). Diarrhea and constipation. In R.A. Gates & R.M. Fink (Eds.), Oncology nursing secrets (3rd ed., pp. 372–397). St. Louis, MO: Elsevier Mosby. McMillan, S.C., Tofthagen, C., Small, B., Karver, S., & Craig, D. (2013). Trajectory of medication-induced constipation in patients with cancer [Online exclusive]. Oncology Nursing Forum, 40, E92–E100. McQuade, R.M., Stojanovska, V., Abalo, R., Bornstein, J.C., & Nurgali, K. (2016). Chemotherapyinduced constipation and diarrhea: Pathophysiology, current and emerging treatments. Frontiers in Pharmacology, 7, 414. https://doi.org/10.3389/fphar.2016.00414 National Cancer Institute. (2018). Gastrointestinal complications (PDQ®) [Health professional version]. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications​ /HealthProfessional Nelson, A.D., & Camilleri, M. (2016). Opioid-induced constipation: Advances and clinical guidance. Therapeutic Advances in Chronic Disease, 7, 121–134. https://doi.org/10.1177/2040622315627801 Siemens, W., Gaertner, J., & Becker, G. (2015). Advances in pharmacotherapy for opioid-induced constipation—A systematic review. Expert Opinion on Pharmacotherapy, 16, 515–532. https://doi. org/10​.1517/14656566.2015.995625 Thorpe, D.M., Byar, K.L., Conley, S., Held-Warmkessel, J., & Ramsdell, M.J. (2017). Constipation. Retrieved from https://www.ons.org/pep/constipation Woolery, M., Bisanz, A., Lyons, H.F., Gaido, L., Yenulevich, M., Fulton, S., & McMillan, S.C. (2008). Putting evidence into practice: Evidence-based interventions for the prevention and management of constipation in patients with cancer. Clinical Journal of Oncology Nursing, 12, 317–337. https:// doi.org/10.1188/08.CJON.317-337

Elizabeth Abernathy, RN, MSN, AOCNS®

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Cough PROBLEM Cough is defined as a pulmonary protective reflex that serves as a defense mechanism to clear the airways from both secretions and inhaled particles. It can occur acutely (lasting for a maximum of three weeks), subacutely (three to eight weeks), or chronically (lasting longer than eight weeks) (Sherry, 2014). Cough is common among patients with cancer, occurring in almost 43% of general patients (Chan, Tse, & Sham, 2015) and up to 90% of those with advanced lung cancer (Iyer, Roughley, Rider, & Taylor-Stokes, 2014). In nonmalignant situations, acute cough is related largely to infection; subacute cough occurs most commonly following an acute infectious process; and chronic cough can be related to irritants, medications, or conditions such as asthma or gastroesophageal reflux disease (Sherry, 2014).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Cough may result from many malignant processes, including primary or metastatic lung tumors, pleural or pericardial effusions, and carcinomatosis (Molassiotis, Smith, Mazzone, Blackhall, & Irwin, 2017). b. Radiation therapy has a cytotoxic effect on underlying lung tissue, which can lead to radiation-induced lung injury. It also lowers the production of surfactant in the lung, which can lead to cough. Long-term side effects of radiation therapy include pneumonitis and fibrosis, which frequently lead to cough months following the completion of treatment. c. Cough can be a symptom of cardiac dysfunction from chemotherapy or biologic agent exposure (e.g., anthracyclines, trastuzumab). Other agents (e.g., bleomycin, cyclophosphamide) can result in a pulmonary toxicity that causes cough (Olsen, LeFebvre, & Brassil, in press). d. Treatment with certain immunotherapy agents (e.g., ipilimumab, nivolumab, pembrolizumab) can result in immune-related adverse events such as pneumonitis, which is commonly manifested by cough and can result in death if left untreated (Chuzi et al., 2017; Ventola, 2017). 2. What medications is the patient taking? Obtain medication history, including antineoplastic agents as well as prescription and over-the-counter medications. Approximately 5%–20% of patients on angiotensin-converting enzyme inhibitor therapy develop a dry, nonproductive cough within the first few weeks of beginning therapy (Pereira et al., 2016). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 109

Cough 3. Ask the patient to describe symptoms in detail. a. Elevated respiratory and pulse rate b. Associated wheezing or rhonchi (ask to speak to the patient and listen directly, if possible) c. Associated chest pain, dyspnea, or fever d. Productive versus nonproductive cough: If productive, qualify and quantify sputum production (amount, color, with or without blood). e. Associated cyanosis or pallor f. Timing of symptoms: Does it occur all day or only in the morning? Are there any aggravating factors? 4. Obtain history of the problem, including acute versus chronic symptoms. 5. Review past medical history. a. Comorbid lung conditions (e.g., asthma or chronic obstructive pulmonary disease, pneumonia, bronchitis, recent upper or lower respiratory tract infection, tuberculosis) b. Underlying cardiac disease (e.g., congestive heart failure, cardiomegaly) c. Gastroesophageal reflux disease d. Obesity e. Detailed smoking history, including types, amounts, and length of time used; exposure to secondhand smoke f. Allergies (including environmental irritants) g. Recent exposure to an ill individual h. Exposure to occupational irritants 6. Assess for changes in activities of daily living and function.

Signs and Symptoms

Action

•• Sudden, unexpected increase in dyspnea at rest •• Chest pain •• Frothy pink sputum or gross hemoptysis •• Facial swelling •• Change in mental status

Seek emergency care immediately.

•• Increasing dyspnea with activity •• Non-neutropenic fever •• Increased edema or swelling •• Change in cough or sputum production •• Uncontrollable cough •• Wheezing, rhonchi, or crackles

Seek medical care within 24 hours.

•• Subacute or chronic cough, lasting more than three weeks

Follow homecare instructions and seek medical care if no improvement within 24–48 hours.

Cross-references: Dyspnea Note. Based on information from Glennon, 2015; Sherry, 2014.

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Cough

HOMECARE INSTRUCTIONS ••Comply with medical therapy (e.g., antibiotics, antitussives, bronchodilators, opioids, proton pump inhibitors), respiratory treatment, and oxygen, as prescribed. ••Drink plenty (1–2 L) of fluids (unless restricted because of cardiac dysfunction or kidney disease) to help thin out secretions (unless underlying congestive heart failure is present). ••Avoid precipitating factors that worsen cough (e.g., perfumes, tobacco smoke, cold or dry air). ••Consider use of a warm humidifier (cold humidified air may lead to bronchospasm). ••Monitor for fever or any sign of infection, and avoid contact with individuals who are sick.

Report the Following Problems

••Fever (temperature higher than 101.5°F [38.6°C], or 100.4°F [38.1°C] if receiving chemotherapy) ••Change in sputum production (color, hemoptysis) ••Swelling of the feet or hands ••Unrelieved heartburn symptoms, if applicable

Seek Emergency Care Immediately if Any of the Following Occurs

••Worsening dyspnea, especially if accompanied by chest pain or gross hemoptysis ••Increased work of breathing (elevated respiratory or heart rate)

REFERENCES Chan, K.-S., Tse, D.M.W., & Sham, M.M.K. (2015). Dyspnoea and other respiratory symptoms in palliative care. In N. Cherny, M. Fallon, S. Kaasa, R.K. Portenoy, & D.C. Currow (Eds.), Oxford textbook of palliative medicine (5th ed., pp. 421–434). Oxford, UK: Oxford University Press. Chuzi, S., Tavora, F., Cruz, M., Costa., R., Chae, Y.K., Carneiro, B.A., & Giles, F.J. (2017). Clinical features, diagnostic challenges, and management strategies in checkpoint inhibitor-related pneumonitis. Cancer Management and Research, 9, 207–213. https://doi.org/10.2147/CMAR.S136818 Glennon, C. (2015). Dyspnea. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 283–317). Pittsburgh, PA: Oncology Nursing Society. Iyer, S., Roughley, A., Rider, A., & Taylor-Stokes, G. (2014). The symptom burden of non-small cell lung cancer in the USA: A real-world cross-sectional study. Supportive Care in Cancer, 22, 181–187. https://doi.org/10.1007/s00520-013-1959-4 Molassiotis, A., Smith, J.A., Mazzone, P., Blackhall, F., & Irwin, R.S. (2017). Symptomatic treatment of cough among adult patients with lung cancer: CHEST guideline and expert panel report. Chest, 151, 861–874. https://doi.org/10.1016/j.chest.2016.12.028 Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Pereira, A.N.P., Júnior, R.A., Macedo, C.R.B., Teixeira, R.R.D.N., Magalhães, I.R., Sondré, D.S., … Muniz, J.Q.V. (2016). Angiotensin-converting enzyme inhibitor-induced cough prevalence in refractory hypertensive patients. Journal of Hypertension and Management, 2, 15. https://doi.org​ /10.23937/2474-3690/1510015 Sherry, V. (2014). Cough. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 183–188). Pittsburgh, PA: Oncology Nursing Society. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 111

Cough Ventola, C.L. (2017). Cancer immunotherapy, part 2: Efficacy, safety, and other clinical considerations. Pharmacy and Therapeutics, 42, 452–463.

Heather Thompson Mackey, MSN, RN, ANP-BC, AOCN®

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Deep Vein Thrombosis PROBLEM Deep vein thrombosis (DVT), a type of venous thromboembolism, is a partial or complete occlusion of blood flow in the deep veins caused by a thrombus (clot) (Robison, 2017). A DVT may occur in any vein but is most commonly found in the calves, thighs, or pelvis.

ASSESSMENT CRITERIA (Manasanch & Lozier, 2013; Rodriguez, 2014; Story, 2014) 1. What is the cancer diagnosis, and what treatment is the patient receiving? DVT is most commonly seen in patients with cancer of the lung, pancreas, stomach, brain, breast, ovary, prostate, bladder, or colon, or with multiple myeloma or acute promyelocytic leukemia. Risk factors for DVT include sepsis, presence of a venous access device, cardiac disease, obesity, thrombocytosis, lupus, polycythemia vera, recent surgery, bedridden status, recent casting of extremities, infections, and fractures. 2. What medications is the patient taking? Obtain medication history. a. Dietary supplements and herbs b. COX-2 inhibitors c. Medications used to treat atrial fibrillation d. Nonsteroidal anti-inflammatory drugs e. Anticoagulants f. Immunomodulatory agents such as thalidomide and lenalidomide with corticosteroids 3. Ask the patient to describe symptoms in detail. a. Pain, tenderness, or a feeling of tightness in the calf, especially when walking b. Vein distension in lower legs c. Tenderness or warmth over the involved vein d. Calf pain by dorsiflexion of foot and knee at 30° flexion e. Fever f. Positive Homan sign g. Swelling or discoloration in the calf; swelling of more than 3 cm in circumference in symptomatic leg 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 113

Deep Vein Thrombosis d. Any associated symptoms (e.g., chest pain, shortness of breath) 5. Review past medical history (increased risk). a. History of DVT, phlebitis, or pulmonary embolism b. Complex medical illness (e.g., liver, cardiac, or renal disease) 6. Assess for changes in activities of daily living and function, including immobility and lengthy travel by car or plane. 7. Ask the patient about any recent joint replacement surgery, major surgery, trauma or recent fracture, application of a cast, or peripheral vascular disease. Signs and Symptoms

Action

•• Chest pain or shortness of breath

Seek emergency care. Call an ambulance immediately.

•• History of risk factors with symptoms of pain, redness, positive Homan sign, warmness at site, pain with ambulation, tightness and tenderness in calf

Seek emergency care.

Note. Based on information from O’Leary, 2018; Rodriguez, 2014.

HOMECARE INSTRUCTIONS (Kitchen, Lawrence, Speicher, & Frumkin, 2016) ••Elevate leg. ••Avoid constrictive clothing. ••Reduce ambulation until seen by the physician. ••Change positions frequently. ••Do not rub the affected site. ••Do not apply ice or heat unless instructed by the physician. ••Report changes in condition immediately. ••Do not cancel office appointments for any reason. ••Seek medical attention immediately if the symptoms worsen or recur, even if they are in an opposite limb. ••Continue anticoagulant medications.

Seek Emergency Care Immediately if Any of the Following Occurs ••Shortness of breath (sudden onset) ••Crackles/wheezes, rales ••Chest pain (increased with deep breathing) ••Hemoptysis (late symptom) ••Cough, diaphoresis, or syncope ••Unexplained back or abdominal pain ••Fever (low grade) ••Tachypnea (more than 24 breaths/minute) ••Anxiety, apprehensiveness, or restlessness

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REFERENCES Kitchen, L., Lawrence, M., Speicher, M., & Frumkin, K. (2016). Emergency department management of suspected calf-vein deep venous thrombosis: A diagnostic algorithm. Western Journal of Emergency Medicine, 17, 384–390. https://doi.org/10.5811/westjem.2016.5.29951 Manasanch, E.E., & Lozier, J.N. (2013). Venous thromboembolism. In G.P. Rodgers & N.S. Young (Eds.), The Bethesda handbook of clinical hematology (3rd ed., pp. 311–327). Philadelphia, PA: Lippincott Williams & Wilkins. O’Leary, C.M. (2018). Bleeding and thrombosis. In M. Kaplan (Ed.), Understanding and managing oncologic emergencies: A resource for nurses (3rd ed., pp. 1–44). Pittsburgh, PA: Oncology Nursing Society. Robison, J. (2017). Hematologic emergencies. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 377–398). St. Louis, MO: Elsevier. Rodriguez, A.L. (2014). Bleeding and thrombotic complications. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 287–316). Burlington, MA: Jones & Bartlett Learning. Story, K.T. (2014). Deep venous thrombosis. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 349–361). Pittsburgh, PA: Oncology Nursing Society.

Mary Murphy, RN, MS, AOCN®, ACHPN Terri Gross, RN, BS, CHPN

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Depressed Mood PROBLEM A depressed mood is a feeling of sadness, disappointment, or upset, which may affect energy level, appetite, and sleep patterns. Feelings of depression are very common and normal responses for patients diagnosed with cancer and are often experienced by caregivers as well. The stress surrounding a cancer diagnosis may result in worries or fear of death, suffering, pain, loss of role, and more. Grief is normal for patients and loved ones as they experience lifestyle changes secondary to a cancer diagnosis. A sadness that persists for a long period of time or interferes with daily activities needs to be addressed. Clinical depression has been reported in one out of every four individuals with cancer (American Cancer Society, 2016).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Recent diagnosis or recurrence, treatment failure, advanced disease stage, unrelieved symptoms (particularly pain), and body image issues following recent disfiguring surgery may be associated with a depressed mood (Fang et al., 2014). The prevalence of depression among patients with cancer is 5%–16% (Walker et al., 2013). Because fatigue and depression occur concurrently, fatigue can be a cue for the practitioner to investigate for depression (Rhondali et al., 2012). b. Cancers with higher rates of suicide (Carlsson et al., 2013; Lydiatt, Moran, & Burke, 2009; Turaga, Malafa, Jacobsen, Schell, & Sarr, 2011; Urban et al., 2013) i. Head and neck ii. Prostate iii. Pancreatic iv. Lung 2. What medications is the patient taking? Obtain medication history. Many common medications (e.g., interferons, analgesics, steroids, hormones, anxiolytics, anticonvulsants, antihypertensives) prescribed for patients with cancer can have depression as a side effect. 3. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors d. Any associated symptoms (e.g., sadness, crying, insomnia, change in appetite, change in sleep pattern, suicidal tendencies) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 117

Depressed Mood 4. Review past medical history. a. Age (younger people seem to adapt more poorly than older people) b. History of depression or substance abuse i. Include any history of sadness, lasting more than two weeks, unrelated to illness or a major life event. ii. Ask the questions “Are you feeling depressed?” (Anguiano, Mayer, Piven, & Rosenstein, 2012) and “What have you been enjoying over the past two weeks?” iii. Family history of depression or substance abuse c. History of myocardial infarction, surgical procedures d. Recent body image changes e. Hypothyroidism f. Addison disease, Cushing disease g. Diabetes mellitus h. Metabolic abnormalities (e.g., electrolytes, calcium, vitamin B12, folate) (Valentine, 2015) 5. Obtain social history, including use of alcohol, illicit drugs, and tobacco. 6. Assess for changes in activities of daily living and function. 7. Assess for the following criteria: a. Frequent somatic complaints, such as frequent calls, office visits, and emergency department visits i. More than five visits per year ii. Multiple unexplained symptoms iii. Irritable bowel syndrome b. Work, family, or other relationship problems c. History of postpartum mood disorders d. Perimenopausal status (Jaqtap, Prasad, & Chaudhury, 2016) e. Spouse with depressive illness (Ahn, Kim, & Zhang, 2016) f. Recent bereavement or loss (e.g., death, divorce) g. Low income status or financial duress (Wilmot & Dauner, 2017) Signs and Symptoms A Are five or more of the following signs or symptoms present most of the day, nearly every day, during the same two-week period? •• Loss of interest or pleasure in activities* •• Depressed mood, feeling sad or empty* •• Hopelessness •• Insomnia or hypersomnia •• Significant weight loss or decrease or increase in appetite •• Psychomotor agitation or retardation (as observed by others) •• Fatigue or loss of energy •• Decreased or no interest in sexual activities

Action Yes—Go to B. No—Go to C.

(Continued on next page)

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Depressed Mood (Continued)

Signs and Symptoms

Action

•• Feelings of worthlessness or excessive or inappropriate guilt • • Diminished ability to think or concentrate or indecisiveness •• Recurrent thoughts of death, suicidal ideation with or without a plan, or suicide attempt or specific plan B Not accounted for by: •• Bereavement •• General medical condition or treatment

Yes—Go to D. No—Go to C.

C Are any of the symptoms attributable to side effects of treatment? Describe signs or symptoms related to treatment (e.g., fatigue, difficulty sleeping, poor appetite).

Yes—Provide homecare instructions. No—Go to D.

D •• Is the patient suicidal? •• What plans for suicide does the patient have? •• How lethal are the plans? •• Is there a gun in the house? •• Lethal medication available? •• Social isolation? •• Amputation? •• Emotional and physical exhaustion? •• Sensory loss? •• Inability to eat or swallow? •• Loss of bowel or bladder control? •• Impulsive? •• Severe fatigue? •• Poor prognosis? •• Use of alcohol or substances? •• Psychotic (hear voices telling them what to do)? •• Males are at a higher risk.

Yes—Seek emergency care immediately. May need to call an ambulance. May need to pursue voluntary or involuntary admission to hospital. Yes, but no plan— Continue talking and call a prescriber. No—Schedule an appointment with a mental health provider.

If the patient meets criteria for suicidal thoughts (D), see the following options. Location of Patient Home

Action Keep on the phone. Can the family bring the patient to the clinic or emergency department? If not, call 911 to take the patient to the nearest emergency department. Because this can be a life-or-death situation, family can be notified without fear of violating the Health Insurance Portability and Accountability Act. Document suicidal remarks, gestures, or self-destructive comments or behaviors in the patient’s medical record. (Continued on next page)

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Depressed Mood (Continued)

Location of Patient Clinic

Action Assess social supports. Mobilize as much of the patient’s support system as possible. Alert the healthcare team. Get someone to stay with the patient. Document suicidal remarks, gestures, or self-destructive comments or behaviors in the patient’s medical record. If there is inadequate staff or assistance to monitor and control the patient’s behavior, call 911.

* At least one of these must be present. Cross-references: Anxiety, Fatigue, Menopausal Symptoms Note. Based on information from American Psychiatric Association, 2013; Roth & Wiesel, 2015.

HOMECARE INSTRUCTIONS ••Practice patience because treatments for depression may take weeks to months to deliver noticeable improvement. ••Recognize and know symptoms because depression can recur. ••Review any written materials to help with depressed mood. Consider cliniciansuggested support groups. ••Consider grief counseling, if applicable. ••Draw on personal strengths and use cognitive strategies for coping. ••Keep crisis hotline numbers readily available (National Suicide Prevention Lifeline [800-273-TALK (8255)]).

SOURCES FOR SUPPORT GROUPS AND INFORMATION This list is not all inclusive of resources available. ••American Cancer Society: www.cancer.org; 800-227-2345 ••American Psychosocial Oncology Society: www.apos-society.org; 866-276-7443 ••CancerCare: www.cancercare.org; 800-813-4673 ••Depression.org: www.depression.org; 800-239-1265 ••Depression and Bipolar Support Alliance: www.dbsalliance.org; 800-826-3632 ••Mental Health America: www.mentalhealthamerica.net; 800-969-6642 ••National Alliance on Mental Illness: www.nami.org; 703-524-7600 or 888-999NAMI ••National Cancer Institute Cancer Information Service: www.cancer.gov/contact; 800-422-6237 ••U.S. Department of Health and Human Services: www.hhs.gov; 202-619-0257 or 877-696-6775 120 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Depressed Mood

REFERENCES Ahn, S., Kim, S., & Zhang, H. (2016). Changes in depressive symptoms among older adults with multiple chronic conditions: Role of positive and negative social support. International Journal of Environmental Research and Public Health, 26, 14. https://doi.org/10.3390/ijerph14010016 American Cancer Society. (2016). Anxiety, fear and depression: Having cancer affects your emotional health. Retrieved from https://www.cancer.org/treatment/treatments-and-side-effects/emotional-side​ -effects/anxiety-fear-depression.html American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-V®. Arlington, VA: Author. Anguiano, L., Mayer, D.K., Piven, M.L., & Rosenstein, D. (2012). A literature review of suicide in cancer [Online exclusive]. Cancer Nursing, 35, E14–E26. https://doi.org/10.1097/NCC​.0b013e31822fc76c Carlsson, S., Sandin, F., Fall, K., Lambe, M., Adolfsson, J., Stattin, P., & Bill-Axelson, A. (2013). Risk of suicide in men with low-risk prostate cancer. European Journal of Cancer, 49, 1588–1599. https://​ doi.org/10.1016/j.ejca.2012.12.018 Fang, C.-K., Chang, M.-C., Chen, P.-J., Lin, C.-C., Chen, G.-S., Lin, J., … Li, Y.-C. (2014). A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer. Supportive Care in Cancer, 22, 3165–3174. https://doi.org/10.1007/s00520-014-2290-4 Jaqtap, B.L., Prasad, B.S.V., & Chaudhury, S. (2016). Psychiatric morbidity in perimenopausal women. Industrial Psychiatry Journal, 25, 86–92. https://doi.org/10.4103/0972-6748.196056 Lydiatt, W., Moran, J., & Burke, W.J. (2009). A review of depression in the head and neck cancer patient. Clinical Advances in Hematology and Oncology, 7, 397–403. Rhondali, W., Perceau, E., Berthiller, J., Saltel, P., Trillet-Lenoir, V., Tredan, O., … Filbet, M. (2012). Frequency of depression among oncology outpatients and association with other symptoms. Supportive Care in Cancer, 20, 2795–2802. https://doi.org/10.1007/s00520-012-1401-3 Roth, A., & Wiesel, T.R.W. (2015). Psychiatric emergencies. In J.C. Holland, W.S. Breitbart, P.B. Jacobsen, M.J. Loscalzo, R. McCorkle, & P.N. Butlow (Eds.), Psycho-oncology (3rd ed., pp. 267–273). https://doi.org/10.1093/med/9780199363315.003.0035 Turaga, K.K., Malafa, M.P., Jacobsen, P.B., Schell, M.J., & Sarr, M.G. (2011). Suicide in patients with pancreatic cancer. Cancer, 117, 642–647. https://doi.org/10.1002/cncr.25428 Urban, D., Rao, A., Bressel, M., Neiger, D., Solomon, B., & Mileshkin, L. (2013). Suicide in lung cancer: Who is at risk? Chest, 144, 1245–1252. https://doi.org/10.1378/chest.12-2986 Valentine, A.V. (2015). Mood disorders. In J.C. Holland, M. Golant, D.B. Greenberg, M.K. Hughes, J.A. Levenson, M.J. Loscalzo, & W.F. Pirl (Eds.), Psycho-oncology: A quick reference on the psychosocial dimensions of cancer symptom management (2nd ed., pp. 53–62). New York, NY: Oxford University Press. Walker, J., Hansen, C.H., Martin, P., Sawhney, A., Thekkumpurath, P., Beale, C., … Sharpe, M. (2013). Prevalence of depression in adults with cancer: A systematic review. Annals of Oncology, 24, 895– 900. https://doi.org/10.1093/annonc/mds575 Wilmot, N.A., & Dauner, K.N. (2017). Examination of the influence of social capital on depression in fragile families. Journal of Epidemiology and Community Health, 71, 296–301. https://doi.org/10​ .1136/jech-2016-207544

Mary K. Hughes, MS, RN, CNS, CT

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Diarrhea PROBLEM Diarrhea is an abnormal increase in the quantity, frequency, or liquidity of stool that is different from the usual pattern of elimination. Although no standard definition of diarrhea exists, the National Cancer Institute Cancer Therapy Evaluation Program Common Terminology Criteria for Adverse Events (2017) defines diarrhea as “an increase in frequency and/or loose or watery bowel movements” (p. 26). Diarrhea may be accompanied by a sense of bloating, cramping, abdominal pain, or the inability to control defecation. It can negatively affect quality of life and lead to many complications, such as loss of fluids and electrolytes, dehydration, infections, impaired skin integrity, and treatment delays (Muehlbauer et al., 2009). Diarrhea may be a symptom of cancer, including cancers of the gastrointestinal tract and neuroendocrine tumors, or caused by a chemotherapy regimen, targeted therapy, immunotherapy, radiation therapy, or surgery. The prevalence of treatment-induced diarrhea can be up to 80% (Muehlbauer & Lopez, 2014; Muehlbauer et al., 2009). Other causes include anxiety, medications, and nutritional intake. Diarrhea also can result from bowel disorders, including Crohn disease, irritable bowel syndrome, partial bowel obstruction, and bacterial and viral infections, including Clostridium difficile (Muehlbauer & Lopez, 2014; Olsen, LeFebvre, & Brassil, in press).

ASSESSMENT CRITERIA (Dunphy & Walker, 2017; Muehlbauer & Lopez, 2014; Olsen et al., in press) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Diarrhea is a common side effect of cancer and cancer therapy, including surgery, chemotherapy, targeted therapy, immunotherapy, and radiation therapy. With the advent of newer anticancer therapies, understanding the cause and proper assessment of diarrhea is paramount for appropriate management. a. Chemotherapy and targeted therapy may affect the lining of the intestinal tract and can induce diarrhea. The exact pathophysiology of diarrhea from anticancer agents is often multifaceted and, in some cases, can be unknown (Dunphy & Walker, 2017). b. Gastrointestinal toxicities of immunotherapy can manifest as diarrhea, abdominal pain, or melena. The mechanism for development of diarrhea with immunotherapy is different from the mechanism for chemotherapy or radiation therapy. In severe cases, the patient may develop enterocolitis, Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 123

Diarrhea which can be life threatening or require surgical intervention. Ipilimumab has the highest reported prevalence (35%) among current approved therapies. Usual treatment for immunotherapy-related moderate to severe diarrhea is systemic corticosteroids or other immunosuppression agents (Acharya & Jeter, 2013). c. Radiation therapy may induce diarrhea when the treatment area includes the pelvis, abdomen, or lower thoracic or lumbar spine. Radiation seed implants for prostate cancer may also cause diarrhea. d. Cancers of the gastrointestinal tract (e.g., stomach, colon, rectum) often cause diarrhea. e. Malignancies, such as neuroendocrine tumors and others that produce hormones, may also cause diarrhea. 2. What medications is the patient taking? Obtain medication history. Anticancer therapies contributing to diarrhea include IV chemotherapy (e.g., 5-fluorouracil, irinotecan), IV immunotherapy (e.g., interleukin-2, checkpoint inhibitors), and oral therapy (e.g., tyrosine kinase inhibitors, capecitabine). Evaluate for other medications contributing to diarrhea, including antibiotics, laxatives, diuretics, antihypertensives, antiemetics, sorbitol medications (or foods), magnesium-based antacids, and COX-2 inhibitors. If the patient is receiving immune-based therapy, it is imperative to recognize the symptoms of immune-related colitis. 3. Obtain history of bowel habits. a. Frequency b. Liquid versus formed stool c. Color, odor, and presence of undigested food or fat d. Presence of mucus or blood 4. Ask the patient to describe symptoms in detail. a. Number of stools in 24 hours b. Color and consistency of stools c. Weight loss d. Urine output and character e. Signs of dehydration (e.g., dry mouth, decreased urine output, lethargy, weakness, decreased skin turgor) 5. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors i. What remedies has the patient tried, and what have been the results? ii. What has the patient done in the past for diarrhea management, and what was the effect? d. Any associated symptoms (e.g., abdominal pain or cramps, fever, weight loss, stool incontinence, nausea or vomiting, decreased urine output) 6. Review past medical history. 7. Assess for changes in activities of daily living and function. 124 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Diarrhea 8. Obtain diet history. a. Food intolerance b. Aversions c. Allergies d. Consumption of well water e. Ingestion of unpasteurized milk or its products f. Consumption of raw seafood 9. Assess social history. a. Recent travel abroad b. Exposure to farm animals or animal feces Signs and Symptoms

Action

•• Grossly bloody stool •• Signs of severe dehydration –– Severe lethargy or weakness –– Heart palpitations –– Decreased urine output –– Sunken eyes –– Orthostatic hypotension –– Dizziness •• Temperature higher than 100.4°F (38°C) with suspected neutropenia •• Symptoms of immune-mediated colitis, such as diarrhea accompanied by blood in stool, severe abdominal pain, or tenderness •• Symptoms of bowel perforation, such as diarrhea associated with severe abdominal pain, fever, chills, nausea, and vomiting

Seek emergency care. Call an ambulance immediately.

•• Excessive thirst, dry mouth •• Temperature higher than 100.4°F (38°C) without suspected neutropenia •• Diarrhea for more than five days •• More than four to six stools above baseline per day for two days •• Swollen or painful abdomen •• More than 10 stools per day •• Weight loss of more than five pounds since diarrhea began •• Continued diarrhea despite antidiarrheal treatment •• Decreased turgor; pinched skin does not spring back •• Grade 3 or 4 nausea and vomiting

Seek urgent care within 24 hours.

•• Less than four stools per day •• Chronic diarrhea •• Other family members with diarrhea •• Recent travel to a foreign country •• New prescription

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Nausea and Vomiting, Pain Note. Based on information from Dunphy & Walker, 2017; Fay et al., 2016; MedlinePlus, 2016; Muehlbauer & Lopez, 2014; Olsen et al., in press.

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Diarrhea

HOMECARE INSTRUCTIONS (Dunphy & Walker, 2017; Muehlbauer & Lopez, 2014; Olsen et al., in press; Shaw & Taylor, 2012) ••Consider food and fluid modifications. –– Drink 8–10 eight-ounce glasses of fluids per day (e.g., water, diluted cranberry juice, sports drinks, decaffeinated tea or coffee). –– Eat foods high in soluble fiber (e.g., bananas, oatmeal, applesauce, skinned turkey, chicken, rice, toast). –– Consider foods containing pectin, a natural fiber that decreases diarrhea. These foods include beets, peeled apples, white rice, bananas, baked potatoes without skin, white bread, plain pasta, avocadoes, and asparagus tips. –– Eat easy-to-digest foods high in protein, calories, and potassium. –– Cook all vegetables well. Raw vegetables are difficult to digest. –– Eat small, frequent meals. Do not eat large meals. –– Eat foods at room temperature, as hot and cold temperature foods may instigate diarrhea. –– Avoid foods high in insoluble fiber (e.g., raw fruits and vegetables, skins, seeds, legumes). –– Avoid milk and dairy products, caffeine, alcohol, sucrose, and sorbitol. –– Avoid greasy, fatty, spicy, or fried foods and foods containing olestra. –– Refrain from taking fiber supplements. ••Implement a rectal skin care routine. –– Clean the perineal area well with mild soap and water or aloe-based baby wipes. Apply barrier ointment (e.g., zinc oxide) for protection. –– Sitz baths may add comfort. –– Examine the rectal area for red, scaly, or broken skin. If this is present, report it to the healthcare provider. –– Record the frequency, quality, and volume of stools during the course of treatment. ••If diarrhea lasts more than 24 hours, notify the healthcare provider. –– Consult a healthcare provider before taking any over-the-counter antidiarrheal medications. These can be very effective but may not be appropriate for this situation. If treatment with immunotherapy or targeted therapies has been prescribed, consultation with the healthcare team should begin prior to starting antidiarrheal. –– If prescribed, keep track of medications administered—type, amount, and frequency.

Report the Following Problems

(Muehlbauer & Lopez, 2014; Olsen et al., in press) ••Inability to keep fluids down for 24 hours ••Diarrhea lasting more than 24 hours ••Dark yellow urine or absence of urine production ••More than four to six bowel movements above baseline per day for two days in a row 126 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Diarrhea ••Grade 2 or greater nausea and vomiting that accompanies diarrhea ••Dizziness ••Rectal bleeding ••Temperature higher than 100.4°F (38°C) ••Swollen or painful abdomen ••Red, scaly, or broken skin of the rectal area

REFERENCES Acharya, U.H., & Jeter, J.M. (2013). Use of ipilimumab in the treatment of melanoma. Clinical Pharmacology: Advances and Applications, 5(Suppl. 1), 21–27. https://doi.org/10.2147/CPAA.S45884 Dunphy, E.P., & Walker, S. (2017). Gastrointestinal symptoms. In J. Eggert (Ed.), Cancer basics (2nd ed., pp. 431–474). Pittsburgh, PA: Oncology Nursing Society. Fay, A.P., Moreira, R.B., Nunes Filho, P.R.S., Albuquerque, C., & Barrios, C.H. (2016). The management of immune-related adverse events associated with immune checkpoint blockade. Expert Review of Quality of Life in Cancer Care, 1, 89–97. https://doi.org/10.1080/23809000.2016.1142827 MedlinePlus. (2016). Gastrointestinal perforation. Retrieved from https://medlineplus.gov/ency/ article/000235.htm Muehlbauer, P.M., & Lopez, R. (2014). Diarrhea. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 185–212). Burlington, MA: Jones & Bartlett Learning. Muehlbauer, P.M., Thorpe, D., Davis, A., Drabot, R., Rawlings, B.L., & Kiker, E. (2009). Putting evidence into practice: Evidence-based interventions to prevent, manage, and treat chemotherapy- and radiotherapy-induced diarrhea. Clinical Journal of Oncology Nursing, 13, 336–341. https://doi. org/10.1188/09.CJON.336-341 National Cancer Institute Cancer Therapy Evaluation Program. (2017). Common terminology criteria for adverse events [v.5.0]. Retrieved from https://ctep.cancer.gov/protocolDevelopment/electronic _applications/ctc.htm Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Shaw, C., & Taylor, L. (2012). Treatment-related diarrhea in patients with cancer. Clinical Journal of Oncology Nursing, 16, 413–417. https://doi.org/10.1188/12.CJON.413-417

Kerri A. Dalton, MSN, RN, AOCNS®

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Difficulty or Pain With Urination PROBLEM Burning or pain with urination can be coupled with an urgent need to urinate. Frequency of urination can also coexist. Hemorrhage or clot formation can complicate the process of urination, resulting in pain or dysuria. Difficulty or pain with urination can be the result of disease, treatment sequelae, or infectious processes, and thus should always be evaluated (Cisneros & Lazarte, 2015; Das, 2017; Mutale, 2014; Wiser, 2017; Yarbro & Berry, 2014).

ASSESSMENT CRITERIA (Conde & Workman, 2017; Shelton, 2018; Tyler & Profusek, 2018; Webster, 2017; Yarbro & Berry, 2014) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Multiple causes of painful or difficult urination exist, including those from the cancer itself, cancer treatment, and from infectious or inflammatory processes. a. Urinary tract infection is a common cause of difficult or painful urination and should be high on the differential for these patient complaints. b. Bladder cancer treatment with bacillus Calmette-Guérin may result in urinary frequency, urgency, and pain. c. Hemorrhagic cystitis may result from chemotherapy treatments such as ifosfamide and cyclophosphamide. d. Sequelae from radiation therapy, such as for prostate cancer or gynecologic pelvic radiation can cause cystitis- or urinary tract infection–type side effects that present with frequency, urgency, or dysuria. e. Sequelae from surgical or invasive procedures involving the genitourinary tract, including but not limited to the kidney, prostate, bladder, and urethra, can contribute to painful or difficult urination. f. Urinary retention can result from spinal cord injury as a result of bone metastasis or tumor extension, such as with spinal cord compression. 2. What medications is the patient taking? a. Obtain medication history, including recent prescription and over-thecounter medications (e.g., anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs, alternative or complementary therapies). b. Review recent chemotherapies, including agents used, routes, doses, and timing of last dose. c. Discuss radiation therapy or other interventions that could affect urinary output. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 129

D i f f i c u l t y o r Pa i n W i t h U r i n a t i o n

3.

4.

5.

6.

7.

8.

d. Alpha-adrenergic, anticholinergic, pseudoephedrine, and phenylpropanolamine medications may cause difficulty in urination and urinary retention (Mutale, 2014; Webster, 2017; Yarbro & Berry, 2014). Consider how well the patient has been hydrated. a. Have the patient recall fluid intake over the past 24–48 hours. b. Ask about gastrointestinal complaints such as diarrhea or nausea and vomiting. c. Question whether the patient has been light-headed or dizzy (Shelton, 2018; Yarbro & Berry, 2014). Is the patient pregnant? a. Discuss patient presentation of symptoms as they relate to pregnancy and sexual health. b. Determine contraceptive use. c. Consider sexual activity and trauma (Mutale, 2014). Ask the patient to describe symptoms in detail. a. Discomfort or pain on urination, including before starting a stream and after completed (burning, hot, electric) b. Frequency of urination over the past 24–48 hours c. A feeling that the bladder is not fully emptying d. Time of last urination e. Color of urine, including any visible blood, mucus, or sediment f. Odor of urine g. Any discharge from genitourinary structures h. Any fevers or chills (Conde & Workman, 2017; McCurdy & Bryant, 2017; Mutale, 2014; Shelton, 2014; Yarbro & Berry, 2014) Obtain history of the problem. a. Precipitating factors: If known, encourage reflection on recent events. b. Onset and duration c. Relieving factors d. Smoking or alcohol intake e. Ability to start and end urine stream f. Presence or absence of lower back pain g. Any associated symptoms (e.g., blood, discharge, fever) (Cisneros & Lazarte, 2015; Das, 2017; Mutale, 2014; Wiser, 2017; Yarbro & Berry, 2014) Review past medical history (Das, 2017; Mutale, 2014; Shelton, 2018; Wiser, 2017; Yarbro & Berry, 2014). a. Cancer and cancer treatment history: Discuss recent and prior history. b. Recent urinary catheterization, interventions, or trauma c. Urinary tract infections and outcomes or sequelae, if known d. Sexual history (date of last intercourse; protected or unprotected; sexually transmitted infections or sexual trauma) e. Nonmalignant genitourinary history Assess for changes in activities of daily living and function.

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Signs and Symptoms

Action

•• Urinary retention •• Acute severe flank or back pain •• Lower extremity weakness •• Temperature higher than 101.5°F (38.6°C) without suspected neutropenia •• Temperature higher than 100.4°F (38°C) with suspected neutropenia •• Chills, malaise, or rigors

Seek emergency care. Call an ambulance immediately.

•• Hematuria •• Dysuria •• Burning with urination •• Frequent urination, nocturia •• Cloudy or malodorous urine or discharge •• Suprapubic pain or tenderness •• Unable to urinate for more than eight hours •• Flu-like symptoms for longer than 72 hours •• Joint pain, cough, or rash after bacillus CalmetteGuérin treatment

Seek urgent care within 24 hours.

•• If the patient has received recent bacillus CalmetteGuérin treatment –– Dysuria, burning, or difficulty urinating –– Frequent urination, nocturia –– Sense of incomplete voiding –– Slow stream, dribbling

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Fever With Neutropenia, Hematuria Note. Based on information from Das, 2017; Mutale, 2014; Shelton, 2018; Webster, 2017; Wiser, 2017; Yarbro & Berry, 2014.

HOMECARE INSTRUCTIONS (Cisneros & Lazarte, 2015; Das, 2017; Shelton, 2018; Wiser, 2017; Yarbro & Berry, 2014) ••Drink 8–10 eight-ounce glasses of fluid each day (unless contraindicated). Alcohol is not included in hydration amounts; remember to report consumption to clinician. ••Cranberry juice may reduce bacterial adherence to bladder wall. ••Avoid caffeinated and acidic beverages, as they can be irritants or stimulants. ••Females should cleanse the genital area from front to back. ••Avoid urinary stasis by urinating frequently. ••Postcoital urination is suggested. ••Take showers instead of tub baths to decrease infection risk. ••Monitor urinary output. ••Practice pelvic floor exercises. ••Use of a voiding diary may be helpful. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 131

D i f f i c u l t y o r Pa i n W i t h U r i n a t i o n

Seek Emergency Care Immediately if Any of the Following Occurs

(Das, 2017; Webster, 2017; Wiser, 2017; Yarbro & Berry, 2014) ••Shortness of breath or difficulty breathing ••Loss of consciousness, unresponsiveness, or changes in cognition ••Temperature elevation that persists 48–72 hours after initiation of treatment ••Development of fever, chills, or rigors ••Inability to pass urine

REFERENCES Cisneros, E.C., & Lazarte, S.M. (2015). General infectious diseases. In T.M. De Fer & H.F. Sateia (Eds.), The Washington manual of outpatient internal medicine (2nd ed., pp. 517–565). Philadelphia, PA: Wolters Kluwer. Conde, F.A., & Workman, T. (2017). Genitourinary cancers. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 69–80). St. Louis, MO: Elsevier. Das, A. (2017). Urinary tract infection (UTI) in females. In F.J. Domino, R.A. Baldor, J. Golding, & M.B. Stephens (Eds.), The 5-minute clinical consult 2018 (26th ed., pp. 1028–1029). Philadelphia, PA: Wolters Kluwer. McCurdy, P.L., & Bryant, M.E. (2017). Urethritis. In F.J. Domino, R.A. Baldor, J. Golding, & M.B. Stephens (Eds.), The 5-minute clinical consult 2018 (26th ed., pp. 1026–1027). Philadelphia, PA: Wolters Kluwer. Mutale, F.A. (2014). Dysuria. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 705–708). Pittsburgh, PA: Oncology Nursing Society. Shelton, B.K. (2018). Infection. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 817–850). Burlington, MA: Jones & Bartlett Learning. Shelton, G. (2014). Penile discharge. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 721–724). Pittsburgh, PA: Oncology Nursing Society. Tyler, A., & Profusek, P. (2018). Bladder cancer. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 1227–1242). Burlington, MA: Jones & Bartlett Learning. Webster, J.S. (2017). Urologic emergencies. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 363–366). St. Louis, MO: Elsevier. Wiser, A.L. (2017). Urinary tract infection (UTI) in males. In F.J. Domino, R.A. Baldor, J. Golding, & M.B. Stephens (Eds.), The 5-minute clinical consult 2018 (26th ed., pp. 1030–1031). Philadelphia, PA: Wolters Kluwer. Yarbro, C., & Berry, D.L. (2014). Bladder disturbances. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 265–283). Burlington, MA: Jones & Bartlett Learning.

Gary Shelton, DNP, NP, ANP-BC, AOCNP®, ACHPN The author would like to acknowledge Mary Szyszka, APN, MSN, AOCN®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Dizziness PROBLEM Dizziness is a subjective term because it can be experienced with or without vertigo. Dizziness without vertigo can be described as faintness or a sensation of passing out. Dizziness with vertigo includes the sense that either the individual or objects around the individual are moving. It is often accompanied by nausea and vomiting. There are two types of vertigo: central, when the cause of the vertigo is a lesion involving the brain, most commonly in the brain stem or cerebellum; and peripheral, when the cause is a disturbance in the inner ear vestibular system or a problem with the vestibular nerve, which connects the inner ear to the brain stem (MacGill, 2017). Some precipitating causes of dizziness in patients with cancer include dehydration (from nausea and vomiting, poor nutrition, or diarrhea), anemia, hypotension, possible new-onset brain metastasis, and side effects from certain chemotherapies (e.g., cisplatin, cytarabine, ifosfamide).

ASSESSMENT CRITERIA (Breastcancer.org, 2017; Browall et al., 2017) 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Dizziness with vertigo may result from lesions in the inner ear, cranial nerve VIII, brain stem, or cerebral cortex. b. Cancer diagnoses prone to brain metastasis include breast, prostate, lung, kidney, melanoma, head and neck, soft tissue sarcomas, and testicular cancers. c. Review the chemotherapy regimen, including infusions, injections, and oral therapies. Some medications used to treat patients with cancer can cause dizziness, including cisplatin, cytarabine, fulvestrant, ifosfamide, temozolomide, toremifene, trastuzumab, sunitinib, and others (Breast cancer.org, 2017). 2. What medications is the patient taking? Obtain medication history. In addition to some cancer treatment agents, several other medications can cause dizziness, including analgesics, antihistamines, antidepressants, tranquilizers, barbiturates, anti-inflammatory drugs, diuretics, antibiotics, and cardiovascular agents. 3. Ask the patient to describe symptoms in detail. 4. Questions to ask include “Do you feel light-headed?”; “Do you feel as if the world is spinning around, as though you were on a playground roundabout?”; “Do you feel like your head is spinning but other objects in the room are stable?” Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 133

Dizziness 5. Obtain history of the problem. a. Precipitating factors i. Quickly standing or changing position (orthostatic hypotension) ii. A history of breathlessness, dizziness, nausea, and dry mouth when under stress. This has been defined as the “emotional cluster” of symptoms (Browall et al., 2017). b. Onset (gradual or acute) and duration (acute or chronic) c. Relieving factors d. Any associated symptoms (e.g., tinnitus, hearing loss, positional changes, nausea, vomiting, diaphoresis) e. Has the patient had any gait changes, falls, or resulting injuries? f. Has the patient had any double vision, loss or change of visual fields, facial numbness or drooping, or trouble moving one side (hemiparesis)? 6. Review past medical history. a. Has the patient experienced dizziness in the past? Did the symptoms resolve spontaneously or was treatment required? If treatment was provided, ascertain the treatment and effectiveness. b. Does the patient have a history of Ménière disease? c. Has the patient experienced a recent upper respiratory or ear infection? d. Review any recent laboratory values to determine if any abnormalities may be a contributing factor. Signs and Symptoms

Action

•• Chest pain •• Difficulty breathing

Seek emergency care. Call an ambulance immediately.

•• Incontinence of bowel or bladder •• Hemiparesis •• Facial numbness •• Double vision, loss of visual fields •• Temperature higher than 100.4°F (38°C) with suspected neutropenia

Seek emergency care.

•• Nausea or vomiting (unexplained, not secondary to vertigo) •• Headache or ear pain •• Known diabetic •• Evidence of gastrointestinal bleeding •• Temperature higher than 101°F (38.3°C) without suspected neutropenia

Seek urgent care within 24 hours.

•• Recent chemotherapy, pain medication, or anxiolytic medication •• Spinning feeling •• Nausea

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Diarrhea, Fever With Neutropenia, Fever Without Neutropenia, Headache, Nausea and Vomiting Note. Based on information from Breastcancer.org, 2017; Browall et al., 2017; MacGill, 2017.

