BC Cancer Professionals' Consensus on Managing Diarrhea during Cancer Treatment, Study notes of Nursing

Download BC Cancer Professionals' Consensus on Managing Diarrhea during Cancer Treatment and more Study notes Nursing in PDF only on Docsity! The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk. Page 1 of 8 Symptom Management Guidelines: DIARRHEA NCI GRADE AND MANAGEMENT | RESOURCES | CONTRIBUTING FACTORS | APPENDIX Definition Cancer – Related Diarrhea (CRD): An abnormal increase in stool frequency, volume, and liquidity that is different from the usual patterns of bowel elimination; results from cancer or related treatment(s). FOCUSED HEALTH ASSESSMENT PHYSICAL ASSESSMENT SYMPTOM ASSESSMENT Vital Signs  As clinically indicated Weight  Take current weight and compare to pre – treatment or last recorded weight  Calculate Body Mass Index (BMI) Hydration Status  Skin turgor, capillary refill, mucous membranes  Assess for: - amount and character of urine - daily intake and output - thirst and dry mouth - weakness and dizziness - most recent lab results Abdominal Assessment  Auscultate abdomen - assess presence and quality of bowel sounds  Abdominal pain, tenderness, distention Stool Examination  Inspect stool for colour (visible blood or mucous), consistency, volume, and odour Skin Integrity  Perineal or peristomal skin integrity  Note any areas of erythema, edema, exudates, bleeding or skin breakdown Mental Status  Confusion, alterations in level of consciousness Functional Status  Activity level/ECOG or PPS Normal  What are your normal bowel habits?  Do you have an ostomy? If so, how many times do you normally empty/change the bag?  Are you aware of any medications that you are taking that could cause diarrhea? Onset  When did diarrhea begin?  How many bowel movements in the last 24 hours?  If ostomy, how many times did you empty/change bag? Provoking / Palliating  What brings on the diarrhea?  Anything that makes the diarrhea better? Worse? Quality  Describe your last bowel movement  Was there any blood or mucous?  Was it loose or watery?  Can you estimate the amount, large or small volume?  Can you describe the odour? Region / Radiation- N/A Severity / Other Symptoms  How bothered are you by this symptom? (on a scale of 0 – 10, with 0 being not at all to 10 being the worst)  Have you been experiencing any: - Abdominal cramping - Diarrhea overnight (nocturnal stools) - Incontinence of stool - Fever - possible infection - Dry mouth, thirst, dizziness, weakness, dark urine -possible dehydration - Severe abdominal pain, bloating, nausea, vomiting - possible bowel obstruction - Skin breakdown around your rectum/colostomy  Are you able to keep fluids down? What are you drinking? How much? What is your dietary intake? Are you urinating normally? Treatment  What medications or treatments have you tried? Has this been effective? Understanding / Impact on You  Is your diarrhea interfering with your normal daily activity (ADLs)? Value - What do you believe is causing your diarrhea? The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk. Page 2 of 8 DIARRHEA GRADING SCALE NCI Common Terminology Criteria for Adverse Events (Version 4.03) GRADE 1 (Mild) GRADE 2 (Moderate) GRADE 3 (Severe) GRADE 4 (Life - threatening) GRADE 5 Increase of <4 stools per day over baseline; mild increase in ostomy output compared to baseline Increase of 4 - 6 stools per day over baseline; moderate increase in ostomy output compared to baseline Increase of ≥7 stools per day over baseline; incontinence; hospitalization indicated; severe increase in ostomy output compared to baseline; limiting self- care ADL Life threatening consequences; urgent intervention indicated Death Special Considerations for Irinotecan Early Onset Diarrhea  Occurs during or within 24h of administration  Cholinergic response that may be accompanied with other symptoms such as abdominal cramping, diaphoresis watery eyes, salivation, and rhinitis. Manage symptoms with Atropine.  