Chemotherapy on med/surg unit

[veronica butterfly, ADN, RN]

I work at a small hospital on a med/surg unit that takes all sorts of patients. We have an outpatient Cancer Center attached to the hospital and we occasionally get their patients overnight for dehydration, n & v, or blood transfusions. We also on rare occasion give chemotherapy, a couple of our nurses have taken the ONS course and are certified to give it. There is a push now to start giving more chemotherapy and are certifying more of us nurses. I'm currently registered in the 2 day course and have some concerns. A few questions if anyone has time...

1. for pts hospitalized for hydration or transfusions who have just had chemo, I now realize that we should be gloving/gowning up when emptying urine, etc. I don't think this is always the case, or date of last chemo treatment is not even asked. Now I'm wondering about disposing of linens too as I read my ONS book. For 48-72 hours after they've gotten chemo, shouldn't we be putting their bed linens in separate disposal? On an oncology floor, are your patients' linens kept separate from rest of hospital?

2. basic question. How many patients does an oncology nurse have if she is administering chemo? From what we learned the first day of class, the nurse needs to be with the patient either constantly or frequently depending on what drug it is. Forgive me if this is a completely stupid question, it's all new to me and I don't have any experience. I just know we run from room to room keeping senile little ladies in bed and our pocket phones are ringing off the hook... never seems we spend any length of time in one room.

3. I've heard our pharmacy doesn't prime tubing and spike the chemo before sending it to us. Isn't this totally wrong?

4. Do you have kits of meds ready for possibly anaphylactic reactions? do you have standing orders for these?

I also plan to post a question on the med/surg bulletin board to see if other general floors are doing chemo. Thanks much!

[skygirlhil]

I am an extern currently at a large comprehensive cancer center...i can answer some of your questions from what I readily observe on our unit....

linens are NOT kept separately

when dumping urine, "chemo gowns" are advised ( these are plastic-like disposable gowns) with nitrite (non latex) gloves. this "uniform" is going to be dependent upon each individual facility policy.

our pharmacy DOES NOT spike and hang chemo. the chemo is brought to the pharmacy in a plastic bag labeled "hazardous materials". The RN then takes this bag into the patients room (gowns and gloves first....as explained above), spikes the chemo inside of the "hazaraous materials" bag and then hangs the bag.

the RNs on our unit typically have 3-4 patients. There are a few chemos I know of that require frequent vital signs when first hung - q 15 for the first 30 minutes and q 30 for the remainder of the infusion. One of these agents is called Rituxan. The nurse may, too, stay in the room for the first 15 minutes or so of the infusion due to the fact that infusion reactions typically occur right away.

"kits of meds" are contained in our accu dose. if the RN is on top of things he/she will acquire this before beginning the infusion and either place it in the patients' med drawer, so that in case an infusion reaction were to occur the RN would not have to waste time with the accu dose.

hope this helps...i am hardly an expert....but I have learned alot as an extern in a few short weeks!! let me know if i can try to help you any other way!

[veronica butterfly, ADN, RN]

Thank you, that info does help!

[tanhaight]

We don't keep linens separately but if they are soiled and it's within the 48 hours post chemo we put them in a biohazard bag and label it indicating chemo precautions. Where it goes from there, I don't know.

Our pharmacy does spike and prime the chemo. We just asked them to as it is best practice and safer, and so all chemo arrives prepared for us to hang. They have a hood they can do it under in pharmacy, we have a bag only.

Flush the toilet twice. Double glove with chemo gloves, a pain yes, but necessary. Hang your chemo then peel off the outer gloves and then program the pump to reduce contamination.

A chemo cart should have an extravasation kit with the antidotes for chemos that are vesicants and a spill kit. Emergency meds should be in this cart too which is supposed to remain locked and in the patients room.

Skyhilgirl is right in that Rituxin needs a one to one nurse for first time. Second time it's 3:1 I think. Big risk for anaphylaxis. Something like Adriamycin IVP takes 20 minutes with you pushing it slowly at the bedside...we have other RNs take the LVNs IVs while we do Adria. We do frequent vital signs on all chemos and remember, a patient can have a reaction at the end of the chemo on their 5th cycle of it. The body just decides it's had enough I guess!

The ONS website can answer a lot of your questions and provide guidelines for standards of care. We base a lot of ours on their recommendations.

Good luck!

[me5115]

I work in a hospital base out pt chemo center, Its sounds very similar to your situation, Its a small community hospital. Except our in pt med surg nurses NEVER HANG CHEMO. We have a union and they probably would throw a fit. For the same reasons, if you dont do it every day, Its is scary....

Another reason why is our in pts are charged a flat day rate, so they may pay $2,000 a day, Well a cycle of some chemo could be $25,000. Thats a lot of money to eat. Whats your hospital do regarding billing?

Also, we have to have a MD in the building at all times while chemo is running, Will you have to call the ER doctor if there is a reaction?

Just some thoughts..Good luck

[rn undisclosed name]

I work in an oncology unit. Our ratio with our patients is 5:1 regardless if there is an chemo. Our staffing is so good that many times I have 3 patients. Maybe 4. I have yet to have 5 patients. It is the travelers and agency nurses who will get 5. We do not have separate linens. We really don't do anymore frequent monitoring with chemo. VS are q4h. I can't think of the chemo med (it's for patients with leukemia) right now but when we are worried about the CNS being involved we check the patients gait, hand writing, pointing with their finger to their nose, etc. We do also do tele on our floor in certain rooms and some patients may be placed on tele. Our chemo already comes up pre-primed from pharmacy and they have the special hood. If for some reason it is not all the way primed we connect the chemo and our pumps have a function so that we can backprime the tubing. Our chemo is always hung as a piggyback (except for Taxol). We also have chemo kits on our unit. I have not yet had to use one.

[veronica butterfly, ADN, RN]

I work in a hospital base out pt chemo center, Its sounds very similar to your situation, Its a small community hospital. Except our in pt med surg nurses NEVER HANG CHEMO. We have a union and they probably would throw a fit. For the same reasons, if you dont do it every day, Its is scary....

Another reason why is our in pts are charged a flat day rate, so they may pay $2,000 a day, Well a cycle of some chemo could be $25,000. Thats a lot of money to eat. Whats your hospital do regarding billing?

Also, we have to have a MD in the building at all times while chemo is running, Will you have to call the ER doctor if there is a reaction?

Just some thoughts..Good luck

Wow, not sure about the billing, that's a great question. And no, we do not have doctors on the floor on evenings and nights. We just have to page them... I am union too, that's also a good point.

I am hopeful that our hospital will do more inpt chemo but I just don't feel we at all prepared. We do it soooo rarely. I checked our "chemo cart" last night which is tucked away in storage. There was a great chemo drug book, lots of gloves, and an extravasation and spill kit... but no BSA calculator and no gowns. We're just not ready. I would like to lead the way, but I just don't have the experience.