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Dizziness

HOMECARE INSTRUCTIONS ••Stay with a family member, if possible. ••Sit with legs elevated or lie down. ••If vertigo is positional, move slowly and address safety issues to prevent injury or falls. Rise from a sitting position slowly and remove any obstacles on the floor such as throw rugs. If needed, walk along the wall to help brace against falls, and slowly move forward. ••Do not drive or operate any motor vehicles or heavy machinery, such as an automobile or tractor, until dizziness is gone. ••Report to a physician within 72 hours for evaluation if symptom continues.

REFERENCES Breastcancer.org. (2017). Dizziness. Retrieved from http://www.breastcancer.org/treatment/side_effects​ /dizziness Browall, M., Brandberg, Y., Nasic, S., Rydberg, P., Bergh, J., Rydén, A., … Wengström, Y. (2017). A prospective exploration of symptom burden clusters in women with breast cancer during chemotherapy treatment. Supportive Care in Cancer, 25, 1423–1429. https://doi.org/10.1007/s00520-016-3527-1 MacGill, M. (2017). Everything you need to know about vertigo. Medical News Today. Retrieved from https://www.medicalnewstoday.com/knowledge/160900/vertigo-causes-symptoms-treatments

Laura B. Houchin, MSN, RN, AOCNS®

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136 . . . . . . . . Telephone Triage

Dysgeusia (Taste Dysfunction) PROBLEM Many individuals living with cancer experience alterations in taste perception or sensitivity to the basic taste modalities (i.e., sweet, sour, bitter, salty, and savory [umami]). Current estimates suggest 40%–90% of patients with cancer will experience some degree of taste dysfunction before, during, or following treatment. Taste disorders include dysgeusia, hypogeusia, and ageusia (see Table 2), with much of the literature focusing on the occurrence and self-management of dysgeusia. Taste perception is a complex process that requires functioning taste receptor cells (TRCs) and intact neuropathways. TRCs mediate taste perception and are located in taste buds on the surface of the tongue, oropharynx, and upper esophagus. Taste stimuli enter the taste buds and activate TRCs to release neurotransmitter. This triggers afferent nerves to send signals to the brain. Saliva plays a pivotal role in the taste process. By diluting and distributing food molecules during the process of mastication, saliva facilitates the contact of taste stimuli with taste buds and TRCs. Impaired taste can have a significant impact on quality of life, dietary habits, and social interactions (Epstein, Smutzer, & Doty, 2016; McLaughlin & Mahon, 2012).

Table 2. Definitions of Taste Dysfunctions Term

Definition

Pathophysiology

Dysgeusia

A persistent bitter, metallic, or hot taste in mouth

Injury to gustatory nerve fibers or ascending nerve pathways

Hypogeusia

The condition of having decreased tasting ability

Injury to taste receptor cells, or receptor cell innervations Epithelial changes (mouth sores) or changes in saliva composition

Ageusia

The condition of not being able to taste one or more entire taste modality

Loss of taste receptor cells, severe changes in saliva composition, and severe damage to gustatory nerve fibers

Note. From “Understanding Taste Dysfunction in Patients With Cancer,” by L. McLaughlin and S.M. Mahon, 2012, Clinical Journal of Oncology Nursing, 16, p. 175. Copyright 2012 by Oncology Nursing Society. Adapted with permission.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 137

D y s g e u s i a ( Ta s t e D y s f u n c t i o n )

2.

3.

4.

a. Dysgeusia occurs predominately in cancers of the head and neck. It is also common in lymphoma and breast, colon, and lung cancers (Coa et al., 2015). b. Research is limited in treatment-naïve patients. Taste alterations have been reported and may be due to tumor-related proinflammatory cytokines and disruption of normal microorganisms (Murtaza, Hichami, Khan, Ghiringhelli, & Khan, 2017). c. Head and neck surgery can cause nerve damage, alterations in the structure or function of the parotid gland and tongue, and postoperative wounds. d. Radiation therapy can cause damage to the number and structure of TRCs, as well as damage to the parotid gland, causing hyposalivation and dry mouth. e. Chemotherapy alters the structure and number of TRCs, interrupts direct contact with TRCs through gingival fluids or capillary diffusion, disrupts saliva production, and alters signal transmission secondary to neuropathy (Epstein et al., 2016; Murtaza et al., 2017). f. The mechanism of taste alteration is poorly understood for targeted therapies (Vigarios, Epstein, & Sibaud, 2017). i. Mammalian target of rapamycin inhibitors (everolimus) ii. Kinase inhibitors (dacomitinib, afatinib, sunitinib, cabozantinib, crizotinib) iii. Hedgehog pathway inhibitors (vismodegib) What medications is the patient taking? Obtain medication history. Include date of last chemotherapy/targeted therapy. Approximately two-thirds of approved medications can cause taste alterations. These are most frequently associated with antibiotics, antihypertensives, antidepressants, anticonvulsants, muscle relaxants, lipid-lowering agents, and vitamins and supplements (Epstein et al., 2016; Malaty & Malaty, 2013). Obtain history of the problem. a. Severity b. Precipitating factors c. Onset and duration d. Relieving factors e. Impact on quality of life f. Changes in dietary habits g. Any associated symptoms (e.g., weight loss, xerostomia, decreased food or fluid intake, pain when eating, burning sensation in mouth, difficulty swallowing or chewing) (McLaughlin & Mahon, 2012) Review past medical history. a. Comorbid diseases (e.g., neurologic or neurodegenerative diseases, autoimmune disorders, hepatic or renal failure, endocrine disorders or diabetes) b. Psychiatric conditions (e.g., depression, bipolar disorder, anorexia) (Malaty & Malaty, 2013)

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D y s g e u s i a ( Ta s t e D y s f u n c t i o n ) c. Upper respiratory infection, chronic rhinosinusitis, or allergic rhinitis d. Oral hygiene, dental or periodontal disease, mucosal infection e. Tobacco and alcohol use (Epstein et al., 2016) Signs and Symptoms

Action

•• Swollen or bleeding gums, inability to swallow, or severe oral pain

Seek emergency care.

•• Stomatitis, glossitis (raw tongue), atrophic lingua (slick tongue), or weight loss

Seek urgent care within 24 hours.

•• Patient reports food tasting like cardboard or metal; food tastes too salty, sweet, sour, or bitter.

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Oral Mucositis, Pain, Xerostomia (Dry Mouth)

HOMECARE INSTRUCTIONS ••Avoid cigarette smoking. ••Maintain good oral hygiene; brush before and after meals. ••Rinse mouth with a solution of ½ teaspoon of salt and ½ teaspoon of baking soda in 1 cup of warm water to neutralize bad taste. ••Keep mouth moist by maintaining adequate fluid intake, spraying with water, artificial saliva, or saline. ••If water tastes unpleasant, add lemon or lime, fresh berries, or watermelon to improve taste. Taking in liquids through other nonirritating foods and drinks (e.g., soup, watermelon, tea, milk, sports drinks, apple juice) may also be considered. ••Suck on sugar-free sour candies to stimulate saliva production (for patients who have enough saliva to dissolve candy). ••Marinate beef, pork, or chicken in teriyaki sauce, sweet and sour sauce, or marinades made with citrus juices or wine. If red meat is unappealing, try other highprotein foods such as fish, chicken, turkey, eggs, cheese, beans, nuts, nut butters, tofu, or high-protein smoothies. ••Tart flavors may taste better during treatment and may improve the taste of other foods, such as lemon, lime, vinegars, and pickled foods (avoid if mouth or throat is sore). ••Frozen, cold, or room-temperature foods may taste better than hot foods (avoid if receiving oxaliplatin) and have less odor. ••If food tastes bland, flavor with seasonings such as oregano, basil, rosemary, cinnamon, dill, cayenne, mint, and lemon. ••If food tastes too sweet, add something sour or slightly bitter, such as frozen cranberries to a smoothie, or decaffeinated powdered coffee to chocolate or vanilla liquid nutritional supplements. ••If experiencing a metallic or bitter taste, try the following: –– Sucking on fresh citrus fruit slices or frozen fruit (melon balls, grapes) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 139

D y s g e u s i a ( Ta s t e D y s f u n c t i o n ) –– Chewing sugar-free gum or sucking mint-, lemon-, or orange-flavored candies –– Using plastic utensils and glass cookware ••Eliminate cooking smells by using an exhaust fan, cooking on an outdoor grill, or buying precooked foods. ••Eat small, frequent meals. ••Eat in pleasant surroundings with family and friends for distraction. ••Do not eat one to two hours before chemotherapy or radiation therapy and for up to three hours after therapy. ••If possible, have someone else prepare the food. ••Try Synsepalum dulcificum, or “miracle fruit,” a naturally occurring sweetener, which acts on the TCRs and masks unpleasant tastes for a short period of time. Several small pilot studies have demonstrated safety and improvement in negative taste sensations (Wilken & Satiroff, 2012). ••Multiple studies on taking zinc have been conducted, with conflicting results. Talk to a provider for more information (Lyckholm et al., 2012).

Report the Following Problems ••Weight loss ••Depression ••Nausea and vomiting ••Stomatitis or mucositis

Seek Emergency Care Immediately if Any of the Following Occurs ••Uncontrolled bleeding from mouth ••Inability to swallow ••Severe pain in mouth

REFERENCES Coa, K.I., Epstein, J.B., Ettinger, D., Jatoi, A., McManus, K., Platek, M.E., … Moskowitz, B. (2015). The impact of cancer treatment on the diets and food preferences of patients receiving outpatient treatment. Nutrition and Cancer, 67, 339–353. https://doi.org/10.1080/01635581.2015.990577 Epstein, J.B., Smutzer, G., & Doty, R.L. (2016). Understanding the impact of taste changes in oncology care. Supportive Care in Cancer, 24, 1917–1931. https://doi.org/10.1007/s00520-016-3083-8 Lyckholm, L., Heddinger, S.P., Parker, G., Coyne, P.J., Ramakrishnan, V., Smith, T.J., & Henkin, R.I. (2012). A randomized, placebo controlled trial of oral zinc for chemotherapy-related taste and smell disorders. Journal of Pain and Palliative Care Pharmacotherapy, 26, 111–114. https://doi.org/10​ .3109/15360288.2012.676618 Malaty, J., & Malaty, I. (2013). Smell and taste disorders in primary care. American Family Physician, 88, 852–859. Retrieved from https://www.aafp.org/afp/2013/1215/p852.html McLaughlin, L., & Mahon, S.M. (2012). Understanding taste dysfunction in patients with cancer. Clinical Journal of Oncology Nursing, 16, 171–178. https://doi.org/10.1188/12.CJON.171-178 Murtaza, B., Hichami, A., Khan, A.S., Ghiringhelli, F., & Khan, N.A. (2017). Alteration in taste perception in cancer: Causes and strategies of treatment. Frontiers in Physiology, 8, 134. https://doi. org/10.3389/fphys.2017.00134 Vigarios, E., Epstein, J.B., & Sibaud, V. (2017). Oral mucosal changes induced by anticancer targeted therapies and immune checkpoint inhibitors. Supportive Care in Cancer, 25, 1713–1739. https:// doi.org/10.1007/s00520-017-3629-4 140 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

D y s g e u s i a ( Ta s t e D y s f u n c t i o n ) Wilken, M.K., & Satiroff, B.A. (2012). Pilot study of “miracle fruit” to improve food palatability for patients receiving chemotherapy [Online exclusive]. Clinical Journal of Oncology Nursing, 16, E173–E177. https://doi.org/10.1188/12.CJON.E173-E177

Pamela H. Carney, MSN, RN, OCN® The author would like to acknowledge Victoria Wenhold Sherry, MSN, CRNP, AOCNP®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Dysphagia PROBLEM Dysphagia is defined as difficulty swallowing, which prevents the normal passage of food and liquid. Swallowing difficulty can negatively affect not only a person’s ability to maintain an adequate nutritional status but also the person’s quality of life, as limited food choices and prolonged or altered eating times affect one’s level of comfort with social interactions (Hayward & Shea, 2009). Dysphagia occurs in up to one-half of patients with head and neck cancer and is commonly associated with odynophagia (painful swallowing) and esophagitis (Hayward & Shea, 2009). An interprofessional team approach to managing dysphagia, including a physician, nurse, registered dietitian, and speech-language pathologist, can optimize the patient’s plan of care and treatment outcome.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Cancers of the head and neck can commonly promote dysphagia due to tumor obstruction or surgery, or dysphagia may be the result of definitive treatment with chemoradiation (Balusik, 2014). Chemoradiation improves tumor control but can result in an increased incidence and severity of life-threatening swallowing-related toxicities, including dysphagia, aspiration, progressive weight loss, and feeding tube dependence (Agarwal et al., 2011). This can contribute to further complications such as increased risk of infection and treatment interruptions, thus decreasing treatment effectiveness and prolonging recovery time. 2. What medications is the patient taking? Obtain medication history, including the date of last chemotherapy treatment. 3. Ask the patient to describe symptoms in detail (Carr, 2018; Denaro, Merlano, & Russi, 2013). a. Coughing or clearing throat before, during, or after eating b. Early: “lump” in the throat with or without swallowing; always trying to clear throat c. Murphy’s trigger symptoms: excessive chewing, drooling, and complaint of food sticking d. Dry throat: “food gets stuck”; the need to swallow food several times before it goes down e. Burning sensation of the substernal area with or without swallowing f. Coughing or choking with foods or liquids leaking from the nose g. Difficulty or pain with swallowing h. Choking or vomiting because of the inability to pass food or fluid Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 143

Dysphagia 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration: intermittent with mealtimes or continuous (solids vs. liquids) c. Relieving factors (e.g., dietary modifications) d. History of dysphagia e. Treatment of oral infections f. Current diet and fluid intake 5. Review past medical history. a. Cerebrovascular accident, gastroesophageal reflux disease, or pneumonia b. Altered nutritional status c. Weight loss (more than 5% over one month or more than 10% over six months) d. Infections of the oral, pharyngeal, or esophageal mucosa e. Alcohol or tobacco use f. Placement of nasogastric tube or other invasive procedures of the esophagus g. Gastrostomy tube or percutaneous endoscopic gastrostomy tube placement 6. Assess need for medical nutrition therapy. a. Patients with cancer are at risk for malnutrition as they undergo various types of treatment. Those with dysphagia have difficulty swallowing foods and liquids; therefore, they may not be able to maintain or attain an optimal nutritional status. b. Patients undergoing surgeries for tumors in the oral, pharyngeal, and esophageal areas may require feeding tube placement during surgery. These patients may not be able to eat after surgery to allow healing. If the patients require radiation therapy, they also may not be able to orally consume required calories and protein. c. A decline in nutritional status may be evidenced by reduced caloric and protein intake, weight loss, reduced subcutaneous body fat, muscle loss, fluid accumulation, and reduced hand grip strength. Two or more of these findings may indicate a diagnosis of malnutrition. d. Because malnutrition can affect patients’ ability to tolerate chemotherapy or radiation therapy, decrease quality of life, require hospitalization, and affect mortality (Thompson et al., 2017), referral to a registered dietitian nutritionist (RDN) is recommended, preferably one specializing in oncology. It is best to refer to the RDN for medical nutrition therapy at diagnosis and prior to the initiation of treatment to obtain a baseline assessment with recommendations to the physician, as well as to provide education to patients to reduce the risk of malnutrition. e. Medical nutrition therapy i. Calorie, protein, and fluid requirements ii. Meal planning with the patient and/or caregiver iii. Small, frequent meals with soft and moist foods 144 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Dysphagia iv. Food consistency options (blended smoothly or ground) v. Vitamin and mineral replacement vi. Supplements (add calories and protein) vii. Enteral nutrition support recommendations viii. Parenteral nutrition support recommendations (only if the gastrointestinal tract is not functional) 7. Collaborate with the RDN to evaluate patient nutritional needs, weight history, and pain management needs once or twice a week at minimum. 8. Consult with a speech-language pathologist for evaluation and treatment to determine appropriate food and liquid consistency and to decrease the risk for muscle atrophy for swallowing and choking. Swallowing exercises prescribed by a speech-language pathologist during and after treatment can improve overall outcomes (Hayward & Shea, 2009). Signs and Symptoms

Action

•• Inability to swallow with increasing pain, swelling, or compromised airway •• Change in level of consciousness •• Coughing, choking, or vomiting from inability to pass foods or liquids (or aspiration suspected) •• Temperature higher than 100.4°F (38°C); chills with suspected neutropenia

Seek emergency care. Call an ambulance immediately.

•• Increased difficulty swallowing; unable to eat or drink •• Increase in vomiting or pain •• If feeding tube is present, report nausea and vomiting, indigestion, or diarrhea. •• Feeding tube becomes clogged or redness, pain, swelling, or leakage from the insertion site •• Decreased urine output that is cloudy or dark •• Dizziness, increased weakness or fatigue

Seek urgent care within 24 hours.

•• Lump in throat or sore throat •• Excessive chewing, drooling, and complaint of food sticking (difficulty swallowing)

Follow homecare instructions. Refer to speechlanguage pathologist.

Cross-references: Esophagitis, Fever With Neutropenia, Fever Without Neutropenia, Oral Mucositis

HOMECARE INSTRUCTIONS ••Follow the nutrition care plan as developed by the RDN. ••Follow exercise/safety plan as developed by the speech-language pathologist. ••Take medications as directed. ••Sit upright to maximize swallowing. ••Prevent aspiration: Remain sitting for 30 minutes after meals; sleep at a 45° angle. ••Take analgesics as ordered for pain relief to improve intake. If swallowing pills becomes difficult, notify healthcare provider. Not all pills can be crushed. ••Do not smoke or consume alcohol. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 145

Dysphagia ••Avoid mouth rinses that contain alcohol. ••Perform daily mouth care as instructed, including after meals.

Seek Emergency Care Immediately if Any of the Following Occurs

••Inability to swallow with increasing pain, swelling, or compromised airway ••Coughing, choking, or vomiting from inability to pass foods or liquids (or aspiration suspected) ••Change in level of consciousness ••Temperature higher than 100.4°F (38°C); chills with suspected neutropenia

REFERENCES Agarwal, J., Palwe, V., Dutta, D., Gupta, T., Laskar, S.G., Budrukkar, A., … Shrivastava, S.K. (2011). Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer. Dysphagia, 26, 399–406. https://doi.org/10.1007/s00455-011​ -9326-4 Balusik, B. (2014). Management of dysphagia in patients with head and neck cancer. Clinical Journal of Oncology Nursing, 18, 149–150. https://doi.org/10.1188/14.CJON.149-150 Carr, E. (2018). Head and neck malignancies. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 1573–1598). Burlington, MA: Jones & Bartlett Learning. Denaro, N., Merlano, M.C., & Russi, E.G. (2013). Dysphagia in head and neck cancer patients: Pretreatment evaluation, predictive factors, and assessment during radio-chemotherapy, recommendations. Clinical and Experimental Otorhinolaryngology, 6, 117–126. https://doi.org/10.3342/ceo​ .2013.6.3.117 Hayward, M.C., & Shea, A.M. (2009). Nutritional needs of patients with malignancies of the head and neck. Seminars in Oncology Nursing, 25, 203–211. https://doi.org/10.1016/j.soncn.2009.05.003 Thompson, K.L., Elliott, L., Fuchs-Tarlovsky, V., Levin, R.M., Coble Voss, A., & Piemonte, T. (2017). Oncology evidence-based nutrition practice guideline for adults. Journal of the Academy of Nutrition and Dietetics, 117, 297–310.e47. https://doi.org/10.1016/j.jand.2016.05.010

Jackie Matthews, RN, MS, APRN-CNS, AOCN®, ACHPN Karen Feldmeyer, MSA, RDN, LD

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Dyspnea PROBLEM Dyspnea is a term used to describe difficult or labored breathing. It is a complex, subjective sensation that can be a challenge to manage, as it has multiple dimensions and can result from a variety of causes (Glennon, 2015). It can occur acutely (with sudden onset and a duration of less than one month) or chronically (duration greater than one month). When dyspnea occurs chronically, it can be persistent and variable in intensity (Glennon, 2015). In nonmalignant situations, acute dyspnea is related largely to airway obstruction, cardiac conditions (e.g., congestive heart failure), hemorrhage, hyperventilation syndrome, inhalation of irritants, pneumonia, pulmonary edema/emboli, or spontaneous or traumatic pneumothorax (Glennon, 2015; Sherry, 2014). Chronic dyspnea can be related to anemia, cardiac disease, obesity, obstructive lung disease (e.g., asthma, chronic obstructive pulmonary disease), or upper airway conditions (Glennon, 2015; Sherry, 2014).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Dyspnea is most common in patients with chest malignancies; however, it can also affect patients with other malignancies. Dyspnea has been estimated to affect 15%–55% of patients at the time of diagnosis and as many as 70% of patients with terminal disease (Shelton et al., 2017). It is common in patients with metastatic disease resulting in endobronchial lesions, pleural effusions, hepatomegaly, or ascites. Structural cardiac complications due to malignancy, such as pericardial effusion or superior vena cava syndrome, can also lead to dyspnea. b. Some causes of dyspnea are related indirectly to a diagnosis of cancer, including paraneoplastic syndromes, electrolyte imbalances, cachexia, fatigue, and pulmonary emboli (Chan, Tse, & Sham, 2015; Dudgeon, Kristjanson, Sloan, Lertzman, & Clement, 2001). c. Following lung resection surgery, dyspnea is a common result of decreased lung capacity. d. Long-term side effects of radiation therapy include fibrosis and pneumonitis, which can cause dyspnea. e. Patients receiving certain types of antineoplastic therapies, including chemotherapy, biologic therapy, or hormone therapy, can experience dyspnea as a short- or long-term side effect of their medication (Glennon, 2015). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 147

Dyspnea i. Chemotherapy agents associated with dyspnea include arsenic trioxide, bleomycin, busulfan, fludarabine, gemcitabine, thalidomide, and topotecan (Olsen, LeFebvre, & Brassil, in press). Anthracyclines are associated with cardiac toxicity, which can lead to heart failure, causing dyspnea. ii. Biologic therapy, also known as immunotherapy and biotherapy, can lead to pneumonitis. Associated agents include aldesleukin, alemtuzumab, ipilimumab, nivolumab, oprelvekin, pembrolizumab, and trastuzumab (Chuzi et al., 2017; Olsen et al., in press; Ventola, 2017). iii. Tamoxifen, a selective estrogen receptor modulator hormonal therapy agent, can increase the risk of thromboembolic disease and result in pulmonary embolism. 2. What medications is the patient taking? Obtain medication history, including antineoplastic agents and prescription and over-the-counter medications. 3. Ask the patient to describe symptoms in detail. a. Elevated respiratory and pulse rate b. Associated wheezing, rhonchi, or stridor (ask to speak to the patient and listen to directly, if possible) c. Associated chest pain, cough, or fever d. If cough present: Ask whether it is a productive versus a nonproductive cough. If productive, qualify and quantify sputum production, including its amount, color, whether it is with or without blood, and any other measurable features. e. Associated cyanosis or pallor f. Timing of symptoms: Does a symptom occur all day or only in the morning? Are there any aggravating factors? 4. Obtain history of the problem. a. Acute versus chronic symptoms b. Changes in mental status (e.g., somnolence, restlessness, confusion) 5. Review past medical history. a. Comorbid lung conditions (e.g., asthma or chronic obstructive pulmonary disease, pneumonia, bronchitis, neurologic disease, recent upper or lower respiratory tract infection, tuberculosis) b. Underlying cardiac disease (e.g., congestive heart failure, cardiomegaly) c. Anemia d. Obesity e. Detailed smoking history (e.g., types, amounts, length of time used) f. Allergies g. Anxiety h. Cachexia i. Recent history of injury or trauma 6. Assess for changes in activities of daily living and function. 148 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Dyspnea

Signs and Symptoms

Action

•• Sudden, unexpected increase in dyspnea at rest •• Chest pain •• Frothy pink sputum or gross hemoptysis •• Facial swelling •• Change in mental status

Seek emergency care. Call an ambulance immediately.

•• Temperature higher than 100.4°F (38°C) with suspected neutropenia

Seek emergency care.

•• Increasing dyspnea with activity •• Temperature higher than 101.5°F (38.6°C) without suspected neutropenia •• Increased edema or swelling •• Change in cough or sputum production •• Uncontrollable cough •• New-onset wheezing

Seek medical care within 24 hours.

•• Cough •• Shortness of breath

Follow homecare instructions and seek medical care if no improvement within 24–48 hours.

Cross-references: Anxiety, Cough, Deep Vein Thrombosis Note. Based on information from Glennon, 2015; Sherry, 2014.

HOMECARE INSTRUCTIONS ••Comply with medical therapy (e.g., antibiotics, antitussives, bronchodilators, opioids), respiratory treatment, oxygen, as prescribed. ••Schedule activities that require more exertion (e.g., bathing) around periods of rest. ••Get adequate sleep and rest. ••Drink plenty (1–2 L) of fluids (unless restricted because of cardiac dysfunction or kidney disease) to help thin out secretions (unless underlying congestive heart failure is present). ••Avoid precipitating factors that worsen dyspnea (e.g., anxiety, perfumes, tobacco smoke, cold or dry air). Stay inside on days when the air quality is poor. ••Monitor for fever or any sign of infection and avoid contact with individuals who are sick. ••Sitting upright and pursed-lip breathing can lessen dyspnea, as can relaxation training.

Report the Following Problems

••Fever (temperature higher than 101.5°F [38.6°C], or 100.4°F [38.1°C] if receiving chemotherapy or if neutropenia is suspected) ••Change in sputum production (color, hemoptysis) ••Swelling of the feet or hands Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 149

Dyspnea

Seek Emergency Care Immediately if Any of the Following Occurs

••Worsening dyspnea, especially if accompanied by chest pain or gross hemoptysis ••Swelling of the face ••Increased work of breathing (elevated respiratory or heart rate) ••Changes in mental status (somnolence, restlessness, confusion) ••Temperature higher than 100.4°F (38°C) with known neutropenia

REFERENCES Chan, K.-S., Tse, D.M.W., & Sham, M.M.K. (2015). Dyspnoea and other respiratory symptoms in palliative care. In N. Cherny, M. Fallon, S. Kaasa, R.K. Portenoy, & D.C. Currow (Eds.), Oxford textbook of palliative medicine (5th ed., pp. 421–434). Oxford, UK: Oxford University Press. Chuzi, S., Tavora, F., Cruz, M., Costa., R., Chae, Y.K., Carneiro, B.A., & Giles, F.J. (2017). Clinical features, diagnostic challenges, and management strategies in checkpoint inhibitor-related pneumonitis. Cancer Management and Research, 9, 207–213. https://doi.org/10.2147/CMAR.S136818 Dudgeon, D.J., Kristjanson, L., Sloan, J.A., Lertzman, M., & Clement, K. (2001). Dyspnea in cancer patients: Prevalence and associated factors. Journal of Pain and Symptom Management, 21, 95–102. https://doi.org/10.1016/S0885-3924(00)00258-X Glennon, C. (2015). Dyspnea. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 283–317). Pittsburgh, PA: Oncology Nursing Society. Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Shelton, B.K., Adames, A., Dagher, H.F., Dolan, E., Miller, P., Oliveira, L., … Tyson, L.B. (2017). Dyspnea. Retrieved from https://www.ons.org/pep/dyspnea Sherry, V. (2014). Dyspnea. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 189–195). Pittsburgh, PA: Oncology Nursing Society. Ventola, C.L. (2017). Cancer immunotherapy, part 2: Efficacy, safety, and other clinical considerations. Pharmacy and Therapeutics, 42, 452–463.

Heather Thompson Mackey, MSN, RN, ANP-BC, AOCN®

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Esophagitis PROBLEM Esophagitis is an inflammatory response of the mucosal lining of the esophagus. It is often a dose-limiting toxicity, as it is markedly higher when radiation and chemotherapy are combined (Fogh & Yom, 2014). As with oral mucositis, esophagitis can be measured by severity, including erythema, swelling, ulceration, infection, and possible hemorrhage (Camp-Sorrell, 2018). Odynophagia (painful swallowing) is the hallmark, resulting in multiple swallowing problems, nutritional deficits, fatigue, dehydration, malnutrition, and poor quality of life.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Esophagitis is common in patients undergoing radiation therapy for head and neck cancers, lung cancer, lymphomas of the chest, or other diseases within the mediastinum. The onset of esophagitis can occur two to three weeks into treatment, at 20–30 Gy. Patients on steroid treatment or immunosuppressive agents from cancer therapy may develop esophagitis caused by a fungal infection. This is different from esophagitis caused by the treatment itself, as it may warrant treatment with an oral antifungal medication (Metz, 2018). The patient’s treatment plan can further result in an increased risk of infection, hospitalization, initiation of parenteral feeding, and treatment interruptions, thus decreasing treatment effectiveness and prolonging recovery time (BarAd, Ohri, & Werner-Wasik, 2012). 2. What medications is the patient taking? Obtain medication history. a. Include the date of last chemotherapy, as nadir in the presence of esophagitis may predispose the patient to local or systemic infections. b. Identify prolonged use of broad-spectrum antibiotics. c. Assess for use of steroids. d. Assess for use of proton pump inhibitors and antacids. 3. Ask the patient to describe symptoms in detail (e.g., nausea, vomiting, diarrhea, mucositis). a. “Lump” in the throat with or without swallowing b. Dry throat: “food gets stuck” c. Burning sensation of the substernal area with or without swallowing d. Epigastric pain e. Difficulty or pain with swallowing f. Choking or vomiting because of food becoming lodged Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 151

Esophagitis 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration: intermittent with mealtimes or continuous (solids vs. liquids) c. Relieving factors (e.g., topical anesthesia, systemic analgesia, dietary modifications) d. Treatment of oral candida e. Current diet and fluid intake 5. Review past medical history. a. Weight loss (more than 5% over one month or more than 10% over six months) b. Oral hygiene regimen c. Typical and recent dietary intake d. Alcohol or tobacco use e. Gastrostomy tube or percutaneous endoscopic gastrostomy tube placement 6. Assess need for medical nutrition therapy. a. Patients with cancer are at risk for malnutrition as they undergo various types of treatment. Those with esophagitis have difficulty with the passage of food through the esophagus. Pain or a burning sensation occurs often, making eating difficult and unpleasant. b. A decline in nutritional status may be evidenced by reduced caloric and protein intake, weight loss, reduced subcutaneous body fat, muscle loss, fluid accumulation, and reduced hand grip strength. Two or more of these findings may indicate a diagnosis of malnutrition. c. Because malnutrition can affect patients’ ability to tolerate chemotherapy and radiation therapy, decrease quality of life, require hospitalization, and affect mortality (Thompson et al., 2017), referral to a registered dietitian nutritionist (RDN) is recommended, preferably one specializing in oncology. It is best to refer to the RDN for medical nutrition therapy at diagnosis and prior to the initiation of treatment to obtain a baseline assessment with recommendations to the physician, as well as to provide education to the patient to reduce the risk of malnutrition. d. Medical nutrition therapy i. Calorie, protein, and fluid requirements ii. Meal planning with the patient and/or caregiver iii. Small, frequent meals with soft and moist foods iv. Food consistency options (blended smoothly or ground) v. Vitamin and mineral replacement vi. Supplements (add calories and protein) vii. Enteral nutrition support recommendations viii. Parenteral nutrition support recommendations (only if the gastrointestinal tract is not functional) 7. Collaborate with the RDN to evaluate patient nutritional needs, weight history, and pain management needs once or twice a week at minimum. 152 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Esophagitis

Signs and Symptoms

Action

•• Presence of or sudden increase in frank blood with cough •• Persistent fever with temperature higher than 100.4°F (38°C); chills with suspected neutropenia •• Inability to swallow with increasing pain, swelling, or compromised airway •• Choking or vomiting from inability to pass foods or liquids •• Chest pain •• Change in level of consciousness

Seek emergency care. Call an ambulance immediately.

•• Oral assessment indicates increase in inflammation, white patches, or coated tongue. •• Unable to drink fluids •• Decreased urine output that is cloudy or dark •• Dizziness, increased weakness or fatigue •• Increasing difficulty swallowing or sore throat

Seek urgent care within 24 hours.

•• Sore throat or lump in throat •• Difficulty swallowing

Follow homecare instructions.

Cross-references: Dysphagia, Fever With Neutropenia, Fever Without Neutropenia, Nausea and Vomiting, Oral Mucositis

HOMECARE INSTRUCTIONS (Metz, 2018) ••Follow the nutrition care plan as developed by the RDN. –– Eat soft-textured, nonfibrous, nonacidic foods. –– Limit hot food and beverages, and drink plenty of cool liquids. –– Drink high-calorie/high-protein milkshakes or liquid nutrition supplements. ••Increase fluid intake to 2–3 L/day or as recommended by dietitian. ••Take topical anesthetics as ordered (30 minutes prior to meals). ••Take antacids and proton pump inhibitors as directed. ••Perform daily mouth care as instructed, including after meals. ••Inspect the oral cavity daily for changes in inflammation, presence of white or yellow patches, and coating of the tongue. ••Take analgesics as ordered for pain relief to improve intake. If swallowing pills becomes difficult, notify healthcare provider. Not all pills can be crushed. ••Take temperature daily. ••Do not smoke or use alcohol. ••Avoid mouth rinses that contain alcohol. ••Add humidity to room air and during sleeping to promote moisture (50%–60% household humidity).

Seek Emergency Care Immediately if Any of the Following Occurs

••Presence of or increase in frank blood with cough ••Change in level of consciousness ••Inability to swallow with increasing pain, swelling, or compromised airway Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 153

Esophagitis ••Persistent fever with temperature higher than 100.4°F (38°C); chills with suspected neutropenia

REFERENCES Bar-Ad, V., Ohri, N., & Werner-Wasik, M. (2012). Esophagitis, treatment-related toxicity in non-small cell lung cancer. Reviews on Recent Clinical Trials, 7, 31–35. https://doi. org/10.2174/157488712799363235 Camp-Sorrell, D. (2018). Chemotherapy toxicities and management. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 497–554). Burlington, MA: Jones & Bartlett Learning. Fogh, S., & Yom, S.S. (2014). Symptom management during the radiation oncology treatment course: A practical guide for the oncology clinician. Seminars in Oncology, 41, 764–775. https://doi. org/10.1053/j.seminoncol.2014.09.020 Metz, J. (2018). Esophagitis. Retrieved from https://www.oncolink.org/cancer-treatment/radiation/ side-effects/esophagitis Thompson, K.L., Elliott, L., Fuchs-Tarlovsky, V., Levin, R.M., Coble Voss, A., & Piemonte, T. (2017). Oncology evidence-based nutrition practice guideline for adults. Journal of the Academy of Nutrition and Dietetics, 117, 297–310.e47. https://doi.org/10.1016/j.jand.2016.05.010

Jackie Matthews, RN, MS, APRN-CNS, AOCN®, ACHPN Karen Feldmeyer, MSA, RDN, LD

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Fatigue PROBLEM Cancer-related fatigue (CRF) is defined by the National Comprehensive Cancer Network® (NCCN®, 2018) as a “distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” (p. FT-1). Perceived by patients as the most distressing cancer-associated symptom, CRF negatively affects function and quality of life across the cancer continuum. The etiology of CRF is not clear; however, research suggests that interconnected biologic alterations involving elevation in proinflammatory cytokines, dysregulation of 5-hydroxytryptophan, hypothalamic-pituitary-adrenal axis dysfunction, circadian rhythm disturbances, and increased vagal tone may be contributing factors. Often, fatigue experienced by patients with cancer and survivors has many causal factors. Thus, it is important to evaluate all potential factors that could contribute to CRF. Every patient should be screened for CRF at the initial visit and regularly during and following treatment. Management strategies must be tailored to the individual (Berger, Mitchell, Jacobsen, & Pirl, 2015; Mitchell et al., 2014; NCCN, 2018).

ASSESSMENT CRITERIA (Berger et al., 2015; Erickson, Spurlock, Kramer, & Davis, 2013; Kolak et al., 2017; Mitchell et al., 2014) 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Fatigue is a common and persistent symptom, from diagnosis through survivorship. b. CRF may be more pronounced in recurrent, advanced disease or at the end of life. c. Chemotherapy: Fatigue is almost universal and frequently reported at nadir. d. Radiation therapy: Cumulative fatigue peaks around the fifth week of treatment and decreases about two months after the end of treatment. About 30% of patients develop chronic fatigue. e. Concurrent chemoradiation: Fatigue incidence is higher than single-modality treatment. f. Bone marrow/stem cell transplant: Fatigue can persist up to one year posttransplant. g. Biologic therapy: flu-like symptoms, including fatigue h. Those most likely to report moderate to severe fatigue are on active treatment with poor performance status, have experienced weight loss of greater than 5% within six months, and use opioids. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 155

Fa t i g u e 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications, herbals, vitamins, and supplements. Polypharmacy may compound CRF. a. Have there been any recent medication changes or additions? b. Polypharmacy (four or more medications) or the combination of drug classes may increase CRF (e.g., narcotics, antiemetics, antidepressants, antihistamines). c. Many drugs have sedative side effects. i. Opioids ii. Secobarbital iii. Benzodiazepines iv. Antianxiety (anxiolytic) v. Anticonvulsants vi. Antihistamines vii. Beta-blockers (bradycardia) 3. Obtain history of the problem. a. Severity (on a 0–10 numeric scale): 0 = no fatigue; 1–3 = mild fatigue; 4–6 = moderate fatigue; 7–9 = severe fatigue; 10 = worst fatigue imaginable (Berger et al., 2015) b. Onset and duration i. When did fatigue begin? ii. How often did you experience it in the past week? iii. How many hours per day are you fatigued? c. Relieving and intensifying factors i. What makes the fatigue better or worse? ii. Is it relieved by rest? iii. Do you have trouble sleeping? iv. Do you experience daytime sleepiness? v. Do you experience sadness, discouragement, anxiety, or boredom? d. Interference with function i. Do you have difficulty accomplishing tasks? ii. Has fatigue interfered with your social life? iii. Do you have difficulty fulfilling responsibilities at home or work? e. Any associated symptoms (Mitchell, 2018; NCCN, 2018) i. Pain ii. Fever, infection iii. Cognitive dysfunction or decreased mental concentration iv. Sleep disturbances (e.g., sleep apnea, restless legs syndrome, insomnia) v. Nausea, vomiting, or diarrhea vi. Difficulty breathing vii. Muscle weakness 4. Review past medical history (Mitchell, 2018; NCCN, 2018). a. Pain 156 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Fa t i g u e b. Anemia c. Infection d. Endocrine dysfunctions (e.g., hot flashes, hypothyroidism, hypogonadism, adrenal insufficiency) e. Cardiopulmonary dysfunction f. Renal, hepatic, or neurologic dysfunction g. Hepatic disease h. Gastrointestinal disease/dysfunction i. Alcohol or substance abuse j. Emotional distress, depression, or anxiety k. Sleep disturbances l. Nutritional deficit or imbalance 5. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Unable to wake up

Seek emergency care. Call an ambulance immediately.

•• Severe fatigue that is disabling; patient is bedridden. •• Temperature higher than 100.4°F (38°C) with suspected neutropenia •• Adverse reaction to psychostimulant (e.g., methylphenidate, modafinil, prednisone, dexamethasone)

Seek emergency care.

•• Severe fatigue or loss of ability to perform some activities •• Dizziness •• Temperature higher than 100.4°F (38°C) without suspected neutropenia

Schedule office visit in 24–48 hours.

•• Moderate fatigue or difficulty performing some activities of daily living

Follow homecare instructions. Notify MD if no improvement.

•• Increased fatigue over baseline but not altering daily lifestyle

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Fever With Neutropenia, Fever Without Neutropenia Note. Based on information from Erickson et al., 2013; Mitchell, 2018; National Comprehensive Cancer Network, 2018.

HOMECARE INSTRUCTIONS (Erickson et al., 2013; Mitchell, 2018; Mitchell et al., 2014; NCCN, 2018) ••Participate in the appropriate and optimal physical activity/exercise for the individual. –– Start slowly (e.g., walking, gentle stretching, yoga). –– Try short periods of exercise with frequent rest breaks. –– Avoid uneven surfaces. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 157

Fa t i g u e –– Avoid activity that puts you at risk for falls or injury. –– Aim for daily physical activity. ••If able, include endurance activities (e.g., walking, swimming, cycling) and resistance training (e.g., weights, resistance bands). ••Seek a physical therapist or exercise specialist for assessment and an exercise prescription. ••Exercise is recommended with caution in patients with the following: –– Bone metastases –– Thrombocytopenia –– Anemia –– Fever or active infection –– Physical limitations secondary to metastases or comorbid conditions –– Safety issues (risk of falls) ••Manage stress through various means. –– In-person or online support groups –– Expressive writing, journaling –– Supportive counseling –– Relaxation breathing –– Progressive muscle relaxation –– Mindfulness-based stress reduction –– Meditation ••Practice energy conservation. –– Prioritize important tasks and eliminate or delegate others. –– Keep frequently used items within reach. –– Do not stand too long. Sit when preparing meals, washing dishes, ironing, etc. –– Alternate periods of activity and rest throughout the day. –– Plan ahead, as rushing uses energy. –– Keep an activity journal for a few weeks to identify patterns of energy and fatigue. –– Use adaptive devices such as a jar opener, reaching or grabbing tool, shower chair, or bedside commode. ••Optimize sleep quality. –– Cognitive behavioral therapy can address negative thought patterns and behaviors that interfere with sleep. –– Sleep restriction: Match the time in bed with sleep requirements. –– Avoid caffeine at least six to eight hours before bedtime. –– Stop smoking. –– Avoid alcohol and high-sugar foods in the evening. –– Use the bedroom only for sleep and sex. –– Limit daytime naps to 30 minutes. –– Establish a routine prior to sleep that promotes relaxation. –– Create a conducive sleep environment (dark, quiet, and comfortable). –– Avoid gaming, watching TV, and using a computer or cell phone late at night. –– Encourage a balanced diet and adequate intake of fluids, electrolytes, calories, protein, carbohydrates, fat, vitamins, and minerals. 158 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Fa t i g u e

Report the Following Problems

••Blood in urine or stool ••Weight loss ••Fever (temperature above the normal or baseline temperature) without neutropenia ••Inability to perform activities of daily living ••Inability to conceptualize thoughts

Seek Emergency Care Immediately if Any of the Following Occurs

••Fainting ••Unconsciousness ••Temperature higher than 100.4°F (38°C) with suspected neutropenia

REFERENCES Berger, A.M., Mitchell, S.A., Jacobsen, P.B., & Pirl, W.F. (2015). Screening, evaluation, and management of cancer-related fatigue: Ready for implementation to practice? CA: A Cancer Journal for Clinicians, 65, 190–211. https://doi.org/10.3322/caac.21268 Erickson, J.M., Spurlock, L.K., Kramer, J.C., & Davis, M.A. (2013). Self-care strategies to relieve fatigue in patients receiving radiation therapy. Clinical Journal of Oncology Nursing, 17, 319–324. https://doi.org/10.1188/13.CJON.319-324 Kolak, A., Kamińska, M., Wysokińska, E., Surdyka, D., Kieszko, D., Pakieła, M., & Burdan, F. (2017). The problem of fatigue in patients suffering from neoplastic disease. Contemporary Oncology, 21, 131–135. https://doi.org/10.5114/wo.2017.68621 Mitchell, S.A. (2018). Cancer-related fatigue. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 883–904). Burlington, MA: Jones & Bartlett Learning. Mitchell, S.A., Hoffman, A.J., Clark, J.C., DeGennaro, R.M., Poirier, P., Robinson, C.B., & Weisbrod, B.L. (2014). Putting evidence into practice: An update of evidence-based interventions for cancerrelated fatigue during and following treatment. Clinical Journal of Oncology Nursing, 18(Suppl.), 38–58. https://doi.org/10.1188/14.CJON.S3.38-58 National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Cancer-related fatigue [v.2.2018]. Retrieved from https://www.nccn.org​ /professionals/physician_gls/pdf/fatigue.pdf

Pamela H. Carney, MSN, RN, OCN® The author would like to acknowledge Anne Invernale, RN, BSN, for her contribution to this protocol that remains unchanged from the previous of this book.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 159

160 . . . . . . . . Telephone Triage

Fever With Neutropenia PROBLEM When taken using an oral thermometer, normal body temperature is 98.6°F (37°C). Fever in a neutropenic patient is defined as a sustained oral temperature higher than 100.4°F (38°C) for more than one hour or a single temperature higher than 101°F (38.3°C). Febrile neutropenia is considered a medical emergency, as it can be a potentially life-threatening event and lead to cancer treatment delays and dose reductions (Kurtin, 2016). Up to 60% of patients who become febrile have an established infection (National Comprehensive Cancer Network® [NCCN®], 2017). A neutropenic patient cannot mount a normal response to infection, and fever is often a late sign of an infectious process and may be life threatening (O’Leary, 2015). Rosa and Goldani (2014) recommended that the target time for the initiation of antibiotics should be 30 minutes from the onset of a fever in a neutropenic patient. They also found that mortality rate increased by 18% for each hour the initiation of antibiotics was delayed.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? The risk of infection is directly related to the severity and duration of neutropenia (NCCN, 2017). Other risk factors include age 65 or older, female sex, malnutrition, and comorbidities (e.g., chronic obstructive pulmonary disease, diabetes, renal or liver disease). Neutropenia can occur secondary to malignancies that involve bone marrow infiltration, such as leukemia, and to chemotherapy or radiation therapy (Kurtin, 2016). 2. What medications is the patient taking? Obtain medication history. a. Include a history on current cancer treatments, both immunosuppressive agents such as cytotoxic therapies, which could lead to neutropenia resulting in an increase in risk for infection, and other treatments that may result in fever as a side effect, such as BRAF inhibitors and immunotherapy agents. b. Inquire about current or recent use of corticosteroids. Long-term corticosteroid use may lower the resistance to infection. Rapid cessation of steroids taken for longer than two weeks may lead to steroid withdrawal syndrome, which may include fever, fatigue, joint pain, muscle stiffness, or tenderness (Fields, 2017). 3. Ask the patient to describe symptoms in detail. a. Maximum temperature in the past 24 hours Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 161

Fever With Neutropenia b. Evidence of any other signs of infection (Kurtin, 2016) i. Red, draining, or tender lesions/sores ii. Mucositis or white patches in the oral cavity iii. Diarrhea iv. Red, draining, or tender indwelling catheter exit site v. Sore throat vi. Cough vii. Pain or discomfort with urination viii. Chills 4. Obtain history of the problem. a. Precipitating factors (e.g., exposure to others with infections, especially tuberculosis; pets; travel; recent blood product administration) (NCCN, 2017) b. Onset and duration, including temperature spikes and time of temperature elevation c. Relieving factors (e.g., any antipyretic medications taken prior to the call) 5. Review past medical history. a. Exposure to others with upper respiratory infection or flu b. The most common cause of neutropenia is chemotherapy, and the timing of neutrophil nadir is predictable and can be estimated based on the agent given. i. Always identify the chemotherapy agents given and when. ii. Review the patient’s latest complete blood count and absolute neutrophil counts, as well as prior counts of both during other chemotherapy cycles. This helps to predict the degree of neutropenia, as it typically worsens with each course of therapy if not treated with a growth factor. c. Infection history and recent antibiotics taken (Kurtin, 2016) 6. Assess for changes in activities of daily living and function. Signs and Symptoms •• Temperature higher than 100.4°F (38°C) for more than an hour or a single temperature spike of 101°F (38.3°C) combined with one of the following: –– Change in mental status: restlessness, irritability, confusion, or somnolence –– Rapid breathing, difficulty swallowing, or wheezing –– Signs of dehydration ** Decreased urine output ** Sunken eyes ** Excessive thirst, dry mouth ** Pinched skin does not spring back –– Signs of shock ** Light-headedness ** Pale, cold, or moist skin ** Thirst ** Rapid pulse

Action Seek emergency care. Call an ambulance immediately.