Instruct patient to contact healthcare providers (BC Cancer Nurse Telephone Line or Physician on call) to determine whether patient needs to come to cancer agency or go to emergency department for atropine treatment  Prophylactic atropine may be indicated for subsequent treatments Late Onset/Delayed Diarrhea  Occurs more than 24h after administration  Can be prolonged and lead to potentially life–threatening dehydration and electrolyte imbalance if not proactively managed  Must be treated immediately with high dose loperamide  Patient Education: - Always keep supply of loperamide at home (available at pharmacy without a prescription) - Take two tablets (4 mg) after 1st loose stool then one tablet (2 mg) every 2h until diarrhea- free for 12h - Overnight may take 4 mg every 4h to allow longer sleep period - Loperamide daily dosage may exceed package recommendations. Reinforce importance of taking higher dosage to stop diarrhea - Contact healthcare providers (BC Cancer Nurse Telephone Line or Physician) if diarrhea does not improve within 24h after starting loperamide or if diarrhea lasts more than 36h (as antibiotics may be prescribed) Special Considerations for Immunotherapy (Checkpoint Inhibitors) Immune-Mediated Adverse Reactions  Can cause severe and fatal immune-mediated adverse reactions including: enterocolitis, intestinal perforation, hepatitis, dermatitis, neuropathy, endocrinopathy, and toxicities in other organ systems  Permanent discontinuation of treatment is recommended for severe immune-mediated reactions  Onset usually occurs during the beginning of treatment, but may occur months after last dose  All patients should be given Ipilimumab Alert Card, or an immunotherapy alert card when treatment is started The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk. Page 5 of 8 GRADE 3 or 4 Diarrhea OR Persistent Grade 1 or 2 diarrhea with one or more of the following symptoms: T ≥ 38° C, abdominal cramping, nausea and vomiting, sepsis, neutropenia, blood in stool, dehydration EMERGENT: Requires IMMEDIATE medical attention Patient Care and Assessment  Patients will generally require hospital admission. Notify physician of assessment, facilitate arrangements as necessary  If patient is on Immunotherapy, remind patient to present Immunotherapy Alert Card  Collaborate with physician: - To rule out other causes or concomitant causes of diarrhea - To hold chemotherapy until symptoms resolve. Chemotherapy may then be restarted at a reduced dose. Refer to specific chemotherapy protocols for direction See BC Cancer Chemotherapy Protocols  Lab tests that may be ordered: - Complete blood count (CBC), electrolyte profile, BUN/creatinine - Stool analysis – C. difficile toxin assay, culture and sensitivity (Salmonella, E. coli, Campylobacter, infectious colitis), ova and parasites, blood and leukocytes  Nursing Support: - Monitor vital signs as clinically indicated - Record intake and output and daily weight - Pain and symptom assessment and management as appropriate Dietary Management  IV hydration to replace lost fluids and electrolytes  Patients may require bowel rest and be NPO  Enteral or parenteral nutrition (TPN) may be indicated Pharmacological Management  Avoid/discontinue any medications that may cause or exacerbate diarrhea in collaboration with physician and pharmacist  Medications that may be prescribed: - Octreotide (subcutaneous or IV) - Antibiotics (oral or intravenous route) - Systemic analgesia - Corticosteroids (Refer to protocol specific algorithm if patient on Immunotherapy – DO NOT administer corticosteroids if bowel perforation is suspected / confirmed) RESOURCES & REFFERALS Referrals  Patient support center or telephone care management  Pain and Symptom Management/Palliative Care (PSMPC)  Oncology Nutrition Services (Dietitian)  Home Health Nursing Management Guidelines  BC Cancer Guidelines for