(Continued on next page)

162 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Fever With Neutropenia (Continued)

Signs and Symptoms

Action

•• Signs and symptoms of infection

Seek urgent care within 24 hours.

•• Temperature 100.4°F (38°C) or lower

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Difficulty or Pain With Urination, Fever Without Neutropenia, Oral Mucositis

HOMECARE INSTRUCTIONS ••Take temperature anytime you feel hot or chilled, and repeat every four hours. ••Follow neutropenic precautions if absolute neutrophil count is less than 1,000/mm3. ••Avoid antipyretic medications when neutropenia is present to avoid masking symptoms of infection and sepsis.

Neutropenic Precautions

(Kurtin, 2016; National Cancer Institute, 2015; Olsen, LeFebvre, & Brassil, in press) ••Maintain good personal hygiene, including washing hands after using the bathroom. ••Practice preventive oral care, including brushing teeth with a soft toothbrush twice daily and flossing daily. Use an oral rinse with salt water after each meal. ••Avoid crowds and exposure to anyone with signs of infection. ••Do not change cat litter or clean up animal excreta. ••Use nothing per rectum. ••Use daily stool softeners to avoid constipation.

Report the Following Problems

••Sustained oral temperatures higher than 100.4°F (38°C) for more than one hour or a single temperature higher than 101°F (38.3°C) ••Chills with or without fever ••New cough with or without sputum or worsening cough ••Burning on urination ••Pain at site of port or catheter ••New sore throat or mouth ••Any area with redness or swelling

Seek Emergency Care Immediately if Any of the Following Occurs

••Sustained oral temperatures higher than 100.4°F (38°C) for more than one hour or a single temperature higher than 101°F (38.3°C) ••Changes to level of consciousness ••Shortness of breath ••Signs of shock Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 163

Fever With Neutropenia

REFERENCES Fields, T.R. (2017). Steroid side effects: How to reduce corticosteroid side effects: How to reduce drug side effects. Retrieved from https://www.hss.edu/conditions_steroid-side-effects-how-to-reduce​ -corticosteroid-side-effects.asp Kurtin, S. (2016). Alterations in hematologic and immune function. In J.K. Itano (Ed.), Core curriculum for oncology nursing (5th ed., pp. 322–339). St. Louis, MO: Elsevier. National Cancer Institute. (2015). Infection and neutropenia during cancer treatment. Retrieved from https://www.cancer.gov/about-cancer/treatment/side-effects/infection National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Prevention and treatment of cancer-related infections [v.1.2018]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf O’Leary, C. (2015). Neutropenia and infection. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 483–504). Pittsburgh, PA: Oncology Nursing Society. Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Rosa, R.G., & Goldani, L.Z. (2014). Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrobial Agents and Chemotherapy, 58, 3799– 3803. https://doi.org/10.1128/AAC.02561-14

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164 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition) .

Fever Without Neutropenia PROBLEM Fever is a body temperature of 100.5°F (38.1°C) or higher (oral temperature) that most often will fluctuate over the course of a day. Fever is most commonly caused by an infection, but other causes can include inflammatory conditions, drug reactions, or tumor growth. Sometimes, the cause may not be known (American Cancer Society, 2015).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Fever can be an adverse event associated with cancer treatments, including chemotherapy, immunotherapy, biologic therapy, and some targeted therapies, such as BRAF and MEK inhibitors. Biologic therapy– and immunotherapy-induced fevers are often associated with a flu-like syndrome, which can include rigors, fatigue, myalgia, and nausea and vomiting. b. Fever can result from an infection. c. Some cancers, such as leukemia and lymphoma, are often associated with fever (American Cancer Society, 2014). d. It is important to rule out the presence of neutropenia in the patient. If the patient is currently receiving cancer therapy or is diagnosed with leukemia, suspect neutropenia and follow the protocol for Fever With Neutropenia, as a low-grade fever can be a medical emergency. 2. What medications is the patient taking? Obtain medication history. a. Chemotherapy: Fever may be a result of a drug reaction at the time of infusion or in the 72 hours following infusion with paclitaxel, docetaxel anhydrous, and gemcitabine (Ogawara et al., 2016). b. Biologic therapy (e.g., interferons, interleukins, colony-stimulating/growth factors, vaccines, gene therapies, nonspecific immunomodulation agents) (Keith & Abueg, 2016; Olsen, LeFebvre, & Brassil, in press) c. Targeted therapy (e.g., small molecule inhibitors [BRAF and MEK inhibitors], monoclonal antibodies) (National Cancer Institute, 2014; Olsen et al., in press; Welsh & Corrie, 2015) d. Inquire about current or recent use of corticosteroids. Long-term corticosteroid use may lower the resistance to infection. Rapid cessation of steroids taken for longer than two weeks may lead to steroid withdrawal syndrome, which may include fever, fatigue, joint pain, muscle stiffness, or tenderness (Fields, 2017). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 165

Fever Without Neutropenia 3. Ask the patient to describe symptoms in detail. a. Maximum temperature in the past 24 hours b. Evidence of any other signs of infection (Kurtin, 2016) i. Red, draining, or tender lesions/sores ii. Mucositis or white patches in the oral cavity iii. Diarrhea iv. Red, draining, or tender indwelling catheter exit site v. Sore throat vi. Cough vii. Pain or discomfort with urination viii. Chills 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration, including temperature spikes and time of temperature elevation c. Relieving factors (e.g., any antipyretic medications taken prior to the call) 5. Review past medical history. a. Chronic medical conditions that increase susceptibility to infections (e.g., HIV, diabetes mellitus, autoimmune disease) b. Recent exposure to others with upper respiratory infection or flu c. Recent medical procedures or surgeries 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Change in mental status: restlessness, irritability, confusion, or somnolence •• Signs of dehydration in an older adult or immunocompromised individual –– Decreased urine output –– Sunken eyes –– Excessive thirst, dry mouth –– Pinched skin does not spring back •• Signs of shock –– Light-headedness –– Pale, cold, or moist skin –– Thirst –– Rapid pulse •• Temperature higher than 103°F (39.4°C) and unresponsive to fever-reducing measures •• Rapid breathing, difficulty swallowing, or wheezing

Seek emergency care. Call an ambulance immediately.

•• Headache, neck stiffness, or photophobia •• Temperature higher than 101°F (38.3°C) in a high-risk patient, such as patients with HIV, leukemia, or those using steroids •• Fever that persists longer than 72 hours with no known cause

Seek urgent care within 24 hours.

(Continued on next page)

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Fever Without Neutropenia (Continued)

Signs and Symptoms

Action

•• Shortness of breath •• Cough with green or yellow sputum •• Frequent or painful urination •• Rash •• Earache, sore throat, or swollen glands •• Recent surgical procedure

Seek urgent care within 24 hours.

•• Congestion, sneezing, and body aches •• Illness in other family members •• Fever responsive to self-care measures

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Difficulty or Pain With Urination, Fever With Neutropenia, Oral Mucositis

HOMECARE INSTRUCTIONS ••Increase fluid intake (unless contraindicated). ••Rest. ••Take usual medications for fever and aches (acetaminophen or ibuprofen), following instructions on label. ••Take a lukewarm sponge bath or bath soak; do NOT use alcohol rubs or alcohol in water soaks as it causes increased discomfort. ••Check temperature every two to four hours or following chills. If no improvement, notify physician.

Report the Following Problems

••Temperature higher than 103°F (39.4°C) ••Fever that persists for more than 24 hours with no known cause ••Rash ••Frequent urination, blood, or pain with urination ••Signs of dehydration ••Abdominal pain

Seek Emergency Care Immediately if Any of the Following Occurs ••Seizure ••Change in level of consciousness ••Difficulty breathing ••Signs of shock

REFERENCES American Cancer Society. (2014). Signs and symptoms of cancer. Retrieved from https://www.cancer. org/cancer/cancer-basics/signs-and-symptoms-of-cancer.html American Cancer Society. (2015). Fever. Retrieved from https://www.cancer.org/treatment/treatments​ -and-side-effects/physical-side-effects/fever.html# Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 167

Fever Without Neutropenia Fields, T.R. (2017). Steroid side effects: How to reduce corticosteroid side effects: How to reduce drug side effects. Retrieved from https://www.hss.edu/conditions_steroid-side-effects-how-to-reduce​ -corticosteroid-side-effects.asp Keith, B., & Abueg, K.D. (2016). Nursing implications of targeted therapies and biotherapy. In J.K. Itano (Ed.), Core curriculum for oncology nursing (5th ed., pp. 251–267). St. Louis, MO: Elsevier. Kurtin, S. (2016). Alterations in hematologic and immune function. In J.K. Itano (Ed.), Core curriculum for oncology nursing (5th ed., pp. 322–339). St. Louis, MO: Elsevier. National Cancer Institute. (2014). Targeted therapy to treat cancer. Retrieved from https://www.cancer​ .gov/about-cancer/treatment/types/targeted-therapies Ogawara, D., Fukuda, M., Ueno, S., Ohue, Y., Takemoto, S., Mizoguchi, K., … Kohno, S. (2016). Drug fever after cancer chemotherapy is most commonly observed on posttreatment days 3 and 4. Supportive Care in Cancer, 24, 615–619. https://doi.org/10.1007/s00520-015-2820-8 Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Welsh, S.J., & Corrie, P.G. (2015). Management of BRAF and MEK inhibitor toxicities in patients with metastatic melanoma. Therapeutic Advances in Medical Oncology, 7, 122–136. https://doi.org/10​ .1177/1758834014566428

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Flu-Like Symptoms PROBLEM The term flu-like symptoms can be defined as a cluster of three or more symptoms that occur together, are related to each other (Gobel, 2016), and have “adverse effects on patient outcomes” (Dodd et al., 2011, p. 33). Symptoms may include sudden onset of fever, chills and rigors (usually before the fever), myalgia, headache, malaise, cough, poor appetite, nausea, vomiting, diarrhea, and fatigue (Chemocare, n.d.; Gobel, 2016; University of New Mexico [UNM] Comprehensive Cancer Center, n.d.). Flu-like symptoms can be caused by cancer treatments, such as chemotherapy or biologic agents, or by supportive care treatments and may abate once the treatment is stopped (Gobel, 2016). Chemotherapy drugs associated with flu-like symptoms include but are not limited to asparaginase, bendamustine, bleomycin, cladribine, cytarabine, dacarbazine, docetaxel, fludarabine, gemcitabine, hydroxyurea, paclitaxel, procarbazine, topotecan, vincristine, and vinblastine (Eggert, 2017; Gobel, 2016; Olsen, 2017). Biologic agents associated with flu-like symptoms include but are not limited to bacillus Calmette-Guérin, granulocyte colony-stimulating factor, granulocyte macrophage–colony-stimulating factor, interferons, interleukins, and monoclonal antibodies. Supportive care agents such as IV bisphosphonates can also result in flu-like symptoms (Eggert, 2017).

ASSESSMENT CRITERIA (Gobel, 2016) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Verify if the patient is being treated with chemotherapy and/or biologic therapy and whether the patient has received bisphosphonates. Determine the date of the most recent treatment. 2. What medications is the patient taking? Obtain medication history. 3. Ask the patient to describe symptoms in detail, including current symptoms, onset, duration, relieving factors, provoking factors, and severity and impact on the patient. a. Severity should be objectively quantified (e.g., current temperature, impact on ability to carry out activities of daily living, pain level). b. The extent of severity can be evaluated using the National Cancer Institute Cancer Therapy Evaluation Program Common Terminology Criteria for Adverse Events grading scales for flu-like symptoms, fever, chills, myalgia, diarrhea, vomiting, and fatigue (see https://ctep.cancer.gov/protocol Development/electronic_applications/ctc.htm). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 169

Flu-Like Symptoms c. Assess the following: i. Fever ii. Chills iii. Rigors iv. Myalgia v. Headache vi. Malaise vii. Cough viii. Poor appetite ix. Nausea x. Vomiting xi. Diarrhea xii. Fatigue 4. Review past medical history (e.g., comorbidities). Signs and Symptoms

Action

•• Neutropenic following chemotherapy with temperature higher than 100.4°F (38°C) •• Temperature higher than 102°F (38.9°C) without suspected neutropenia •• Severe flu-like symptom cluster, limiting ability to carry out activities of daily living •• Change in mental status

Seek emergency care.

•• Symptoms not relieved by current homecare instructions within 24 hours

Seek urgent care within 24 hours.

•• If flu-like syndrome is expected from the current therapy

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Anorexia, Cough, Diarrhea, Fatigue, Fever With Neutropenia, Fever Without Neutropenia, Headache, Myalgia and Arthralgia, Nausea and Vomiting

HOMECARE INSTRUCTIONS (Eggert, 2017; Gobel, 2016; UNM Comprehensive Cancer Center, n.d.) Treat individual symptoms. ••Fever (non-neutropenic) –– Use nonsteroidal anti-inflammatory drugs such as acetaminophen or ibuprofen unless contraindicated. –– Aspirin can also be used by adults if platelet count is above 50,000/mm3. –– Try tepid baths or ice packs as tolerated. –– Maintain hydration. ••Chills –– For severe chills, a prescription for a narcotic such as meperidine or hydromorphone may be necessary. –– Use comfort measures such as warm clothing, blankets, or a hot water bottle (use caution in areas treated with radiation therapy and risk of burns). 170 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Flu-Like Symptoms ••Myalgia and headache –– Use nonsteroidal anti-inflammatory drugs such as acetaminophen or ibuprofen unless contraindicated. –– Opioids and prednisone may be prescribed. –– Apply heat or cold on muscles. –– Apply a cool cloth on forehead. –– Rest in a quiet, dimly lit room. –– Apply heat and massage for headaches at the back of the head. ••Malaise/fatigue –– Balance periods of activity with rest periods. –– Eat a balanced diet. ••Cough –– Use an antitussive such as codeine, dextromethorphan, or benzonatate. –– Use a decongestant if needed. –– Use an antihistamine if experiencing a runny nose. –– Use a humidifier if experiencing a dry cough.

Seek Emergency Care Immediately if Any of the Following Occurs ••Elevated temperature for more than three days ••Vomiting ••Seizures ••Changes in vision ••Change in mental status

REFERENCES Chemocare. (n.d.). Flu-like syndrome. Retrieved from http://chemocare.com/chemotherapy/side-effects/ flulike-syndrome.aspx Dodd, M.J., Cho, M.H., Cooper, B.A., Petersen, J., Bank, K.A., Lee, K.A., & Miaskowski, C. (2011). Identification of latent classes in patients who are receiving biotherapy based on symptom experience and its effect on functional status and quality of life. Oncology Nursing Forum, 38, 33–42. https://doi.org/10.1188/11.ONF.33-42 Eggert, J. (2017). Precision medicine: Biologics and targeted therapies. In J. Eggert (Ed.), Cancer basics (2nd ed., pp. 221–259). Pittsburgh, PA: Oncology Nursing Society. Gobel, B.H. (2016). Metabolic complications in cancer care. In D. Camp-Sorrell (Ed.), inPractice. Retrieved May 3, 2018, from https://www.inpractice.com/Textbooks/Oncology-Nursing/Symptom -Management/Metabolic-Effects/Chapter-Pages/Page-2.aspx Olsen, M. (2017). Chemotherapy. In J. Eggert (Ed.), Cancer basics (2nd ed., pp. 197–221). Pittsburgh, PA: Oncology Nursing Society. University of New Mexico Comprehensive Cancer Center. (n.d.). Flu-like syndrome. Retrieved from http://cancer.unm.edu/cancer/cancer-info/cancer-treatment/side-effects-of-cancer-treatment/less -common-side-effects/cold-or-flu-illness/flu-like-syndrome

Tayreez Mushani, BScN, MHS, CON(C), CHPCN(C) The author would like to acknowledge Joanne D. Hayes, BSN, MA, for her contribution to this protocol that remains unchanged from the previous edition of this book.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 171

172 . . . . . . . . Telephone Triage

Hand-Foot Syndrome PROBLEM Hand-foot syndrome (HFS), also known as palmar-plantar erythrodysesthesia or acral erythema, occurs as a side effect of certain chemotherapy or biologic agents (Eaby-Sandy, Grande, & Viale, 2012; Macedo, Lima, dos Santos, & Sasse, 2014). Affected areas include the palms of the hands, soles of the feet, and other pressure-prone areas. Patients may initially experience symmetrical, mild redness and edema on the palms and soles with tingling sensations in the hands, usually at the fingertips. Symptoms on the hands and feet can advance to increased redness and tingling, as well as numbness, pain, pruritus, and swelling. Some patients may have trouble walking or grasping items. Progression of HFS can lead to a more intense burning pain, tenderness, ulceration, blistering, and moist desquamation (Chen, Zhang, Wang, & Shen, 2013; Miller, Gorcey, & McLellan, 2014; Olsen, LeFebvre, & Brassil, in press; Robison, 2011). Symptoms usually develop 2–12 days after the chemotherapy or biologic therapy administration (Olsen et al., in press). Incidence rates for HFS vary with specific chemotherapy drugs and range from 6%–62% (Chen et al., 2013; Eaby-Sandy et al., 2012; Macedo et al., 2014; Miller et al., 2014). The single drugs with the highest reported HFS incidence are capecitabine (50%–60%), pegylated liposomal doxorubicin (40%–50%), and docetaxel (6%– 58%) (Miller et al., 2014). Certain chemotherapy regimens can increase the risk of HFS. For example, the reported incidence of combination doxorubicin and continuous 5-fluorouracil (5-FU) is 89%, while combination docetaxel and capecitabine incidence is 56%–63% (Degen et al., 2010). Incidence rates for HFS can be as high as 62% for several of the newer targeted multikinase inhibitors. Notable examples include sorafenib (10%–62%), sunitinib (10%–50%), vemurafenib (60%), and regorafenib (47%) (Boussemart et al., 2013; Degen et al., 2010; Grothey et al., 2013). Combination biologic regimens can also increase the risk of HFS. For example, the incidence rate for combination sorafenib and bevacizumab is 79% (Degen et al., 2010). Incidence and severity of HFS symptoms are also related to drug dose and prolonged exposure of patient cells to the drug. Higher incidence is seen in drugs with formulations that prolong serum drug levels or concentrate the drug at affected sites (Miller et al., 2014; Olsen et al., in press). Examples include continuous infusion 5-FU and capecitabine, an oral prodrug of 5-FU that produces sustained tissue drug levels (Miller et al., 2014).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 173

Ha n d - F o o t S y n d r o m e 2. What medications is the patient taking? Obtain medication history, including allergies. a. Chemotherapy: Drugs that can cause HFS include bleomycin, capecitabine, cisplatin, cyclophosphamide, cytarabine, daunorubicin, docetaxel, doxorubicin, etoposide, 5-FU (continuous infusion), floxuridine, fludarabine, gemcitabine, hydroxyurea, idarubicin, ixabepilone, liposomal encapsulated doxorubicin, methotrexate, mitotane, thiotepa, and vinorelbine (Cancer.Net, 2017; Miller et al., 2014; Olsen et al., in press; Robison, 2011). b. Multikinase inhibitors: Drugs that can cause HFS include axitinib, cabozantinib, pazopanib, sorafenib, sunitinib, and vemurafenib (Cancer.Net, 2017; Miller et al., 2014; Olsen et al., in press; Robison, 2011). 3. Ask the patient to describe symptoms in detail. a. Specific symptoms experienced (e.g., redness, swelling, numbness, tingling, pain, pruritus) b. Location of symptoms c. Appearance of symptoms d. Discomfort rated on the numeric scale of 0–10 (0 = no pain; 10 = worst possible pain) (Pasero & McCaffery, 2011) 4. Obtain history of the problem. a. Precipitating factors i. Hot water (e.g., washing dishes, long showers, hot baths) ii. Impact on feet (e.g., jogging, aerobics, walking, jumping) iii. Use of tools that require squeezing hand on a hard surface (e.g., garden tools, household tools, kitchen knives) iv. Rubbing (e.g., applying lotion, massaging) b. Onset and duration c. Relieving factors d. Any associated symptoms (e.g., fever, blistering, skin flaking or peeling, ulceration, pain, paresthesias or dysesthesias, discoloration of the skin) 5. Review past medical history. a. Recent infection: Redness of hands and feet with peeling also may result from Streptococcus or other infectious or viral processes. b. Exposure to infection 6. Assess for changes in activities of daily living and function. 7. Review the grade of HFS using the National Cancer Institute Cancer Therapy Evaluation Program Common Terminology Criteria for Adverse Events (see Table 3). Currently, dose reductions or treatment interruptions are the most effective strategies to manage HFS, with symptoms resolving in one to two weeks (Miller et al., 2014). Healthcare practitioners can refer to the drug product information to determine the specific recommended dose modification or delay in treatment for grade 3 or 4 HFS (Macedo et al., 2014; Miller et al., 2014). 174 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ha n d - F o o t S y n d r o m e Table 3. Grading of Hand-Foot Syndrome Grade

Clinical Presentation

1

Minimal skin changes or dermatitis (e.g., erythema, edema, hyperker­ atosis) without pain

2

Skin changes (e.g., peeling, blisters, bleeding, fissures, edema, hyperkeratosis) with pain; limiting instrumental ADLs

3

Severe skin changes (e.g., peeling, blisters, bleeding, edema, hyperkeratosis) with pain; limiting self-care ADLs

ADLs—activities of daily living Note. From Common Terminology Criteria for Adverse Events [v.5.0], by National Cancer Institute Cancer Therapy Evaluation Program, 2017. Retrieved from https://ctep.cancer.gov/protocolDevelop ment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf.

Signs and Symptoms

Action

•• Severe skin changes (e.g., peeling, blisters, bleeding, edema, hyperkeratosis, moist desquamation, ulceration, odor, itching, discoloration)—grade 3 HFS –– Presence of pain, severe discomfort, tingling, or numbness –– Symptoms interfere with self-care ADLs –– Patient is taking medications at home known to cause HFS –– Fever

Seek emergency care. Do not wait to see if symptoms improve; call MD. Stop taking oral medications known to cause HFS (e.g., capecitabine, sorafenib, sunitinib). Discuss use of celecoxib with MD. Take pain medication, as ordered.

•• Moderate skin changes (e.g., pain, blisters, bleeding, edema, hyperkeratosis)—grade 2 HFS –– Redness, swelling, numbness, tingling of hands or feet –– Mild to moderate pain that interferes with instrumental ADLs –– Patient is taking medications at home known to cause HFS –– No fever

Do not wait to see if your symptoms improve; call MD. Seek urgent care within 24 hours. Stop taking oral medications known to cause HFS (e.g., capecitabine, sorafenib, sunitinib). Apply cold compresses and/or emollient cream to hands and feet.

•• Minimal skin changes (e.g., redness, warmth, swelling, dryness, hyperkeratosis) without pain—grade 1 HFS –– No interference with ADLs –– Mild or no tingling or numbness –– Patient is taking medications at home known to cause HFS –– No fever

Follow homecare instructions. Notify MD if no improvement.

ADLs—activities of daily living; HFS—hand-foot syndrome Cross-references: Fever With Neutropenia, Fever Without Neutropenia, Pain, Rash Note. Based on information from Macedo et al., 2014; National Cancer Institute Cancer Therapy Evaluation Program, 2017; Olsen et al., in press.

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Ha n d - F o o t S y n d r o m e

HOMECARE INSTRUCTIONS ••Avoid prolonged heat exposure on hands and feet. –– Avoid washing dishes in hot water. –– Do not take long showers or hot baths; keep water cool or tepid in shower or bathwater. –– Stay away from sources of heat, including saunas, sitting in the sun, or sitting in front of a sunny window. –– Avoid wearing rubber or vinyl dishwashing gloves without a liner to clean with hot water. The rubber traps heat and sweat against the skin. Try using white cotton gloves underneath rubber gloves (Breastcancer.org, 2017; Cancer.Net, 2017; Olsen et al., in press). ••Avoid activities that cause friction or put pressure on the skin. –– Keep pressure off hands and feet; avoid kneeling for long periods or leaning on elbows. –– Take a break from some forms of exercise to avoid impact on feet (e.g., jogging, aerobics, power walking, jumping, racquet sports). –– Do not use tools that require the squeezing of hands on a hard surface (e.g., garden tools, hammer, screwdrivers, household tools, kitchen knives); squeezing or chopping motions can cause excessive pressure and friction on hands, leading to leakage of medications into tissue. –– Avoid rubbing (e.g., applying lotion, massaging). –– Do not wear tight-fitting clothing or shoes; wear thick socks, soft slippers, or loose, well-ventilated shoes; try to not walk barefoot. –– Attempt to prevent injury to feet and hands (Breastcancer.org, 2017; Cancer.Net, 2017; Olsen et al., in press). ••Other instructions to identify and prevent HFS include the following: –– Monitor for and report signs of infection (e.g., increased redness, pain, warmth, drainage, odor). –– Practice good personal hygiene. When washing hands, use mild soap and pat skin dry. Do not rub skin. –– Elevate hands and feet when sitting or lying down. –– Stay away from harsh chemicals (e.g., laundry detergent, household cleaning products), as these can irritate the skin. –– Use sunscreen on all exposed skin when going outside (Williams et al., 2017). –– Consider visiting a podiatrist to remove any thick calluses and thick nails (Breastcancer.org, 2017; Cancer.Net, 2017; Olsen et al., in press). ••Strategies to manage HFS include the following: –– Cool hands and feet by applying cold compresses (e.g., ice packs wrapped in a towel, packages of frozen vegetables, cool running water, a wet towel) to the affected area for 15–20 minutes at a time for comfort. Do not apply ice directly on the skin (Williams et al., 2017). –– Elevate extremities to reduce swelling. –– Keep hands and feet moist by using mild, alcohol-free, urea-based emollient creams (e.g., Aveeno®, Bag Balm®, Lubriderm®, Udderly Smooth®) (Williams et al., 2017). 176 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ha n d - F o o t S y n d r o m e * Try to pat the cream into the skin; rubbing it in too vigorously can cause friction. * Apply liberally and often (three times a day) to hands and feet, if skin is intact. * After cream is applied at night, put on cotton gloves or socks to help cream absorption. If skin is not intact, consult with the nurse or doctor. ••Discuss the use of celecoxib with a physician, as it has demonstrated statistically significant improvement in HFS (Williams et al., 2017; Zhang et al., 2012). ••A meta-analysis showed no clinical benefits for pyridoxine (vitamin B6) in preventing HFS (Chen et al., 2013; Macedo et al., 2014; Williams et al., 2017). It is no longer recommended. ••Take pain medication as directed by a physician or nurse. ••Talk to physicians about other ways to manage the HFS. Options may include lowering the drug dosage, changing the treatment schedule, or temporarily stopping treatment (Breastcancer.org, 2017; Cancer.Net, 2017; Olsen et al., in press).

Report the Following Problems

••Temperature higher than 100.4°F (38°C) with or without signs of infection ••Uncontrolled pain ••Drainage or odor from open areas ••Inability to perform normal daily functions ••Sudden or gradual onset of numbness or tingling

Seek Emergency Care Immediately if Any of the Following Occurs

••Blister formation, desquamation (peeling of skin—dry or moist), and infectious complications ••Temperature higher than 100.4°F (38°C) with suspected neutropenia

REFERENCES Boussemart, L., Routier, E., Mateus, C., Opletalova, K., Sebille, G., Kamsu-Kom, N., … Robert, C. (2013). Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: A study of 42 patients. Annals of Oncology, 24, 1691–1697. https://doi.org/10.1093/annonc/mdt015 Breastcancer.org. (2017). Hand-foot syndrome (HFS) or palmar-plantar erythrodysesthesia (PPE). Retrieved from http://www.breastcancer.org/treatment/side_effects/hand_foot_synd Cancer.Net. (2017). Hand-foot syndrome or palmar-plantar erythrodysesthesia. Retrieved from http://www.cancer.net/navigating-cancer-care/side-effects/hand-foot-syndrome-or-palmar-plantar​ -erythrodysesthesia Chen, M., Zhang, L., Wang, Q., & Shen, J. (2013). Pyridoxine for prevention of hand-foot syndrome caused by chemotherapy: A systematic review. PLOS ONE, 8, e72245. https://doi.org/10.1371/journal​ .pone.0072245 Degen, A., Alter, M., Schenck, F., Satzger, I., Völker, B., Kapp, A., & Gutzmer, R. (2010). The hand-footsyndrome associated with medical tumor therapy—Classification and management. Journal der Deutschen Dermatologischen Gesellschaft, 8, 652–661. https://doi.org/10.1111/j.1610-0387.2010​.07449.x Eaby-Sandy, B., Grande, C., & Viale, P.H. (2012). Dermatologic toxicities in epidermal growth factor receptor and multikinase inhibitors. Journal of the Advanced Practitioner in Oncology, 3, 138–150. https://doi.org/10.6004/jadpro.2012.3.3.2 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 177

Ha n d - F o o t S y n d r o m e Grothey, A., Van Cutsem, E., Sobrero, A., Siena, S., Falcone, A., Ychou, M., … Laurent, D. (2013). Regorafenib monotherapy for previously treated metastatic colorectal cancer (CORRECT): An international, multicenter, randomized, placebo-controlled, phase 3 trial. Lancet, 381, 303–312. https://​ doi.org/10.1016/S0140-6736(12)61900-X Macedo, L.T., Lima, J.P.N., dos Santos, L.V., & Sasse, A.D. (2014). Prevention strategies for chemotherapy-induced hand–foot syndrome: A systematic review and meta-analysis of prospective randomized trials. Supportive Care in Cancer, 22, 1585–1593. https://doi.org/10.1007/s00520-014-2129-z Miller, K.K., Gorcey, L., & McLellan, B.N. (2014). Chemotherapy-induced hand-foot syndrome and nail changes: A review of clinical presentation, etiology, pathogenesis, and management. Journal of the American Academy of Dermatology, 71, 787–794. https://doi.org/10.1016/j.jaad.2014.03.019 National Cancer Institute Cancer Therapy Evaluation Program. (2017). Common terminology criteria for adverse events [v.5.0]. Retrieved from https://ctep.cancer.gov/protocolDevelopment/electronic​ _applications/ctc.htm Olsen, M.M., LeFebvre, K.B., & Brassil, K.J. (Eds.). (in press). Chemotherapy and immunotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. Pasero, C., & McCaffery, M. (2011). Assessment tools. In C. Pasero & M. McCaffery (Eds.), Pain assessment and pharmacologic management (pp. 49–142). St. Louis, MO: Elsevier Mosby. Robison, J.G. (2011). Skin reactions: Rash, palmar-plantar erythrodysesthesia, xerosis, paronychia, photosensitivity, and pruritus. In L.H. Eaton, J.M. Tipton, & M. Irwin (Eds.), Putting evidence into practice: Improving oncology patient outcomes, volume 2 (pp. 77–121). Pittsburgh, PA: Oncology Nursing Society. Williams, L., Ciccolini, K., Johnson, L.A., Robison, J., Shelton, G., & Lucas, S. (2017). Skin reactions. Retrieved from https://www.ons.org/pep/skin-reactions Zhang, R.X., Wu, X.J., Wan, D.S., Lu, Z.H., Kong, L.H., Pan, Z.Z., & Chen, G. (2012). Celecoxib can prevent capecitabine-related hand-foot syndrome in stage II and III colorectal cancer patients: Results of a single-center, prospective randomized phase III trial. Annals of Oncology, 23, 1348– 1353. https://doi.org/10.1093/annonc/mdr400

Jeanene “Gigi” Robison, MSN, APRN-CNS, AOCN® The author would like to acknowledge Ana Nuñez, MSN, RN, OCN®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

178 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Headache PROBLEM A headache is defined as a pain in any part of the head presenting as a throbbing or dull ache to a sharp pain. Headache pain can be felt unilaterally or bilaterally. It can be isolated to a specific region of the head, radiate from one area to another, or have a viselike quality (Mayo Clinic, 2018). A headache may be acute or chronic and can be life threatening. Emergent and nonemergent headache etiologies include the following (Barritt, Miller, Davagnanam, & Matharu, 2016; Lin & Avila, 2017; Nolan & DeAngelis, 2015; Tabatabai & Swadron, 2016): ••Emergent causes: The brain, cerebrospinal fluid (CSF), and blood have fixed volumes within the rigid cranium of 80%, 10%, and 10%, respectively. Increasing volume (particularly if occurring rapidly) in one decreases the available room for the other two. If untreated, the limited ability to compensate results in increased intracranial pressure (ICP) and ultimately cerebral ischemia. Other potentially emergent events in patients with cancer include intracranial hemorrhage, infectious meningitis, and posterior reversible encephalopathy. ••Nonemergent causes: Some examples are stress, sinus congestion or infection, aseptic (chemical) meningitis, flu, and flu-like syndrome.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Evaluate the patient’s recent cancer treatments. Cancer therapies that may induce central nervous system (CNS) toxicity or bleeding may result in a headache (Gharwan & Groninger, 2016; Le & Loghin, 2014; Lin & Avila, 2017; Nelson & Taylor, 2014; Nolan & DeAngelis, 2015; Soffietti, Trevisan, & Rudà, 2014; Tabatabai & Swadron, 2016; Velander, DeAngelis, & Navi, 2012). a. Although new headaches can occur with radiation therapy, chemotherapy, or craniotomy, consider other, more serious potential causes before attributing symptoms to therapy. b. Partial or whole-brain radiation therapy can disrupt the blood–brain barrier, increase edema, and cause transient acute or subacute injury with increased ICP. c. A headache is common after intrathecal chemotherapy (secondary to chemical meningitis) and is a nonspecific side effect of many chemotherapy drugs (e.g., dacarbazine, 5-fluorouracil, fludarabine, gemcitabine, hydroxyurea, high-dose methotrexate, procarbazine, temozolomide, thalidomide, Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 179

Headache topotecan, vincristine), retinoids (e.g., alitretinoin, tretinoin), and biologic and targeted therapies (e.g., alemtuzumab, bortezomib, cetuximab, erlotinib, imatinib, interferons, interleukins, pazopanib, rituximab, ruxolitinib, semaxanib, trastuzumab, tumor necrosis factor, vandetanib). d. Headaches may also be a side effect of tamoxifen, erythropoietin, bisphosphonates, antibiotics (e.g., amphotericin B, vancomycin), or corticosteroid withdrawal (rebound edema). e. CNS hemorrhage, particularly in patients with acute leukemia, can occur secondary to chemotherapy or other drugs with platelet toxicity (e.g., carboplatin, gemcitabine, heparin, vancomycin, rarely after antiangiogenic agents [bevacizumab, sorafenib, sunitinib]). f. Numerous therapies (e.g., platinum analogs, antimetabolites, folate antagonists, anthracyclines, vinca alkaloids, some targeted agents, bone marrow/ stem cell transplants, corticosteroids, immunosuppressant agents) have been implicated in posterior reversible encephalopathy that starts from 30 minutes to three months after treatment. Symptoms include headache, impaired thinking, seizures, altered consciousness, visual changes, and possible progression to ischemia, hemorrhage, or cerebral infarction. Prompt recognition and treatment usually leads to full recovery. 2. Ask the patient to describe symptoms in detail. a. Evaluate the patient for any signs and symptoms of a CNS (or other) infection, particularly bacterial meningitis, which carries a 15% mortality rate (Barritt et al., 2016; Gladstone & Bigal, 2010). i. Fever with headache may signal a CNS or systemic infection, septicemia, or another cause (e.g., serotonin syndrome). Headaches with systemic or viral infections are usually relatively mild compared to other symptoms, such as fever, malaise, and muscle aches. ii. An abrupt headache that becomes severe over minutes or hours is the usual presentation of bacterial meningitis, which may be preceded by an ear, sinus, or lung infection. The headache often worsens with sudden movements. About 50% of patients with cancer do not have the classic triad of meningitis—fever, nuchal (neck) rigidity, and change in mental status—but virtually all have at least one or two symptoms. iii. A flu-like illness may precede lymphocytic or viral meningitis, in which a moderate to severe headache (e.g., frontal, retro-orbital, occipital, all-over), fever, and neck stiffness are common symptoms. b. Evaluate if the patient has any associated focal CNS symptoms (Nelson & Taylor, 2014; Tabatabai & Swadron, 2016). i. New neurologic deficits along with a headache constitute a “red flag.” ii. Neurologic deficits include vomiting, photophobia or other visual changes, syncope, seizures (partial or generalized), decreased level of consciousness or coma, change in strength or gait, orientation, personality, and any focal/partial (accompanied by tremor in an extremity, staring, or speech arrest) or generalized seizures. 180 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Headache c. Evaluate if the patient has a malignancy with the potential to infiltrate or compress brain structures, or otherwise cause an increase in ICP (Page & Rabbitt, 2017). i. Up to 60% of patients with brain metastases have headaches. Brain metastases are common with lung or breast cancer or melanoma. They are less common in renal cell, gastrointestinal, or other solid tumors, non-Hodgkin lymphoma, and relapsed leukemia. ii. Up to 70% of patients with primary brain cancers have headaches, particularly during end stage secondary to mass effect from tumor and increased ICP. 3. Obtain history of the problem, including exploring the patient’s subjective report of headache pain (Barritt et al., 2016; Lin & Avila, 2017; Nelson & Taylor, 2014; Schwedt, 2013). a. Severity: Ask the patient to describe the quality of the pain. i. Patients typically describe brain tumor pain similarly to a tension headache or migraine or as a shooting or throbbing pain. ii. Patients describe thunderclap headaches as “the worst headache I have ever had,” “an explosion in my head,” or “like getting hit with a bat.” iii. Assess pain using a 0–10 scale (0 = pain; 10 = the worst pain imaginable) or another numeric or verbal descriptor scale (none, mild, moderate, or severe). b. Precipitating factors: Had the patient experienced any trauma (e.g., fall or blow to the head) that preceded the headache? c. Onset and duration: Ask the patient when the headache started and if a pattern to the pain exists. i. Headaches related to primary or metastatic brain tumors usually become progressively severe over time. ii. Headaches secondary to rapidly increasing ICP may be worse at night (and may even awaken the patient) or occur as brief “waves” lasting 5–20 minutes throughout the day. These headaches may also be triggered by coughing, pain in other sites, or position changes (e.g., lying to sitting, sitting to standing) and mistakenly attributed to orthostasis. iii. CSF leak may induce orthostatic headaches that worsen upon standing. iv. A thunderclap headache has a sudden onset and reaches peak severity within one minute. It may occur with subarachnoid or other brain hemorrhage, ischemic stroke, or hypertensive crisis and should be treated as a medical emergency. v. Inquire about the location of the pain. Patients with flu-like symptoms may have retrobulbar (behind the eyeballs) headaches, and those with sinus congestion often report frontal headaches. Pain in the back of the head or neck may signal stress and muscle tension. Patients with brain tumors often describe their headaches similarly. d. Relieving factors: Patients with meningitis may find that a flexed body posture decreases muscles spasms of the head, neck, and spine. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 181

Headache 4. Review past medical history, including any recent diagnostic procedures that lead to a headache (e.g., lumbar puncture or craniotomy with CSF leak). Signs and Symptoms

Action

•• Headache following head trauma •• Sudden, severe headache described as “the worst I have ever had” •• Headache accompanied by –– Seizures –– Syncope and visual changes –– Known or suspected grade 4 thrombocytopenia –– Uncontrolled or labile hypertension –– Stiff neck (nuchal rigidity) and fever –– Drowsiness –– Vomiting –– Change in consciousness, orientation, personality, strength, or gait

Seek emergency care.

•• Headache worse in the morning, not associated with sinus congestion or fullness •• Awakens the patient from sleep •• Pain uncontrolled by current analgesic regimen •• Pain interferes with activity

Seek urgent care within 24 hours.

•• Headache with flu-like symptoms •• Pain in facial area over sinuses •• Pain or soreness in shoulders and neck •• History of temporomandibular joint dysfunction or pain in joint •• History of grinding teeth (bruxism) •• Recently stopped drinking coffee, eating chocolate, or smoking

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Flu-Like Symptoms, Pain Note. Based on information from Barritt et al., 2016; Lin & Avila, 2017; Nelson & Taylor, 2014; Nolan & DeAngelis, 2015; Schwedt, 2013; Tabatabai & Swadron, 2016.

HOMECARE INSTRUCTIONS ••Observe for any change in headache or head pain status. ••Drink clear liquids sparingly until the reason for headache is determined. ••Rest in a dark, quiet room. ••Elevate head to decrease ICP and facilitate venous blood drainage. ••Apply ice pack or heat, depending on preference, to head and neck. ••Take analgesics as instructed by the physician or nurse.

Seek Emergency Care Immediately if Any of the Following Occurs

••Loss of or altered consciousness, including restlessness or drowsiness ••Vomiting ••Temperature higher than 101°F (38.3°C), or higher than 100.4°F (38°C) if neutropenia is suspected 182 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Headache ••Seizure activity ••Patients with a clinical presentation of headache and visual complaints warrant further consideration for the possibility of secondary etiologies. Clarifying the nature of the patient’s visual symptoms is paramount in determining the likelihood of serious disease. Headache and binocular visual loss, idiopathic intracranial hypertension, and intracranial masses should be strongly considered.

REFERENCES Barritt, A., Miller, S., Davagnanam, I., & Matharu, M. (2016). Rapid diagnosis vital in thunderclap headache. Practitioner, 260, 23–28. Gharwan, H., & Groninger, H. (2016). Kinase inhibitors and monoclonal antibodies in oncology: Clinical implications. Nature Reviews Clinical Oncology, 13, 209–227. https://doi.org/10.1038/nrclinonc​ .2015.213 Gladstone, J., & Bigal, M.E. (2010). Headaches attributable to infectious diseases. Current Pain and Headache Reports, 14, 299–308. https://doi.org/10.1007/s11916-010-0125-7 Le, E.M., & Loghin, M.E. (2014). Posterior reversible encephalopathy syndrome: A neurologic phenomenon in cancer patients. Current Oncology Reports, 16, 383. https://doi.org/10.1007/s11912​ -014-0383-3 Lin, A.L., & Avila, E.K. (2017). Neurologic emergencies in the patients with cancer: Diagnosis and management. Journal of Intensive Care Medicine, 32, 99–115. https://doi.org/10.1177/0885066615619582 Mayo Clinic. (2018). Symptoms: Headache. Retrieved from https://www.mayoclinic.org/symptoms​ /headache/basics/definition/sym-20050800 Nelson, S., & Taylor, L.P. (2014). Headaches in brain tumor patients: Primary or secondary? Headache: The Journal of Head and Face Pain, 54, 776–785. https://doi.org/10.1111/head.12326 Nolan, C.P., & DeAngelis, L.M. (2015). Neurologic complications of chemotherapy and radiation therapy. CONTINUUM: Lifelong Learning in Neurology, 21, 429–451. https://doi.org/10.1212/01​ .CON.0000464179.81957.51 Page, M.S., & Rabbitt, J. (2017). Central nervous system cancers. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 41–51). St. Louis, MO: Elsevier. Schwedt, T.J. (2013). Thunderclap headaches: A focus on etiology and diagnostic evaluation. Headache: The Journal of Head and Face Pain, 53, 563–569. https://doi.org/10.1111/head.12041 Soffietti, R., Trevisan, E., & Rudà, R. (2014). Neurologic complications of chemotherapy and other newer and experimental approaches. Handbook of Clinical Neurology, 121, 1199–1218. https://doi​ .org/10.1016/B978-0-7020-4088-7.00080-8 Tabatabai, R.R., & Swadron, S.P. (2016). Headache in the emergency department: Avoiding misdiagnosis of dangerous secondary causes. Emergency Medicine Clinics of North America, 34, 695–716. https://doi.org/10.1016/j.emc.2016.06.003 Velander, A.J., DeAngelis, L.M., & Navi, B.B. (2012). Intracranial hemorrhage in patients with cancer. Current Atherosclerosis Reports, 1, 373–381. https://doi.org/10.1007/s11883-012-0250-3

Rita Wickham, PhD, RN

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 183

184 . . . . . . . . Telephone Triage

Hematuria PROBLEM Hematuria, or blood in the urine, can result from as little as 1 ml of blood in a liter of urine. This can produce a visible change in urine color. Hematuria can be constant or intermittent, quite visible or microscopic. Infection, injury, or inflammatory responses to the genitourinary tract can result in hematuria. Persistent hematuria may be serious and should not be ignored (Chen, 2016; Dalrymple & Ramage, 2017; Garg & Cheng, 2015; Mutale, 2014).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Urothelial cancers (e.g., kidney, bladder, prostate) are commonly associated with hematuria. Of note, hematuria is present in up to 90% of individuals with bladder cancer (Chen, 2016; Middleton, 2017; Mutale, 2014; Tyler & Profusek, 2018). b. Cancer therapies, as well as other chemical exposures, often result in hematuria. These include chemotherapies (e.g., cyclophosphamide, ifosfamide, bacillus Calmette-Guérin) and biologic therapies (e.g., interleukin-2, leuprolide acetate). Other agents include benzenes and aromatic amines (Mutale, 2014). c. Hematuria can result from radiation therapy to the pelvic area or from invasive procedures such as catheterization, cystoscopy, and renal or prostate biopsies (Middleton, 2017; Mutale, 2014). d. Problems with the urinary tract can cause hematuria, including urinary tract infections, glomerulonephritis, and kidney stones. Irritation or inflammation to the urinary tract structures or urethra, including the sequelae of infection, can cause hematuria (Middleton, 2017; Mutale, 2014; Tyler & Profusek, 2018). e. Comorbid conditions such as hemophilia, leukemia, or sickle cell disease can be present in patients with urothelial cancer, thus complicating assessment of hematuria (Mutale, 2014; Tyler & Profusek, 2018). 2. What medications is the patient taking? a. Obtain medication history, including recent prescription and over-the-counter medications (e.g., anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs, alternative or complementary therapies). b. Review recent chemotherapies, including agents used, routes, doses, and timing of last dose (Garg & Cheng, 2015; Middleton, 2017; Mutale, 2014). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 185

H e m at u r i a 3. Ask the patient to describe symptoms in detail (Conde & Workman, 2017; Garg & Cheng, 2015; Middleton, 2017; Tyler & Profusek, 2018). a. Discomfort or pain on urination, including before starting a stream and after completed (burning, hot, electric) b. Amount of blood in the urine as described by color: pink, red, dark red, brown c. Presence of clots with description d. Frequency of urination e. A feeling that the bladder is not fully emptying f. Pattern of urination, which includes an altered stream and/or urgency g. Any fever or chills (the most common cause of hematuria in adults other than malignancies is a urinary tract infection) h. Back or flank pain; any suprapubic tenderness i. Dizziness or light-headedness; signs of lower blood volume or hypotension 4. Obtain history of the problem. a. Precipitating factors: Encourage reflection of recent events. b. Onset and duration c. Relieving factors d. Smoking or alcohol intake e. Recently performed diagnostic procedures, such as scopes or biopsies f. Recent sexual activity, including assessment of any associated trauma g. Any associated symptoms (e.g., inability to urinate or pain with urination, joint pain, swelling, rash, diarrhea) (Conde & Workman, 2017; Dalrymple & Ramage, 2017; Garg & Cheng, 2015; Mutale, 2014) 5. Review past medical history (Conde & Workman, 2017; Garg & Cheng, 2015). 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Gross hematuria/massive bleeding

Seek emergency care. Call an ambulance immediately.

•• Persistent, bright-red blood and/or clots •• Urinary retention, ongoing clot formation •• Temperature higher than 100.4°F (38°C) with suspected neutropenia, or higher than 103°F (39°C) without suspected neutropenia •• Urinary output decreased or absent •• Dizziness or light-headedness

Seek emergency care.

•• Slight fever; higher than 103°F (39°C) without suspected neutropenia •• Change in urinary frequency •• Pain or burning with urination •• Urinary retention

Seek urgent care within 24 hours.

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186 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

H e m at u r i a (Continued)

Signs and Symptoms

Action

•• Burning urination with decreased fluid intake •• Bladder spasms •• Mild hematuria or frequency after interventions

Follow homecare instructions. Notify MD if no improvement within 24–48 hours.

Cross-references: Difficulty or Pain With Urination, Fever With Neutropenia, Fever Without Neutropenia, Pain Note. Based on information from Garg & Cheng, 2015; Middleton, 2017; Mutale, 2014.

HOMECARE INSTRUCTIONS (Garg & Cheng, 2015; Middleton, 2017; Mutale, 2014) ••Drink 8–10 eight-ounce glasses of fluid each day (unless contraindicated). Alcohol is not included in hydration amounts; remember to report consumption to clinician. ••Limit activities and encourage rest. ••Take any medications or other interventions to assist with comfort as prescribed by the healthcare team. ••Remember that some symptoms are not abnormal (e.g., spasms). ••For a thorough understanding of the material, consult with the healthcare team on any educational materials related to recent therapies, surgeries, genitourinary procedures, or side effects of medications. ••Consult with the healthcare team on any follow-up. ••If triage uncovers symptoms treatable at home, assist the patient by reaching out to the healthcare team for orders or direction (e.g., urinalysis or urine culture for dysuria or fever).

Report the Following Problems

(Garg & Cheng, 2015; Middleton, 2017; Tyler & Profusek, 2018) ••Dysuria ••Fever ••Decreased urinary output ••Urinary or clot retention ••Persistent, bright-red blood or clots in urine ••Any bleeding not associated with menses or known urinary procedure

Seek Emergency Care Immediately if Any of the Following Occurs (Garg & Cheng, 2015; Middleton, 2017; Mutale, 2014) ••Unresponsiveness ••Massive bleeding or hemorrhage

REFERENCES Chen, K.Y. (2016). Urologic malignancies. In A.F. Cashen & B.A. Van Tine (Eds.), The Washington manual hematology and oncology subspecialty consult (4th ed., pp. 329–339). Philadelphia, PA: Wolters Kluwer. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 187

H e m at u r i a Conde, F.A., & Workman, T. (2017). Genitourinary cancers. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 69–80). St. Louis, MO: Elsevier. Dalrymple, R.A., & Ramage, I.J. (2017). Fifteen-minute consultation: The management of microscopic haematuria. ADC Education and Practice Edition, 102, 230–234. https://doi.org/10.1136​ /archdischild-2016-312508 Garg, A.K., & Cheng, S. (2015). Hematuria and nephrolithiasis. In T.M. De Fer & H.F. Sateia (Eds.), The Washington manual of outpatient internal medicine (2nd ed., pp. 508–516). Philadelphia, PA: Wolters Kluwer. Middleton, T.O. (2017). Hematuria. In F.J. Domino, R.A. Baldor, J. Golding, & M.B. Stephens (Eds.), The 5-minute clinical consult 2018 (26th ed., pp. 436–437). Philadelphia, PA: Wolters Kluwer. Mutale, F.A. (2014). Hematuria. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 709–714). Pittsburgh, PA: Oncology Nursing Society. Tyler, A., & Profusek, P. (2018). Bladder cancer. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 1227–1242). Burlington, MA: Jones & Bartlett Learning.

Gary Shelton, DNP, NP, ANP-BC, AOCNP®, ACHPN The author would like to acknowledge Mary Szyszka, APN, MSN, AOCN®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

188 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Hemoptysis PROBLEM Hemoptysis is defined as the expectoration of blood from the lower respiratory tract, a spectrum that varies from blood-streaking of sputum to coughing up large amounts of pure blood. Massive hemoptysis is the expectoration of 100–600 ml of blood in 24 hours, or a bleeding rate more than 100 ml/hr. It is considered serious and potentially life threatening and requires immediate attention to protect the airway, ensure proper ventilation, and address the bleeding source (Lecithin, 2018). Coughing up blood typically means that blood is coming from the respiratory tract. Pseudohemoptysis is when blood does not originate from the respiratory tract (Weinberger, 2018). Coughing up blood is not the same as bleeding from the nose, mouth, throat, or stomach, which can also enter the respiratory tract. In some cases, the patient cannot tell where the blood originates. Coughed up blood often appears to have bubbles because it is mixed with air and mucus. It is usually bright red but may be rust colored. Infection accounts for 60%–70% of all cases (Moses, 2018). It causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels. Other causes of hemoptysis include bronchitis, bronchiectasis, pneumonia, influenza, cancers, traumas, certain cardiovascular conditions, and tuberculosis.

ASSESSMENT CRITERIA (Weinberger, 2018) 1. Determine the onset of hemoptysis. Ask when the patient first noted blood in the sputum/mucus, if it began suddenly, and if hemoptysis had occurred in the past. 2. Determine the quantity of blood. Ask the patient to estimate the amount of blood produced (e.g., teaspoon, cupful). 3. Determine the quality of the symptom. Ascertain if blood-streaked mucus (phlegm) exists. 4. Establish a time pattern. a. How many times has the patient coughed up blood? b. Has it increased recently? c. How many times has this occurred today, yesterday, and in the past week? 5. Determine aggravating factors. a. Has the patient been sick? b. Does the patient have any lung or pulmonary problems? c. Does the patient use alcohol? d. Does the patient smoke? Has the patient previously smoked? e. Does the patient use cocaine? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 189

Hemopt ysis f. Does the patient have a history of allergies? g. Did the patient have a recent surgery or procedure on the mouth or throat? h. Has the patient experienced any weight loss? i. Does the patient have a headache, back pain, or bone pain? j. Does the patient have a history of lung cancer? k. Does the patient have HIV or AIDS? l. Has the patient been in an accident or had trauma? 6. What medications is the patient taking? a. Does the patient use blood thinners or nonsteroidal anti-inflammatory drugs? b. What over-the-counter treatments or supplements does the patient use? c. Does the patient have any allergies? 7. Ask the patient to describe other symptoms in detail. a. Shortness of breath b. Fever c. Malaise d. Cough i. How long has the cough lasted? ii. Is the cough worse at night? iii. Does the patient have gastroesophageal reflux disease or acid reflux? e. Does the patient have trouble swallowing? f. Has the patient been vomiting? Rule out hematemesis. 8. Review past medical history. a. Is the patient being treated for any medical problems? b. Has the patient had any significant illness in the past (e.g., stroke, cancer, tuberculosis, hypertension, blood or clotting disorders)? c. Has the patient had any recent surgeries or hospitalizations? d. Has the patient had a deep vein thrombosis? e. Has the patient recently traveled outside the United States? f. Do any family members or close contacts have tuberculosis? g. Does the patient have a tracheotomy? h. Does the patient have any close relatives with blood disorders? i. Has the patient received chemotherapy? Signs and Symptoms •• Coughing up large amounts of blood •• Unknown reason for coughing up blood (more than a few teaspoons) •• Chest pain •• Shortness of breath •• Cyanosis •• Mental status changes •• Other bleeding, such as hematemesis, blood in the urine or stool, or black tar–like stools

Action Seek emergency care. Call an ambulance immediately.

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Hemopt ysis (Continued)

Signs and Symptoms

Action

•• Bloody mucus for more than seven days •• Chronic cough •• Temperature higher than 102°F (38.9°C) without suspected neutorpenia or a fever that lasts longer than 48 hours •• Dizziness or light-headedness •• If cough is getting worse or more severe

Seek medical care within 24 hours.

•• Blood-streaked sputum following an upper respiratory infection

Follow homecare instructions and seek medical care if no improvement within 24–48 hours.

Note. Based on information from Lecithin, 2018; Phillips, 2017; Weinberger, 2018.

HOMECARE INSTRUCTIONS (ClinicalKey, 2017; Phillips, 2017) ••Blood-streaked sputum is often a result of an upper respiratory infection, and if it resolves, it is not usually a cause for worry. ••People who smoke and have blood-streaked sputum require a medical consultation. ••Take all prescribed medications as directed by a healthcare provider. ••Only take over-the-counter medications, including cough suppressants, if directed by a healthcare provider. ••Do not smoke. ••Keep track of the amount of coughed-up blood. ••If on a blood thinning medication, maintain therapeutic levels.

Report the Following Problems

(Lecithin, 2018) ••Dizziness or light-headedness ••Blood in the urine or stool ••Non-neutropenic fever higher than 102°F (38.9°C) or a fever lasting longer than two days ••Bleeding from the nose, mouth, or throat that will not stop on its own ••Small amounts of blood coughed up for more than seven days ••Cough is getting worse or more severe

Seek Emergency Care Immediately if Any of the Following Occurs

(Lecithin, 2018; Phillips, 2017; Weinberger, 2018) ••Unexplained coughing up of blood (more than a few teaspoons) ••Cough produces large volumes of blood ••Chest pain ••Shortness of breath ••Change in mental status ••If vomiting blood, experiencing bloody urine or stool, or noting black tar–like stools Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 191

Hemopt ysis

REFERENCES ClinicalKey. (2017). Hemoptysis: Easy to read. Retrieved from https://www-clinicalkey-com.ccmain​ .ohionet.org/#!/content/patient_handout/5-s2.0-pe_ExitCare_DI_Hemoptysis_Easy_to_Read_en Lecithin, N. (2018). Hemoptysis. In R.S. Porter (Ed.), The Merck manual of diagnosis and therapy: Professional version. Retrieved from http://www.merckmanuals.com/professional/pulmonary -disorders/symptoms-of​-pulmonary-disorders/hemoptysis Moses, S. (2018). Hemoptysis causes. Retrieved from http://www.fpnotebook.com/Lung/Sx/HmptysCs​ .htm Phillips, M.M. (2017, April 24). Coughing up blood. MedlinePlus. Retrieved from www.medlineplus​ .gov/ency/article/003073.htm Weinberger, S.E. (2018). Etiology and evaluation of hemoptysis in adults. In H. Holllingsworth (Ed.), UpToDate. Retrieved April 30, 2018, from https://www.uptodate.com/contents/etiology-and​ -evaluation-of-hemoptysis-in-adults

Erin J. Ross, DNP, MS, ANP-BC, CORLN

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Hiccups (Singultus) PROBLEM Hiccups are erratic contractions of respiratory muscles (diaphragm, inspiratory, and intercostal) that cause air to rush into the lungs. This is accompanied by the abrupt closure of the glottis, which produces the “hic” sound. Episodes of hiccups occur at a rate of 4–60 times per minute and are usually brief and self-limiting. Hiccups are a reflex in which afferent signals from the head, neck, thoracic structures, and abdominal viscera synapse at the “hiccups center” in the brain stem, which subsequently generates efferent motor impulses via phrenic and accessory nerves to the diaphragm and respiratory muscles (Gonella & Gonella, 2015). Neurotransmitters involved in hiccups, such as dopamine, gamma-aminobutyric acid, serotonin, and possibly norepinephrine, acetylcholine, and histamine, constitute potential pharmacologic targets (Chang & Lu, 2012; Nausheen, Mohsin, & Lakhan, 2016). Serious hiccups—persistent (continuing longer than 48 hours) or intractable (lasting more than one month)—are precipitated by underlying damage, irritation, or inflammation of one or more nerves of the hiccup reflex (Nausheen et al., 2016; Rizzo, Vitale, & Montagnini, 2014). The quoted range of uncontrolled hiccups in people with advanced cancer is 1%–27% (Calsina-Berna, García-Gomez, González-Barboteo, & Porta-Sales, 2012; Kako, Kobayashi, Kanno, & Tagami, 2017). Consequences may include impaired oral intake, weight loss, gastrointestinal reflux, altered social interactions, sleep disturbances, fatigue, anxiety and depression, and intensification of other morbidities, such as dyspnea, aspiration pneumonia, cardiac arrhythmias, and even death (Chang & Lu, 2012; Kako et al., 2017; Rizzo et al., 2014). Patients with cancer often have multiple and overlapping conditions that can initiate hiccups (Goyal, Mehmood, Mishra, & Bhatnagar, 2013; Rizzo et al., 2014).

ASSESSMENT CRITERIA (Chang & Lu, 2012; Goyal et al., 2013; Kako et al., 2017; Lee et al., 2016; Rizzo et al., 2014) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Malignancies associated with hiccups include esophageal, gastric, colon, lung, pancreatic, or renal cancers, hepatoma or liver metastases, primary or metastatic brain tumors, leukemia, and lymphoma. 2. What medications is the patient taking? a. Corticosteroids, antibiotics, benzodiazepines, or opioids b. Chemotherapy (e.g., carboplatin, cisplatin, cyclophosphamide, docetaxel, etoposide, gemcitabine, irinotecan, paclitaxel, vincristine, vinorelbine) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 193

H i c c u p s ( S i n g u lt u s ) 3. Ask the patient to describe symptoms in detail. 4. When did the hiccups start, and how long have they persisted? a. Less than 48 hours: does not require immediate medical evaluation b. More than 48 hours (persistent) or one month (intractable): requires medical evaluation 5. Obtain history of the problem. a. Severity: On a scale from 0 to 10, where 0 is no hiccups and 10 is the worst imaginable hiccups, how severe are your hiccups (a rating of 7 or higher is severe) (Lee et al., 2013)? b. Precipitating factors i. Men are at a much higher risk for hiccups than women, and younger women are at a greater risk than older women. ii. Comorbid conditions (1) Gastrointestinal (e.g., gastroesophageal reflux disease [GERD], herpes simplex– or Candida-related esophagitis, gallbladder disease, pancreatitis, peptic ulcer or Helicobacter pylori infection, gastric distension, small bowel obstruction, ascites) (2) Cardiothoracic (e.g., myocardial infarction, pericardial or pleural effusion, pneumonia, mediastinitis, mediastinal lymphadenopathy, pleuritis) (3) Central nervous system (e.g., meningitis, encephalitis); hemorrhage (4) Metabolic (e.g., hyponatremia, hypocalcemia, hypokalemia, hyperglycemia/uncontrolled diabetes, uremia/renal failure) (5) Other (e.g., vagus or phrenic nerve irritation, fear, anxiety, surgery) c. Onset and duration d. Any associated symptoms (e.g., inability to eat or drink, weight loss, GERD, sleep difficulties) or more serious acute problems (e.g., shortness of breath, eating brings on coughing spells) 6. Assess for changes in activities of daily living and function. 7. Ask the patient to rate the impact of hiccups on usual quality-of-life activities on a 0–10 scale. Signs and Symptoms

Action

•• Respiratory distress •• Aspiration •• Chest pain •• Dyspnea or difficulty breathing •• Perioral cyanosis or mottled skin •• Postsurgical wound dehiscence

Seek immediate emergency care. Call an ambulance.

•• Unrelenting hiccups for 48 hours or more with accompanying exhaustion or dyspnea

Seek urgent care within two hours. (Continued on next page)

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H i c c u p s ( S i n g u lt u s ) (Continued)

Signs and Symptoms

Action

•• Hiccups lasting for more than 24 hours with fatigue, loss of appetite, and insomnia

Seek urgent care within 24 hours.

•• Hiccups for less than 24 hours; heartburn

Follow homecare instructions. Notify MD if no improvement.

HOMECARE INSTRUCTIONS Treatment depends on the duration and severity of hiccups. Some small randomized controlled studies of acupuncture or drugs for serious hiccups are available to guide management (Choi, Lee, & Ernst, 2012; Moretto, Wee, Wiffen, & Murchison, 2013; Wang & Wang, 2014; Zhang, Zhang, Zhang, Xu, & Zhang, 2014). Case series, case reports, and tradition largely are the basis for the management of serious hiccups, which starts with identifying and alleviating the underlying cause, if possible. ••Folk remedies are commonly used and can be repeated if hiccups recur (CalsinaBerna et al., 2012; Chang & Lu, 2012; Gonella & Gonella, 2015; Kako et al., 2017). –– Hold breath or breathe into a paper bag. –– Bite a lemon wedge, or sip lemon juice or vinegar; for dysphagic patients, instill 0.1 ml of vinegar into nares with a 1 ml syringe without needle. This causes slight discomfort. –– Eat a spoonful of granulated sugar or peanut butter. –– Stimulate the soft palate with a cotton applicator. –– Apply pressure over the eyebrow area. –– Gargle or sip ice water or peppermint water. –– Sniff black pepper to induce sneezing. –– Perform a modified Heimlich maneuver (three thrusts at 10-second intervals). –– Pull knees to chest and bear down (Valsalva maneuver). ••Nonpharmacologic measures are also used (Calsina-Berna et al., 2012; Chang & Lu, 2012; Choi et al., 2012). –– Acupressure is a noninvasive alternative to acupuncture. Acupressure techniques for hiccups can be found online (see www.livestrong.com/article/101179 -hiccups-pressure-points). –– Nebulized normal saline (2 ml over five minutes) ••Provider-ordered oral medications are another common option (Calsina-Berna et al., 2012; Chang & Lu, 2012; Hernandez, Fasnacht, Sheyner, King, & Stewart, 2015; Moretto et al., 2013; Porzio et al., 2010; Şeker et al., 2012; Thompson & Brooks, 2013; Thompson, Leal, & Brzezinski, 2014). –– For example, take simethicone 15–30 ml (antigas) every four hours, metoclopramide (prokinetic) 10 mg every six hours, and perhaps a proton pump inhibitor, which may reduce gas, bloating, and pain. –– Other oral drugs successful in quelling some cases of hiccups include chlorpromazine, baclofen, olanzapine, gabapentin, pregabalin, sertraline, amitriptyTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 195

H i c c u p s ( S i n g u lt u s ) line, desipramine, clonazepam, amantadine, lidocaine, haloperidol, and other older drugs.

Report the Following Problems

••Hiccup effects, especially decreased ability or desire to eat, weight loss, impaired sleep, and depression ••Hiccups that do not improve or worsen

Seek Emergency Care Immediately if Any of the Following Occurs ••Shortness of breath or difficulty breathing ••Coughing, worsening of symptoms with eating solid foods ••Blueness around lips or mouth ••Inability to swallow

REFERENCES Calsina-Berna, A., García-Gomez, G.G., González-Barboteo, J., & Porta-Sales, J. (2012). Treatment of chronic hiccups in cancer patients: A systematic review. Journal of Palliative Medicine, 15, 1142– 1150. https://doi.org/10.1089/jpm.2012.0087 Chang, F.-Y., & Lu, C.-L. (2012). Hiccup: Mystery, nature and treatment. Journal of Neurogastroenterology and Motility, 18, 123–130. https://doi.org/10.5056/jnm.2012.18.2.123 Choi, T.-Y., Lee, M.S., & Ernst, E. (2012). Acupuncture for cancer patients suffering from hiccups: A systematic review and meta-analysis. Complementary Therapies in Medicine, 20, 447–455. https://​ doi.org/10.1016/j.ctim.2012.07.007 Gonella, S., & Gonella, F. (2015). Use of vinegar to relieve persistent hiccups in an advanced cancer patient. Journal of Palliative Medicine, 18, 467–470. https://doi.org/10.1089/jpm.2014.0391 Goyal, A., Mehmood, S., Mishra, S., & Bhatnagar, S. (2013). Persistent hiccups in cancer patient: A presentation of syndrome of inappropriate antidiuretic hormone induced hyponatremia. Indian Journal of Palliative Care, 19, 110–112. https://doi.org/10.4103/0973-1075.116712 Hernandez, S.L., Fasnach, K.S., Sheyner, I., King, J.M., & Stewart, J.T. (2015). Treatment of refractory hiccups with amantadine. Journal of Pain and Palliative Care Pharmacotherapy, 29, 374–377. https://doi.org/10.3109/15360288.2015.1101640 Kako, J., Kobayashi, M., Kanno, Y., & Tagami, K. (2017). Intranasal vinegar as an effective treatment for persistent hiccups in a patient with advanced cancer undergoing palliative care. Journal of Pain and Symptom Management, 54, e2–e4. https://doi.org/10.1016/j.jpainsymman.2017.02.011 Lee, G.-W., Kim, R.B., Go, S.I., Cho, H.S., Lee, S.J., Hui, D., … Kang, J.H. (2016). Gender differences in hiccup patients: Analysis of published case reports and case-control studies. Journal of Pain and Symptom Management, 51, 278–283. https://doi.org/10.1016/j.jpainsymman .2015.09.013 Lee, G.-W., Oh, S.Y., Kang, M.H., Kang, J.H., Park, S.H., Hwang, I.G., … Bruera, E. (2013). Treatment of dexamethasone-induced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist, 18, 1229–1234. https://doi.org/10.1634/theoncologist.2013-0224 Moretto, E.N., Wee, B., Wiffen, P.J., & Murchison, A.G. (2013). Interventions for treating persistent and intractable hiccups in adults. Cochrane Database of Systematic Reviews, 2013(1). https://doi​ .org/10.1002/14651858.CD008768.pub2 Nausheen, F., Mohsin, H., & Lakhan, S.E. (2016). Neurotransmitters in hiccups. SpringerPlus, 5, 1357. https://doi.org/10.1186/s40064-016-3034-3 Porzio, G., Aielli, F., Verna, L., Aloisi, P., Galletti, B., & Ficorella, C. (2010). Gabapentin in the treatment of hiccups in patients with advanced cancer: A 5-year experience. Clinical Neuropharmacology, 33, 179–180. https://doi.org/10.1097/WNF.0b013e3181de8943 196 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

H i c c u p s ( S i n g u lt u s ) Rizzo, C., Vitale, C., & Montagnini, M. (2014). Management of intractable hiccups: An illustrative case and review. American Journal of Hospice and Palliative Medicine, 31, 220–224. https://doi​ .org/10.1177/1049909113476916 Şeker, M.M., Aksoy, S., Özdemir, N.Y., Uncu, D., Civelek, B., Akınci, M.B., & Zengin, N. (2012). Successful treatment of chronic hiccup with baclofen in cancer patients. Medical Oncology, 29, 1369–1370. https://doi.org/10.1007/s12032-011-9910-3 Thompson, A.N., Leal, J.E., & Brzezinski, W.A. (2014). Olanzapine and baclofen for the treatment of intractable hiccups. Pharmacotherapy, 34, e4–e8. https://doi.org/10.1002/phar.1378 Thompson, D.F., & Brooks, K.G. (2013). Gabapentin therapy of hiccups. Annals of Pharmacotherapy, 47, 897–903. https://doi.org/10.1345/aph.1S018 Wang, T., & Wang, D. (2014). Metoclopramide for patients with intractable hiccups: A multicentre, randomised, controlled pilot study. Internal Medicine Journal, 44, 1205–1209. https://doi.org/10​ .1111/imj.12542 Zhang, C., Zhang, R., Zhang, S., Xu, M., & Zhang, S. (2014). Baclofen for stroke patients with persistent hiccups: A randomized, double-blind, placebo-controlled trial. Trials, 15, 295. https://doi.org​ /10.1186/1745-6215-15-295

Rita Wickham, PhD, RN

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198 . . . . . . . . Telephone Triage

Immune-Related Adverse Events PROBLEM Immune-related adverse events (irAEs) are a distinct group of symptoms that result from activation of the immune system associated with immunotherapy. Checkpoint inhibitors enhance antitumor immunity by blocking negative regulators of T-cell function and reactivating cytotoxic T cells to destroy tumor cells. This imbalance in the immune system leads to the development of autoimmune manifestations, another form of irAE (Boutros et al., 2016; Michot et al., 2016). All irAEs are distinct in both mechanism and management compared to those experienced with chemotherapy or targeted therapy, thus requiring early recognition, appropriate intervention, and close monitoring to minimize the risk of severe or life-threatening consequences (Champiat et al., 2016; Kottschade et al., 2016; Naidoo et al., 2015). Side effects most commonly involve the pulmonary, gastrointestinal, hepatic, dermatologic, and endocrine systems (Corsello et al., 2013). Patients may experience irAEs any time after initiation of immunotherapy, as early as a few days after the first dose, or as late as after treatment discontinuation. Ongoing awareness and detailed assessment are critical to minimize the long-term consequences of irAEs (Kottschade et al., 2016; Nishino, Giobbie-Hurder, Hatabu, Ramaiya, & Hodi, 2016; Rubin, 2012; Spain, Diem, & Larkin, 2016).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Are organs involved with primary or metastatic disease, thus increasing the risk of autoimmune organ dysfunction? b. Did the patient have prior thoracic radiation therapy? 2. What medications is the patient taking? Obtain medication history. 3. Ask the patient to describe symptoms in detail. a. New-onset or worsening cough or shortness of breath: Consider pneumonitis. b. Rash or pruritus: Consider dermatitis. c. Diarrhea: Consider colitis. d. Abdominal pain, nausea, or anorexia: Consider hepatitis or colitis. e. Fatigue: Consider endocrinopathies. f. Headache with dry mouth (xerostomia): Consider hypophysitis. 4. Review laboratory results and consider or rule out the following: a. Increased liver function tests (hepatitis) b. Increased creatinine (nephritis) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 199

I m m u n e - R e l at e d A d v e r s e E v e n t s c. Decreased thyroid-stimulating hormone endocrinopathies (hyperthyroidism) d. Increased thyroid-stimulating hormone endocrinopathies (hypothyroidism) e. Increased fasting glucose (type 2 diabetes) 5. Obtain history of the problem. a. Severity b. Precipitating factors c. Onset and duration d. Any associated symptoms 6. Review past medical history. Refer to the Common Terminology Criteria for Adverse Events by the National Cancer Institute Cancer Therapy Evaluation Program for definitions of adverse events (https://ctep.cancer.gov/protocoldevelopment/electronic_applications /ctc.htm). This is a valuable standardized grading system for symptoms and treatmentrelated side effects. The American Society of Clinical Oncology (ASCO), the Society for Immunotherapy of Cancer (SITC), and the National Comprehensive Cancer Network® (NCCN®) have developed practice and consensus guidelines to assist clinicians in the assessment and management of irAEs (Brahmer et al., 2018; NCCN, 2018; Puzanov et al., 2017). Other practitioners have focused on immunotherapy and have provided detailed algorithms for irAE management and assessment (Bayer et al., 2017; Belum et al., 2016; Fecher, Agarwala, Hodi, & Weber, 2013; Ginex, Brassil, & Ely, 2017; Gordon et al., 2017; Hofmann et al., 2016; Madden & Hoffner, 2017; Martin, 2017; McGettigan & Rubin, 2017; Mistry, Forbes, & Fowler, 2017; Naidoo et al., 2017; Olszanski & Zitella, 2017; Rubin, 2017; Weber, Kähler, & Hauschild, 2012; Wiley et al., 2017; Zimmer et al., 2016). Signs and Symptoms

Action

•• New or worsening cough or shortness of breath •• Rash or itching (pruritus) •• Diarrhea

Seek same-day physical examination, pulse oximetry, chest x-ray, or computed tomography scan of chest with contrast. Seek care within 48 hours, including physical examination and topical agents. Consider oral antihistamines. Grade 1: BRAT (bananas, rice, applesauce, toast) diet Grade 2: Begin loperamide and reassess in 24 hours. If no improvement, change to diphenoxylate and atropine sulfate (Lomotil®). Obtain stool samples for cultures and Clostridium difficile. Begin oral steroids. Grade 3: Consult gastroenterologist. Hospitalize for IV fluids and IV steroids.

•• Abdominal pain, nausea, anorexia, or fatigue

Obtain liver function panel. Consider including gamma-glutamyl transferase test and direct and indirect bilirubin. (Continued on next page)

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I m m u n e - R e l at e d A d v e r s e E v e n t s (Continued)

Signs and Symptoms

Action

•• Headache, nausea, fatigue, xerostomia, or visual changes

Obtain thyroid, pituitary, and adrenal function tests. Consider magnetic resonance imaging of brain with contrast for evaluation of hypophysitis.

Note. Based on information from Brahmer et al., 2018.

HOMECARE INSTRUCTIONS ••Communicate early and regularly upon symptom onset and if any changes occur in side effect severity. ••Compliance and adherence to supportive care recommendations is important, including dietary guidelines and over-the-counter and prescription medications and products. ••Track oral steroid doses with calendars or diary sheets supplied by healthcare providers. Steroid taper is slow and may require dose increases if symptoms worsen.

Homecare Resources

••Patient education is vital. Key resources for patient education include the following: –– NCCN Immunotherapy Teaching and Monitoring Tool (www.nccn.org) –– Managing Toxicities Associated With Immune Checkpoint Inhibitors: Consensus Recommendations From the SITC Toxicity Management Working Group on Managing Toxicities Associated With Immune Checkpoint Inhibitors (https://jitc .biomedcentral.com/articles/10.1186/s40425-017-0300-z) –– SITC Immune-Related Adverse Event Management Guidelines (November 2017) (www.sitcancer.org/home; subscription required to view most content) –– Melanoma Nursing Initiative (www.themelanomanurse.org) –– ASCO supportive care and treatment-related issues (www.asco.org/practice -guidelines/quality-guidelines/guidelines/supportive-care-and-treatment -related-issues#/29866)

Report the Following Problems

••Nausea, vomiting, diarrhea, or abdominal pain within 24 hours of onset of symptoms ••New or worsening cough or shortness of breath within 24 hours of onset of symptoms ••No improvement within 24 hours or condition worsens following initiation of over-the-counter or prescription medication, including steroids ••Onset of new side effects

Seek Emergency Care Immediately if Any of the Following Occurs

••Acute chest pain or shortness of breath ••Dizziness or light-headedness in combination with diarrhea and vomiting or fever and chills ••Severe headache or vision changes Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 201

I m m u n e - R e l at e d A d v e r s e E v e n t s

REFERENCES Bayer, V., Amaya, B., Baniewicz, D., Callahan, C., Marsh, L., & McCoy, A.S. (2017). Cancer immunotherapy: An evidence-based overview and implications for practice. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 13–21. https://doi.org/10.1188/17.CJON.S2.13-21 Belum, V.R., Benhuri, B., Postow, M.A., Hellmann, M.D., Lesokhin, A.M., Segal, N.H., … Lacouture, M.E. (2016). Characterization and management of dermatologic adverse events to agents targeting the PD-1 receptor. European Journal of Cancer, 60, 12–25. https://doi.org/10.1016/j.ejca.2016.02.010 Boutros, C., Tarhini, A., Routier, E., Lambotte, O., Ladurie, F.L., Carbonnel, F., … Robert, C. (2016). Safety profiles of anti-CTLA-4 and anti-PD-1 antibodies alone and in combination. Nature Reviews Clinical Oncology, 13, 473–486. https://doi.org/10.1038/nrclinonc.2016.58 Brahmer, J.R., Lacchetti, C., Schneider, B.J., Atkins, M.B., Brassil, K.J., Caterino, J.M., … Thompson, J.A. (2018). Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 36, 1714–1768. https://doi.org/10.1200/JCO.2017.77.6385 Champiat, S., Lambotte, O., Barreau, E., Belkhir, R., Berdelou, A., Carbonnel, F., … Marabelle, A. (2016). Management of immune checkpoint blockade dysimmune toxicities: A collaborative position paper. Annals of Oncology, 27, 559–574. https://doi.org/10.1093/annonc/mdv623 Corsello, S.M., Barnabei, A., Marchetti, P., De Vecchis, L., Salvatori, R., & Torino, F. (2013). Endocrine side effects induced by immune checkpoint inhibitors. Journal of Clinical Endocrinology and Metabolism, 98, 1361–1375. https://doi.org/10.1210/jc.2012-4075 Fecher, L.A., Agarwala, S.S., Hodi, F.S., & Weber, J.S. (2013). Ipilimumab and its toxicities: A multi­ disciplinary approach. Oncologist, 18, 733–743. https://doi.org/10.1634/theoncologist.2012-0483 Ginex, P.K., Brassil, K.J., & Ely, B. (2017). Immunotherapy: Exploring the state of the science. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 9–12. https://doi.org/10.1188/17.CJON.S2.9-12 Gordon, R., Kasler, M.K., Stasi, K., Shames, Y., Errante, M., Ciccolini, K., … Fischer-Cartlidge, E. (2017). Checkpoint inhibitors: Common immune-related adverse events and their management. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 45–52. https://doi.org/10.1188/17.CJON.S2.45-52 Hofmann, L., Forschner, A., Loquai, C., Goldinger, S.M., Zimmer, L., Ugurel, S., … Heinzerling, L.M. (2016). Cutaneous, gastrointestinal, hepatic, endocrine, and renal side-effects of anti-PD-1 therapy. European Journal of Cancer, 60, 190–209. https://doi.org/10.1016/j.ejca.2016.02.025 Kottschade, L., Brys, A., Peikert, T., Ryder, M., Raffals, L., Brewer, J., … Markovic, S. (2016). A multi­disciplinary approach to toxicity management of modern immune checkpoint inhibitors in cancer therapy. Melanoma Research, 26, 469–480. https://doi.org/10.1097/CMR.0000000000000273 Madden, K.M., & Hoffner, B. (2017). Ipilimumab-based therapy: Consensus statement from the faculty of the Melanoma Nursing Initiative on managing adverse events with ipilimumab monotherapy and combination therapy with nivolumab. Clinical Journal of Oncology Nursing, 21(Suppl. 4), 30–41. https://​doi.org/10.1188/17.CJON.S4.30-41 Martin, C. (2017). Oncolytic viruses: Treatment and implications for patients with gliomas. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 60–64. https://doi.org/10.1188/17.CJON.S2.60-64 McGettigan, S., & Rubin, K.M. (2017). PD-1 inhibitor therapy: Consensus statement from the faculty of the Melanoma Nursing Initiative on managing adverse events. Clinical Journal of Oncology Nursing, 21(Suppl. 4), 42–51. https://doi.org/10.1188/17.CJON.S4.42-51 Michot, J.M., Bigenwald, C., Champiat, S., Collins, M., Carbonnel, F., Postel-Vinay, S., … Lambotte, O. (2016). Immune-related adverse events with immune checkpoint blockade: A comprehensive review. European Journal of Cancer, 54, 139–148. https://doi.org/10.1016/j.ejca.2015.11.016 Mistry, H.E., Forbes, S.G., & Fowler, N. (2017). Toxicity management: Development of a novel and immune-mediated adverse events algorithm. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 53–59. https://doi.org/10.1188/17.CJON.S2.53-59 Naidoo, J., Page, D.B., Li, B.T., Connell, L.C., Schindler, K., Lacouture, M.E., … Wolchok, J.D. (2015). Toxicities of the anti-PD-1 and anti-PD-L1 immune checkpoint antibodies. Annals of Oncology, 26, 2375–2391. https://doi.org/10.1093/annonc/mdv383 Naidoo, J., Wang, X., Woo, K.M., Iyriboz, T., Halpenny, D., Cunningham, J., … Hellmann, M.D. (2017). Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. Journal of Clinical Oncology, 35, 709–717. https://doi.org/10.1200/JCO.2016.68.2005 202 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

I m m u n e - R e l at e d A d v e r s e E v e n t s National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Management of immunotherapy-related toxicities [v.1.2018]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf Nishino, M., Giobbie-Hurder, A., Hatabu, H., Ramaiya, N.H., & Hodi, S. (2016). Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: A systematic review and meta-analysis. JAMA Oncology, 2, 1607–1616. https://doi.org/10.1001/jamaoncol​ .2016.2453 Olszanski, A.J., & Zitella, L.J. (2017). Advances in the use of immunotherapy in oncology. Journal of the Advanced Practitioner in Oncology, 8, 221–225. https://doi.org/10.6004/jadpro.2017.8.3.2 Puzanov, I., Diab, A., Abdallah, K., Bingham, C.O., III, Brogdon, C., Dadu, R., … Ernstoff, M.S. (2017). Managing toxicities associated with immune checkpoint inhibitors: Consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group. Journal of Immunotherapy of Cancer, 5, 95. https://doi.org/10.1186/s40425-017-0300-z Rubin, K.M. (2012). Managing immune-related adverse events to ipilimumab: A nurse’s guide [Online exclusive]. Clinical Journal of Oncology Nursing, 16, E69–E75. https://doi.org/10.1188/12.CJON​ .E69-E75 Rubin, K.M. (2017). Advances in melanoma: The rationale for the Melanoma Nursing Initiative. Clinical Journal of Oncology Nursing, 24(Suppl. 4), 7–10. https://doi.org/10.1188/17.CJON.S4.7-10 Spain, L., Diem, S., & Larkin, J. (2016). Management of toxicities of immune checkpoint inhibitors. Cancer Treatment Reviews, 44, 51–60. https://doi.org/10.1016/j.ctrv.2016.02.001 Weber, J.S., Kähler, K.C., & Hauschild, A. (2012). Management of immune-related adverse events and kinetics of response with ipilimumab. Journal of Clinical Oncology, 30, 2691–2697. https://doi.org​ /10.1200/JCO.2012.41.6750 Wiley, K., LeFebvre, K.B., Wall, L., Baldwin-Medsker, A., Nguyen, K., Marsh, L., & Baniewicz, D. (2017). Immunotherapy administration: Oncology Nursing Society recommendations. Clinical Journal of Oncology Nursing, 21(Suppl. 2), 5–7. https://doi.org/10.1188/17.CJON.S2.5-7 Zimmer, L., Goldinger, S.M., Hofmann, L., Loquai, C., Ugurel, S., Thomas, I., … Heinzerling, L.M. (2016). Neurological, respiratory, musculoskeletal, cardiac and ocular side-effects of anti-PD-1 therapy. European Journal of Cancer, 60, 210–225. https://doi.org/10.1016/j.ejca.2016.02.024

Laura S. Wood, RN, MSN, OCN® Heather Vanderploeg, RN, BSN, OCN®, CBCN®

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Lymphedema PROBLEM Lymphedema is caused by an accumulation of lymph fluid in the interstitial spaces caused by an increase in production of lymph fluid or by an obstruction of the lymphatic drainage system that leads to persistent swelling of the affected body part. The most common causes of lymphedema are radiation therapy and lymph node dissection. Depending on the surgery or radiation therapy performed, lymphedema can affect the head and neck, breast, genitalia, or lower limbs; however, it is most often reported in the upper extremities of women with breast cancer associated with axillary lymph node dissection and fibrosis after radiation therapy. Lower extremity lymphedema occurs in as many as 80% of those who have had lymph node dissection in the groin or compression of pelvic or inguinal lymph nodes (Armer et al., 2017).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Was a lymph node dissection performed? b. The most common sites of obstruction are the pelvic, inguinal, and axillary nodes. 2. What medications is the patient taking? Obtain medication history. 3. Ask patient to describe symptoms in detail. a. Pain b. Onset and extent of edema c. Skin changes d. Exercise patterns e. Range of motion f. Specifically, ask about any heaviness, swelling, or tightness in the areas at or near the cancer treatment. This is critical, as these symptoms may present before visible swelling occurs (Vogel, 2017). 4. Obtain history of the problem. a. Severity b. Precipitating factors: may occur after an injury, infection, excessive physical exertion, or airplane travel c. Onset and duration: may be sudden or gradual d. Relieving factors e. Any associated symptoms i. Other early indications of lymphedema include self-reported sensations of heaviness, swelling, tingling, fatigue, or aching. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 205

Ly m p h e d e m a ii. Assess for Stemmer sign, in which the skin and dorsum of the fingers and toes cannot be lifted or can only be lifted with difficulty (Cope, 2014). f. Presence of any risk factors, including age, lymph node dissection, radiation therapy to lymph node area, invasive procedures, trauma or infections involving the affected area or limb, and comorbid conditions that can increase risk for lymphedema, such as obesity, diabetes, and hypertension (Mayo Clinic, 2017) 5. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Redness/erythema (including redness traveling up and down limb) and heat in affected area •• Pain or soreness that is in one area or appeared suddenly •• Swelling—Question whether swelling is relieved with elevation. •• Sudden increase in edema in an extremity

Seek urgent care within 24–48 hours.

•• Tightness of clothing or rings, numbness, or pain

Seek care within one week.

Cross-references: Deep Vein Thrombosis

HOMECARE INSTRUCTIONS ••Lymphedema can develop in any part of the body or limbs. ••Signs or symptoms of lymphedema to watch for include a full sensation in the limb or limbs; skin feeling tight; decreased flexibility in the hand, wrist, or ankle; difficulty fitting into clothing in one specific area; or ring/wristwatch/bracelet tightness. ••Patients who have undergone lymph node dissections should avoid blood draws, injections, IV placement, and blood pressure monitoring in the affected extremity. Use extra precautions to avoid injury to the affected extremity. Avoid using automated blood pressure devices at home on affected or at-risk limbs (Vogel, 2017). ••Planning the treatment program depends on the cause of the lymphedema. For example, if the initial signs and symptoms of swelling are caused by infection (redness, rash, heat, blister, or pain), antibiotics will need to be prescribed first. Treating an infection often reduces some of swelling and discoloration. A course of antibiotic therapy of at least 14 days is recommended after an acute episode has responded clinically; it may take one to two months of therapy for symptoms to completely resolve in some patients. Recurrent infections occur in almost 25% of patients with lymphedema who experience an episode of initial cellulitis (Reichart, 2017). ••If the lymphedema is not caused by infection, depending on the severity of the lymphedema, the recommended treatment plan should be determined using an approach based on complex decongestive therapy (CDT) methods. CDT is a twophase therapy: an intensive phase in which the limb volume is reduced during treatment by a therapist, and a maintenance phase in which the patient is instructed in self-management (Rogan et al., 2016). 206 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ly m p h e d e m a –– The intensive phase comprises five components or modalities: * Manual lymph drainage: compression applied through short-stretch compression bandages * Compression garments (garments should be individualized for each patient) * Meticulous skin and nail care (patients at risk for lymphedema should use neutral pH soaps and emollient creams) * Remedial exercises * Education in self-care –– The maintenance phase comprises simple lymphatic drainage, nightly compression bandaging, daytime use of compression garments, skin care, and exercise. ••Avoid extremes of temperature: Avoid exposure to extreme cold, which can be associated with rebound swelling or chapping of skin. Avoid prolonged (greater than 15 minutes) exposure to heat, particularly hot tubs or saunas.

Report the Following Problems

••Painful swelling, erythema, and heat in affected area (suspect cellulitis) ••Sudden onset of severe pain, swelling, tenderness, area is warm to touch, obvious blueness or other discoloration, increased pain with dorsiflexion (suspect deep vein thrombosis) (Cope, 2014)

REFERENCES Armer, J.M., Beck, M., Burns, B.R., Deng, J., Fu, M.R., Giammicchio, K.A., … Singer, M. (2017). Lymphedema. Retrieved from https://www.ons.org/pep/lymphedema Cope, D. (2014). Lymphedema. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 943–947). Pittsburgh, PA: Oncology Nursing Society. Mayo Clinic. (2017). Lymphedema. Retrieved from https://www.mayoclinic.org/diseases-conditions​ /lymphedema/symptoms-causes/syc-20374682 Reichart, K. (2017). Lymphedema: Improving screening and treatment among at-risk breast cancer survivors. Clinical Journal of Oncology Nursing, 21, 21–25. https://doi.org/10.1188/17.CJON.21-25 Rogan, S., Taeymans, J., Luginbuehl, H., Aebi, M., Mahnig, S., & Gebruers, N. (2016). Therapy modalities to reduce lymphoedema in female breast cancer patients: A systematic review and meta-analysis. Breast Cancer Research and Treatment, 159, 1–14. https://doi.org/10.1007/s10549-016-3919-4 Vogel, W.H. (2017). Lymphedema. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 319–321). St. Louis, MO: Elsevier.

Susan Newton, APRN, MS, AOCN®, AOCNS® The author would like to acknowledge Kirsten Singleton, RN, BSN, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Malignant Ascites PROBLEM Malignant ascites is the accumulation of fluid that contains cancer cells within the abdomen (National Cancer Institute, n.d.). It occurs when cancer disrupts the formation and absorption of peritoneal fluids. This type of ascites can result from a primary malignancy of the liver or from metastatic disease from a variety of cancers (e.g., peritoneal carcinomatosis).

ASSESSMENT CRITERIA (Flowers et al., 2013) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Malignant ascites occurs commonly with intra-abdominal malignancies such as lymphoma, mesothelioma, and ovarian, colon, stomach, liver, fallopian tube, and pancreatic cancers. Malignant ascites may also occur because of metastatic disease to the liver. 2. What medications is the patient taking? 3. Ask the patient to describe symptoms in detail. a. Signs i. Weight gain ii. Abdominal girth iii. Lower extremity edema b. Symptoms i. Abdominal or lower back pain ii. Abdominal fullness, pressure, or distension iii. Urinary frequency or urgency iv. Shortness of breath v. Decreased appetite or early satiety vi. Nausea vii. Fatigue 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors d. Previous efforts to self-manage symptoms e. Perceived effectiveness of self-management efforts 5. Review past medical history. a. Concurrent disease (e.g., liver disease) b. Previous treatments for malignant ascites Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 209

Ma l i g n a n t A s c i t e s c. Presence of medical devices or procedures for draining (e.g., indwelling peritoneal catheter, peritoneal port-a-cath, peritoneovenous shunt, trans­ jugular intrahepatic portosystemic shunts, ascites drainage devices) 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Severe shortness of breath •• Acute abdominal pain •• Temperature higher than 100.4°F (38°C) with suspected neutropenia or temperature of 101°F (38.3°C) for more than an hour without suspected neutropenia (Flowers et al., 2013) •• Unresponsiveness

Seek emergency care immediately.

•• Difficulty breathing •• Abdominal discomfort •• Weight gain of more than five pounds in past two days •• Uncontrolled nausea and vomiting for more than 24 hours •• Changes in mental status (increased somnolence) •• Inability to perform self-care activities of daily living (e.g., dressing, feeding, grooming, bathing, toileting) •• Malfunction in drainage device or catheter

Seek urgent care within 24 hours.

•• Swelling of ankles •• Inability to eat or drink fluids for 24 hours •• Weight gain of more than five pounds in past week •• Inability to perform instrumental activities of daily living (e.g., managing finances, medications, home maintenance, preparing meals, shopping, transportation) •• Inability to sleep or rest because of shortness of breath or abdominal discomfort •• Lack of bowel movement for more than three days beyond usual bowel elimination pattern

Seek care within 24–48 hours.