Chemotherapy-Induced Diarrhea: http://www.bccancer.bc.ca/nursing-site/Documents/GuidelinesforManagementofCID.pdf  Medical Management of Malignant Bowel Obstruction: http://www.bccancer.bc.ca/family- oncology-network-site/Documents/MedicalManagementofMalignantBowelObstruction.pdf Patient Education  CDiff and VRE pamphlets (H:\EVERYONE\Infection Control\PAMPHLETS)  http://www.bccancer.bc.ca/health-info/coping-with-cancer/nutrition-support  Coping with Cancer - Diarrhea: http://www.bccancer.bc.ca/health-info/coping-with- cancer/managing-symptoms-side-effects/diarrhea  NCI Managing Chemotherapy Side Effects: https://www.cancer.gov/publications/patient- education/diarrhea.pdf  NCI Managing Radiation Therapy Side Effects – What to do When you Have Loose Stools: The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk. Page 6 of 8 https://www.cancer.gov/publications/patient-education/radiation-side-effect-diarrhea.pdf  Canadian Cancer Society – Diarrhea: http://www.cancer.ca/en/cancer-information/diagnosis- and-treatment/managing-side-effects/diarrhea/?region=on  ASCO Cancer.Net – Diarrhea: https://www.cancer.net/navigating-cancer-care/side- effects/diarrhea Irinotecan  Monograph: http://www.bccancer.bc.ca/drug-database- site/Drug%20Index/Irinotecan_monograph.pdf  Patient handout: http://www.bccancer.bc.ca/drug-database- site/Drug%20Index/Irinotecan_handout_1January2011.pdf  Immunotherapy  Immunotherapy Nursing Process  Immunotherapy Patient Letter  Immunotherapy Alert Card  Ipilimumab Alert Card  Please refer to protocol specific algorithms to guide management of immune mediated side effects Alert Guidelines H:\EVERYONE\nursing\REFERENCES AND GUIDELINES\Telephone Nursing Guidelines\Alert Guideline(available to internal BCCA staff only):  Intestinal Obstruction Bibliography List  http://www.bccancer.bc.ca/nursing-site/Documents/Bibliograpy%20-%20Master%20List.pdf The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk. Page 7 of 8 Appendix Contributing Factors Cancer Related  Colon  Neuroendocrine tumors (e.g. VIPomas, carcinoid, gastrinomas)  Lymphoma  Pancreatic  Pheochromocytoma  Graft vs. host disease after bone marrow transplant Treatment Related Systemic Treatment:  Capecitabine  5 – fluorouracil  Irinotecan  Leucovorin  Most small molecule oral tyrosine kinase inhibitors (TKIs)  Immunotherapy – Checkpoint inhibitors (e.g. Ipilimumab, nivolumab, pemrolizumab) Biotherapy (e.g. high dose Interferon or Interleukin– 2) Radiation Treatment Fields:  Pelvic  Abdominal  Lumbar  para-aortic fields  lung  head and neck Surgical Treatment:  Celiac plexus block  Large or small bowel resection  Cholecystectomy, esophagogastrectomy Gastrectomy, pancreaticoduodenectomy (Whipple procedure)  Vagotomy  Terminal ileal resection and loss of ileocecal valve Medications and Supplements  Laxatives (e.g. stool softeners, stimulant laxatives)  Antibiotics (e.g. cephalexin, amoxicillin, clindamycin, clavulanic acid-amoxicillin)  Prokinetic agents (e.g. metoclopramide, methyldopa, cochicine, digoxin)  Antihypertensives  Misoprostol  Potassium supplements  Magnesium-containing antacids / supplements  Liquid medications containing sorbitol (e.g. acetaminophen elixir)  Caffeine  Alcohol  Herbal supplements (e.g. milk thistle, aloe, cayenne, saw palmetto, ginseng, coenzyme Q10, high dose vitamin C) Medical History  Partial bowel obstruction, fecal impaction with overflow  Obstruction of common bile duct  Inflammatory bowel disease (e.g. Crohn’s disease, ulcerative colitis)  Irritable bowel syndrome, diverticulitis, iIschemic colitis  Narcotic withdrawal  Diabetes  Hyperthyroidism  Hypoalbuminemia  Conditions that may require use of warfarin (e.g. venous thrombosis, cardiac surgeries)  Advanced age  Anxiety, stress  Recent travel  Infection- viral (e.g. norovirus), bacterial (e.g. C.difficile, E.coli), parasitic  Post-pyloric hyperosmolar feedings and/or high feeding rate  Food/ lactose intolerance