•• Increased tightness of clothing in the abdominal area •• Abdominal fullness, bloating, heaviness, or tightness •• Indigestion •• Increased frequency of voiding •• Nausea or vomiting

Follow homecare instructions. Notify care team if no improvement in two to three days.

HOMECARE INSTRUCTIONS (Flaherty, 2015; Kistler, 2015; Mayden, 2016) ••Keep the following diet modifications in mind: –– Eat six small, high-protein, high-calorie meals per day. 210 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ma l i g n a n t A s c i t e s –– Maintain fluid intake (3,000 ml per day). –– Follow a salt-restricted diet (less than 2 g per day). –– Sit up for 30 minutes after each meal. ••Implement the following advice for comfort: –– Wear clothing that is loose around the abdominal area. –– Elevate head with pillows to ease work of breathing. –– Elevate lower extremities to reduce edema. –– Position for comfort. –– Use pressure-reduction devices, such as a mattress or heel protectors. ••For activities of daily living, initiate the following: –– Use energy-conservation techniques. * Use assistive devices for ambulation or picking up objects. * Delegate tasks. * Set priorities and plan activities. * Rest as needed. –– Seek assistance from support care provider network as needed. –– Confirm with care team the ability to take medications for malignant ascites as prescribed by the physician, and know side effects to report to the team. –– Confirm with care team the ability to appropriately use and care for any implanted or tunneled medical devices used to manage ascites at home. ••Monitor for critical changes. –– Assess and record weight every other day first thing in the morning, after the bladder has been emptied. –– Take and record temperature once a day. –– Monitor urine output for changes in color (darker) or volume (decreased). –– Monitor for changes in skin over the abdomen and buttocks (increased redness, breakdown). –– Report any redness or leakage around peritoneal device exit or implanted site.

Report the Following Problems

••Lack of improvement in or presence of new signs and symptoms ••Acute changes in severity of signs and symptoms ••Decreased ability to perform instrumental or self-care activities of daily living ••Inability to drain ascites from peritoneal tunneled catheter

Seek Emergency Care Immediately if Any of the Following Occurs

••Severe shortness of breath ••Acute abdominal pain ••Temperature higher than 100.4°F (38°C) with suspected neutropenia or temperature of 101°F (38.3°C) for more than one hour without suspected neutropenia (Flowers et al., 2013) ••Acute changes in levels of consciousness (e.g., reduced alertness, confusion, slow response to stimuli [words, touch], unresponsiveness) ••Redness, swelling, tenderness, or drainage at site of devices for managing malignant ascites Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 211

Ma l i g n a n t A s c i t e s

REFERENCES Flaherty, A.M.C. (2015). Management of malignancy-related ascites. Oncology Nursing Forum, 42, 96–99. https://doi.org/10.1188/15.ONF.96-99 Flowers, C.R., Seidenfeld, J., Bow, E.J., Karten, C., Gleason, C., Hawley, D.K., … Ramsey, S.D. (2013). Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy. Journal of Clinical Oncology, 31, 794–810. https://doi.org/10.1200/JCO.2012.45.8661 Kistler, C.A. (2015). Malignant ascites: Diagnosis and management. Retrieved from http://www​ .cancertherapyadvisor.com/general-oncology/malignant-ascites-cancer-diagnosis-management​ /article/411203 Mayden, K. (2016). Ascites and effusions. In D. Camp-Sorrell & R. Hawkins (Eds.), inPractice. Retrieved from https://www.inpractice.com/Textbooks/Oncology-Nursing/Serious-Manifestations​ -of-Cancer/Ascites-and-Effusions/Chapter-Pages/Page-4.aspx National Cancer Institute. (n.d.). Ascites. In Dictionary of cancer terms. Retrieved from https://www​ .cancer.gov/publications/dictionaries/cancer-terms/def/malignant-ascites

Jane Clark, PhD, RN, AOCN®, GNP-C

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Menopausal Symptoms PROBLEM Menopause is the end of menstruation for at least 12 months as the result of the loss of ovarian function. Cytotoxic therapy may cause damage to the ovaries, resulting in premature menopause (nonreversible) or temporary amenorrhea potentially lasting for years before menses resume. Hormone therapies also may induce either early menopause or temporary amenorrhea (Kaplan & Mahon, 2014; Matthews et al., 2014). In the perimenopausal period, women may experience an array of symptoms, including hot flashes, sweats, mood changes, insomnia, cognitive symptoms, or vaginal dryness (National Institute on Aging, 2016). Symptoms can be more severe in treatment-induced menopause than when natural menopause occurs. Men treated with androgen deprivation therapy experience similar hormonal symptoms, including an 80% incidence of hot flashes (Ahmadi & Daneshmand, 2013).

ASSESSMENT CRITERIA (Erickson & Berger, 2015; Kaplan, 2015; Nishimoto & Mark, 2015) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Oophorectomy, pelvic radiation, castration (both chemical and surgical), and certain chemotherapy and hormonal therapy agents place a person at risk for early menopause and/or menopausal symptoms. 2. What medications is the patient taking? Obtain medication history, including prescription, over-the-counter, and complementary or alternative methods to manage menopausal symptoms. 3. Obtain history of the problem. a. Severity b. Precipitating factors c. Onset and duration d. Frequency e. Relieving factors f. Any associated symptoms (e.g., hot flashes, night sweats, insomnia) 4. Review past medical history (e.g., menstrual status, pattern [regular/irregular], date of last menses). 5. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Chest pain or shortness of breath

Seek emergency care. Call an ambulance immediately. (Continued on next page)

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M e n o pau s a l S y m p to m s (Continued)

Signs and Symptoms

Action

•• Severe headache •• Pain in calf (women on hormone therapy) •• Heavy vaginal bleeding; soaking more than a single pad an hour or bleeding accompanied by weakness or dizziness •• Panic attacks, self-destructive behavior, delirium or disorientation, suicidal ideation or plan, or any life-threatening symptoms

Seek emergency care.

•• Breast lump or tenderness •• Postmenopausal vaginal bleeding •• Persistent nausea or vomiting

Seek urgent care within 24 hours.

•• Sleep disruption that affects activities of daily living •• Mood changes, difficulty making decisions •• Hot flashes and night sweats

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Anxiety, Bleeding, Deep Vein Thrombosis, Depressed Mood, Headache Note. Based on information from Moore-Higgs, 2014; Nishimoto & Mark, 2015.

HOMECARE INSTRUCTIONS Homecare instructions are organized by the symptom/complaint.

Hot Flashes

••Hormone therapy –– Hormone therapy is an effective treatment of symptoms related to menopause (Asi et al., 2016; Weihua & Qing, 2015). –– Menopausal hormone therapy typically includes estrogen and progestin/progesterone (for those with an intact uterus). Use can reduce the incidence of hot flashes but is contraindicated in patients with hormone-sensitive tumors. Follow healthcare provider recommendations. ••Nonhormonal medications –– Some patients benefit from prescription nonhormonal medications for hot flashes. –– Venlafaxine (a selective serotonin reuptake inhibitor antidepressant) and gabapentin (an anticonvulsant) have been studied in several trials where efficacy has been demonstrated and are categorized as likely to be effective in current Oncology Nursing Society Putting Evidence Into Practice (ONS PEP) guidelines (Kaplan & Mahon, 2014). –– Paroxetine was approved in 2013 as a nonhormonal treatment for hot flashes. However, it is a strong inhibitor of CYP2D6, an enzyme that metabolizes tamoxifen, so it should be used with care (Wei et al., 2016). –– Magnesium is an option. It was used in one small study and reduced hot flash scores by 25%–50% (Park, Parker, Boardman, Morris, & Smith, 2011). 214 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M e n o pau s a l S y m p to m s ••Keep a diary of menopausal symptoms. This diary can be used to help identify triggers for hot flashes. Common triggers include hot drinks, caffeine, alcohol, spicy foods, stress, and smoking (Kaplan, 2015; National Institute on Aging, 2016). ••Lower the thermostat and use fans and air conditioning. ••Dress in layers. ••Wear absorbent clothing such as cotton. Avoid wool and synthetics. ••Keep a glass of ice water on hand. ••Consult with a healthcare provider about over-the-counter remedies. Many herbal products contain estrogen-like substances that may be contraindicated in patients with hormone-sensitive tumors. ••Exercise training can reduce objective physiologic severity of menopausal hot flashes (Bailey et al., 2016). ••Relaxation therapy, hypnosis, and acupuncture have been proposed as complementary therapies for hot flashes, but additional research is needed. Garcia et al. (2013) stated that the efficacy of acupuncture for symptoms other than chemotherapy-induced nausea and vomiting could not be determined because of the high risk of bias.

Vaginal Dryness, Itching, and Atrophy

••Hormone therapy is the most effective treatment for dyspareunia (Tan, Bradshaw, & Carr, 2012). Vaginally applied (e.g., estrogen vaginal rings, tablets, creams) or oral hormones could help. Consult with a healthcare provider, as this type of treatment would be contraindicated in patients with hormonesensitive tumors. ••Engage in regular intercourse or use of a vaginal dilator to decrease risk of atrophy and maintain acidic pH (Massa, 2011). ••Perform Kegel exercises for muscular and vascular tone (Massa, 2011). ••Wear cotton underwear; avoid tight-fitting pants, synthetic fabrics, and pantyhose. ••Avoid products that may increase dryness or irritation, such as perfumes, soaps, deodorants, bubble bath products, oil-based petroleum jelly or baby oil, douches, spermicide, antihistamines, and excessive caffeine or alcohol intake (MooreHiggs, 2014). ••Use water-based lubrication products (e.g., K-Y® Jelly, Astroglide®) or vaginal moisturizers (e.g., Replens®, Lubrin®). Be sure to understand the difference between the two products: lubricants are used at the time of intercourse, while moisturizers are used daily. ••Vaginal testosterone may have a role in the management of sexual dysfunction. In small studies, it has been demonstrated to be safe and effective, although it is not currently approved by the U.S. Food and Drug Administration (FDA) (Lemke, Madsen, & Dains, 2017). ••FDA has approved a nonhormone medicine, ospemifene, to treat dyspareunia caused by vaginal changes. It is an estrogen agonist/antagonist. Consult with a healthcare provider first to determine if any contraindications exist (National Institute on Aging, 2016). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 215

M e n o pau s a l S y m p to m s

Insomnia

••Consider a referral to a healthcare professional trained in cognitive behavioral therapy. This therapy improves sleep and is considered the best choice for nonpharmacologic treatment of insomnia (Garland et al., 2014). It is also recommended for practice in current ONS PEP guidelines (Berger et al., 2017). ••Practice regular aerobic exercise. Physical activity has been shown to improve sleep quality among cancer survivors (Chen et al., 2014). ••Avoid napping in the late afternoon or early evening. ••Practice relaxation techniques (e.g., yoga, deep breathing, meditation). ••Avoid alcohol and caffeine, particularly before bedtime. ••Keep a regular bedtime schedule and routine. The nurse should refer the patient to one of the numerous online resources regarding sleep hygiene, such as the National Sleep Foundation website (www.sleepfoundation.org). ••Eat a light dinner. ••Resolve any environmental disturbances (e.g., snoring partner, cell phone, room temperature, levels of ambient noise and light). ••Treating nocturnal hot flashes often improves sleep quality. ••If appropriate, discuss prescribing a hypnotic or over-the-counter sleep aid with a collaborating physician or nurse practitioner. Melatonin could be an option. It has been shown to improve sleep among breast cancer survivors with few adverse effects (Chen et al., 2014).

Seek Emergency Care Immediately if Any of the Following Occurs

••Chest pain ••Severe dyspnea ••Pain in calf (women taking hormone or estrogen-replacement therapy) ••Hemoptysis ••Severe headache ••Severe vaginal bleeding ••Suicidal ideation

REFERENCES Ahmadi, H., & Daneshmand, S. (2013). Androgen deprivation therapy: Evidence-based management of side effects. BJU International, 111, 543–548. https://doi.org/10.1111/j.1464-410X.2012.11774.x Asi, N., Mohammed, K., Haydour, Q., Gionfriddo, M.R., Morey Vargas, O.L., Prokop, L.J., … Hassan Murad, M. (2016). Progesterone vs. synthetic progestins and the risk of breast cancer: A systematic review and meta-analysis. Systematic Reviews, 5, 121. https://doi.org/10.1186/s13643-016-0294-5 Bailey, T.G., Cable, N.T., Aziz, N., Atkinson, G., Cuthbertson, D.J., Low, D.A., & Jones, H. (2016). Exercise training reduces the acute physiological severity of post-menopausal hot flushes. Journal of Physiology, 594, 657–667. https://doi.org/10.1113/JP271456 Berger, A.M., Dean, G., Erickson, J.M., Matthews, E.E., Otte, J.L., Page, M.S., & Vena, C. (2017). Sleep-wake disturbances. Retrieved from https://www.ons.org/pep/sleep-wake-disturbances Chen, W.Y., Giobbie-Hurder, A., Gantman, K., Savoie, J., Scheib, R., Parker, L.M., & Schernhammer, E.S. (2014). A randomized, placebo-controlled trial of melatonin on breast cancer survivors: Impact on sleep, mood, and hot flashes. Breast Cancer Research and Treatment, 145, 381–388. https://doi​ .org/10.1007/s10549-014-2944-4 216 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

M e n o pau s a l S y m p to m s Erickson, J.M., & Berger, A.M. (2015). Sleep-wake disturbances. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 623–647). Pittsburgh, PA: Oncology Nursing Society. Garcia, M.K., McQuade, J., Haddad, R., Patel, S., Lee, R., Yang, P., … Cohen, L. (2013). Systematic review of acupuncture in cancer care: A synthesis of the evidence. Journal of Clinical Oncology, 31, 952–960. https://doi.org/10.1200/JCO.2012.43.5818 Garland, S.N., Carlson, L.E., Stephens, A.J., Antle, M.C., Samuels, C., & Campbell, T.S. (2014). Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: A randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology, 32, 449–457. https://doi.org/10.1200/JCO.2012.47.7265 Kaplan, M. (2015). Hot flashes. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 421–447). Pittsburgh, PA: Oncology Nursing Society. Kaplan, M., & Mahon, S. (2014). Hot flash management: Update of the evidence for patients with cancer. Clinical Journal of Oncology Nursing, 18(Suppl. 3), 59–67. https://doi.org/10.1188/14.CJON.S3.59 -67 Lemke, E.A., Madsen, L.T., & Dains, J.E. (2017). Vaginal testosterone for management of aromatase inhibitor-related sexual dysfunction: An integrative review. Oncology Nursing Forum, 44, 296–301. https://doi.org/10.1188/17.ONF.296-301 Massa, L. (2011). Pelvic floor physical therapy interventions for oncology patients. Topics in Geriatric Rehabilitation, 27, 206–214. https://doi.org/10.1097/TGR.0b013e3182198fc0 Matthews, E.E., Berger, A.M., Schmiege, S.J., Cook, P.F., McCarthy, M.S., Moore, C.M., & Aloia, M.S. (2014). Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: A randomized, controlled trial. Oncology Nursing Forum, 41, 241–253. https://​ doi.org/10.1188/14.ONF.41-03AP Moore-Higgs, G.J. (2014). Menopausal symptoms and menopause. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 779–792). Pittsburgh, PA: Oncology Nursing Society. National Institute on Aging. (2016, October). Menopause: Treatment for symptoms. Tips from the National Institute on Aging. Retrieved from https://order.nia.nih.gov/sites/default/files/2017-07/TS​ _Menopause_508.pdf Nishimoto, P.W., & Mark, D.D. (2015). Sexuality and reproductive issues. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 551–597). Pittsburgh, PA: Oncology Nursing Society. Park, H., Parker, G.L., Boardman, C.H., Morris, M.M., & Smith, T.J. (2011). A pilot phase II trial of magnesium supplements to reduce menopausal hot flashes in breast cancer patients. Supportive Care in Cancer, 19, 859–863. https://doi.org/10.1007/s00520-011-1099-7 Tan, O., Bradshaw, K., & Carr, B.R. (2012). Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: An up-to-date review. Menopause, 19, 109–117. https://doi.org​ /10.1097/gme.0b013e31821f92df Wei, D., Chen, Y., Wu, C., Wu, Q., Yao, L., Wang, Q., … Yang, K.H. (2016). Effect and safety of paroxetine for vasomotor symptoms: Systematic review and meta-analysis. BJOG, 123, 1735–1743. https://doi.org/10.1111/1471-0528.13951 Weihua, L., & Qing, G. (2015). Acupuncture for menopausal hot flashes. Clinical Journal of Oncology Nursing, 19, 230–231. https://doi.org/10.1188/15.CJON.230-231

Deborah Metzkes, RN, BSN, OCN®, MBA The author would like to acknowledge Rae M. Norrod, MS, RN, AOCN®, CNS, and Carol Pilgrim, MSN, FNP-BC, AOCN ®, for their contributions to this protocol that remain unchanged from the previous edition of this book.

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Myalgia and Arthralgia PROBLEM The terms arthralgia and myalgia are commonly used together or interchangeably to label musculoskeletal pain. Arthralgia is defined as the pain experienced in a joint, and myalgia is defined as a generalized muscle pain (Post & Winters, 2016). Musculoskeletal complications can be caused by either the cancer itself, including either primary or metastatic disease, or by the therapies used in cancer treatment.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Arthralgia and myalgia in patients with cancer can be caused by several factors, including chemotherapy, biologic therapy, and immunotherapy. A contributing list of potential causes for diffuse arthralgia and myalgia includes the following (Chiu et al., 2017; Niravath, 2013; Post & Winters, 2016; Pujalte & Albano-Aluquin, 2015; Shmerling, 2016; Weber, Yang, Atkins, & Disis, 2015): a. Drug induced i. Taxanes (e.g., paclitaxel, docetaxel) can cause an acute pain syndrome. It is hypothesized that the pain results from nerve injury similar to the late-effect peripheral neuropathy that is commonly associated with taxanes. ii. Aromatase inhibitors are a common cause of arthralgia, reported in 50%–60% of patients. iii. Biologic agents (e.g., interferons, interleukins) iv. Immunotherapy agents, including but not limited to bacillus CalmetteGuérin and the checkpoint inhibitors (e.g., atezolizumab, ipilimumab, nivolumab, pembrolizumab), have resulted in a small number of patients experiencing inflammatory and immune-related arthritis with accompanying arthralgia and myalgia (Bernini, Manzini, Giuggioli, Sebastiani, & Ferri, 2013; Naidoo et al., 2017). v. Tyrosine kinase inhibitors vi. Colony-stimulating growth factors vii. Statins viii. Bisphosphonates ix. Withdrawal from antidepressant or corticosteroid therapy or sudden withdrawal from long-term use (more than two weeks) of corticosteroids Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 219

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2. 3.

4.

5. 6.

x. Corticosteroid therapy can result in muscle atrophy with subsequent myalgia. xi. Some antibiotics b. Systemic infection, including viral, bacterial, and spirochetal diseases (e.g., influenza or intercurrent viral or viral-like syndromes, HIV, dengue fever, Lyme disease, cytomegalovirus syndrome) c. Overuse syndromes: most common cause of localized myalgia d. Endocrine/metabolic (e.g., prolonged or sudden withdrawal of corticosteroid therapy, electrolyte disturbances, diabetes mellitus, vitamin D deficiency, thyroid disease) e. Autoimmune (e.g., rheumatoid disease, especially polyrheumatica and inflammatory myopathy; lupus) f. Neoplastic/hematologic: initial presentation of certain malignancies (e.g., lymphoma, leukemia) or paraneoplastic syndromes g. Psychiatric (e.g., somatic manifestations, stress, anxiety, tension) h. Other (e.g., fibromyalgia, chronic fatigue syndrome, silicone implant syndrome, vasculitis) What medications is the patient taking? Obtain medication history. Ask the patient to describe symptoms in detail, including mode of onset, character, location, duration, distribution of pain, and any of the following associated symptoms: a. Fever b. Chills c. Edema d. Rash or hyperpigmentation e. Fatigue f. Headache g. Muscle weakness h. Redness, swelling, or warmth at the pain site i. Paresthesia j. Nausea, vomiting, or diarrhea k. Weight change l. Depression Obtain history of the problem. a. Recent treatment and type (e.g., chemotherapy, biologic response modifiers) b. Recent strenuous exercise or overuse c. Precipitating factors d. Relieving factors e. Exacerbating or remitting factors f. Previous trauma Review past medical history (e.g., fibromyalgia, diabetes, neuromuscular disease). Assess for changes in activities of daily living (e.g., sleep patterns) and function.

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Signs and Symptoms

Action

•• Acute injury, paralysis, pending respiratory failure, or other life-threatening symptoms –– Sudden onset of severe, unrelenting pain –– Inability to ambulate –– Extremity or joint swelling with chest pain –– Acute joint deformity •• Difficulty breathing •• Cyanosis: skin, extremity, or lips turning blue

Seek emergency care. Call an ambulance immediately.

•• Diffuse myalgia, fever, chills, arthralgia, fatigue, and back pain could be the presenting signs/ symptoms of bacterial infections, especially endocarditis and impending sepsis. •• Temperature higher than 100.4°F (38°C) with suspected neutropenia •• Recent onset of neurologic manifestations •• New or sudden onset of inability to ambulate or bear weight •• Unexplained difficulty breathing or rapid breathing •• Swelling in one extremity and a recent history of immobility or of blood clots in legs •• Jaundice and dark urine

Seek urgent care within two hours.

•• Progressive symptoms associated with temperature higher than 100.4°F (38°C) •• Unexplained symptoms associated with patient history of bone marrow or organ transplant, recent dental or surgical procedure, or recent history of travel to tropical areas within two weeks of the onset of symptoms •• Constitutional symptoms (symptom indicating a systemic effect of a disease) (e.g., weight loss, night sweats, anorexia, general malaise) •• New headache •• Diffuse muscular weakness •• Recent history of insect or tick bite associated with the following: –– Visual symptoms –– Bilateral symptoms –– Claudication –– Rash –– Regional and generalized lymphadenopathy or other unexplained localized joint redness, swelling, or hyperthermia •• New prescription medicine

Seek urgent care within 24 hours. Consider consultation with infectious disease specialist, neurologist, rheumatologist, or endocrinologist, as indicated.

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M ya l g i a a n d A r t h r a l g i a (Continued)

Signs and Symptoms •• Recent onset without fever or low-grade fever and nonprogressive symptoms •• Onset of symptoms is associated with intercurrent viral or viral-like syndrome. •• Onset of symptoms is drug induced, such as with chemotherapy or targeted agents (e.g., taxanes, tyrosine kinase inhibitors), biologic agents (e.g., interferons, interleukins, hematopoietic growth factors, immunotoxins), aromatase inhibitors, bisphosphonates, or the recent withdrawal of corticosteroids (e.g., dexamethasone, prednisone). •• Symptoms associated with recent extensive physical workout

Action Follow homecare instructions. Notify MD if no improvement. Consult with MD regarding tapering of steroids as indicated.

Cross-references: Fever With Neutropenia, Fever Without Neutropenia, Flu-Like Symptoms, Headache, Nausea and Vomiting Note. Based on information from Ferri, 2018; Shmerling, 2016; Wilkes & Barton-Burke, 2018.

HOMECARE INSTRUCTIONS (Pinals, 2017; Shmerling, 2016) ••In the absence of specific contraindications, and as recommended by the physician, empiric treatment may include heat, acetaminophen, nonsteroidal antiinflammatory drugs, and/or muscle relaxants or other analgesics as prescribed per label instructions for fever and generalized achiness. ••Increase fluid consumption if not contraindicated. ••Limit activity; rest. ••Practice relaxation. ••When the cause cannot be readily identified, the patient should be closely observed and treated symptomatically.

Report the Following Problems

••No improvement or condition worsens ••Fever that persists for 24 hours with unknown cause ••Symptoms are progressive or persistent (more than one week) ••Increasing pain unrelieved by acetaminophen or ibuprofen as recommended by the physician

Seek Emergency Care Immediately if Any of the Following Occurs ••Chest pain ••Unresponsiveness ••Difficulty breathing

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REFERENCES Bernini, L., Manzini, C.U., Giuggioli, D., Sebastiani, M., & Ferri, C. (2013). Reactive arthritis induced by intravesical BCG therapy for bladder cancer: Our clinical experience and systematic review of the literature. Autoimmunity Reviews, 12, 1150–1159. https://doi.org/10.1016/j.autrev.2013.06.017 Chiu, N., Chiu, L., Chow, R., Lam, H., Verma, S., Pasetka, M., … DeAngelis, C. (2017). Taxaneinduced arthralgia and myalgia: A literature review. Journal of Oncology Pharmacy Practice, 23, 56–67. https://doi.org/10.1177/1078155215627502 Ferri, F.F. (2018). Ferri’s clinical advisor 2018: 5 books in 1. St. Louis, MO: Elsevier Health Sciences. Naidoo, J., Cappelli, L.C., Forde, P.M., Marrone, K.A., Lipson, E.J., Hammers, H.J., … Brahmer, J.R. (2017). Inflammatory arthritis: A newly recognized adverse event of immune checkpoint blockade. Oncologist, 22, 627–630. https://doi.org/10.1634/theoncologist.2016-0390 Niravath, P. (2013). Aromatase inhibitor-induced arthralgia: A review. Annals of Oncology, 24, 1443– 1449. https://doi.org/10.1093/annonc/mdt037 Pinals, R.S. (2017). Evaluation of the adult with polyarticular pain. In M. Ramirez Curtis (Ed.), UpToDate. Retrieved May 4, 2018, from https://www.uptodate.com/contents/evaluation-of-the-adult​ -with-polyarticular-pain Post, K.E., & Winters, L. (2016). Cancer-related musculoskeletal toxicities. In D. Camp-Sorrell & R. Hawkins (Eds.), inPractice. Retrieved April 25, 2018, from https://www.inpractice.com/Textbooks​ /Oncology-Nursing/Symptom-Management/Musculoskeletal-Effects.aspx Pujalte, G.G.A., & Albano-Aluquin, S.A. (2015). Differential diagnosis of polyarticular arthritis. American Family Physician, 92, 35–41. Shmerling, R.H. (2016). Approach to the patient with myalgia. In D.J. Sullivan (Ed.), UpToDate. Retrieved April 25, 2018, from https://www.uptodate.com/contents/approach-to-the-patient-with​ -myalgia Weber, J.S., Yang, J.C., Atkins, M.B., & Disis, M.L. (2015). Toxicities of immunotherapy for the practitioner. Journal of Clinical Oncology, 33, 2092–2099. https://doi.org/10.1200/JCO.2014.60.0379 Wilkes, G.M., & Barton-Burke, M. (2018). 2018 oncology nursing drug handbook. Burlington, MA: Jones & Bartlett Learning.

Lori Lindsey, RN, MSN, FNP-BC, CCRC, OCN®

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Nausea and Vomiting PROBLEM Nausea is “the subjective phenomenon of an unpleasant, wavelike sensation experienced in the back of the throat and/or the epigastrium that may culminate in vomiting (emesis)” (National Cancer Institute, 2017c, para. 1). Vomiting is “the forceful expulsion of the contents of the stomach, duodenum, or jejunum through the oral cavity” (National Cancer Institute, 2017c, para. 1). Vomiting is often preceded by nausea, tachycardia (irregular heartbeat), diaphoresis, dizziness, and retching. Retching, or dry heaves, is gastric and esophageal vomiting motions without expulsion of emesis (National Cancer Institute, 2017b). The incidence and severity of chemotherapy-induced nausea and vomiting are affected by the emetogenicity of the chemotherapy agents used, the schedule and route of administration, and individual patient variability (Lee et al., 2017). Chemotherapy-induced nausea and vomiting results in serious malnutrition. A study by Davidson et al. (2012) reported that 26% of patients receiving chemotherapy in an ambulatory setting were malnourished, with a majority reporting limited dietary intake.

PATTERNS OF NAUSEA AND VOMITING ••Acute: experienced during the first 24 hours after chemotherapy administration ••Delayed (late): occurs more than 24 hours after chemotherapy administration and is associated with cisplatin, cyclophosphamide, and other drugs (e.g., doxorubicin, ifosfamide) given at high doses or for two or more consecutive days ••Anticipatory: occurs before a new cycle of chemotherapy is begun, in response to conditioned stimuli, such as the smells, sights, and sounds of the treatment room. It is a classically conditioned response that typically occurs three or four chemotherapy treatments after the patient experiences acute or delayed nausea and vomiting; however, it can occur at any time. ••Breakthrough: occurs within five days of prophylactic use of antiemetics and requires rescue ••Refractory: does not respond to treatment ••Chronic: occurs in patients with advanced cancer and is associated with a variety of potential etiologies. A definitive understanding of cause is neither well known nor well researched, but potential causal factors include gastrointestinal, cranial, metabolic, drug-induced (e.g., morphine), cytotoxic chemotherapy– induced, and radiation-induced mechanisms (National Cancer Institute, 2017b). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 225

Na u s e a a n d V o m i t i n g After the specific patterns of nausea and vomiting are established, an assessment is necessary to chronicle evaluation of the onset, intensity, and relationship to chemotherapy.

ASSESSMENT CRITERIA FOR NAUSEA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. When did the patient receive the last chemotherapy treatment or undergo a transplant? b. What chemotherapy did the patient receive? 2. What medications is the patient taking? a. Is the patient taking an opioid or any new medication (Nolan, Daly, & Rowan, 2012)? b. Obtain information on current use of antiemetics. 3. Ask the patient to describe symptoms in detail. 4. Obtain history of the problem. a. Severity b. Precipitating factors c. Onset and duration d. Relieving factors e. Nonpharmacologic interventions and their effectiveness f. Food and fluid intake over the past 24 hours g. Any associated symptoms (e.g., indications of disease recurrence) 5. Review past medical history.

ASSESSMENT CRITERIA FOR VOMITING (Nolan et al., 2012) 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Is the patient post-transplant? If yes, discuss with hematologist or clinical nurse specialist. b. Is the patient taking oral chemotherapy? 2. What medications is the patient taking? Obtain information on current use of antiemetics. 3. Ask the patient to describe symptoms in detail. a. Character, color, force, and quantity of vomit b. Are other members of the family/household experiencing the same symptoms? c. Diarrhea or constipation d. Abdominal distension 4. Obtain history of the problem. a. Severity b. Precipitating factors 226 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Na u s e a a n d V o m i t i n g c. d. e. f. g.

Onset and duration Relieving factors Nonpharmacologic interventions and their effectiveness Food and fluid intake over the past 24 hours Any associated symptoms, such as signs of dehydration (e.g., decreased urine output, fever, thirst, dry mucous membranes, weakness, dizziness, confusion) 5. Review past medical history.

HOMECARE INSTRUCTIONS ••Review with healthcare provider the prescribed antiemetic therapy, dose schedule, and route. ••Correctly and regularly comply with prescribed medication. ••Take frequent small sips of fluids. ••Eat small amounts of food frequently. ••Supplement diet with ginger or foods containing ginger. ••Take an antiemetic 20 minutes prior to meals. ••Monitor for signs of dehydration. ••Use distraction therapies (e.g., music, moderate exercise, relaxation, breathing exercises) in addition to antiemetic therapy. ••Contact a healthcare provider during clinic hours if symptoms persist or become worse. If the patient is compliant with the antiemetic medication, contact the healthcare provider to receive an alternative antiemetic prescription (Nolan et al., 2012). ••The U.S. Food and Drug Administration has not approved the use of cannabis as a treatment for any medical conditions to date (National Cancer Institute, 2017a). The potential benefits of medical cannabis for people living with cancer include antiemetic effects, appetite stimulation, pain relief, and sleep improvements (Abrams, 2016). Further research is needed before cannabis can become a part of evidence-based oncology practice (Turgeman & Bar-Sela, 2017).

Seek Emergency Care Immediately if Any of the Following Occurs (Nolan et al., 2012) ••Evidence of dehydration ••Unable to eat or drink for 24 hours ••Treatment change not effective within six hours

ADDENDUM A useful grading tool for nausea and vomiting is the Common Terminology Criteria for Adverse Events published by the National Cancer Institute Cancer Therapy Evaluation Program (see Table 4). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 227

Na u s e a a n d V o m i t i n g

Table 4. Grading of Nausea and Vomiting Event Nausea

Vomiting

Grade

Clinical Presentation

1

Loss of appetite without alteration in eating habits

2

Oral intake decreased without significant weight loss, dehydration, or malnutrition

3

Inadequate oral caloric or fluid intake; tube feeding, total parenteral nutrition (TPN), or hospitalization indicated

4

–

5

–

1

Intervention not indicated

2

Outpatient IV hydration; medical intervention indicated

3

Tube feeding, TPN, or hospitalization indicated

4

Life-threatening consequences

5

Death

Note. From Common Terminology Criteria for Adverse Events [v.5.0], by National Cancer Institute Cancer Therapy Evaluation Program, 2017. Retrieved from https://ctep.cancer.gov/protocolDevelop ment/electronic_applications/docs/CTCAE_v5_Quick_Reference_5x7.pdf.

REFERENCES Abrams, D.I. (2016). Integrating cannabis into clinical cancer care. Current Oncology, 23, S8–S14. https://doi.org/10.3747/co.23.3099 Davidson, W., Teleni, L., Muller, J., Ferguson, M., McCarthy, A.L., Vick, J., & Isenring, E. (2012). Malnutrition and chemotherapy-induced nausea and vomiting: Implications for practice [Online exclusive]. Oncology Nursing Forum, 39, E340–E345. https://doi.org/10.1188/12.ONF.E340-E345 Lee, J., Cherwin, C., Czaplewski, L.M., Dabbour, R., Doumit, M., Lewis, C., … Whiteside, S. (2017). Chemotherapy-induced nausea and vomiting. Retrieved from https://www.ons.org/pep/chemotherapy -induced-nausea-and-vomiting-adult National Cancer Institute. (2017a). Cannabis and cannabinoids (PDQ®) [Health professional version]. Retrieved from https://www.cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq#section/all National Cancer Institute. (2017b). Nausea and vomiting related to cancer treatment (PDQ®) [Patient version]. Retrieved from https://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea​-pdq National Cancer Institute. (2017c). Treatment-related nausea and vomiting (PDQ®) [Health professional version]. Retrieved from https://www.cancer.gov/about-cancer/treatment/side-effects/nausea​ /nausea-hp-pdq#section/_11 Nolan, A., Daly, N., & Rowan, E. (2012). St. James’s Hospital haematology oncology telephone triage guidelines. Retrieved from http://www.stjames.ie/Departments/DepartmentsA-Z/M/MedicalOncology​ /DepartmentinDepth/Telephone%20Triage%20Guidelines.pdf 228 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Na u s e a a n d V o m i t i n g Turgeman, I., & Bar-Sela, G. (2017). Cannabis use in palliative oncology: A review of the evidence for popular indications. Israel Medical Association Journal, 19, 85–88.

Pamela J. Pearson, RN The author would like to thank Kathleen Shannon Dorcy, PhD, RN, FAAN, Director of Clinical/ Nursing Research, Education and Practice at Seattle Cancer Care Alliance, and Staff Scientist at Fred Hutchinson Cancer Research Center, for her help in reviewing this content. The author would like to acknowledge Margaret Hickey, RN, MSN, MS, CORLN, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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Oral Mucositis PROBLEM Mucositis affects the mucous membranes that line the gastrointestinal tract and can manifest as inflammation or ulceration, both of which cause pain. If the inflammation or ulcerations occur in the mouth or oropharynx, it is referred to as oral mucositis, which affects 20%–40% of patients who receive standard chemotherapy (Eilers, Harris, Henry, & Johnson, 2014; Gibson et al., 2013; Lalla, Bowen, et al., 2014), 80% of patients undergoing hematopoietic stem cell transplantation (Eilers et al., 2017), and essentially all patients receiving radiation therapy for head and neck cancer (Bonomi & Batt, 2015; Chen et al., 2015; Lalla, Saunders, & Peterson, 2014). Oral mucositis usually begins with asymptomatic erythema of the oral mucosa that may cause patients to complain of burning or tingling in the mouth. Patchy erythema and edema can develop and progress to confluent erythema, edema, and white patches, which can eventually progress into painful ulcers, leading to active bleeding and necrosis in some patients (Al-Dasooqi et al., 2013; Lalla, Saunders, & Peterson, 2014; Sonis, 2013). The mouth is the most frequently documented source of infection in immunocompromised patients.

ASSESSMENT CRITERIA (Lalla, Saunders, & Peterson, 2014; Peterson, Srivastava, & Lalla, 2015) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Mucositis can develop as a side effect from the following: a. Some chemotherapy agents (within 5–7 days of administration, but the myelosuppressive effects of chemotherapy may not occur for as many as 10–12 days following treatment) b. Mammalian target of rapamycin (mTOR) inhibitors (mucositis presents as oral aphthous stomatitis) c. Radiation therapy to the oral cavity (within 7–10 days) d. Hematopoietic stem cell transplantation e. Recent oral surgery f. Poor oral hygiene 2. What medications is the patient taking? Obtain medication history. 3. Ask the patient to describe symptoms in detail. The patient should include the affected location(s) (e.g., lips, tongue, mucous membranes, gingiva [gums], teeth, denture-bearing area) of any of the following symptoms: a. Erythema Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 231

Oral Mucositis b. Ulcerations c. Blisters d. White patches or sticky white film e. Pain f. Difficulty swallowing g. Hoarseness h. Taste alterations i. Fever j. Decreased oral intake k. Sore throat A variety of tools can be used to facilitate oral assessment by members of the healthcare team, including the Oral Assessment Guide (OAG) (Eilers, Berger, & Petersen, 1988), the World Health Organization (1979) scale, the National Cancer Institute (NCI) Cancer Therapy Evaluation Program (2017) Common Terminology Criteria for Adverse Events, and the Beck Oral Assessment Scale (Beck, Agutter, Dudley, Peterson, & McGuire, 2007). A 10-item visual analog tool, the Patient-Reported Oral Mucositis Symptom (PROMS) scale, has also been used to capture the patient’s perspective (Gussgard, Hope, Jokstad, Tenenbaum, & Wood, 2014). 4. Obtain history regarding the following: a. Current oral hygiene practices b. Social history of tobacco and alcohol use 5. Is the patient’s condition stable or worsening? 6. Are any relieving factors effective? a. Ice chips b. Cold water rinses c. Local or systemic analgesics 7. Assess nutritional intake. a. Current diet i. Oral intake (e.g., liquid, soft, regular) ii. Tube feedings b. Any recent weight loss 8. Assess for changes in activities of daily living and function.

Signs and Symptoms •• Uncontrolled bleeding •• Difficulty breathing •• Temperature higher than 100.4°F (38°C) or chills with suspected neutropenia

Action Seek emergency care. Call an ambulance immediately.

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Oral Mucositis (Continued)

Signs and Symptoms

Action

•• Severe ulceration and inability to take nutrition orally or swallow •• Bleeding from gums, oral cavity, or mouth (that does not stop within 5–10 minutes of applying pressure) •• Signs of dehydration –– Decreased urine output –– Sunken eyes –– Pinched skin that does not spring back –– Excessive thirst or dry mouth –– Light-headedness

Seek emergency care.

•• Painful erythema, edema, or ulcers that make swallowing difficult •• White patches (or sticky white film) in the mouth •• Pain unrelieved by acetaminophen or previously prescribed pain relievers •• Inability to eat soft foods •• Foul odor coming from mouth •• Worsening of symptoms

Seek urgent care within 24 hours.

•• Temperature higher than 100.4°F (38°C) without suspected neutropenia •• Painful erythema, edema, ulcers, or white patches but still able to eat and swallow •• Painless ulcers, white patches, erythema, or mild soreness without lesions

Notify healthcare provider and continue homecare instructions.

Note. Based on information from Bensinger et al., 2008; Eilers et al., 2014.

HOMECARE INSTRUCTIONS ••Inspect mouth daily (Peterson, Boers-Doets, Bensadoun, & Herrstedt, 2015) and call healthcare provider if changes occur, including new sores, swelling, bleeding, pain, or white patches (sticky white film). ••Monitor temperature daily and call healthcare provider for fever (temperature higher than 100.4°F [38°C]) without suspected neutropenia. Seek emergency care/call an ambulance immediately for fever (temperature higher than 100.4°F [38°C]) with suspected neutropenia. ••Practice good oral hygiene. –– Use a soft toothbrush (Bonomi & Batt, 2015; De Sanctis et al., 2016; Eilers et al., 2014; Harris, Eilers, Harriman, Cashavelly, & Maxwell, 2008; Kartin, Tasci, Soyuer, & Elmali, 2014; Morton et al., 2008; Peterson, Boers-Doets, et al., 2015). –– Brush teeth at least twice a day (Eilers et al., 2014; Peterson, Boers-Doets, et al., 2015) using a pea-sized amount (or smaller) of Biotène® toothpaste (Jyoti, Shashikiran, & Reddy, 2009). * Biotène toothpaste is recommended; however, flavored toothpaste may make brushing more palatable (bubble gum flavors are the easiest, nonirritating flavors to find). Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 233

Oral Mucositis * Avoid any toothpaste without an American Dental Association (ADA) seal. * Avoid any toothpaste with an ADA seal that contains pyrophosphate, hexametaphosphate, cinnamon flavoring, strong mint flavoring, or sodium lauryl sulfate. * Avoid any toothpaste with an ADA seal that is labeled as “whitening,” “brightening,” or “tartar control.” –– Good technique is critical when brushing. * Brush for two minutes. * Use a gentle rotating/circular motion. * Hold the toothbrush at a 45° angle to the tooth surface (Kartin et al., 2014). * Rinse the brush well using warm water (Peterson, Boers-Doets, et al., 2015). * Allow the toothbrush to air dry between uses. * Do not cover or cap toothbrush (Peterson, Boers-Doets, et al., 2015). * Change toothbrush at least every three months. –– For babies or patients without teeth, use a moistened gauze or clean washcloth two to three times a day to clean the gums. * If in the home setting, paper towels can be used. Do not use facial tissue. * Moisten gauze, washcloth, or paper towel with tap water. Begin using a toothbrush to brush gums and tooth when the first tooth erupts. Biotène toothpaste may be used on the gums. * For adults without teeth, secure clean gauze on the end of a tongue blade to gently clean the gums. * Oral swabs may be used, but they are not as effective in removing debris as a soft toothbrush or moistened gauze, washcloth, or paper towel. –– Floss daily (Eilers et al., 2014) with waxed floss (Bonomi & Batt, 2015) if platelet count is greater than 50,000/mm3 and white blood cell count is greater than 1,000/mm3; avoid any sore or bleeding areas of the gums. Pediatric patients should begin flossing when teeth are touching. –– For patients who wear dentures, use a denture brush or toothbrush and regular toothpaste at least once a day or after meals (Kartin et al., 2014; Peterson, Boers-Doets, et al., 2015). * Clean denture storage container at least once a week. * Wear dentures only when eating foods that need dentures if they are irritating the oral mucosa (Peterson, Boers-Doets, et al., 2015). * Avoid use of dentures if mouth sores are present under them (Peterson, Boers-Doets, et al., 2015). * Do not use denture adhesives. * Do not wear loose dentures. ••Complete lip care at least twice a day with lanolin (Lansinoh® or other lanolin, USP ointments) (Santos et al., 2013; Schubert, Peterson, & Lloid, 1999). Other options include Aloe Vesta® skin protectant, RadiaBlock™ lip balm, Biotène lip moisturizer gel, Aquaphor®, and Eucerin®. –– Lanolin-based creams and ointments are more effective in moisturizing and protecting against damage than petrolatum-based products (Eilers et al., 2014). 234 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Oral Mucositis –– Avoid use of ChapStick®; occlusive lip balms, such as petrolatum, may promote microbial growth (Eilers et al., 2014). ••Use oral rinses (rinse and gargle for 15–30 seconds or as tolerated; do not swallow) at least four times a day, especially after meals, if erythema or bleeding is present. Oral rinse options include the following: –– Salt and baking soda (one-fourth teaspoon regular table salt mixed with onehalf teaspoon baking soda in four ounces of water) (De Sanctis et al., 2016; Eilers et al., 2014; Harris et al., 2008; Kartin et al., 2014; McGuire et al., 2013; Scarpace, Brodzik, Mehdi, & Belgam, 2009; Vokurka et al., 2005) –– Salt water (one teaspoon regular table salt mixed in four cups of water) –– Baking soda rinse (one teaspoon baking soda mixed in eight ounces of water) –– Plain water ••Use of “magic mouthwash” (i.e., a mixture of viscous lidocaine, Mylanta®, and diphenhydramine) is ineffective and should be avoided (American Academy of Nursing, 2015). ••Use of prophylactic dexamethasone oral solution is encouraged to decrease the incidence and severity of oral aphthous stomatitis caused by mTOR inhibitors (Rugo et al., 2017). ••Avoid use of any mouthwashes that contain alcohol (De Sanctis et al., 2016; Eilers et al., 2014; Peterson, Boers-Doets, et al., 2015), including chlorhexidine with alcohol. Acceptable mouthwashes include Biotène dry mouth oral rinse, Biotène PBF oral rinse, SmartMouth™ dry mouth oral rinse, and Oasis® moisturizing mouthwash (Lalla, Bowen, et al., 2014; Nicolatou-Galitis et al., 2013). ••For patients with dry, thick secretions, frequent oral rinses should be encouraged. Consider arranging portable suction to help remove secretions in the back of the throat as needed. ••Consider use of a syringe with suction tubing to help facilitate oral rinses for patients with a sore mouth or for patients who have difficulty opening their mouth. ••Continue oral fluid intake to maintain hydration and decrease viscosity of secretions. Add humidification as needed (Morton et al., 2008). ••Eat high-protein, high-calorie meals often (e.g., six to eight small meals each day), if applicable. –– Add extra calories and protein to food (e.g., add powdered milk to soups and casseroles). –– Add extra fats such as butter, oil, and cream. ••Choose soft, easy-to-chew food. If mouth sores are present or the oral mucosa is sore, take acetaminophen or another prescribed pain medication 30–60 minutes before eating. ••Avoid the following foods and drinks (Morton et al., 2008; Peterson, BoersDoets, et al., 2015): –– Foods with sharp edges –– Hot foods –– Very spicy, sour, or acidic foods and drinks –– Sugary foods and drinks Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 235

Oral Mucositis –– Foods that will stick to teeth –– Alcohol ••Avoid smoking and using chewing tobacco (Morton et al., 2008; Peterson, BoersDoets, et al., 2015).

Report the Following Problems

••Pain not relieved by medications ••Bleeding gums ••Temperature higher than 100.4°F (38°C) without suspected neutropenia ••Foul odor coming from the mouth ••New mouth sores ••New swelling in the mouth ••New white patches ••Difficulty eating ••Worsening symptoms

Seek Emergency Care Immediately if Any of the Following Occurs

••Severe ulceration and inability to eat or swallow ••Uncontrolled bleeding ••Difficulty breathing ••Signs of dehydration ••Temperature higher than 100.4°F (38°C) or chills with suspected neutropenia

REFERENCES Al-Dasooqi, N., Sonis, S.T., Bowen, J.M., Bateman, E., Blijlevens, N., Gibson, R.J., … Lalla, R.V. (2013). Emerging evidence on the pathobiology of mucositis. Supportive Care in Cancer, 21, 2075– 2083. https://doi.org/10.1007/s00520-013-1810-y American Academy of Nursing. (2015). Twenty things nurses and patients should question. Retrieved from http://www.aannet.org/choosing-wisely Beck, S., Agutter, J., Dudley, W., Peterson, D., & McGuire, D. (2007). Developing an information visualization tool for oral mucositis [Abstract]. Oncology Nursing Forum, 34, 522. Bensinger, W., Schubert, M., Ang, K.K., Brizel, D., Brown, E., Eilers, J.G., … Trotti, A.M., III. (2008). NCCN task force report. Prevention and management of mucositis in cancer care. Journal of the National Comprehensive Cancer Network, 6(Suppl. 1), S1–S23. Bonomi, M., & Batt, K. (2015). Supportive management of mucositis and metabolic derangements in head and neck cancer patients. Cancers, 7, 1743–1757. https://doi.org/10.3390/cancers7030862 Chen, S.-C., Lai, Y.-H., Huang, B.-S., Lin, C.-Y., Fan, K.-H., & Chang, J.T.-C. (2015). Changes and predictors of radiation-induced oral mucositis in patients with oral cavity cancer during active treatment. European Journal of Oncology Nursing, 19, 214–219. https://doi.org/10.1016/j.ejon.2014.12.001 De Sanctis, V., Bossi, P., Sanguineti, G., Trippa, F., Ferrari, D., Bacigalupo, A., … Lalla, R.V. (2016). Mucositis in head and neck cancer patients treated with radiotherapy and systemic therapies: Literature review and consensus statements. Critical Reviews in Oncology/Hematology, 100, 147–166. https://doi.org/10.1016/j.critrevonc.2016.01.010 Eilers, J.G., Asakura, Y., Blecher, C.S., Burgoon, D., Chiffelle, R., Ciccolini, K., … Valinski, S. (2017). Mucositis. Retrieved from https://www.ons.org/pep/mucositis Eilers, J.G., Berger, A.N., & Petersen, M.C. (1988). Development, testing, and application of the oral assessment guide. Oncology Nursing Forum, 15, 325–330. 236 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Oral Mucositis Eilers, J.G., Harris, D., Henry, K., & Johnson, L.A. (2014). Evidence-based interventions for cancer treatment-related mucositis: Putting evidence into practice. Clinical Journal of Oncology Nursing, 18, 80–96. https://doi.org/10.1188/14.CJON.S3.80-96 Gibson, R.J., Keefe, D.M.K., Lalla, R.V., Bateman, E., Blijlevens, N., Fijlstra, M., … Bowen, J.M. (2013). Systematic review of agents for the management of gastrointestinal mucositis in cancer patients. Supportive Care in Cancer, 21, 313–326. https://doi.org/10.1007/s00520-012-1644-z Gussgard, A.M., Hope, A.J., Jokstad, A., Tenenbaum, H., & Wood, R. (2014). Assessment of cancer therapy-induced oral mucositis using a patient-reported oral mucositis experience questionnaire. PLOS ONE, 9, e91733. https://doi.org/10.1371/journal.pone.0091733 Harris, D.J., Eilers, J., Harriman, A., Cashavelly, B.J., & Maxwell, C. (2008). Putting evidence into practice: Evidence-based interventions for the management of oral mucositis. Clinical Journal of Oncology Nursing, 12, 141–152. https://doi.org/10.1188/08.CJON.141-152 Jyoti, S., Shashikiran, N.D., & Reddy, V.S. (2009). Effect of lactoperoxidase system containing toothpaste on cariogenic bacteria in children with early childhood caries. Journal of Clinical Pediatric Dentistry, 33, 299–304. https://doi.org/10.17796/jcpd.33.4.83331867x68w120n Kartin, P.T., Tasci, S., Soyuer, S., & Elmali, F. (2014). Effect of an oral mucositis protocol on quality of life of patients with head and neck cancer treated with radiation therapy [Online exclusive]. Clinical Journal of Oncology Nursing, 18, E118–E125. https://doi.org/10.1188/14.CJON.E118-E125 Lalla, R.V., Bowen, J., Barasch, A., Elting, L., Epstein, J., Keefe, D.M., … Elad, S. (2014). MASCC/ ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer, 120, 1453–1461. https://doi.org/10.1002/cncr.28592 Lalla, R.V., Saunders, D.P., & Peterson, D.E. (2014). Chemotherapy or radiation-induced oral mucositis. Dental Clinics of North America, 58, 341–349. https://doi.org/10.1016/j.cden.2013.12.005 McGuire, D.B., Fulton, J.S., Park, J., Brown, C.G., Correa, M.E.P., Eilers, J., … Lalla, R.V. (2013). Systematic review of basic oral care for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21, 3165–3177. https://doi.org/10.1007/s00520-013-1942-0 Morton, R.P., Thomson, V.C., Macann, A., Gerard, C.M., Izzard, M., & Hay, K.D. (2008). Home-based humidification for mucositis in patients undergoing radical radiotherapy: Preliminary report. Journal of Otolaryngology–Head and Neck Surgery, 37, 203–207. National Cancer Institute Cancer Therapy Evaluation Program. (2017). Common terminology criteria for adverse events [v.5.0]. Retrieved from https://ctep.cancer.gov/protocolDevelopment/electronic​ _applications/docs/CTCAE_v5_Quick_Reference_5x7.pdf Nicolatou-Galitis, O., Sarri, T., Bowen, J., Di Palma, M., Kouloulias, V.E., Niscola, P., … Lalla, R.V. (2013). Systematic review of anti-inflammatory agents for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21, 3179–3189. https://doi.org/10.1007/s00520-013-1847-y Peterson, D.E., Boers-Doets, C.B., Bensadoun, R.J., & Herrstedt, J. (2015). Management of oral and gastrointestinal mucosal injury: ESMO clinical practice guidelines for diagnosis, treatment, and follow-up. Annals of Oncology, 26(Suppl. 5), v139–v151. https://doi.org/10.1093/annonc/mdv202 Peterson, D.E., Srivastava, R., & Lalla, R.V. (2015). Oral mucosal injury in oncology patients: Perspectives on maturation of a field. Oral Diseases, 21, 133–141. https://doi.org/10.1111/odi.12167 Rugo, H.S., Seneviratne, L., Beck, J.T., Glaspy, J.A., Peguero, J.A., Pluard, T.J., … Litton, J.K. (2017). Prevention of everolimus-related stomatitis in women with hormone receptor-positive, HER2-negative metastatic breast cancer using dexamethasone mouthwash (SWISH): A single-arm, phase 2 trial. Lancet Oncology, 18, 654–662. https://doi.org/10.1016/S1470-2045(17)30109-2 Santos, P.S., Tinôco-Araújo, J.E., Souza, L.M., Ferreira, R., Ikoma, M.R., Razera, A.P., & Santos, M.M. (2013). Efficacy of HPA Lanolin® in treatment of lip alterations related to chemotherapy. Journal of Applied Oral Science, 21, 163–166. https://doi.org/10.1590/1678-7757201302308 Scarpace, S.L., Brodzik, F.A., Mehdi, S., & Belgam, R. (2009). Treatment of head and neck cancers: Issues for clinical pharmacists. Pharmacotherapy, 29, 578–592. https://doi.org/10.1592/phco.29.5.578 Schubert, M.M., Peterson, D.E., & Lloid, M.E. (1999). Oral complications. In E.D. Thomas, K.G. Blume, & S.J. Forman (Eds.), Hematopoietic cell transplantation (2nd ed., pp. 751–763). Malden, MA: Blackwell Science. Sonis, S.T. (2013). Oral mucositis in head and neck cancer: Risk, biology and management. 2013 American Society of Clinical Oncology Educational Book, 33, e236–e240. https://doi.org/10.1200/ EdBook_AM.2013.33.e236 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 237

Oral Mucositis Vokurka, S., Bystrická, E., Koza, V., Scudlová, J., Pavlicová, V., Valentová, D., … Misaniová, L. (2005). The comparative effects of povidone-iodine and normal saline mouthwashes on oral mucositis in patients after high-dose chemotherapy and APBSCT—Results of a randomized multicentre study. Supportive Care in Cancer, 13, 554–558. https://doi.org/10.1007/s00520-005-0792-9 World Health Organization. (1979). Handbook for reporting results of cancer treatment. Geneva, Switzerland: Author.

Michele Farrington, BSN, RN, CPHON® Sharon Baumler, MSN, RN, CORLN, OCN®

238 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Pain PROBLEM Pain is a significant problem in patients with cancer, occurring in approximately 55% of patients during cancer treatment; 66.4% of patients with advanced, metastatic, or terminal disease; and 39.3% of patients following curative treatment (van den Beukenvan Everdingen, Hochstenbach, Joosten, Tjan-Heijnen, & Janssen, 2016). Pain can be attributed to cancer treatment, the disease itself, or other comorbid conditions.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? 2. What medications is the patient taking? Obtain medication history (Brant, Eaton, & Irwin, 2017). a. Nonopioids (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs, aspirin) b. Adjuvant analgesics (e.g., antidepressants, anticonvulsants, muscle relaxants) c. Opioids (e.g., morphine, oxycodone, fentanyl, hydromorphone) i. Long acting (e.g., MS Contin®, OxyContin®, Duragesic®, Exalgo®) ii. Short acting (e.g., Percocet®, Vicodin®, Dilaudid®) 3. Pain assessment (Brant, 2014; Gallagher, Rogers, & Brant, 2017) a. Location of pain i. Where is the pain located? ii. Is there more than one site? b. Intensity i. On a scale of 0–10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate the pain right now? ii. What is your pain rating on average? What is your pain rating at its worst? What is your pain rating at its best? c. Quality of pain: What words would you use to describe your pain (e.g., sharp, burning, stabbing, radiating, aching)? d. Temporal factors (e.g., onset, duration, variations) i. When did the pain start? ii. Is it constant? iii. Do you have times of more severe pain or flares of pain (i.e., breakthrough pain; differentiate from uncontrolled background pain)? (1) How often does it occur? (2) How long does it last? (3) Is there a time of day it is better or worse? (4) Does anything make your pain better or worse? Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 239

Pa i n iv. Have you noticed that your pain is worse prior to your regularly scheduled pain medications (i.e., end-of-dose failure)? e. Previous treatments i. What types of treatments have you tried to relieve your pain? ii. Did these treatments help? f. Effects of pain, insomnia, depression, or anxiety 4. Ask about any associated symptoms (e.g., fever, swelling, redness). 5. Review past medical history (e.g., hypertension, gastrointestinal ulceration, renal impairment, sleep apnea, arthritis, history of chronic pain). 6. Assess for changes in activities of daily living and function (e.g., physical, social). Signs and Symptoms

Action

•• Signs/symptoms of acute injury, spinal cord compression, pathologic fracture, infection, or other lifethreatening problem •• Sudden onset of severe weakness or unrelenting localized pain; inability to ambulate or decreased sensation in extremities; loss of control of bowel or bladder •• Chest pain

Seek emergency care. Call an ambulance immediately.

•• Sudden onset of moderate to severe pain •• Pain not responsive to current medication regimen •• Pain that interferes with mobility

Seek medical care within two to four hours.

•• Mild to moderate pain that has been increasing •• Pain that is not controlled by current regimen •• Pain that is interfering with activity or sleep

Seek medical care within 24 hours.

•• Mild to moderate aches and pains

Follow homecare instructions. Notify MD if no improvement.

HOMECARE INSTRUCTIONS ••Take acetaminophen, aspirin, or ibuprofen per label instructions for mild pain as recommended by physician. –– Patients with compromised liver function should be cautioned on the use of acetaminophen. –– Ibuprofen should not be used in patients with low platelet counts, gastrointestinal problems (e.g., gastrointestinal bleed), or renal compromise. ••Take prescription analgesics as prescribed. ••Maintain activity as tolerated. ••Keep a pain diary, including pain location, quality, intensity, timing, and interventions taken; nonpharmacologic measures and pain medication taken; and intensity evaluation of the response to trialed interventions. ••Consider complementary therapies. Physical or cognitive behavioral therapy can help reduce pain by involving the body (Eaton, Brant, McLeod, & Yeh, 2017). 240 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Pa i n –– Relaxation techniques –– Heat or cold –– Distraction therapy using music, humor, or hobbies –– Visualization –– Guided imagery –– Massage

Report the Following Problems

••No improvement in pain ••Pain that does not subside with interventions ••Other side effects, such as sedation, nausea, or constipation

Seek Emergency Care Immediately if Any of the Following Occurs

••Excruciating pain ••Immobility ••Low back pain associated with loss of bladder or bowel control; bilateral extremity weakness, which could indicate spinal cord compression

REFERENCES Brant, J.M. (2014). Pain. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 69–92). Burlington, MA: Jones & Bartlett Learning. Brant, J.M., Eaton, L.H., & Irwin, M.M. (2017). Cancer-related pain: Assessment and management with Putting Evidence Into Practice interventions. Clinical Journal of Oncology Nursing, 21(Suppl. 3), 4–7. https://doi.org/10.1188/17.CJON.S3.4-7 Eaton, L.H., Brant, J.M., McLeod, K., & Yeh, C.H. (2017). Nonpharmacologic pain interventions: A review of evidence-based practices for reducing chronic cancer pain. Clinical Journal of Oncology Nursing, 21, 54–79. https://doi.org/10.1188/17.CJON.S3.54-70 Gallagher, E., Rogers, B.B., & Brant, J.M. (2017). Cancer-related pain assessment: Monitoring the effectiveness of interventions. Clinical Journal of Oncology Nursing, 21(Suppl. 3), 8–12. https:// doi.org/10​.1188/17.CJON.S3.8-12 van den Beuken-van Everdingen, M.H.J., Hochstenbach, L.M.J., Joosten, E.A.J., Tjan-Heijnen, V.C.G., & Janssen, D.J.A. (2016). Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. Journal of Pain and Symptom Management, 51, 1070–1090.e9. https://doi.org​ /10.1016/j.jpainsymman.2015.12.340

Jeannine M. Brant, PhD, APRN, AOCN®, FAAN The author would like to acknowledge Melanie Simpson, PhD, RN-BC, OCN®, CHPN, for her contribution to this protocol that remains unchanged from the previous edition of this book.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 241

242 . . . . . . . . Telephone Triage

Paresthesia (Peripheral Neuropathy) PROBLEM Paresthesia is characterized by numbness and tingling and is a common symptom of peripheral neuropathy. Peripheral neuropathy is a disturbance in the peripheral nervous system (outside of the brain and spinal cord) that results in sensory, motor, autonomic, or cranial nerve dysfunction. Associated symptoms include dysesthetic pain, weakness, ataxia, and loss of temperature sensation, position sense, and vibratory sense. Neuropathy may be caused by physical injury, infection, toxic substances, disease, or medications (Cancer.Net, 2017; National Cancer Institute, n.d.).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Peripheral neuropathy may result from direct damage from neurotoxic chemotherapy agents, including vinca alkaloids, platinum compounds (e.g., cisplatin, oxaliplatin), taxanes, epothilones, angiogenesis agents, and proteasome inhibitors. Indirect damage can occur from compression of a nerve associated with metastasis or compression fracture. Other risk factors include age (older than 60 years), concurrent use of neurotoxic drugs, radiation therapy to the spinal cord, diabetes mellitus, malnutrition with vitamin deficiency (B complex), and alcohol abuse (National Cancer Institute, 2017). 2. What medications is the patient taking? Obtain medication history. 3. Ask the patient to describe symptoms in detail. a. Sensations i. Burning pain ii. Sharp stabbing or an electric type of pain iii. Muscle weakness and loss of dexterity iv. Extreme sensitivity to touch b. Any associated symptoms 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration: Symptoms occurring for years suggest hereditary cause; symptoms occurring from weeks to months suggest drug-related toxicity or metabolic cause; and symptoms occurring for days suggest chemotherapy toxicity or Guillain-Barré syndrome. c. Relieving factors d. Any associated symptoms (e.g., inability to move, pain, constipation, abdominal distress, incontinence, urinary retention, sensation changes in Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 243

Pa r e s t h e s i a ( P e r i p h e r a l N e u r o p a t h y ) the hands and feet known as “stocking-glove” distribution) (Hershman et al., 2014) 5. Review past medical history. a. Diabetes mellitus b. Malnutrition c. Alcohol abuse d. Peripheral vascular disease e. Arthritis or other connective tissue disease f. HIV/AIDS g. Chemical exposures h. Previous neurotoxic chemotherapy 6. Assess for changes in activities of daily living and function (e.g., difficulty handling keys, tying shoes, or buttoning shirt; tripping) (Hershman et al., 2014; Tofthagen, Erb, Kanzawa-Lee, & Wood, 2017). Signs and Symptoms • Complete loss of feeling and movement • Pain with and without movement • Bedridden • • • •

Paresthesia interfering with activities of daily living Pain with activities Inability to distinguish temperature sensations Unilateral paresthesia

• Paresthesia including tingling and loss of deep tendon reflexes but interfering with less than 25% of function and not interfering with activities of daily living

Action Seek emergency care. Call an ambulance immediately. Seek urgent care within 24 hours.

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Constipation, Difficulty or Pain With Urination, Pain Note. Based on information from Sweeney, 2002.

HOMECARE INSTRUCTIONS ••Use assistive devices (e.g., cane, orthotic braces, splint) as directed. ••Wear socks and shoes to protect feet. ••Apply nonskid surfaces on floors and tubs. ••Continue walking or other mild exercise. ••Use a potholder or oven mitts when cooking. ••Wear gloves when washing dishes or gardening. ••Inspect skin for cuts, abrasions, and burns daily. Inspect the bottom of feet with a mirror. ••Keep rooms well lighted. ••Use handrails on stairs. ••Use a thermometer to check the temperature of bath water. Avoid extreme temperatures. Ask another person to check the temperature before showering or bathing. ••Use caution when driving and operating machinery. 244 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Pa r e s t h e s i a ( P e r i p h e r a l N e u r o p a t h y ) ••Take vitamin B6, which may improve symptoms, if prescribed by physician. ••Avoid alcohol consumption. ••Avoid repetitive activities that may place stress on a nerve (e.g., playing golf or tennis, typing on a computer keyboard). ••Incorporate integrative medicine (e.g., acupuncture, massage, meditation and relaxation). ••Evidence-based, likely-to-be-effective therapy includes duloxetine and gabapentin with opioid combination (Hershman et al., 2014; Tofthagen et al., 2017).

Report the Following Problems

••Worsening of numbness, tingling, pain, or loss of function

Seek Emergency Care Immediately if Any of the Following Occurs ••Burns ••Uncontrolled bleeding from injuries ••Infection of wounds ••Unrelieved pain ••Sudden loss of function or sensation (Jongen et al., 2013)

REFERENCES Cancer.Net. (2017). Peripheral neuropathy. Retrieved from http://www.cancer.net/navigating-cancer​ -care/side-effects/peripheral-neuropathy Hershman, D.L., Lacchetti, C., Dworkin, R.H., Lavoie Smith, E.M., Bleeker, J., Cavaletti, G., … Loprinzi, C.L. (2014). Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 18, 1941–1967. https://doi.org/10.1200/JCO.2013.54.0914 Jongen, J.L.M., Huijsman, M.L., Jessurun, J., Ogenio, K., Schipper, D., Verkouteren, D.R.C., … Vissers, K.C. (2013). The evidence for pharmacologic treatment of neuropathic cancer pain: Beneficial and adverse effects. Journal of Pain and Symptom Management, 46, 581–590.e1. https://doi.org/10​ .1016/j.jpainsymman.2012.10.230 National Cancer Institute. (n.d.). Neuropathy. In Dictionary of cancer terms. Retrieved from https://​ www.cancer.gov/publications/dictionaries/cancer-terms/def/neuropathy National Cancer Institute. (2017). Nerve problems (peripheral neuropathy) and cancer treatment. Retrieved from https://www.cancer.gov/about-cancer/treatment/side-effects/nerve-problems Sweeney, C.W. (2002). Understanding peripheral neuropathy in patients with cancer: Background and patient assessment. Clinical Journal of Oncology Nursing, 6, 163–166. https://doi.org/10.1188/02​ .CJON.163-166 Tofthagen, C.S., Erb, C.H., Kanzawa-Lee, G., & Wood, S.K. (2017). Peripheral neuropathy. Retrieved from https://www.ons.org/pep/peripheral-neuropathy

Nicole Korak, MSN, FNP-C

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246 . . . . . . . . Telephone Triage

Phlebitis PROBLEM Phlebitis is the inflammation of the intima layer of veins. It is a common and painful complication of peripheral IV cannulation. Symptoms of phlebitis include local pain, redness, edema, and heat (Ghorbani, Foadoddini, Hasanpour Fard, Mahdiabadi, & Kazem Vejdan, 2016; National Cancer Institute, n.d.; Ray-Barruel, Polit, Murfield, & Rickard, 2014). Phlebitis may be caused by infection, mechanical injury, or chemical irritation (do Rego Furtado, 2011; Ghorbani et al., 2016; National Cancer Institute, n.d.). Mechanical phlebitis may be associated with thick and tall catheters, the number of catheterizations, length of IV catheterization, and infusion rate. Chemical phlebitis may be caused by the reaction of the vein with medications or solutions administered via IV infusion. Greater risk for chemical phlebitis occurs with highly acidic solutions or high-osmolality solutions (e.g., hypertonic fluids, amino acids, some antibiotics, blood products). Infectious phlebitis usually occurs by transmission of infecting pathogens from other parts of the body or from the catheter tip to the catheterization site (do Rego Furtado, 2011; Ghorbani et al., 2016). Phlebitis is among the most common complications of IV therapy. It significantly correlates with the length of hospital stay and mortality rate (Ghorbani et al., 2016). Phlebitis often occurs in people who develop superficial thrombophlebitis. In this common thrombo-inflammatory disorder, a thrombus develops in a superficial vein. In contrast, phlebitis may be absent in patients with deep vein thrombosis (Nagarsheth, 2017).

ASSESSMENT CRITERIA 1. Does the patient currently have a peripheral IV catheter or a peripherally inserted central catheter (PICC)? 2. What is the cancer diagnosis, and what treatment is the patient receiving? a. Is the patient currently being treated, or has the patient recently been treated, with IV therapy? b. Has the patient received chemotherapy or biologic agents that could decrease white blood cell count? 3. What medications is the patient taking? 4. Did the patient recently receive irritant IV medications or solutions? a. Irritant chemotherapy agents b. Hypertonic fluids c. Amino acids Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 247

Phlebitis

5.

6.

7.

8. 9.

d. Irritant antibiotics e. Blood products Ask the patient to describe symptoms in detail. a. Where is the phlebitis located (e.g., old IV site, current IV site, PICC or central catheter site)? b. Appearance i. Redness around site ii. Swelling around site iii. Red streak radiating from IV site of concern iv. Purulent drainage at site c. Discomfort, tenderness, or pain along the path of the cannula d. Palpable venous cord e. Warmth along the vein or in affected limb f. Fever g. Redness or swelling in affected limb Rule out the following complications: a. Infection (e.g., purulent drainage, fever) b. Infiltration (e.g., swelling, tightness, cool skin, blanching, burning) c. Extravasation: The initial symptoms resemble infiltration and may include pain at the IV site. The symptoms at progression may include skin blistering and tissue sloughing, which may be caused by the vesicant drug administration. d. Air embolism (e.g., sudden-onset pallor or cyanosis, shortness of breath, cough, tachycardia) e. Pneumothorax (e.g., shortness of breath, chest pain, tachycardia) Obtain history of the problem. a. Precipitating factors i. Absolute neutrophil count less than 500/mm3 (severe risk of infection) ii. Trauma occurring during catheter insertion iii. Prolonged use of same IV site iv. Phlebitis or blood clots v. Recent dehydration: Dehydration may contribute because of an increase in blood viscosity. b. Onset and duration c. Relieving factors d. Any associated symptoms (e.g., ulceration, drainage, blistering) Review past medical history. Assess for changes in activities of daily living and function.

Signs and Symptoms •• Symptoms of air embolism, pneumothorax •• Sudden chest pain or shortness of breath

Action Seek emergency care. Call an ambulance immediately. (Continued on next page)

248 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Phlebitis (Continued)

Signs and Symptoms

Action

•• Red streak migrating upward from site •• Ulcer or wound develops at site •• Purulent drainage from site •• Limb becomes swollen •• Symptoms worsen •• Temperature higher than 100.4°F (38°C)

Seek urgent care within 24 hours.

•• Redness, tenderness, and swelling at an IV site (current or in the past)

Follow homecare instructions. Notify MD if no improvement within 48–72 hours.

Cross-references: Deep Vein Thrombosis, Dyspnea, Fever With Neutropenia, Fever Without Neutropenia Note. Based on information from Camp-Sorrell, 2014; Higginson & Parry, 2011; Infusion Nurses Society, 2016; Jackson, n.d.

HOMECARE INSTRUCTIONS ••Apply warm, moist soaks or packs to the site or the location of the affected extremity. ••Elevate the affected area for 72 hours to decrease swelling. ••If a peripheral IV catheter is present and phlebitis is grade 2 (at least two symptoms are present [e.g., pain, redness, swelling]) or greater, the patient should visit the clinic for device removal. ••For pain, take nonsteroidal anti-inflammatory drugs as prescribed by the physician. ••Discuss use of 2% quercetin cream to treat phlebitis caused by IV catheters. This can be a useful and safe treatment modality, and positive effects of the cream appear very soon after use (Ghorbani et al., 2016). ••If phlebitis from a PICC is not resolved after 48–72 hours, discuss with physician and consider having the catheter removed.

Report the Following Problems

••Development of a red streak that moves upward from site ••Ulcer or wound at site ••Purulent drainage from site ••Swelling of limb ••Worsening of symptoms ••Development of fever (e.g., temperature higher than 100.4°F [38°C]) ••No relief within 48–72 hours

Seek Emergency Care Immediately if Any of the Following Occurs ••Sudden chest pain ••Shortness of breath

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Phlebitis

ADDENDUM ••Determine the score of phlebitis based on patient symptoms, including redness, swelling, pain along the path of the cannula, palpable venous cord, and fever (see Table 5). ••Document phlebitis using a uniform standard scale for measuring grade and severity. ••Report any incidence of phlebitis greater than grade 2 to the appropriate healthcare personnel. ••Continue ongoing observation of sites for 48 hours after removal to detect postinfusion phlebitis. ••Document subsequent phlebitis score and actions taken, if any (Jackson, n.d.). Table 5. Phlebitis Grading Scale Score and Site Observation

Action

0—Site appears healthy.

No signs of phlebitis: Observe cannula.

1—One of the following signs is evident: slight pain near site, slight redness near site.

Possible first signs of phlebitis: Observe cannula.

2—Two of the following are evident: pain at IV site, redness, swelling.

Early stage of phlebitis: Resite cannula.

3—All of the following are evident: pain along path of cannula, redness around site, swelling.

Medium stage of phlebitis: Resite cannula and consider treatment.

4—All of the following are evident and extensive: pain along path of cannula, redness around site, swelling, palpable venous cord.

Advanced stage of phlebitis or start of thrombophlebitis: Resite cannula and consider treatment.

5—All of the following are evident and extensive: pain along path of cannula, redness around site, swelling, palpable venous cord, pyrexia.

Advanced stage of thrombophlebitis: Resite cannula and initiate treatment.

Note. Based on information from Akbari et al., 2014; Jackson, n.d.

REFERENCES Akbari, H., Raufi, S., Hekmat po, D., & Anbari, K. (2014). Comparing the effect of nitroglycerin and clobetazol ointments on prevention of superficial intravenous catheter induced phlebitis. Evidence Based Care Journal, 4, 71–80. https://doi.org/10.22038/EBCJ.2014.2421 Camp-Sorrell, D. (2014). Phlebitis. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 1415–1418). Pittsburgh, PA: Oncology Nursing Society. do Rego Furtado, L.C. (2011). Incidence and predisposing factors of phlebitis in a surgery department. British Journal of Nursing, 20(Suppl. 7), S16–S25. https://doi.org/10.12968/bjon.2011.20.Sup7.S16 250 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Phlebitis Ghorbani, S., Foadoddini, M., Hasanpour Fard, M., Mahdiabadi, M.A., & Kazem Vejdan, S.A. (2016). The effects of quercetin topical cream on phlebitis caused by peripheral intravenous catheters: A randomized controlled trial. Modern Care Journal, 13, e8857. https://doi.org/10.17795/modernc.8857 Higginson, R., & Parry, A. (2011). Phlebitis: Treatment, care and prevention. Nursing Times, 107(36), 18–21. Infusion Nurses Society. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(Suppl. 1), S95–S98. Jackson, A. (n.d.). Phlebitis grading scale [Infographic]. Retrieved from https://www.pedagogy-inc​ .com/PedagogyInc/media/PedagogyMedia/PDF/Phlebitis-Grading-Scale.pdf Nagarsheth, K.H. (2017). Superficial thrombosis. Retrieved from http://emedicine.medscape.com​ /article/463256-overview National Cancer Institute. (n.d.). Phlebitis. In Dictionary of cancer terms. Retrieved from https://www​ .cancer.gov/publications/dictionaries/cancer-terms/def/phlebitis Ray-Barruel, G.G., Polit, D.F., Murfield, J.E., & Rickard, C.M. (2014). Infusion phlebitis assessment measures: A systematic review. Journal of Evaluation in Clinical Practice, 20, 191–202. https://doi​ .org/10.1111/jep.12107

Jeanene “Gigi” Robison, MSN, APRN-CNS, AOCN® The author would like to acknowledge Amy Ford, RN, BSN, OCN®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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252 . . . . . . . . Telephone Triage

Pruritus (Itch) PROBLEM Pruritus is the sensation of itch that promotes scratching for relief. This can be a common and sometimes disabling adverse event from anticancer therapies or from the disease itself, affecting quality of life. Pruritus is initiated through dermal and epidermal nerve endings and is transmitted through C-fibers to the spinal cord. The spinal reflex is to itch, not unlike a deep tendon reflex. The resulting skin changes from scratching can include swelling, inflammation, and ultimately, infection. Pruritus can result from disease or side effects of treatment and should be evaluated (Economou, 2017; Fischer, Rosen, Ensslin, Wu, & Lacouture, 2013; Lester, 2014; Rajagopalan et al., 2017).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Pruritus can be a symptom of or is commonly found in the following diseases and cancers: i. Hematologic malignancies (1) Lymphoma, particularly Hodgkin lymphoma (2) Leukemia (3) Multiple myeloma ii. Sarcomas iii. Visceral tumors iv. Cholestatic liver diseases v. Psychosis and delirium (Bobb & Fletcher, 2016) vi. Endocrinopathies (e.g., carcinoid, thyroid, parathyroid, diabetes mellitus) vii. Any tumor with cutaneous metastases viii. Hematologic disorders (e.g., polycythemia vera, iron-deficiency anemia) ix. AIDS, AIDS-related Kaposi sarcoma, and AIDS-related opportunistic infections x. Autoimmune disorders (Bobb & Fletcher, 2016; Rajagopalan et al., 2017) b. Treatments that may cause pruritus include IV and oral cytotoxic chemotherapy agents (Economou, 2017; see Figure 11). i. Monoclonal antibodies/targeted therapies (e.g., epidermal growth factor receptor inhibitors, BRAF protein kinase inhibitors, immunotherapies targeting cytotoxic T-lymphocyte antigen 4) (Fischer et al., 2013) ii. Biologic response modifiers (e.g., interferons, hematopoietic growth factors) (Economou, 2017) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 253

Pruritus (Itch) iii. Immunotherapies (e.g., interleukin-2, checkpoint inhibitors) (Sibaud, 2017) iv. Opiate and opioid narcotics due to histamine release (Bagegni, Sheldahl, & Dans, 2014; Bobb & Fletcher, 2016; Larkin, 2015) v. Radiation therapy side effects determined by location and duration vi. Graft-versus-host disease as the result of bone marrow transplant (Zack, 2018) Figure 11. Anticancer and Other Agents Most Likely to Cause a Pruritic Reaction Chemotherapy Agents •• Carboplatin •• Cisplatin •• Cytarabine •• Daunorubicin •• Doxorubicin •• Etoposide •• Gemcitabine •• L-Asparaginase •• Melphalan •• Paclitaxel

Targeted Therapies •• Cetuximab •• Erlotinib •• Panitumumab •• Pazopanib •• Rituximab •• Sorafenib •• Sunitinib

Immunotherapy Agents •• Atezolizumab •• Avelumab •• Durvalumab •• Interleukin-2 •• Ipilimumab •• Nivolumab •• Pembrolizumab

Other Agents •• Amphetamines •• Aspirin •• Cocaine •• Growth factors •• Interferon alfa-2a •• Interferon alfa-2b •• Niacin •• Opioids

Note. Based on information from Bobb & Fletcher, 2016; Economou, 2017; Fischer et al., 2013; Sibaud, 2017.

2. What medications is the patient taking (Camp-Sorrell, 2018; Economou, 2017; Fischer et al., 2013; Lester, 2014)? a. Obtain medication history, including recent prescription and over-the-counter medications (e.g., anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs, alternative or complementary therapies). b. Inquire about medications the patient may not consider when asked (e.g., oral targeted therapies, oral chemotherapy agents). c. Consider allergic or hypersensitivity reactions in the differential. d. Inquire about medications for symptom management (e.g., opioids). e. Note antibiotics and their schedules. f. Inquire about routine medications, as well as cyclic medications such as contraceptives. g. Review when last doses were taken and any missed doses, as well as milligram doses and route. 3. Ask the patient to describe symptoms in detail. a. Is the pruritus localized or generalized? If localized, where is it located? b. Is a skin change or rash present? If so, where is it located? Describe the skin change. c. How does pruritus affect activities of daily living? d. Pruritus can be graded to capture the degree of severity (Camp-Sorrell, 2018; Larkin, 2015; Lester, 2014; see Table 6). 254 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Pruritus (Itch) Table 6. Grading of Pruritus Grade

Clinical Presentation

1

Mild or localized; topical intervention indicated

2

Widespread and intermittent; skin changes from scratching (e.g., edema, papulation, excoriations, lichenification, oozing/crusts); oral intervention indicated; limiting instrumental ADLs

3

Widespread and constant; limiting self-care ADLs or sleep; systemic corticosteroid or immunosuppressive therapy indicated

4

–

5

–

ADLs—activities of daily living Note. From Common Terminology Criteria for Adverse Events [v.5.0], by National Cancer Institute Cancer Therapy Evaluation Program, 2017. Retrieved from https://ctep.cancer.gov/protocolDevelop ment/electronic_applications/docs/CTCAE_v5_Quick_Reference_5x7.pdf.

4. Obtain history of the problem. a. Precipitating factors: Suggest awareness of new medications, lotions, soaps, detergents, exposure to animals, or changes in environment. b. Onset and duration: Is there a timeline of the pruritus? c. Relieving factors: Describe the results of using cool, wet cloths; bathing in cool water; applying topical ointments; or other measures that provide relief. d. Does applying heat or taking hot showers make it worse? e. Any associated signs or symptoms (e.g., inflammation, dry skin, rash, pustules, fever, jaundice) (Larkin, 2015; Lester, 2014; Rajagopalan et al., 2017) 5. Review past medical history. Signs and Symptoms

Action

•• Difficulty breathing •• Chest tightness or chest pain •• Sense of overwhelming anxiety or impending doom •• Generalized body rash with wheals or hives (with or without itch)

Seek emergency care. Call an ambulance immediately.

•• Generalized rash without shortness of breath •• Spreading localized rash with or without itch •• Fever •• Pustules or lesions with exudate •• Pustules along a nerve tract •• Bleeding •• Jaundice •• Pain •• Introduction of new medication in the past 24 hours

Seek urgent care within two hours.

(Continued on next page)

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Pruritus (Itch) (Continued)

Signs and Symptoms •• Localized rash with or without itch •• Scaling •• Cracking skin •• Scratch marks or breaks in skin •• Inflammation •• Scabies or lice •• White or red patches •• New exposures, such as animal, plant, or chemical •• New-onset itch without other symptoms

Action Seek urgent care within 24 hours.

Cross-references: Rash Note. Based on information from Bobb & Fletcher, 2016; Camp-Sorrell, 2018; Economou, 2017; Fischer et al., 2013; Larkin, 2015; Lester, 2014; Rajagopalan et al., 2017.

HOMECARE INSTRUCTIONS (Economou, 2017; Fischer et al., 2013; Larkin, 2015; Lester, 2014) ••Increase fluid intake to improve skin hydration. ••Use mild soaps or soaps made for sensitive skin. Oatmeal baths or soap may provide relief. ••Avoid perfumed soaps or bubble baths. ••Bathe only once a day in lukewarm or cool water. Limit baths to 30 minutes. Avoid long, hot showers. ••Apply skin emollients or lotions to bath water or to skin immediately after bathing while skin is still damp and then one or two times throughout the day. Do not use baby powder. ••Avoid lotions containing alcohol. Lotions and emollients recommended for sensitive skin include Eucerin®, Aquaphor®, Alpha Keri®, Lubriderm®, or Nivea®. ••Avoid tight, irritating clothing. Wear loose, soft, cotton garments. ••Use mild laundry detergents, such as those designed for infants, when washing clothing and bed linens. ••Maintain a humid environment through the use of a humidifier. ••Protect skin from the sun with sunscreen (SPF 30 or greater) applied each morning. Wear protective clothing such as long-sleeved shirts and broad-brimmed hats at times of direct sun exposure. ••Try application of a cool washcloth or ice over the site of itching. ••Try rubbing, pressure, or vibration to provide relief. ••For prescriptions or other interventions to assist with patient comfort, consult with the healthcare team, as appropriate. If it is determined that the patient has targeted therapy–induced rash with pruritus, refer the patient to instructions from the healthcare provider.

Report the Following Problems

••Symptoms not responding to homecare interventions, such as itch that continues for more than 48 hours after measures have been implemented 256 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Pruritus (Itch) ••Development of a rash, scaling, cracking, bleeding, redness, white patches, or blistering ••Temperature higher than 100.4°F (38°C) if neutropenia is not suspected, as these symptoms require further evaluation and intervention (Economou, 2017; Larkin, 2015)

Seek Emergency Care Immediately if Any of the Following Occurs

(Camp-Sorrell, 2018; Fischer et al., 2013; Larkin, 2015; Lester, 2014) ••Chest tightness ••Difficulty breathing ••Temperature higher than 100.4°F (38°C) if neutropenia is suspected ••Generalized body rash with wheals or hives

ADDENDUM Treatment should progress from topical to systemic therapy, depending on the cause of pruritus (see Table 7). Table 7. Suggested Pharmacologic Agents for the Treatment of Pruritus Therapy

Dosing

Notes

Topical Menthol and phenol cream

1%–2%, AAA PRN for pruritus

May be compounded at specialty pharmacies or bought over the counter (e.g., Vicks VapoRub®, calamine lotion)

Capsaicin cream

0.025% or 0.075%, AAA TID–QID PRN for pruritus

May cause burning or stinging sensation for the first few days

Antihistamine cream

Diphenhydramine, 2%

Corticosteroid cream

1% or 2.5%, AAA TID–QID PRN for pruritus

Should not be used in fields of radiation Best for local itching and short-term use only

Regenecare® or Regene­ care HA® gel

AAA TID

Useful for dry, itchy, or painful skin, rash, or wound

Remedy® Olivamine® creams (Skin Repair or Nutrashield)

AAA daily

Can be purchased from drugstores

–

(Continued on next page)

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Pruritus (Itch) (Continued)

Table 7. Suggested Pharmacologic Agents for the Treatment of Pruritus Therapy

Dosing

Notes

H1 antihistamines*

Diphenhydramine† 25–50 mg PO/IV every 4–6 hours Hydroxyzine 25–50 mg PO TID–QID PRN for pruritus

–

H2 antihistamines

Famotidine 20 mg PO BID

Particularly effective in Hodgkin lymphoma and polycythemia vera

Corticosteroids

Prednisolone 30–60 mg PO/IV every day Dexamethasone 0.5–8 mg PO every day, divided by BID–QID Methylprednisolone† 10–250 mg IV

May be considered for palliative treatment in Hodgkin lymphoma

Neurokinin-1 receptor antagonists

Aprepitant 80–125 mg PO, every other day to every day

Lacks RCTs supporting its effectiveness in treatment of pruritus Anecdotal reports of relief of chronic itching in patients with solid tumors, cutaneous T-cell lymphoma, and erlotinib-induced pruritus

Selective serotonin reuptake inhibitors*

Paroxetine 5–20 mg PO every day

Typically produces a rapid benefit occurring within 1–3 days and effects lasting 4–6 weeks May cause nausea and vomiting

Mirtazapine 7.5–30 mg PO every day (higher dose more effective)

Lacks RCTs supporting its effectiveness in treatment of pruritus Has antihistamine and serotonin antagonism activity Causes less nausea and vomiting than paroxetine Effective in 1–7 days May also treat insomnia, anorexia, and depression

Systemic

* May have sedative effects Common agents for acute hypersensitivity reactions

† 

AAA—apply to affected area; BID—twice daily; PO—by mouth; PRN—as needed; QID—four times daily; RCT—randomized controlled trial; TID—three times daily Note. Based on information from Bobb & Fletcher, 2016; Economou, 2017; Fischer et al., 2013; Larkin, 2015; Lester, 2014; Rajagopalan et al., 2017; Taneja & Borum, 2017.

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Pruritus (Itch)

REFERENCES Bagegni, J., Sheldahl, A., & Dans, C.D. (2014). Pain management. In T.M. De Fer & H.F. Sateia (Eds.), The Washington manual of outpatient internal medicine (2nd ed., pp. 758–771). Philadelphia, PA: Wolters Kluwer. Bobb, B.T., & Fletcher, D. (2016). Challenging symptoms: Dry mouth, hiccups, fevers, pruritus, and sleep disorders. In C. Dahlin, P.J. Coyne, & B.R. Ferrell (Eds.), Advanced practice palliative nursing (pp. 270–278). New York, NY: Oxford University Press. Camp-Sorrell, D. (2018). Chemotherapy toxicities and management. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 497–554). Burlington, MA: Jones & Bartlett Learning. Economou, D. (2017). Pruritus and xerosis. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 341–343). St. Louis, MO: Elsevier. Fischer, A., Rosen, A.C., Ensslin, C.J., Wu, S., & Lacouture, M.E. (2013). Pruritus to anticancer agents targeting the EGFR, BRAF, and CTLA-4. Dermatologic Therapy, 26, 135–148. https://doi.org/10​ .1111/dth.12027 Larkin, P.J. (2015). Pruritus, fever, and sweats. In B.R. Ferrell, N. Coyle, & J.A. Paice (Eds.), Oxford textbook of palliative nursing (4th ed., pp. 341–348). New York, NY: Oxford University Press. Lester, J. (2014). Pruritus. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 115–119). Pittsburgh, PA: Oncology Nursing Society. Rajagopalan, M., Saraswat, A., Godse, K., Shankar, D.S.K., Kandhari, S., Shenoi, S.D., … Zawar, V.V. (2017). Diagnosis and management of chronic pruritus: An expert consensus review. Indian Journal of Dermatology, 62, 7–17. https://doi.org/10.4103/0019-5154.198036 Sibaud, V. (2017). Dermatologic reactions to immune checkpoint inhibitors: Skin toxicities and immunotherapy. American Journal of Clinical Dermatology, 19, 345–361. https://doi.org/10.1007/s40257​ -017-0336-3 Taneja, S., & Borum, M.L. (2017). Pruritus ani. In F.J. Domino, R.A. Baldor, J. Golding, & M.B. Stephens (Eds.), The 5-minute clinical consult 2018 (26th ed., pp. 828–829). Philadelphia, PA: Wolters Kluwer. Zack, E. (2018). Principles and techniques of bone marrow transplantation. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 555–590). Burlington, MA: Jones & Bartlett Learning.

Gary Shelton, DNP, NP, ANP-BC, AOCNP®, ACHPN The author would like to acknowledge Jennifer S. Webster, MN, MPH, RN, AOCN®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

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260 . . . . . . . . Telephone Triage

Rash PROBLEM Rash is a disorder characterized by the presence of macules (flat) and papules (elevated) on the skin. It is a common side effect of several treatments for patients with cancer, including radiation therapy and systemic therapies. Rashes can be very distressing for patients emotionally and physically (Börjeson, Starkhammar, Unosson, & Berterö, 2012).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? a. Numerous medications, including cancer therapies, may cause a rash. i. Targeted therapy (1) Epidermal growth factor receptor (EGFR) inhibitors may result in an acneform rash, which is characterized by an eruption of papules and pustules typically appearing on the face, scalp, upper chest, and back. Table 8 outlines these agents and the frequency of reported skin rashes. Table 8. Incidence of Rash With Epidermal Growth Factor Receptor–Targeted Therapies Agent

Any Rash Incidence

Grade 3–4 Severe Rash

Afatinib

90%, when first-line EGFR agent 70%, in squamous NSCLC

16%, when first-line EGFR agent 9%, in squamous NSCLC

Cetuximab

89%

12%

Erlotinib

85%

14%

Gefitinib

66%

3%

Lapatinib (+ capecitabine)

28%

2%

Osimertinib

41%

0.5%

Panitumumab

89%

12%

EGFR—epidermal growth factor receptor; NSCLC—non-small cell lung cancer Note. Based on information from Amgen, Inc., 2009; AstraZeneca Pharmaceuticals LP, 2015a, 2015b; Boehringer Ingelheim Pharmaceuticals, Inc., 2013; Bristol-Myers Squibb Co., 2012; Novartis Pharmaceuticals Co., 2017; OSI Pharmaceuticals, Inc., 2010.

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 261

Ra s h

b. c. d. e. f. g.

h.

(2) Multitargeted agents (e.g., sorafenib, sunitinib) (3) Other targeted agents (e.g., imatinib) ii. Chemotherapy: Figure 12 provides a listing of chemotherapy agents (not all inclusive) with rash as a reported adverse effect. iii. Immunotherapy (e.g., atezolizumab, ipilimumab, nivolumab, pembrolizumab) iv. Other medications that can cause rash (e.g., antibiotics, antiseizure medications, pain medications, corticosteroids, blood thinners, nonsteroidal anti-inflammatory agents) (Lacouture, 2012) Radiation therapy may result in rash-like skin reactions, including dermatitis, burn, or a radiation recall reaction. Infection can manifest in rash-like appearance (e.g., candidiasis, cellulitis, chicken pox, erythema multiforme, herpes simplex, herpes zoster [shingles], impetigo, measles, rubella, scabies, Lyme disease). Allergic reactions often manifest as a rash and may be caused by an antibiotic or other drug allergy, atopic dermatitis, angioedema, or contact dermatitis. Environmental reactions may present as a rash and may be caused by sunburn, a chemical irritant, overwashing or overdrying of skin, or plant or animal exposure. Autoimmune conditions (e.g., cutaneous lupus, erythema nodosum, dermatomyositis, systemic lupus erythematosus, thrombocytopenic purpura, petechiae, psoriasis, eczema) may manifest with rash-like symptoms. Rash may result from the cancer itself, including abdominal/gastrointestinal tumors, adrenocorticotropic hormone–producing tumors, basal cell and squamous cell carcinoma, carcinoid, colon cancer, cutaneous T-cell lymphoma, Kaposi sarcoma, leukemia, melanoma, and neurofibroma. Rash may be psychosomatic resulting from stress, anxiety, or tension.

Figure 12. Anticancer Agents With Rash as a Potential Side Effect •• Aldesleukin •• Alemtuzumab •• Asparaginase •• Atezolizumab •• Avelumab •• Bexarotene •• Bicalutamide •• Bleomycin •• Bortezomib •• Capecitabine •• Carboplatin •• Chlorambucil •• Cisplatin •• Cladribine •• Clofarabine

•• Cyclophosphamide •• Cytarabine •• Doxorubicin •• Durvalumab •• Epoetin alfa •• Estramustine phosphate •• Etoposide •• Filgrastim •• 5-Fluorouracil •• Gemcitabine •• Goserelin •• Ibritumomab •• Ifosfamide •• Interferons

•• Interleukin-2 •• Ipilimumab •• Irinotecan •• Lenalidomide •• Leucovorin •• Mechlorethamine •• Medroxyprogesterone •• Melphalan •• Methotrexate •• Mitoxantrone •• Nivolumab •• Octreotide •• Oprelvekin •• Pembrolizumab

•• Pemetrexed •• Procarbazine •• Rituximab •• Taxanes (e.g., docetaxel, paclitaxel) •• Temozolomide •• Temsirolimus •• Teniposide •• Thalidomide •• Thiotepa •• Tositumomab •• Trastuzumab •• Vincristine •• Vinorelbine

Note. Based on information from Lacouture, 2012; Sibaud, 2018; Wilkes, 2018.

262 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ra s h 2. What medications is the patient taking? Obtain medication and allergy history. Table 8 and Figure 12 provide listings of anticancer therapies with rash as an associated side effect. 3. Ask the patient to describe symptoms in detail. a. Onset of rash b. Initial location of rash c. Areas where rash has spread d. Conjunctival involvement e. Color f. Texture (raised, flat, or blistered) g. Change in character of rash with time h. Any associated symptoms (e.g., itching, burning, numbness, pain, fever, headache, malaise, arthralgia, conjunctivitis) i. Aggravating factors, such as sunlight j. Alleviating factors and treatments tried k. Contact with those who have a similar rash l. Recent travel m. Insect bites or stings n. New skin products (e.g., lotion, soap, laundry detergent) o. New medications p. Radiation therapy q. Pruritus r. Crusting of skin s. Pain, redness, warmth, or tingling t. Drainage or “weeping” 4. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors d. Any associated symptoms (e.g., allergic reactions, infections, systemic conditions) 5. Review past medical history. a. Exposure to people with a similar rash b. Diabetes c. Kidney disease d. Skin diseases (e.g., psoriasis, eczema) 6. Assess for changes in activities of daily living and function. Signs and Symptoms

Action

•• Acute skin changes and associated systemic symptoms, such as swelling of throat, stridor, wheezing, dyspnea, chest pain, severe headache, eye involvement, desquamation, high fever, or mottled skin below the waist

Seek emergency care. Call an ambulance immediately for acute respiratory symptoms. (Continued on next page)

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 263

Ra s h (Continued)

Signs and Symptoms

Action

•• Infection: drainage from lesion •• Uncontrolled pruritus •• History of new drug (suspected drug-induced rash in absence of respiratory symptoms) •• Systemic symptoms associated with infections or viral syndrome, such as fever, myalgias, or arthralgias

Seek urgent care within 24 hours.

•• Rash related to chemotherapy, biologic therapy, or targeted therapy agents –– Hand-foot syndrome –– Papulopustular rash (often on the face and chest) –– Mild pruritus –– Mild pain or discomfort from skin alteration –– Nonprogressive symptoms

Follow homecare instructions. Notify MD if no improvement or if condition worsens.

Cross-references: Hand-Foot Syndrome, Pruritus (Itch)

HOMECARE INSTRUCTIONS ••Report changes in itching or rash to healthcare provider. ••Report presence of drainage from skin lesions. ••Apply cool compresses to inflamed area. ••Apply topical medication as prescribed. ••Take oral medication as prescribed and notify healthcare provider of side effects. Expect drowsiness from antihistamines and take safety precautions. ••Wear loose-fitting cotton clothing. ••Keep fingernails cut short and wear soft mittens at night to avoid scratching. ••Avoid hot baths and showers. ••Avoid sunlight and use sunscreen and sun protection. ••Hand-foot syndrome: Refer to Hand-Foot Syndrome protocol. ••Follow precautions for EGFR acneform rash. –– Moisturize with fragrance-free cream. –– Apply topical steroid or antibiotic cream as ordered by clinician. –– Take oral antibiotics as prescribed. –– If indicated, avoid extreme temperatures and direct sunlight. –– Keep nails clean and trimmed while on therapy to avoid paronychia (Lacouture et al., 2011). –– If prescribed afatinib or erlotinib, take on an empty stomach, as they interact with food and may result in an increased risk of side effects.

Report the Following Problems

••Rash progression ••No improvement over the next three days ••Fever that persists for 24 hours ••Increasing pain or uncontrolled pruritus 264 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Ra s h

Seek Emergency Care Immediately if Any of the Following Occurs ••Severe headache ••Difficulty breathing and throat tightening ••Chest pain ••High fever ••Eye involvement

REFERENCES Amgen Inc. (2009). Vectibix® (panitumumab) [Package insert]. Thousand Oaks, CA: Author. AstraZeneca Pharmaceuticals LP. (2015a). Iressa® (gefitinib) [Package insert]. Wilmington, DE: Author. AstraZeneca Pharmaceuticals LP. (2015b). Tagrisso® (osimertinib) [Package insert]. Wilmington, DE: Author. Boehringer Ingelheim Pharmaceuticals, Inc. (2013). Gilotrif® (afatinib) [Package insert]. Ridgefield, CT: Author. Börjeson, S., Starkhammar, H., Unosson, M., & Berterö, C. (2012). Common symptoms and distress experienced among patients with colorectal cancer: A qualitative part of mixed method design. Open Nursing Journal, 6, 100–107. https://doi.org/10.2174/1874434601206010100 Bristol-Myers Squibb Co. (2012). Erbitux® (cetuximab) [Package insert]. Princeton, NJ: Author. Lacouture, M.E. (2012). Dr. Lacouture’s skin care guide for people living with cancer. Cold Spring Harbor, NY: Harborside Press. Lacouture, M.E., Anadkat, M.J., Bensadoun, R.-J., Bryce, J., Chan, A., Epstein, J.B., … Murphy, B.A. (2011). Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Supportive Care in Cancer, 19, 1079–1095. https://doi.org/10.1007/s00520​ -011-1197-6 Novartis Pharmaceuticals Co. (2017). Tykerb® (lapatinib) [Package insert]. East Hanover, NJ: Author. OSI Pharmaceuticals, Inc. (2010). Tarceva® (erlotinib) [Package insert]. Melville, NY: Author. Sibaud, V. (2018). Dermatologic reactions to immune checkpoint inhibitors: Skin toxicities and immunotherapy. American Journal of Clinical Dermatology, 19, 345–361. https://doi.org​/10.1007/s40257 -017-0336-3 Wilkes, G.M. (2018). Chemotherapy: Principles of administration. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer nursing: Principles and practice (8th ed., pp. 417–496). Burlington, MA: Jones & Bartlett Learning.

Beth Eaby-Sandy, MSN, CRNP

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266 . . . . . . . . Telephone Triage

Seizures PROBLEM Seizures are potentially life-threatening manifestations of structural or metabolic brain dysfunction (Weller, Stupp, & Wick, 2012). Although seizures are one of the most common presenting symptoms of primary brain tumors, they are also often reported in patients with advanced cancer associated with brain metastases or leptomeningeal disease, chemotherapy exposure, cranial irradiation, stroke, infection, and paraneoplastic disorders. Seizures are often characterized as transient episodes of neurologic dysfunction caused by abnormal neuronal activity and resulting in altered consciousness and uncontrolled motor activity (Fisher, Cross, French, et al., 2017; Weller et al., 2012). According to the International League Against Epilepsy, it is important to distinguish the seizure type to determine the appropriate therapies, enable proper communication in clinical care, and maintain optimal research and teaching methods (Fisher, Cross, D’Souza, et al., 2017; Fisher, Cross, French, et al., 2017). Seizures can have either a focal (previously referred to as partial) or generalized onset. Focal seizures can be classified as aware (previously referred to as simple partial) or impaired awareness (previously referred to as complex partial). Generalized seizures can be classified as motor or nonmotor (absence).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving (Villanueva, Codina, & Elices, 2008)? a. Brain tumors account for approximately 4% of seizures; however, as many as 30%–50% of patients with brain tumors present with seizures. New seizures or changes in the frequency and type of seizures in patients with brain tumors often suggest tumor progression or recurrence. b. Low-grade gliomas are more epileptogenic than higher-grade tumors. c. Seizure in a patient with known cancer should generate suspicion of brain metastasis. Tumors known to have a higher likelihood of metastasizing to the brain include lung, breast, kidney, and melanoma. d. Seizures are associated with infiltrative lesions, including meningeal carcinomatosis (invasion of neoplastic cells into the subarachnoid space), intravascular lymphomatosis (diffuse occlusion of arterioles, capillaries, and venules by malignant lymphomatous cells), and gliomatosis cerebri (diffuse neoplastic infiltration of glial cells in the brain). e. Seizures have been associated with paraneoplastic syndromes (e.g., limbic encephalitis, other forms of focal, recurrent encephalitis), metabolic Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 267

Seizures encephalopathy, glycemic and electrolyte abnormalities (e.g., sodium, potassium, calcium, magnesium), central nervous system opportunistic infections, antibiotics (e.g., penicillins, cephalosporins, quinolones, carbapenems), and analgesics. f. Seizures have also been associated with cancer treatments, including chemotherapy, biologic therapy, radiation therapy, and certain supportive care medications. 2. What medications is the patient taking? Obtain medication history. a. Older-generation antiepileptic drugs that are known inducers of cytochrome P450–dependent hepatic enzymes (e.g., carbamazepine, phenobarbital, phenytoin) are metabolized faster and can decrease the efficacy of chemotherapy agents (e.g., vinca alkaloids, taxanes, methotrexate) and corticosteroids (e.g., dexamethasone) (Saria et al., 2013; Scott, 2015; Weller et al., 2012). Review serum drug levels if within therapeutic range. Assess adherence to antiepileptic medications. b. Drug-induced seizures may result from toxicities of common medications used in the oncology setting (Ruffmann, Bogliun, & Beghi, 2006). Epileptogenic drugs and their seizure risks are included in Table 9. 3. Obtain history of the problem. a. Severity: When did the seizure begin? How did it proceed? b. Precipitating factors: Any triggers? Seizures may be provoked by states that reduce the seizure threshold (e.g., fever, fatigue, stress, alcohol intake, use of certain medications). c. Onset and duration: Was the onset abrupt? How long did the seizure last? d. Any associated symptoms: Any changes in muscle tone, posture, and movement; aura prior to seizure activity; or postictal somnolence? e. Recovery: What was your next memory after the episode? How long did it take to feel back to normal? Did your muscles hurt? Did you have a headache after? f. Appropriate classification of seizures relies mainly on history and is often only aided by diagnostic investigations (Davidson & Derry, 2015). Because the patient’s consciousness may have been impaired before, during, and/or after the seizure event, a detailed history from a witness (if available) is crucial. Important questions to ask include the following: i. Number of episodes witnessed ii. Description of episode(s) iii. Duration of episode(s) iv. Time to return to preseizure state v. Event immediately preceding the episode vi. Loss of consciousness vii. Changes in skin color (e.g., lips turning blue) viii. Eyes open or closed during the episode 268 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Seizures Table 9. Epileptogenic Drugs Seizure Risk Drug Type

High

Intermediate

Low

Minimal

Analgesics and anesthetics

Meperidine

Propofol

Iodine contrast media Lidocaine

Antibacterials

Penicillins

Isoniazid Mefloquine

Ciprofloxacin Nalidixic acid Norfloxacin

–

Amitriptyline Desipramine Imipramine Maprotiline Nortriptyline Protriptyline

Bupropion Doxepin Fluoxetine Monoamine oxidase inhibitors

–

Antidepressants

–

Antineoplastic and immunosuppressant agents

Cyclosporine

Busulfan Chlorambucil Ifosfamide

Antipsychotics

Clozapine

Phenothiazines

Haloperidol

–

Acyclovir Foscarnet Ganciclovir

–

Antivirals

–

Zidovudine

Cardiovascular agents

–

Alcohol

Illicit drugs

Amphetamines Cocaine

Phencyclidine

Respiratory agents

Theophylline

Phenylpropanolamine

–

Enflurane Etomidate Naloxone

–

Heroin

–

Betablockers Mexiletine –

–

–

Note. Based on information from Ruffmann et al., 2006.

4. Review past medical history: Predisposing factors may include birth trauma, febrile convulsion, central nervous system infection, head injury, family history, and stroke (Davidson & Derry, 2015). 5. Assess for changes in activities of daily living and function: Does the patient drive? 6. Assess for the following special considerations (Pillow, Kimmel, Doctor, & Howes, 2017): a. Eclampsia (seizures in pregnancy) b. Trauma (post-traumatic seizures) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 269

Seizures c. Intracranial hemorrhage (stroke related to intracranial hemorrhage) d. Alcohol withdrawal (6–48 hours after cessation of drinking) e. Medication withdrawal (barbiturate or benzodiazepine) Signs and Symptoms

Action

• Sudden tonic-clonic (grand mal) seizure activity, with or without loss of consciousness, loss of bowel or bladder control, and confusion • Seizure unrelieved by usual measures • Seizure accompanied by fever, bleeding, or new neurologic symptoms, such as headache, visual changes, or focal weakness • Any sustained injury because of the seizure • Seizure lasting longer than five minutes or multiple seizures in a row • Skin rash, which may indicate an autoimmune response to seizure medication

Seek emergency care. Call an ambulance immediately.

• Patient with a known seizure disorder experiences a typical event with recovery • Signs suggesting that other clinical conditions may have provoked the seizure, such as fever, intracranial hemorrhage, or fluid and electrolyte disturbance • New neurologic symptoms that suggest recurrence or progression of tumor, such as headache, visual changes, focal weakness, sensory changes, or cognitive disturbance

Seek care within 24 hours.

• Focal aware seizures (formerly called simple partial seizure): focal neurologic events with no impairment of consciousness • Nonmotor seizures (formerly called absence or petit mal): brief and have no obvious motor symptoms

Seek care within 24–48 hours.

Cross-references: Confusion/Change in Level of Consciousness Note. Based on information from Lovely, 2009; Walker & Le, 2014.

HOMECARE INSTRUCTIONS ••Avoid alcohol while taking anticonvulsants. ••Seizure medications may be teratogenic; discuss birth control with healthcare provider. ••Do not abruptly discontinue antiepileptic drugs because seizure frequency may increase. If anticonvulsants are to be withdrawn, each drug is tapered over two to four weeks. ••Do not drive a car or operate complex machinery until sufficient experience has been gained with the effects of an antiepileptic drug to gauge whether it adversely affects mental or motor performance. ••State laws vary regarding driving restrictions for patients who have had seizures. Some states require healthcare providers to report patients with seizures to the department of motor vehicles, and some require a seizure-free period of a specified length before the patient can drive again. 270 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Seizures ••Referral to an epilepsy center may be helpful for patients who have persistent seizures despite use of anticonvulsant medications. ••Patients on an antiepileptic drug should have a complete blood count and serum chemistries, including liver enzymes, obtained at regular intervals to monitor for hematopoietic, renal, or hepatic dysfunction. ••Antiepileptic drug levels should be monitored at intervals and whenever the patient reports symptoms that may suggest subtherapeutic or supratherapeutic blood levels.

Seek Emergency Care Immediately if Any of the Following Occurs

••Tonic-clonic seizure activity lasting longer than five minutes, multiple seizures occurring without recovery and consciousness does not return, or focal impaired awareness seizure lasting longer than 30 minutes ••Bruising ••Bleeding ••Rash ••Abdominal pain ••Vomiting ••Jaundice ••Lethargy ••Coma ••Marked increase in seizure frequency

Helpful Websites

••American Brain Tumor Association: www.abta.org ••Epilepsy Foundation: www.epilepsy.com ••National Brain Tumor Society: http://braintumor.org

REFERENCES Davidson, L., & Derry, C. (2015). Seizure classification key to epilepsy management. Practitioner, 259, 13–19. Fisher, R.S., Cross, J.H., D’Souza, C., French, J.A., Haut, S.R., Higurashi, N., … Zuberi, S.M. (2017). Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia, 58, 531– 542. https://doi.org/10.1111/epi.13671 Fisher, R.S., Cross, J.H., French, J.A., Higurashi, N., Hirsch, E., Jansen, F.E., … Zuberi, S.M. (2017). Operational classification of seizure types by the International League Against Epilepsy: Position paper of the ILAE commission for classification and terminology. Epilepsia, 58, 522–530. https://​ doi.org/10.1111/epi.13670 Lovely, M.P. (2009). Seizures. In C.C. Chernecky & K. Murphy-Ende (Eds.), Acute care oncology nursing (2nd ed., pp. 455–466). St. Louis, MO: Saunders. Pillow, M.T., Kimmel, K., Doctor, S.U., & Howes, D.S. (2017). Seizure assessment in the emergency department. Retrieved from https://emedicine.medscape.com/article/1609294-overview Ruffmann, C., Bogliun, G., & Beghi, E. (2006). Epileptogenic drugs: A systematic review. Expert Review of Neurotherapeutics, 6, 575–589. https://doi.org/10.1586/14737175.6.4.575 Saria, M.G., Corle, C., Hu, J., Rudnick, J.D., Phuphanich, S., Mrugala, M.M., … Kesari, M. (2013). Retrospective analysis of the tolerability and activity of lacosamide in patients with brain tumors: Clinical article. Journal of Neurosurgery, 118, 1183–1187. https://doi.org/10.3171/2013.1.JNS12397 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 271

Seizures Scott, B.J. (2015). Neuro-oncologic emergencies. Seminars in Neurology, 35, 675–682. https://doi.org​ /10.1055/s-0035-1564684 Villanueva, V., Codina, M., & Elices, E. (2008). Management of epilepsy in oncological patients. Neurologist, 14(Suppl. 1), S44–S54. https://doi.org/10.1097/01.nrl.0000340791.53413.f4 Walker, J.G., & Le, E.M. (2014). Seizures. In D. Camp-Sorrell & R.A. Hawkins (Eds.), Clinical manual for the oncology advanced practice nurse (3rd ed., pp. 1217–1230). Pittsburgh, PA: Oncology Nursing Society. Weller, M., Stupp, R., & Wick, W. (2012). Epilepsy meets cancer: When, why, and what to do about it? Lancet Oncology, 13, e375–e382. https://doi.org/10.1016/S1470-2045(12)70266-8

Marlon Garzo Saria, PhD, RN, AOCNS®, FAAN The author would like to acknowledge Susan Newton, RN, MS, AOCN®, AOCNS®, for her contribution to this protocol that remains unchanged from the previous edition of this book.

272 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Sleep–Wake Disturbances INSOMNIA PROBLEM Insomnia is characterized by complaints of difficulty initiating or maintaining sleep, or nonrestorative sleep, lasting for at least one month and causing significant distress or impairment in functioning (Buysse, 2013). Disturbed sleep is a common and distressing problem affecting more than one-third of patients with cancer, both during and after completion of active treatment (Savard & Morin, 2001). Sleep–wake disturbances may be seen more often in women, Caucasians, and older adults (Vogel, 2017). These disturbances can arise from multiple etiologies, including but not limited to disease- and treatment-related factors (e.g., pain, fever, fatigue, dyspnea, cough, diarrhea, pruritus, hot flashes related to alterations in hormone and cytokine production, changes in melatonin and cortisol levels) (Erickson, 2015; Matthews & Berger, 2014; Vogel, 2017). Many factors can increase the risk of sleeping problems in patients with cancer, including demographic, lifestyle, environmental, disease, and treatment factors, as well as unmanaged symptoms. Lifestyle factors include recent life stressors, anxiety, depression, daytime napping patterns, and excessive environmental stimulation (Erickson, 2015; Lamberti, 2014; Vogel, 2017).

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Some cancers are thought to cause more difficulty with insomnia than others. Notably, patients with brain cancer may experience more trouble with normal sleep because of changes in normal brain physiology. Reported rates of insomnia are also higher in lung, breast, gynecologic, and hematologic cancers, as well as in malignant melanoma (Erickson, 2015; Vogel, 2017). 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications. a. Some medications used in cancer treatment, such as steroids, frequently cause problems with insomnia. For most indications, steroids can be taken either as a single dose in the morning or in divided doses no later than 4 pm. The provider must approve any change in prescribed medication. b. Certain categories of medications, such as phenothiazines, can cause a jittery wakefulness in some patients, especially if taken frequently. c. Other medications that can cause or worsen insomnia are over-thecounter cold and allergy medications, beta-blockers, statins, theophylTelephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 273

S l e e p – Wa k e D i s t u r b a n c e s line, selective serotonin reuptake inhibitors, nicotine patches, and thyroid supplements. d. Additionally, caffeine, alcohol, diet aids, or street drugs may also impair sleep–wake patterns. e. It is important to inquire about the use of any sleep aids, such as sedatives, hypnotics, and supplements (e.g., melatonin) (Palesh et al., 2010; Vogel, 2017). 3. Ask the patient to describe symptoms in detail. Uncontrolled pain, fatigue, depression, anxiety, nausea, hot flashes, or dyspnea can cause or worsen insomnia. 4. Ask the patient to describe sleep difficulties in detail. a. Does the patient have difficulty falling asleep? b. Does the patient wake in the middle of the night? Does the patient know why? c. Is the patient waking early, before feeling that he or she has had a full night’s sleep? d. Is the patient experiencing movement or jerking motions? e. Is the patient having nightmares? 5. Ask the patient to describe sleep patterns in detail. The following parameters are recommended to evaluate sleep–wake disturbances (Erickson, 2015): a. Total sleep time: How many minutes does the patient spend asleep while in bed? b. Sleep latency: How many minutes are between the time the patient lies down and when the patient falls asleep? c. Awakenings: How many times does the patient wake up during a sleep period? d. Wake after sleep onset: How many minutes after sleep onset does the patient wake up? e. Quality of perceived sleep: Does the patient feel well rested after waking up? f. Daytime napping: How many minutes does the patient spend napping? g. Daytime sleepiness: How many times does the patient fall asleep without intention? h. Sleep efficiency: Divide the number of minutes of sleep by the number of minutes in bed. i. Circadian rhythm: Is the patient able to awaken and go to sleep at times commonly required for work? 6. Obtain history of the problem. a. Precipitating factors: Has the patient noticed anything that causes trouble sleeping? b. Onset and duration: When did this start? Is it every night? c. Relieving factors: Has anything improved the patient’s sleeping patterns? d. Any associated symptoms (e.g., excessive daytime sleepiness, fatigue, insomnia, sleep-disordered breathing) (Absolon et al., 2014) 274 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

S l e e p – Wa k e D i s t u r b a n c e s 7. Review past medical history. Obtain detailed history of sleep disorders (e.g., insomnia, narcolepsy, obstructive sleep apnea) (Vogel, 2017). Obstructive sleep apnea can result in daytime sleepiness and fragmented sleep. The STOP-Bang questionnaire can be used to screen patients (see Figure 13). A “yes” response to three or more items indicates a high risk of obstructive sleep apnea, and the patient should be referred to a sleep medicine specialist or sleep center. A “yes” response to fewer than three items indicates a low risk of obstructive sleep apnea (Nations & Mayo, 2016). Figure 13. STOP-Bang Questionnaire S—Snoring. Does the patient snore loudly (loud enough to be heard through closed doors)? T—Tiredness. Does the patient often feel fatigued, sleepy, or tired during the daytime? O—Observed as stopped breathing during sleep. Has anyone observed the patient stop breathing while sleeping? P—Treatment for high blood pressure. Has the patient ever been or is the patient currently being treated for high blood pressure? B—Body mass index > 35 kg/m² A—Age > 50 years N—Neck circumference > 40 cm G—Gender (male) Note. Figure courtesy of Toronto Western Hospital, University Health Network, University of Toronto. Copyright 2012 by www.stopbang.ca. Used with permission. All rights reserved.

Signs and Symptoms

Action

•• Difficulty falling asleep •• Difficulty staying asleep •• Decreased sleep quality •• Daytime drowsiness and/or decreased mental clarity

Follow homecare instructions. Notify MD if no improvement.

Note. Based on information from Nations & Mayo, 2016.

HOMECARE INSTRUCTIONS (Matthews & Berger, 2014; Vogel, 2017) ••Take measures to enhance sleep. –– Exercise per provider’s instructions. Low- to moderate-effort aerobic exercise can enhance sleep. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 275

S l e e p – Wa k e D i s t u r b a n c e s –– Practice good sleep hygiene. * Limit daytime napping to less than 30 minutes. * Avoid caffeine close to bedtime and moderate alcohol intake. * Avoid heavy, rich, fatty, fried, or spicy foods prior to bedtime. * Establish a regular, relaxing bedtime routine. –– Get daytime sun exposure if possible. –– Employ stress reduction techniques. Yoga, meditation, and relaxation have been shown to reduce stress and improve sleep. ••At the next provider visit, ask about a referral for cognitive behavioral therapy for insomnia. Cognitive behavioral interventions work to identify helpful and unhelpful sleep behaviors, establish sleep goals, and develop skills to solve problems and implement new behaviors to facilitate sleep (Garland et al., 2014). –– Go to bed at the same time every night and only when sleepy. –– Get out of bed whenever unable to fall asleep and go to another room. Return only when sleepy again. –– Wake at the same time each day. –– Avoid daytime napping. If needed, limit to 30 minutes. –– Use the bedroom for sleep and sex only.

Report the Following Problems

••Excessive daytime drowsiness or compromised ability to function

OVERSEDATION PROBLEM Oversedation can occur in patients with cancer because of extreme chronic fatigue, overmedication, or disease progression.

ASSESSMENT CRITERIA 1. What is the cancer diagnosis, and what treatment is the patient receiving? Sedation can be seen with increased intracranial pressure in brain cancer or any primary cancer that commonly metastasizes to the brain (Armstrong et al., 2017). 2. What medications is the patient taking? Obtain medication history, including over-the-counter medications. Sedation is an expected effect with opioids, especially for the first 72 hours on a new medication. If the patient is not taking his or her opioid prescription exactly as prescribed, is requiring frequent PRN doses, or is combining this medication with other prescribed, over-the-counter, or herbal agents, oversedation may occur (Pasero & McCaffery, 2011). Fully evaluate medication combinations and frequency of PRN administrations. A call must be placed to the provider for any change in ordered medication. 3. Ask the patient to describe symptoms in detail. 276 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

S l e e p – Wa k e D i s t u r b a n c e s 4. Extreme chronic fatigue, especially with accompanying anemia or electrolyte imbalances, may cause oversedation (Barsevick et al., 2010). Signs and Symptoms

Action

•• Patient falls asleep very easily and is difficult to arouse

Seek emergency care if patient is extremely sedated, unarousable, or has decreased respirations. Notify MD if no improvement.

Note. Based on information from Barsevick et al., 2010.

Seek Emergency Care Immediately if Any of the Following Occurs

••Respiratory rate less than 10 breaths per minute if not the patient’s baseline ••Inability to arouse ••Extreme sedation

REFERENCES Absolon, N.A., Truant, T.L., Balneaves, L.G., Goodwin, F., Cashman, R.L., Wong, M.E., & Witmans, M.B. (2014). “I can’t sleep!”: Gathering the evidence for an innovative intervention for insomnia in cancer patients. Canadian Oncology Nursing Journal, 24, 154–165. https://doi.org/10.5737​/1181912x243154159 Armstrong, T.S., Shade, M.Y., Breton, G., Gilbert, M.R., Mahajan, A., Scheurer, M.E., … Berger, A.M. (2017). Sleep-wake disturbance in patients with brain tumors. Neuro-Oncology, 19, 323–335. https://​ doi.org/10.1093/neuonc/now119 Barsevick, A., Beck, S.L., Dudley, W.N., Wong, B., Berger, A.M., Whitmer, K., … Stewart, K. (2010). Efficacy of an intervention for fatigue and sleep disturbance during cancer chemotherapy. Journal of Pain and Symptom Management, 40, 200–216. https:// doi.org/10.1016/j.jpainsymman.2009.12.020 Buysse, D.J. (2013). Insomnia. JAMA, 309, 706–716. https://doi.org/10.1001/jama.2013.193 Erickson, J.N. (2015). Sleep-wake disturbances. In C.G. Brown (Ed.), A guide to oncology symptom management (2nd ed., pp. 623–647). Pittsburgh, PA: Oncology Nursing Society. Garland, S.N., Carlson, L.E., Stephens, A.J., Antle, M.C., Samuels, C., & Campbell, T.S. (2014). Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: A randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology, 32, 449–457. https://doi.org/10.1200/JCO.2012.47.7265 Lamberti, M.P. (2014). Improving sleep-wake disturbances in patients with cancer. Clinical Journal of Oncology Nursing, 18, 509–511. https://doi.org/10.1188/14.CJON.509-511 Matthews, E.E., & Berger, A. (2014). Sleep disturbances. In C.H. Yarbro, D. Wujcik, & B.H. Gobel (Eds.), Cancer symptom management (4th ed., pp. 93–109). Burlington, MA: Jones & Bartlett Learning. Nations, R., & Mayo, A.M. (2016). Using research to advance nursing practice. Critique of the STOPBang sleep apnea questionnaire. Clinical Nurse Specialist, 30, 11–15. Retrieved from https://www​ .nursingcenter.com/journalarticle?Article_ID=3256055&Journal_ID=54033&Issue_ID=3256011 Palesh, O.G., Roscoe, J.A., Mustian, K.M., Roth, T., Savard, J., Ancoli-Israel, S., … Morrow, G.R. (2010). Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. Journal of Clinical Oncology, 28, 292–298. https://doi.org/10.1200/JCO.2009.22.5011 Pasero, C., & McCaffery, M. (Eds.). (2011). Pain assessment and pharmacologic management. St. Louis, MO: Elsevier. Savard, J., & Morin, C.M. (2001). Insomnia in the context of cancer: A review of a neglected problem. Journal of Clinical Oncology, 19, 895–908. https://doi.org/10.1200/JCO.2001.19.3.895 Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 277

S l e e p – Wa k e D i s t u r b a n c e s Vogel, W.E. (2017). Sleep disturbances. In S. Newton, M. Hickey, & J.M. Brant (Eds.), Mosby’s oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed., pp. 350–352). St. Louis, MO: Elsevier.

Lisa Blackburn, MS, APRN-CNS, AOCNS® Andrea Bales, MS, RN, CNL, OCN®

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Venous Access Device Problems PROBLEM Venous access device problems develop when a patient notes an issue with a tunneled central venous catheter, peripherally inserted central catheter, or implanted port.

ASSESSMENT CRITERIA 1. Obtain history of the problem. a. Precipitating factors b. Onset and duration c. Relieving factors d. Appearance of the catheter site e. Whether the catheter is in use f. Any associated symptoms 2. What type of catheter does the patient have? a. When was it placed? b. Are stitches still present in the port insertion wound? c. How many lumens does the catheter have? d. Has the patient ever had a central venous access device before the present one was placed? e. What is the catheter being used for? 3. Does the patient have adequate supplies to care for the catheter at home? a. What type of dressing, if any, is the patient using on the catheter? b. How often is it dressed? c. How often is it flushed? d. Who is flushing and dressing the catheter (e.g., home health nurse, infusion nurse, family member)? 4. Is the patient using neutral pressure injection caps and/or an alcohol-impregnated port protector for the catheter? a. Are they present on each lumen? b. When were they last changed? 5. What chronic illnesses does the patient have? 6. Does the patient have an infection anywhere (see Figure 14)? a. Where is the infection located? b. Does the patient have a known risk factor for catheter-associated infection, such as longer duration of catheter placement, catheter placed during an emergency, administration of parenteral nutrition through the catheter, cancer, renal failure, recent surgery, or presence of other invasive Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 279

Venous Access Device Problems Figure 14. Signs of Localized Infection in a Patient With a Central Venous Access Device Signs of Exit Site Infection •• Pain •• Erythema •• Induration •• Purulent exudate at exit site* Signs of Port Pocket Infection •• Wound dehiscence •• Pain •• Induration •• Erythema Signs of Eschar Due to Necrosis •• Boggy consistency of tissue to palpation •• Purulent exudate from port site or needle puncture area* Signs of Subcutaneous Tract Infection of Tunneled Catheter •• Pain •• Induration in tunnel area •• Erythema •• Purulent exudate from exit site * Patients with neutropenia may not display purulence at infected sites. Note. Based on information from Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016.

7.

8.

9.

10.

device(s) while the catheter was used in the hospital (Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016)? Does the patient have a condition associated with venous thrombosis? a. Cancer b. Diabetes c. Irritable bowel syndrome d. Coagulation disorder e. End-stage renal disease f. Sickle cell disease (Brunson et al., 2017) Other pertinent questions include the following: a. Is the patient taking oral contraceptives or anticoagulants? b. Has the patient recently had a fall or an injury? c. Has the patient recently had surgery (Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016)? Does the patient have a history of blood clots or a coagulation disorder? a. Factor V Leiden b. Antiphospholipid syndrome (also called antiphospholipid antibody syndrome) c. Prothrombin mutation (Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016) What is the catheter being used for? a. Antineoplastic therapy

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11. 12. 13. 14. 15. 16. 17. 18. 19.

b. Antibiotics c. Fluid administration d. Total parenteral nutrition e. Lipids If the patient is receiving antineoplastics, what type of therapy is the patient receiving (vesicant, irritant, or nonvesicant), and when was the last treatment? When was the patient’s last infusion into the central venous catheter? If receiving home IV infusions, when was the IV tubing last changed? What was the last white blood cell count, neutrophil count, and platelet count? Could the patient’s current counts be low? Has the patient taken his or her temperature, and if so, when? What was the temperature reading? Does the patient have chills? Is the patient’s port accessed? Who accessed the port last, and was it flushed after access? Has anyone ever had difficulty getting a blood return from any lumen of the catheter or port? If so, which lumen and when? Has anyone ever had difficulty flushing the catheter or port? If so, which lumen and when? Has the patient ever received treatment to declog or declot the catheter? What lumen was occluded? Was a declotting agent administered to treat occlusion of the catheter lumen? If so, when, and who gave the treatment? Is there a problem with one or more lumens of the catheter, the port, or the catheter insertion site? a. What problem is the patient having with the catheter now? b. Is the catheter exit site red, wet, stinging, painful, or swollen? c. Is there a streak from the exit site along the vein where the catheter is inserted? d. Is there any change in the color of the skin over the port or around the catheter site? Is the site where the Huber needle is inserted leaking? Is a former puncture site leaking? i. How much leakage is there? ii. When did it start? iii. Does anything make it worse? iv. Does anything make it stop? v. What color is the leakage—clear, the color of the chemotherapy drug, bloody, serosanguinous? vi. What color is the fluid in the Huber needle tubing? e. Is the port pocket area fluctuant or boggy? Does it hurt? Does it look bruised? f. Is there a break or crack in the catheter, port needle, or cap? g. Is there a change in the ability to infuse fluids or flush? Is there an odd sensation? i. Arm, shoulder, or chest pain ii. Gurgling in the neck or vague back discomfort when the catheter is flushed Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 281

Venous Access Device Problems h. Does the patient have any swelling in the arms, neck, or chest? Is a “fluid wave” visible in the arms, neck, or chest? 20. Assess for changes in activities of daily living and function. a. Increase in activity in the limb where the catheter is present b. Trauma to the port pocket or catheter exit site Signs and Symptoms

Action

•• Suspected air embolism –– Line is open to air –– Patient with dyspnea, tachypnea, shoulder or chest pain, or anxiety –– Patient with altered mental status, altered speech, numbness, or paralysis

Seek emergency care. Clamp catheter proximal to any observed break or leak. Place patient on left side in Trendelenburg position.

•• Suspected extravasation –– Infusion of vesicant –– Painful, burning, swollen, or red site (port pocket, tunnel, or exit site) –– Very moist port dressing and infusion of vesicant –– Huber needle dislodged from port site

Seek emergency care. Stop the infusion immediately. Elevate the site. Vesicant antidotes for some medications must be given in less than six hours.

•• Fractured catheter –– Broken or leaking catheter

Seek emergency care. Clamp catheter above fracture if possible. Call 911 if any signs of air embolism develop.

•• Suspected pulmonary embolism –– Chest pain, palpitations, dizziness, or confusion

Seek emergency care. Stop the infusion.

•• Accidental catheter removal –– Catheter fell out or was accidentally pulled out

Seek emergency care. Cover exit site with occlusive dressing. Hold pressure at entrance site (where suture line was in neck).

•• Port erosion –– Port eroded through the skin

Seek emergency care. Cover site with occlusive dressing.

•• Tunneled catheter cuff visible at exit site

Seek urgent care within 12 hours. Secure catheter in place by taping it to chest.

•• Catheter tip malposition –– Difficulty flushing or flushes only in certain positions –– Patient reports palpitations, “heart racing” tingling sensation, or gurgling noise in neck; arm, shoulder, head, neck, or back pain when catheter is flushed

Seek urgent medical attention within 12 hours. Stop the infusion and clamp the catheter.

(Continued on next page)

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Venous Access Device Problems (Continued)

Signs and Symptoms

Action

•• Suspected deep vein thrombosis –– Pain, edema, and decreased range of motion in extremity adjacent to catheter with or without pain in shoulder, chest wall, neck, or chest –– Engorged peripheral veins

Seek urgent care within 12 hours. Stop the infusion.

•• Exit site bleeding –– Oozing or frank bleeding from exit site

Seek urgent care if bleeding does not subside after 30–60 minutes of direct pressure. Apply local pressure. Reinforce or change dressing as needed.

•• Catheter occlusion –– Inability to flush or infuse fluid –– Inability to draw blood –– Sluggish flushing or blood return

Seek urgent care within 12 hours. Cap line. Do not flush forcefully.

Note. Based on information from Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016; Schulmeister, 2017.

ADDENDUM Ideally, a telephone triage call should end with the patient or caregiver performing a “teach-back” or recitation of follow-up steps and key aspects of care (see Table 10). Documentation of the telephone triage call should include time, date, type of device, to which provider the patient’s symptoms were reported and how they were reported, advice given, patient response to advice, outcome of verbal teach-back on telephone, referrals made, resources recommended, and the follow-up plan. A follow-up phone call, appointment, or chart review by a nurse to ensure that the patient’s condition has improved may be appropriate (Mackey, 2017). Table 10. Venous Access Device Teaching Topic

Content

Rationale for catheter or treatment

Review the rationale for catheter placement, importance of proper care, and need for treatment or evaluation of the catheter complication discussed on the telephone.

Identification of device

Review name of device inserted and intended use (e.g., laboratory sample collection, medication or fluid administration). Remind the patient to keep manufacturer’s identification card in wallet and present when device should be used. If device is power injectable, the patient/caregiver must notify healthcare workers, especially before imaging tests. Note the length of PICC that should be visible, and encourage the patient/caregiver to call if length changes. (Continued on next page)

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Venous Access Device Problems (Continued)

Table 10. Venous Access Device Teaching Topic

Content

Prevention of further complications

Review how to prevent likely future complications.

Care and maintenance

Have the patient/caregiver detail key aspects of care, including the following: •• Keeping dressing occlusive, clean, and dry •• Proper daily hygiene: Cover catheter during showering or bathing. Avoid immersing the catheter. •• The safe time frame to start swimming and types of water to avoid. Refer to institutional policy on hot tubs, freshwater lakes, oceans, pools, etc. •• When to change the dressing •• How and when to change needleless system device or neutralpressure end cap •• Dressing change procedure: gauze versus transparent with or without chlorhexidine gluconate–impregnated patch •• Frequency of line flushing, solution to be used, and which lumens to flush •• Use of catheter securement device for PICCs •• Signs of infection •• Contact information to report difficulties with catheter

Activity instructions

The patient/caregiver must be educated on the activities to avoid while port or catheter is in place, as well as how to prevent dislodgment of PICC or noncoring port needle.

IV therapy at home

Does the patient/caregiver feel comfortable giving IV therapy at home? Is another clinic, provider’s office, home health nurse, or infusion therapy nurse visit needed?

Demonstration of catheter care

If poor catheter care technique may have played a role in a complication reported by telephone, consider a home health, clinic, or physician’s office visit with a nurse to complete return demonstration of catheter care by the patient/caregiver.

Supplies for catheter care

Ensure the stock of supplies at home as reported by the patient/ caregiver is adequate for needs. Have the patient/caregiver identify where and how more supplies can be ordered. Inquire about monetary concerns regarding supplies, and refer to resources if ability to pay is a problem.

Miscellaneous

Ensure the patient, caregiver, and family members are aware of signs and symptoms to report.

PICC—peripherally inserted central catheter Note. Based on information from Gorski, Hadaway, Hagle, McGoldrick, Meyer, et al., 2016; Gorski, Hadaway, Hagle, McGoldrick, Orr, et al., 2016.

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REFERENCES Brunson, A., Lei, A., Rosenberg, A.S., White, R.H., Keegan, T., & Wun, T. (2017). Increased incidence of VTE in sickle cell disease patients: Risk factors, recurrence and impact on mortality. British Journal of Haematology, 178, 319–326. https://doi.org/10.1111/bjh.14655 Gorski, L., Hadaway, L., Hagle, M.E., McGoldrick, M., Meyer, B., & Orr, M. (Eds.). (2016). Policies and procedures for infusion therapy (5th ed.). Norwood, MA: Infusion Nurses Society. Gorski, L., Hadaway, L., Hagle, M.E., McGoldrick, M., Orr, M., & Doellman, D. (Eds.). (2016). Infusion nursing standards of practice. Journal of Infusion Nursing, 39(Suppl. 1), S1–S159. Mackey, H.T. (2017). Education, documentation, and legal issues for access devices. In D. Camp-Sorrell & L. Matey (Eds.), Access device standards of practice for oncology nursing (pp. 153–160). Pittsburgh, PA: Oncology Nursing Society. Schulmeister, L. (2017). Complications of long-term venous access devices. In D. Camp-Sorrell & L. Matey (Eds.), Access device standards of practice for oncology nursing (pp. 79–98). Pittsburgh, PA: Oncology Nursing Society.

Lynne Brophy, MSN, RN-BC, APRN-CNS, AOCN® Misty Lamprecht, MS, APRN-CNS, AOCN®, BMTCN®

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Xerostomia (Dry Mouth) PROBLEM Xerostomia, or hyposalivation, is dryness of the mouth. It can be a frequent complaint among older adults, individuals with systemic diseases such as diabetes, and patients undergoing radiation therapy for head and neck cancers or total body irradiation, and it is a side effect of multiple medications. A reduction in saliva enhances the growth of microorganisms in the oral cavity, increases the incidence of periodontal disease, and alters a patient’s sensation of taste (Fogh & Yom, 2014). Xerostomia can have a subsequent effect on swallowing, thus decreasing optimal nutritional status as evidenced by decreased oral intake and involuntary weight loss (Hayward & Shea, 2009). Oral complications from cancer treatment can compromise a patient’s health and quality of life; cause changes in communication, swallowing, and mood; and affect the ability to complete planned cancer treatment (Epstein et al., 2012; National Institute of Dental and Craniofacial Research [NIDCR], 2009).

ASSESSMENT CRITERIA (Hayward & Shea, 2009; NIDCR, 2009) 1. What is the cancer diagnosis, and what treatment is the patient receiving? Xerostomia can be a result of radiation therapy or a direct extension of the tumor. It can also result from chemotherapy and other medications. As a side effect of radiation therapy for head and neck cancers, xerostomia is not only reported while the patient is receiving treatment but is also the most significant late effect, lasting several months (Hayward & Shea, 2009; Jensen et al., 2010). The goal of symptom management includes maintaining mucosal integrity and minimizing oral or systemic infection. Prior to initiation of radiation therapy to the head and neck area or chemotherapy that induces oral cavity changes, a dental consult should be obtained (NIDCR, 2009). 2. What medications is the patient taking? Obtain medication history. Xerostomia is a side effect of numerous medications, including antihypertensives, antidepressants, antihistamines, diuretics, anticholinergics, and opioids, as well as others. Chemotherapy agents include cytarabine, doxorubicin, 5-fluorouracil, methotrexate, vinblastine, and vincristine. 3. Ask the patient to describe symptoms in detail. a. Quality of saliva (thin and watery vs. thick and ropy) b. Dryness and/or coating on the lips, mucosa, or tongue c. Degree of mucositis (e.g., erythema, ulceration, hemorrhage of the gums or mucosa) Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 287

Xerostomia (Dry Mouth) d. Dysarthria (difficulty articulating words) e. Dysgeusia (disorder of the sense of taste) f. Burning or pain of the oral mucosa or tongue g. Sensitivity of teeth and gums h. Difficulty or pain with swallowing 4. Obtain history of the problem. a. Precipitating factors (e.g., medications, hot foods, denture use) b. Onset and duration c. Relieving factors (e.g., frequent mouth care, sips of water throughout the day, moistened foods, sugar-free gum or candy) d. Use of saliva substitutes or salivary stimulants e. Ability to wear dentures and rating of comfort with eating 5. Review past medical history. a. Comorbidities (e.g., diabetes) b. Nutritional status c. Oral hygiene regimen d. Previous oral or dental disease (e.g., increased candidiasis, herpes simplex virus) 6. Assess need for medical nutrition therapy. a. Patients with cancer are at risk for malnutrition as they undergo various types of treatment. Xerostomia can play a role in decreased nutrient intake due to thick mucus that makes masticating and swallowing food difficult. A very dry mouth can also promote food sticking to the teeth and side of the mouth. Moisture added to foods and frequent sips of water allow food to pass to the back of the throat and be swallowed. Citrus fruits and sour candy can stimulate the production of saliva and aid in swallowing. b. A decline in nutritional status may be evidenced by reduced caloric and protein intake, weight loss, reduced subcutaneous body fat, muscle loss, fluid accumulation, and reduced hand grip strength. Two or more of these findings may indicate a diagnosis of malnutrition. c. Because malnutrition can affect patients’ ability to tolerate chemotherapy and radiation therapy, decrease quality of life, require hospitalization, and affect mortality (Thompson et al., 2017), referral to a registered dietitian nutritionist (RDN) is recommended, preferably one specializing in oncology. It is best to refer to the RDN for medical nutrition therapy at diagnosis and prior to the initiation of treatment to obtain a baseline assessment with recommendations to the physician, as well as to provide education to the patient to reduce the risk of malnutrition. d. Medical nutrition therapy i. Calorie, protein, and fluid requirements ii. Meal planning with the patient and/or caregiver iii. Small, frequent meals with soft and moist foods iv. Food consistency options (blended smoothly or ground) v. Vitamin and mineral replacement 288 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

Xerostomia (Dry Mouth) vi. Supplements (add calories and protein) vii. Enteral nutrition support recommendations viii. Parenteral nutrition support recommendations (only if the gastro­ intestinal tract is not functional) Signs and Symptoms

Action

•• Temperature higher than 100.4°F (38°C); chills with suspected neutropenia

Seek emergency care. Generally, xerostomia is not an emergent condition.

•• Increased difficulty swallowing •• Oral assessment indicates increase in inflammation or presence of ulceration (white patches, confluent patches) •• Decreased urine output that is cloudy or dark •• Dizziness, increased weakness, or fatigue •• Increased difficulty swallowing

Seek urgent care within 24 hours.

•• Oral assessment indicates dry lips and mucous membranes with thick secretions •• Difficulty swallowing

Follow homecare instructions. Notify MD if no improvement.

Cross-references: Oral Mucositis

HOMECARE INSTRUCTIONS (Epstein et al., 2012; Hayward & Shea, 2009) ••Follow the nutrition care plan as developed by the RDN. –– Try sucking on ice chips, sugar-free candy, frozen grapes, or flavored ice pops. –– Avoid caffeine (e.g., coffee, tea, colas), alcohol, and tobacco. –– Add fresh lemon or citrus to water (Fogh & Yom, 2014). –– Consume high-calorie/high-protein supplements. –– Choose soft, moist foods with added sauces. –– Avoid dry foods (e.g., tough meats, raw vegetables, breads, crackers, chips, pretzels). –– Carry a water bottle throughout the day. Aim to drink 8–10 cups (approximately 2 L) of caffeine-free fluids per day. ••Keep sugar-free hard candies or sugar-free gum on hand. ••Perform an oral cavity assessment daily. ••Perform oral care after each meal, at bedtime, or as directed. Use a soft-bristle toothbrush; floss using waxed dental floss, if no pain and if platelets are adequate; and use alcohol-free mouth rinse. ••Rinse frequently with a salt and baking soda solution to cut thick, ropy secretions and for basic oral hygiene. ••Use oral care agents, saliva substitutes, and salivary stimulants as directed. ••Use analgesics, anesthetics, and antibiotics as directed. ••Maintain regular dental visits as directed. Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 289

Xerostomia (Dry Mouth)

Report the Following Problems

••Oral assessment indicates an increase in inflammation or presence of ulceration (white patches, confluent patches) ••Dizziness, increased weakness, or fatigue ••Decreased urine output that is cloudy or dark ••Increased difficulty swallowing

Seek Emergency Care Immediately if Any of the Following Occurs

••Temperature higher than 100.4°F (38°C); chills with suspected neutropenia

REFERENCES Epstein, J.B., Thariat, J., Bensadoun, R.-J., Barasch, A., Murphy, B.A., Kolnick, L., … Maghami, E. (2012). Oral complications of cancer and cancer therapy. CA: A Cancer Journal for Clinicians, 62, 400–422. https://doi.org/10.3322/caac.21157 Fogh, S., & Yom, S.S. (2014). Symptom management during the radiation oncology treatment course: A practical guide for the oncology clinician. Seminars in Oncology, 41, 764–775. https://doi. org/10.1053/j.seminoncol.2014.09.020 Hayward, M.C., & Shea, A.M. (2009). Nutritional needs of patients with malignancies of the head and neck. Seminars in Oncology Nursing, 25, 203–211. https://doi.org/10.1016/j.soncn.2009.05.003 Jensen, S.B., Pedersen, A.M.L., Vissink, A., Andersen, E., Brown, C.G., Davies, A.N., … Brennan, M.T. (2010). A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: Prevalence, severity and impact on quality of life. Supportive Care in Cancer, 18, 1039– 1060. https://doi.org/10.1007/s00520-010-0827-8 National Institute of Dental and Craniofacial Research. (2009). Oral complications of cancer treatment: What the dental team can do. Retrieved from https://www.nidcr.nih.gov/sites/default/files/2017-09/ oral-complications-cancer-dental-team.pdf Thompson, K.L., Elliott, L., Fuchs-Tarlovsky, V., Levin, R.M., Coble Voss, A., & Piemonte, T. (2017). Oncology evidence-based nutrition practice guideline for adults. Journal of the Academy of Nutrition and Dietetics, 117, 297–310.e47. https://doi.org/10.1016/j.jand.2016.05.010

Jackie Matthews, RN, MS, APRN-CNS, AOCN®, ACHPN Karen Feldmeyer, MSA, RDN, LD

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Appendices Appendix A. Telephone Nursing Practice Guideline Purpose: Provide standardization guidelines for telephone nursing practice for the outpatient clinics at the Huntsman Cancer Hospital and Clinics (HCH). Definitions: Telephone Triage: a systematic process designed to screen the patient’s symptoms for urgency and to guide the patient to the appropriate level of care in the appropriate time frame based on verbal telephone interview alone—hearing and talking with the patient or patient surrogate. Telephone Triage Nursing Care: The nursing care provided by oncology nurses to patients includes: advice, patient education, symptom management, homecare instructions, psychosocial support, and making referrals and appointments. Scope: The scope of telephone nursing practice at HCH includes: 1. Acute or emergent problems, with clear disposition requirements (e.g., call 911, refer to the emergency room) 2. Change in patient condition where intervention is designated by an algorithm. Oncology Nursing Society’s telephone triage references or provider instructions are utilized to guide practice. 3. Questions related to patients’ treatment plan (e.g., treatment schedule, anticipated toxicities, select laboratory, radiology test results) 4. Patient education 5. Nursing or protocol-specific interventions prescribed for pain, symptom, and medication management; homecare needs; and the nursing plan of care 6. Questions about medical equipment, which may be referred to homecare, as appropriate 7. Lab or diagnostic testing results, which are in normal limits, as requested by the patient 8. Notification of patients and provision of education related to management of changes in status as directed by the physician or advanced provider. Implementation: A. PROCESS The process of telephone nursing involves a series of specific steps. These include: 1. Assessment and data collection 2. Analysis and synthesis of information, identification, and prioritization of the problem 3. Intervention, including directives for where and when treatment should take place 4. Documentation of the components of Telephone Triage Nursing Care with each telephone encounter 5. Evaluation and follow-up (Continued on next page)

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Appendices (Continued)

Appendix A. Telephone Nursing Practice Guideline B. ALGORITHM/PROTOCOL GUIDELINES An algorithm or protocol guides the process of telephone triage for the specific patient problem. The algorithms utilized at HCH are adopted from Oncology Nursing Society’s Telephone Triage for Oncology Nurses references or provider instructions. The guidelines are approved for use by the HCH Outpatient Medical Director and the HCH Nursing Leadership Group. C. CONSULTATION/REFERRAL Triage nurse must confer with or refer the patient to the appropriate physician or advanced practice provider for determination of disposition in specific situations in compliance with the scope of practice in Utah. Any medical order received in these situations, such as a verbal order, must be documented and co-signed by the responsible physician or advanced provider per HCH policy. The following situations require notification to the appropriate physician or advanced provider: 1. Acute or emergent problems where notification of a physician or advanced provider is designated in the algorithm or protocol, including unrelieved pain 2. Potential need for change in the medical treatment plan, including medication and procedures 3. Prescription refills 4. Abnormal radiology results that demonstrate a change in the patient’s condition and/or abnormal tumor marker tests must be given to the patient by the attending or advanced provider D. PATIENT CONFIDENTIALITY It is the responsibility of the nurse conducting telephone triage to comply with all HIPAA patient confidentiality standards. E. PROBLEM PHONE CALLS 1. Resolving problem calls with supervisory/collegial help For patient-related issues, the following chain of command should be followed: a. Appropriate Advanced Provider b. Physician c. Medical Director of Outpatient Services 2. How to respond to abusive callers (e.g., yelling, screaming, cursing, threatening calls) a. Attempt to locate the real problem b. Tell the caller he or she will be assisted if he or she can calmly explain the situation c. If the abusive behavior persists, instruct the caller that the call will be terminated if the abuse does not stop d. If the call is terminated, instruct the caller you are terminating the call and refer the situation to the attending physician and/or advanced provider e. Document the telephone encounter Note. Courtesy of Huntsman Cancer Hospital, University of Utah Health Care. Used with permission.

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Appendices Appendix B. After Chemotherapy Follow-Up: Call Guidelines Patient name:_______________________ Age:________ Doctor:_________________ Phone number:______________________Diagnosis:___________________________ Chemotherapy:______________________Treatment date:_______________________ Date: _______ Day: ___+___ Follow-up call: Placed call: ___:___ Ended call: ___:___ 1. How well are you doing?______________________________________________ Do you have social issues?  Yes, __________________________________  No 2. Are you feeling okay?_________________________________________________  Fever higher than 101°F  Pain at injection site If yes to either,  Instructed to call the office  Transferred call 3. Are you eating and drinking?  Yes, no problems  No, not eating or drinking  Nausea or vomiting If yes, were you given medication?______________________________________ Have you used it?___________________________________________________  Instruct to call the office or transfer call. 4. Are you moving your bowels?  Yes, no problems  Problems  Diarrhea How many times per day?_____________________________________________ Are you using medication?____________________________________________  Instruct to call the office or transfer call.  Constipation When was your last bowel movement?___________________________________  Instruct to call the office or transfer call. 5. Let’s talk about your medications. Are you taking medications that were prescribed?  Yes  No Do you have any questions about your medications?  Yes  No  Instruct to call the office or transfer call if the patient has questions. 6. Do you know when your next appointment is?  Yes, ______________________  No, instruct to call for appointment or look up. Staff member name:____________________________________________________ Note. Courtesy of Abramson Cancer Center at Pennsylvania Hospital. Used with permission.

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Appendices

Appendix C. St. Luke’s Telephone Triage Form

(Unit Secretary to complete) Date: ___________  Time: _________ Name: _________________________________ Caller: _________________________  Relationship: ___________ DOB: ____________ Phone Numbers: Home: ___________  Work:_________________ ALT:_____________ Pharmacy Name: ________________  Pharmacy Number: ______________________  OK to leave message  Non-urgent

 Urgent

 OK to speak to family  Emergent

 Walk-in

Last appointment:_________________  Next appointment:_______________________ Reason for Call Chief Complaint/Need (nausea, lab test results, refill, etc.):_______________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Message taken by: ______________________________________________________ Triage Assessment (RN to complete) Time RN Called: ____________ Gastrointestinal: _____________________________________________________________________ _____________________________________________________________________ Pain/Score: _____________________________________________________________________ _____________________________________________________________________ Fever/Other Symptoms: _____________________________________________________________________ _____________________________________________________________________ Test/Lab Results: _____________________________________________________________________ _____________________________________________________________________ MD/NP Reviewing:____________________ Date:___________ Time:______________ Action Taken: __________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Continued on next page)

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Appendices (Continued)

Appendix C. St. Luke’s Telephone Triage Form Patient Education Topic/Medication:________________________________________________________ Who was taught:  Patient  Family  Other: ______________________________ Handout Given: _________________________________________________________ Learner Response: ______________________________________________________ Time Spent: ___________________________________________________________ Patient/Caregiver Response: ______________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ RN:______________________  Time Spent: _________________________________ RN Signature:_________________________ Date:____________ Time:_____________ NOTES:_______________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Note. Courtesy of St. Luke’s Mountain States Tumor Institute. Used with permission.

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Appendices

Appendix D. Sample Oral Chemotherapy Adherence/Adverse Event Telephone Encounter Form Date: Time: Patient: D.O.B.: Provider: Oral chemotherapy: Start date: Current ordered dose: Patient adherence: Yes/No Reason for not adherent: Plan to improve adherence: Monitoring parameters (BP/EKG, etc.): Up to date: Yes/No Needs to be completed: Assessment of side effects: List side effects patient is experiencing.

Plan to manage side effects:

(Continued on next page)

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Appendices (Continued)

Appendix D. Sample Oral Chemotherapy Adherence/Adverse Event Telephone Encounter Form Refill process confirmed: Yes/No Follow-up provider visit: Yes/No Note. Copyright 2018 by Elizabeth Bettencourt, RN, MSN, OCN®, Oral Chemotherapy Nurse Navigator, Sutter Health Palo Alto Medical Foundation. Used with permission.

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Index The letter f after a page number indicates that relevant content appears in a figure; the letter t, in a table.

A accountability, 59, 60f acral erythema. See hand-foot syndrome (HFS) active listening, 17 acuity level, 24 Advanced Practice Registered Nurse (APRN) Compact, 52 advice, telephone, 59, 60f afatinib, rash due to, 261t after-hours call management, 26 ageusia, 137t aggravating factors, 21 air embolism, 248, 282 Airway, Breathing, Circulation, and Deficit/Disability (ABCD) mnemonic, 20 ALARM model, 78, 78f alcohol and bone loss, 99 algorithms, 25–26, 292 allergic reaction, rash due to, 262 alleviating factors, 21 alopecia, 73–75 assessment criteria for, 73 cold caps for, 75 defined, 73 homecare instructions for, 74–75 problems to report with, 75 timing of, 74 tips for, 74–75 alternative care models, 6 Ambulatory Care Nurse Certification Exam, 67 ambulatory care settings, 1, 6 Ambulatory Certification Review Course, 67 amenorrhea, temporary, 213

anagen phase, 73 analgesics, seizures due to, 269t anaphylaxis, 87 anesthetics, seizures due to, 269t anorexia, 81–83 assessment criteria for, 81–82 and cachexia, 81 defined, 81 emergency care for, 83 frequency of, 19, 19f homecare instructions for, 82–83 overview of, 81 problems to report with, 83 signs and symptoms of, 82 answering machines, 64 answering service, 14 antibacterials, seizures due to, 269t antibiotic therapy problems, 85–88 assessment criteria for, 85–86 emergency care for, 88 homecare instructions for, 86 overview of, 85 problems to report with, 87 signs and symptoms of, 87 antidepressants, seizures due to, 269t antiepileptic drugs, 268, 270, 271 antihistamine(s) oversedation due to, 276–277 for pruritus, 258t antihistamine cream for pruritus, 257t

antineoplastic agents, seizures due to, 269t antipsychotics, seizures due to, 269t antivirals, seizures due to, 269t anxiety, 89–91 assessment of, 22, 89–90 defined, 89 emergency care for, 91 frequency of, 18, 19, 19f homecare instructions for, 90 problems to report with, 91 signs and symptoms of, 89, 90 appetite loss, 81–83 aprepitant for pruritus, 258t aromatase inhibitors, myalgia and arthralgia due to, 219 arthralgia, 219–222 assessment criteria for, 219–220 defined, 219 emergency care for, 222 homecare instructions for, 222 problems to report with, 222 signs and symptoms of, 220, 221–222 ascites. See malignant ascites assessment vs. clinical decision support tools, 20 comprehensive, 17–23 methods of, 15–17, 20–23 in nursing process, 55 prioritization of issues in, 17–20, 19f

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INDEX standardized processes and tools for, 16–17 systematic patient, 7 in telephone triage, 7–8 validation of, 23 virtual, 30 assistive personnel (AP), scope of practice of, 55 associated factors, 22 atypical presentations, 18 autoimmune conditions, rash due to, 262 automatic call distributor system, 34–38

B bacillus Calmette-Guérin, urination difficulty or pain due to, 129, 131 background noise, 34 Bell, Alexander Graham, 1, 67–68 BETTER model, 78–79 biologic response modifiers, pruritus due to, 253 biologic therapy. See immunotherapy biotherapy. See immunotherapy bleeding, 93–96 assessment criteria for, 93–94 causes of, 93 emergency care for, 95–96 homecare instructions for, 95–96 problems to report with, 95 signs and symptoms of, 93–94 blood clots, venous access device problems due to, 280 blood loss, amount of, 94 bone density, 97, 98t bone loss, 97–100 assessment criteria for, 97–99 homecare instructions for, 99–100 overview of, 97 terminology for, 97, 98t

bone marrow transplant, fatigue due to, 155 bone mass, low, 98t bone mineral density test, 97 brain tumors, seizures due to, 267 breach of duty, 57 breathlessness, 19, 19f

C cachexia, 81 calcium for bone loss, 99 California Board of Registered Nursing, 53 “Call a Nurse” initiatives, 6 call center, 6, 7 automatic call distributor system for, 34–38 call recording system for, 38 call volume of, 33–34 equipment for, 34–39 ergonomics in, 34, 39f headset for, 39 noise level in, 34 patient survey for, 35f–36f provider survey for, 37f–38f scope of business of, 33–34, 35f–38f setup of, 33–41 staffing skill mix of, 39 staff training for, 40 workflow in, 39–40, 41f workspace and environment of, 34–40, 39f, 41f caller(s), 33 abusive, 292 caller ID systems, 64 call recording system, 38 call routing, 14 call type, 14 call volume, 33–34, 63 cancer-related fatigue (CRF), 155–159 assessment criteria for, 155–157 defined, 155 emergency care for, 159 epidemiology of, 19, 19f etiology of, 155 with flu-like symptoms, 171

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homecare instructions for, 157–158 problems to report with, 159 signs and symptoms of, 157 cannabis for nausea and vomiting, 227 capsaicin cream for pruritus, 257t cardiovascular agents, seizures due to, 269t care delivery models, 11–14, 13f factors that influence, 14–15 caregiver, 8 care management, 6 case law, 57–59, 60f catagen phase, 73 catheter accidental removal of, 282 fractured, 282 catheter-associated infection, 279–280, 280f catheter occlusion, 283 catheter problems. See venous access device problems catheter tip malposition, 282 celecoxib for hand-foot syndrome, 177 centralized staffing, 15 cetuximab, rash due to, 261t characteristics of symptoms, 22 checklists, 28–29 checkpoint inhibitors, 199 chemical exposure, 21 chemoradiation, fatigue due to, 155 chemotherapy adherence/adverse event telephone encounter form for oral, 296–297 alopecia due to, 73–75 anorexia due to, 73, 74 antibiotic therapy problems with, 86 bleeding due to, 93 constipation due to, 105– 106 diarrhea due to, 123 dysgeusia due to, 138

INDEX dyspnea due to, 148 fatigue due to, 155 fever due to, 165 follow-up after, 293 hair loss due to, 74 hand-foot syndrome due to, 174 headache due to, 179–180 nausea and vomiting due to, 225–228 oral mucositis due to, 231 peripheral neuropathy due to, 243 rash due to, 262 chills, 170 chronic callers, 18, 66–67 cigarette smoking and bone loss, 99 circadian rhythm, 274 clinical competency, 67 clinical context in decision making, 12 clinical decision support (CDS) tools, 25–28 adjustments or customization of, 27 vs. assessment, 20 decision-making strategies of, 26 defined, 26 integration into electronic medical record of, 26 overreliance on, 26–27 paper vs. electronic, 26 proprietary, 26 recommendations for effective use of, 27 value of, 26 Clostridium difficile, 87 coagulopathies bleeding due to, 93 venous access device problems due to, 280 cognitive behavioral therapy for insomnia, 276 cognitive processing in Greenberg Model, 13, 13f cold caps, 75 Common Terminology Criteria for Adverse Events (CTCAE), 18, 43

communication challenges to, 68 failure in, 58–59 and liability, 61 with special populations, 65–67 competency clinical, 67 telehealth, 15 complex decongestive therapy (CDT) for lymphedema, 206–207 compliance, 24 comprehensive assessment, 17–23 methods for, 20–23 prioritization of issues in, 17–20, 19f validation of, 23 concurrent chemoradiation, fatigue due to, 155 confidentiality, 9, 16, 63–65, 292 confusion, 101–103 assessment criteria for, 101–102 defined, 101 emergency care for, 103 homecare instructions for, 102–103 signs and symptoms of, 102 consciousness change, 101– 103 assessment criteria for, 101–102 defined, 101 emergency care for, 103 homecare instructions for, 102–103 signs and symptoms of, 102 constipation, 105–108 assessment criteria for, 105–107 due to chemotherapeutic agents, 105–106 defined, 105 diet for, 107 emergency care for, 109 epidemiology of, 19, 19f, 105 homecare instructions for, 108–109

opioid-induced, 105 problems to report with, 109 signs and symptoms of, 108 consultation, 292 continuity of care, 29–30 corticosteroid(s) fever due to, 165 insomnia due to, 273 neutropenic fever due to, 161 for pruritus, 258t corticosteroid cream for pruritus, 257t COSTaRS Remote Symptom Practice Guides for Adults on Cancer Treatments, 26 cough, 109–111 assessment criteria for, 109–110 defined, 109 emergency care for, 111 epidemiology of, 109 with flu-like symptoms, 171 homecare instructions for, 111 problems to report with, 111 signs and symptoms of, 110 cultural differences, communication with, 66 cumulative trauma disorders, 34 cystitis, hemorrhagic, 129

D data, subjective vs. objective, 23 data collection sources, 17 data fields, 28–29 Data to Wisdom Continuum, 12 decentralized staffing, 15 decision making patient or caregiver inclusion in, 24 sources of information for, 12 strategies for, 26 Decision-Making Triad, 12

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 301

INDEX decision support tools. See clinical decision support (CDS) tools decision trees, 26 deep vein thrombosis (DVT), 113–114, 283 dehydration, fever and, 167 demoralization, 18 dentures, 234 depressed mood, 117–120 assessment criteria for, 22–23, 117–118 defined, 117 epidemiology of, 18, 19, 19f, 117 homecare instructions for, 120 signs and symptoms of, 118–120 sources for support groups and information on, 120 and suicide, 117, 119–120 dexamethasone for pruritus, 258t diagnosis, inaccurate, 16 diarrhea, 123–127 assessment criteria for, 123–125 causes of, 123–124 defined, 123 diet for, 126 epidemiology of, 19f, 123 homecare instructions for, 126–127 problems to report with, 126–127 signs and symptoms of, 123, 125 diet for anorexia, 82–83 for constipation, 107 for malignant ascites, 210– 211 for oral mucositis, 235–236 DigniCap, 75 diphenhydramine cream for pruritus, 257t diphenhydramine for pruritus, 258t direct care, 2–3 dizziness, 133–135

assessment criteria for, 133–134 causes of, 133 defined, 133 homecare instructions for, 125 signs and symptoms of, 134 with and without vertigo, 133 documentation failure in, 59 format for, 28 of guidelines, 63 and liability, 60f, 61 method of, 28–29 routing of, 29–30 of telephone encounter, 8–9, 28–30 timeliness of, 29 drop-downs, 28–29 drug resource reference, 43 dry heaves, 225 dry mouth. See xerostomia duration of symptoms, 22 duty, 57 dysgeusia. See taste dysfunction dysphagia, 143–146 assessment criteria for, 143–145 defined, 143 emergency care for, 146 epidemiology of, 143 homecare instructions for, 145–146 medical nutrition therapy for, 144–145 signs and symptoms of, 143–144, 145 dyspnea, 147–150 assessment criteria for, 147–148 causes of, 147–148 defined, 147 emergency care for, 150 epidemiology of, 147 homecare instructions for, 149–150 problems to report with, 149 signs and symptoms of, 149 dysthymic disorder, 22–23

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dysuria. See urination difficulty or pain

E electronic medical record (EMR) accessibility of, 29 clinical decision support tools and, 26 electronic triage programs, 28–29 emergency departments (EDs), face-to-face triage in, 6–7 emergent calls, 18, 24, 40, 41f emesis. See vomiting emotional distress, 19–20 emotional upset, 18 encephalopathy, posterior reversible, 180 encryption, 23 energy conservation for fatigue, 158 for malignant ascites, 211 Enhanced Nurse Licensure Compact (eNLC), 51–53, 52f environment, 34–40, 39f, 41f environmental reaction, rash due to, 262 epidermal disorders due to antibiotic therapy, 87 epidermal growth factor receptor (EGFR) inhibitors, rash due to, 261–262, 261t, 264 epileptogenic drugs, 268, 269t episode of care, 11 epistaxis, 95 equipment, 34–39 ergonomics, 34, 39f erlotinib, rash due to, 261t erythema, acral. See handfoot syndrome (HFS) erythrodysesthesia, palmarplantar. See hand-foot syndrome (HFS) escalation process, 14, 15, 24

INDEX eschar due to necrosis, 280f esophagitis, 151–154 assessment criteria for, 151–152 causes of, 151 defined, 151 dysphagia and, 143 emergency care for, 153– 154 homecare instructions for, 153 medical nutrition therapy for, 152 signs and symptoms of, 151, 153 etiology of symptom, 21 evaluation in nursing process, 55 of telephone encounter, 8, 24–25 evidence-based knowledge and practice, 12 evidence-based protocols or guidelines, 62 exercise and bone loss, 99 for fatigue, 158 exit site bleeding, 283 exit site infection, 280f expected outcomes, 8 extravasation, 248, 282

F face-to-face triage, 6–7 fall prevention and bone loss, 99–100 family members, communication with, 66 famotidine for pruritus, 258t fatigue. See cancer-related fatigue (CRF) febrile neutropenia. See neutropenic fever fever, 165–167 assessment criteria for, 165–166 causes of, 165 defined, 165 emergency care for, 167 epidemiology of, 19f with flu-like symptoms, 170

homecare instructions for, 167 neutropenic. See neutropenic fever problems to report with, 167 signs and symptoms of, 166–167 flu-like symptoms, 169–171 assessment criteria for, 169–170 causes of, 169 defined, 169 emergency care for, 171 homecare instructions for, 170–171 severity of, 169 signs and symptoms of, 169, 170 follow-up after chemotherapy, 293 follow-up calls, 63, 64 frequent callers, 18, 66–67 friends, communication with, 66

G gabapentin for hot flashes, 214 gastrointestinal disorders due to antibiotic therapy, 87 gatekeepers, 5–6 gefitinib, rash due to, 261t gliomas, seizures due to, 267 gliomatosis cerebri, seizures due to, 267 graft-versus-host disease, pruritus due to, 254 Greenberg Model of Care Delivery in Telephone Nursing Practice, 13–14, 13f, 30 Gross, Carey, 22 guidelines defined, 25 telephone nursing practice, 291–292 for telephone triage, 8, 61, 62–63 gut feeling, 2, 3

H H1 antihistamines for pruritus, 258t H2 antihistamines for pruritus, 258t hair growth, phases of, 73 hair loss, 73–75 hand-foot syndrome (HFS), 173–177 assessment criteria for, 173–174 defined, 173 emergency care for, 177 grading of, 174, 175t homecare instructions for, 176–177 incidence of, 173 problems to report with, 177 signs and symptoms of, 173, 175 harm, 57 Harvard et al. v. The Children’s Clinic of Southwest Louisiana, 58–59 headache, 179–183 assessment criteria for, 179–182 causes of, 179–180 defined, 179 emergency care for, 182–183 with flu-like symptoms, 171 homecare instructions for, 182 symptoms of, 180–181, 182 thunderclap, 181 headset, 39 Health Insurance Portability and Accountability Act (HIPAA), 16, 64 health literacy, 20 hearing impairment, 65–66 hematuria, 185–187 assessment criteria for, 185–186 causes of, 185 defined, 185 emergency care for, 187 epidemiology of, 19, 19f homecare instructions for, 187

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INDEX overview of, 185 problems to report with, 187 signs and symptoms of, 186–187 hemoptysis, 189–191 assessment criteria for, 189–190 causes of, 189 defined, 189 emergency care for, 191 homecare instructions for, 191 massive, 189 problems to report with, 191 pseudo-, 189 signs and symptoms of, 190–191 hemorrhagic cystitis, 129 herbal agents, bleeding due to, 93 hiccups, 193–196 assessment criteria for, 193–194 defined, 193 emergency care for, 196 epidemiology of, 193 homecare instructions for, 195–196 intractable, 193 overview of, 193 pathophysiology of, 193 problems to report with, 196 signs and symptoms of, 194–195 history of symptom, 21 hot flashes, 214–215 hydroxyzine for pruritus, 258t hypogeusia, 137t hyposalivation. See xerostomia

I illicit drugs, seizures due to, 269t immune-related adverse events (irAEs), 199–201 algorithms for, 200

assessment criteria for, 199–200 defined, 199 emergency care for, 201 homecare instructions on, 201 patient education on, 201 practice and consensus guidelines for, 200 problems to report with, 201 resources on, 201 signs and symptoms of, 199, 200–201 immunosuppressant agents neutropenic fever due to, 161 seizures due to, 269t immunotherapy antibiotic therapy problems with, 86 bleeding due to, 93 cough due to, 109 diarrhea due to, 123–124 dyspnea due to, 148 fatigue due to, 155 fever due to, 165 myalgia and arthralgia due to, 219 pruritus due to, 254 rash due to, 262 implementation barriers to, 24 in nursing process, 55 in telephone triage, 8, 291– 292 indirect care, 1 infection assessment of, 21 catheter-associated, 279– 280, 280f epidemiology of, 19f vs. phlebitis, 248 rash due to, 262 infiltration, 248 information gathering in Greenberg Model, 13, 13f information source, 12, 23 insomnia, 273–276 assessment criteria for, 273–275, 275f causes of, 273–274

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defined, 273 epidemiology of, 273 homecare instructions for, 275–276 as menopausal symptom, 216 overview of, 273 problems to report with, 276 signs and symptoms of, 273, 274, 275 interpreting in Greenberg Model, 13, 13f interstate compact, 51–53, 52f intervention, 8, 24 interview, telephone, 7 intravascular lymphomatosis, seizures due to, 267 intuition, 2, 3 itch. See pruritus

J job description, 59

K knowledge in decision making, 12

L language barriers and communication, 65–66 lapatinib, rash due to, 261t law case, 57–59, 60f defined, 56 statutory, 56 types of, 56 legal concerns, 49–69 and case law, 57–59, 60f clinical competency as, 67 communicating with special populations as, 65–67 liability as, 56–63 nursing practice issues as, 50–54, 52f patient confidentiality as, 63–65

INDEX scope of practice as, 54–56 standards of care as, 49–50 legal standards, 50 lengthy calls, 67 liability, 56–63 areas that can increase, 58–59 and case law, 57–59, 60f defined, 57 and recommendations for safe telephone triage care, 59, 60f and risks of telenursing, 56 strategies to minimize, 59–63 what constitutes, 56–57 licensed practical nurses (LPNs), scope of practice of, 55 licensed vocational nurses (LVNs), scope of practice of, 55 Linkous, Jonathan, 52 lip care, 234–235 listening, 16, 20, 56 active, 17 location of symptoms, 22 Louisiana Telehealth Access Act, 54 lymphedema, 205–207 assessment criteria for, 205–206 causes of, 205 complex decongestive therapy for, 206–207 epidemiology of, 205 homecare instructions for, 206–207 problems to report with, 207 signs and symptoms of, 205, 206

M magnesium for hot flashes, 214 major depression, 22–23 malaise, 171 malignant ascites, 209–211 assessment criteria for, 209–210

causes of, 209 defined, 209 emergency care for, 211 homecare instructions for, 210–211 problems to report with, 211 signs and symptoms of, 209, 210 malnutrition due to dysphagia, 144–145 due to esophagitis, 152 due to xerostomia, 288 malpractice case law on, 57–59, 60f defined, 57 strategies to minimize, 59–63 mammalian target of rapamycin (mTOR) inhibitors, oral mucositis due to, 231 managed care, 6 medical diagnosis, defined, 54–55 medical nutrition therapy for dysphagia, 144–145 for esophagitis, 152 for xerostomia, 288–289 medical record, 7 electronic, 26, 29 purposes of, 28 medical triage, defined, 6 medication review, 17 meningeal carcinomatosis, seizures due to, 267 menopausal symptoms, 213– 216 assessment criteria for, 213 emergency care for, 216 homecare instructions for, 214–216 hot flashes as, 214–215 insomnia as, 216 in men, 213 overview of, 213 signs and symptoms of, 213–214 vaginal dryness, itching, and atrophy as, 215 menopause defined, 213 premature, 213 mental status changes due to fever, 167

menthol and phenol cream for pruritus, 257t methylprednisolone for pruritus, 258t minors, communication with, 65 “miracle fruit,” 140 mirtazapine for pruritus, 258t models of telephone nursing, 11–14, 13f factors that influence, 14–15 monoclonal antibodies, pruritus due to, 253 mouthwashes, 235 mucositis, oral. See oral mucositis multikinase inhibitors, handfoot syndrome due to, 174 multiple issues, 18 multistate licensure, 51–53, 52f musculoskeletal disorders, work-related, 34 musculoskeletal system, assessment of, 22 myalgia, 219–222 assessment criteria for, 219–220 defined, 219 emergency care for, 222 as flu-like symptom, 171 homecare instructions for, 222 problems to report with, 222 signs and symptoms of, 220, 221–222

N National Comprehensive Cancer Network (NCCN), Distress Thermometer of, 20 National Council of State Boards of Nursing (NCSBN), 50–52 nausea, 225–228 acute, 225 anticipatory, 225 assessment criteria for, 226 breakthrough, 225

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 305

INDEX chronic, 225 defined, 225 delayed, 225 emergency care for, 227 epidemiology of, 19, 225 grading of, 227, 228t homecare instructions for, 227 patterns of, 225–226 refractory, 225 necrosis, eschar due to, 280f negligence, 57 neurokinin-1 receptor antagonists for pruritus, 258t neuropathy, 19, 19f peripheral, 243–245 neutropenic fever, 161–163 assessment criteria for, 161–162 defined, 161 emergency care for, 163 homecare instructions for, 163 overview of, 161 precautions with, 163 problems to report with, 163 signs and symptoms of, 162–163 Nevada State Board of Nursing, 53 Nightingale, Florence, 67 noise-canceling microphone, 39 noise level, 34 noncompliance, 24 nonsymptom calls, 14 nonurgent calls, 18, 24, 40, 41f North Carolina Board of Nursing (NCBON), 53–54 nurse call lines, 6 Nurse Licensure Compact (NLC), 51–53, 52f Nurse Line, 26 nurse–patient relationship, 5 nursing diagnosis defined, 54 in telephone triage, 8, 24 nursing practice guideline for, 291–292 issues with, 50–54, 52f scope of, 54–56

nursing process, 5, 7–8, 12, 17, 30, 55 nursing standards, 49–50 nutrition therapy for anorexia, 82–83 for dysphagia, 144–145 for esophagitis, 152

O objective data, 23 odynophagia, 143, 151 office hour call management, 26 OLD CARTS mnemonic, 22 older adults, communication with, 66 olivamine creams (Remedy Skin Repair, Remedy Nutrashield), for pruritus, 257t Oncology Nursing Society (ONS) resources on managing oral therapies, 46 onset of symptoms, 21, 22 Onset, Provoking/Palliating Factors, Quality, Radiation/ Region, Severity, Time/ Treatment method, 20–21 ONS Voice, 46 open-ended questions, 60f opioids constipation due to, 105 oversedation due to, 276– 277 pruritus due to, 254 Oral Adherence Toolkit (ONS), 46 Oral Chemotherapy Guide (ONS), 46 oral hygiene for oral mucositis, 233–234 for xerostomia, 289 oral mucositis, 231–236 assessment criteria for, 231–232 causes of, 231 defined, 231 emergency care for, 236 epidemiology of, 231 homecare instructions for, 233–236

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problems to report with, 236 symptoms of, 231–233 oral rinses, 235 oral stomatitis, 19f oral therapies, 43–46 adherence/adverse event telephone encounter form for, 296–297 assessment criteria for, 43–45 drug resource reference on, 43 homecare instructions for, 45 ONS resources on managing, 46 overview of, 43 report to healthcare provider on, 45, 46f organ involvement, 21 osimertinib, rash due to, 261t osteopenia, 97 osteoporosis, 97, 98t out-of-state patients, 51–52, 52f outpatient settings, 1 output in Greenberg Model, 13–14, 13f oversedation, 276–277

P pain, 239–241 assessment criteria for, 20–21, 239–240 causes of, 239 emergency care for, 241 epidemiology of, 19, 19f, 239 homecare instructions for, 240–241 problems to report with, 241 signs and symptoms of, 240 pain diary, 240 palliating factors, 21 palmar-plantar erythrodysesthesia. See hand-foot syndrome (HFS) panitumumab, rash due to, 261t

INDEX paperwork calls, 15 paraneoplastic syndromes, seizures due to, 267–268 parents, communication with, 66 paresthesia, 243–245 assessment criteria for, 243–244 causes of, 243 defined, 243 emergency care for, 245 homecare instructions for, 244–245 problems to report with, 245 signs and symptoms of, 243, 244 paroxetine for hot flashes, 214 for pruritus, 258t patient preferences in decision making of, 12 speaking directly with, 16 patient confidentiality, 9, 16, 63–65, 292 patient education, 24 on immune-related adverse events, 201 on venous access devices, 283, 283t–284t Patient Protection and Affordable Care Act (ACA), 6 patient survey, 35f–36f peripheral neuropathy, 243– 245 assessment criteria for, 243–244 causes of, 243 defined, 243 emergency care for, 245 homecare instructions for, 244–245 problems to report with, 245 signs and symptoms of, 243, 244 personal health information (PHI), 16 personal standards, 50 phenothiazines, insomnia due to, 273 phlebitis, 247–250

assessment criteria for, 247–248 causes of, 247 defined, 247 emergency care for, 249 epidemiology of, 247 grading of, 250, 250t homecare instructions for, 249 overview of, 247 problems to report with, 249 signs and symptoms of, 247, 248–249 phone tree, 14 photos, texting of, 23 planning in nursing process, 55 in telephone triage, 8, 24 platelets, decreased circulating, 93 PLEASURE model, 78, 78f PLISSIT model, 78 pneumonitis, 148 pneumothorax, 248 policies failure to follow, 59 for telephone triage, 8–9, 61 port erosion, 282 port pocket infection, 280f POSHPATE method, 21 posterior reversible encephalopathy, 180 precautions, neutropenic, 163 precipitating factors, 21 prednisolone for pruritus, 258t prescription refills, 15 presence, supportive, 20 presentations, atypical, 18 Pringle, Chantelle, 57–58 Pringle v. Nestor Prime Care Services, 57–58 prioritization of issues, 17–20, 19f privacy, right to, 9, 16, 63–65 proactive calls, 14 problem, 21 problem phone calls, 294 problem situation, policies for managing, 61–62 procedures failure to follow, 59

for telephone triage, 8–9, 61 process challenges, 68 process of telephone nursing, 291 process standards, 50 professional judgment, failure to act on, 59 professional standards, 50 protocols, 8, 25, 292 provider survey, 37f–38f provoking factors, 21 proximate cause, 57 pruritus, 253–258 assessment criteria for, 253–255 causes of, 253–254, 254f defined, 253 emergency care for, 257 grading of, 254, 255t homecare instructions for, 256 pharmacologic agents for, 257, 257t–258t problems to report with, 256–257 signs and symptoms of, 254, 255–256 pseudohemoptysis, 189 psychological distress, 19–20 psychosocial issues, complex, 18–20, 19f psychosocial oncology support, 20 pulmonary embolism, 282 Putting Evidence Into Practice study (ONS), 46

Q qualifications for telephone nurse, 15 quality assurance programs, 63 quality of pain, 21 question(s), open-ended, 60f questioning in Greenberg Model, 13

R radiation of pain, 21 radiation therapy alopecia due to, 73–75

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 307

INDEX anorexia due to, 73, 74 antibiotic therapy problems with, 86 cough due to, 109 diarrhea due to, 124 dysgeusia due to, 138 fatigue due to, 155 hair loss due to, 74 headache due to, 179 oral mucositis due to, 231 pruritus due to, 254 rash due to, 262 rash, 261–265 assessment criteria for, 261–263, 261t, 262t causes of, 261–262, 261t, 262t defined, 261 emergency care for, 265 homecare instructions for, 264 problems to report with, 264–265 signs and symptoms of, 263–264 reason for call, 14, 16 “red flag” complaints, 60f redirecting in Greenberg Model, 13 referral, 292 Regenecare gel for pruritus, 257t Regenecare HA gel for pruritus, 257t region of pain, 21 regulatory standards, 50 relieving factors, 22 repeat callers, 18, 66–67 repetitive actions, 34 report to healthcare provider on oral therapy, 45, 46f resources additional, 63 on immune-related adverse events, 201 on managing oral therapies, 46 respiratory agents, seizures due to, 269t retching, 225 routine calls, 18, 24, 40, 41f

routing of call, 14 of documentation, 29–30

S safety, failure to ensure, 58 saliva in taste process, 137 scalp cooling system, 75 Schmitt-Thompson triage protocols, 26 Scope and Standards of Practice for Professional Telehealth Nursing, 67 scope of business, 33–34, 35f–38f scope of practice, 54–56, 291 screening of calls, 6 seizures, 267–271 absence, 267 assessment criteria for, 267–270, 269t causes of, 267–268, 269t defined, 267 drug-induced, 268, 269t emergency care for, 271 focal (partial), 267 generalized, 267 helpful websites on, 271 homecare instructions for, 270–271 overview of, 267 signs and symptoms of, 270 simple partial vs. complex partial, 267 types of, 267 selective serotonin reuptake inhibitors for pruritus, 258t self-care strategies, review of, 17 self-diagnosis, 60f sensory input, lack of, 2–3, 15–16 severity of symptom, 21, 22 sexual dysfunction, 77–79, 78f assessment criteria for, 77–78, 78f defined, 77 homecare instructions for, 78–79 overview of, 77

308 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

problems to report with, 79 shock, 94 fever and, 167 short calls, 67 side effects, anticipated, 17–18 SIGE CAPS mnemonic, 22–23 simethicone for hiccups, 195 singultus. See hiccups skill validation, 63 skin alterations, 19f skin disorders due to antibiotic therapy, 87 sleep efficiency, 274 sleep hygiene, 276 sleep latency, 274 sleep patterns, 274 sleep quality and fatigue, 158 sleep–wake disturbances, 273–277 insomnia as, 273–276, 275f oversedation as, 276–277 smoking and bone loss, 99 social taboos, 66 socioeconomic differences, communication with, 66 source of information, 12, 23 staffing models, 15 staffing skill mix, 39 staff training, 40 standards of care, 49–50 state nurse practice acts, 50–54 statutory law, 56 stem cell transplant, fatigue due to, 155 stereo headsets, 39 Stevens-Johnson syndrome, 87 St. Luke’s telephone triage form, 294–295 stomatitis, oral, 19f STOP-Bang questionnaire, 275, 275f stress, assessment of, 22 stress management for fatigue, 158 structural standards, 50 subcutaneous tract infection of tunneled catheter, 280f subjective data, 23

INDEX suicidal ideation, 18, 117, 119–120 superficial thrombophlebitis, 247 supportive presence, 20 swallowing difficulty. See dysphagia symptom(s), 21 symptom-focused telephone protocols, 3 symptom intensity, over- or underestimation of, 16 symptom management calls, 14, 15 Synsepalum dulcificum, 140

T tamoxifen, dyspnea due to, 148 targeted therapy antibiotic therapy problems with, 86 diarrhea due to, 123 dysgeusia due to, 138 fever due to, 165 pruritus due to, 253 rash due to, 261–262 taste dysfunction, 137–140 assessment criteria for, 137–139 diet for, 139–140 emergency care for, 140 epidemiology of, 137 homecare instructions for, 139–140 problems to report with, 140 signs and symptoms of, 139 types of, 137t taste process, 137 taste receptor cells (TRCs), 137, 138 taxanes, myalgia and arthralgia due to, 219 telecommunications device for the deaf (TDD), 65–66 telehealth, 1, 2, 49 telehealth competencies, 15 telehealth encounters defined, 11 documentation of, 28–30

evaluation of, 8, 24–25 telehealth nursing. See telenursing telemedicine, defined, 5 telenursing in call centers, 6 care delivery models of, 11–14, 13f defined, 5, 12, 49 examples of, 5 National Council of State Boards of Nursing on, 50–52 process of, 291 use of term, 7 telenursing practice, 11 telenursing practice guidelines, 291–292 telephone advice, 59, 60f telephone calls problem, 292 reason for, 14, 16, 33–34 routing of, 14 timing of, 14 types of, 14 telephone consulting vs. telephone triage, 56 telephone encounter defined, 11 documentation of, 28–30 evaluation of, 8, 24–25 telephone interview, 7 telephone nursing. See telenursing telephone triage advantages of, 16 challenges of, 2–3 defined, 1, 7, 291 documentation in, 8–9 evolving role of nurses in, 5–6 face-to-face vs., 7 form for, 294–295 guidelines or protocols for, 8 importance of, 1–2 nursing process in, 7–8 patient confidentiality in, 9 policies and procedures for, 8–9 purpose and goals of, 59 vs. telephone consulting, 56

uses for, 2 telogen phase, 73 thrombocytopenia, 93, 95 thromboembolism, venous, 113–114 thrombo-inflammatory disorder, 247 thrombophlebitis, superficial, 247 thrombosis, deep vein, 113– 114, 283 thunderclap headache, 181 TICOSMO method, 21–22 timing of call, 14 of symptom, 21 tone of voice, 3 tooth brushing, 233–234 toxic epidermal necrolysis, 87 toxicities, anticipated, 17–18 training of staff, 40 translator service, 65–66 trauma, assessment of, 21 treatment of symptom, 21, 22 trends in health care, 1 triage, defined, 6, 56 tunneled catheter cuff visible at exit site of, 282 subcutaneous tract infection of, 280f

U urgent calls, 18, 24, 40, 41f urinary retention, 129 urinary tract infection, 129 urination difficulty or pain, 129–132 assessment criteria for, 129–130 due to bacillus CalmetteGuérin, 129, 131 causes of, 129 emergency care for, 132 epidemiology of, 19, 19f homecare instructions for, 131 overview of, 129 signs and symptoms of, 130, 131

Telephone Triage for Oncology Nurses (Third Edition) . . . . . . . . 309

INDEX

V vaginal dryness, itching, and atrophy, 215 venlafaxine for hot flashes, 214 venous access device problems, 279–284 accidental catheter removal as, 282t air embolism as, 282t assessment criteria for, 279–282, 280f due to blood clots or coagulation disorder, 280 catheter occlusion as, 283t catheter tip malposition as, 282t deep vein thrombosis as, 283t exit site bleeding as, 283t extravasation as, 282t fractured catheter as, 282t due to infection, 279–280, 280f patient teaching on, 283– 284, 283t–284t port erosion as, 282t

pulmonary embolism as, 282t due to venous thrombosis, 280 venous thromboembolism, 113–114 venous thrombosis, venous access device problems due to, 280 vertigo, 133 virtual assessment, 30 vitamin D for bone loss, 99 voice mail, 14, 64 vomiting, 225–228 acute, 225 anticipatory, 225 assessment criteria for, 226–227 breakthrough, 225 chronic, 225 defined, 225 delayed, 225 emergency care for, 227 epidemiology of, 19f, 225 grading of, 227, 228t homecare instructions for, 227 patterns of, 225–226 refractory, 225

310 . . . . . . . . Telephone Triage for Oncology Nurses (Third Edition)

W wait time, 63 wireless headsets, 39 workflow, 39–40, 41f work-related musculoskeletal disorders, 34 workspace, 34–40, 39f, 41f workstation, ergonomics of, 34, 39f worst-case scenario, 60f

X xerostomia, 287–290 assessment criteria for, 287–289 causes of, 287 defined, 287 emergency care for, 290 medical nutrition therapy for, 288–289 oral hygiene for, 289 overview of, 287 problems to report with, 290 signs and symptoms of, 287–288, 289