List of SOPs - Nurses

62,170 views

Published on

Published in: Health & Medicine, Technology
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
62,170
On SlideShare
0
From Embeds
0
Number of Embeds
11
Actions
Shares
0
Downloads
138
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

List of SOPs - Nurses

  1. 1. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 List of SOPs - Nurses SZN HOO/160 Education and training of non-medical personels SZN HOO/161 Nursing care in Stem cell transplantation patients SZN HOO/162 Prevention and Infection Control Principles SZN HOO/163 Principles of Protective Isolation SZN HOO/164 Monitoring of patients and their environment during stem cell transplantation SZN HOO/165 Dietary and nutritional policy in stem cell transplanted patients SZN HOO/166 Central venous catheter care and nursing SZN HOO/167 Administration of high-dose chemotherapy – the role of a nurse SZN HOO/168 Nurse assistance - administration of cryopreserved stem cells graft SZN HOO/169 Nurse assistance - administration of non-cryopreserved stem cells graft SZN HOO/170 Oral Cavity care in Patients after High-dose Chemotherapy and Stem Cells Transplantation SZN HOO/171 Nausea and vomiting management – the role of a nurse SZN HOO/172 Pain management – the role of a nurse SZN HOO/173 Administration of immunosuppressive drugs Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 1/37
  2. 2. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Standard Operating Procedure (SOP) SZN HOO/160/version01 Education and Training of Non-medical personnel at the Transplant centre 1. Goal The goal is to prepare SOP to ensure specifications, qualifications, training and practice in specialized issues concerning the problem of transplantations of haematopoietic stem cells. It shall ensure and specify all documentation about qualification, training, education and practice of non- medical workers at the Transplant centre. Records must document competences of individual workers. 2. Scope of Application A head nurse, ward nurses, nurses, transplantation coordinators, laboratory workers, physiotherapists, dieticians, auxiliary nurses, nurse´s aides – all the non-medical personnel responsible for the nursing care for patients after transplantations of haematogenous cells. All nursing personnel must meet basic qualification prerequisites in accordance with Act No. 96 / 2004, Regulation No. 424 /2004 Coll. Nurses working without professional supervision must be registered according to Regulation No. 423/2004 Coll. 3. Competences and Responsibilities Head Nurse • She shall verify basic qualification, attestation and registration of workers. • She shall prepare job descriptions and a list of trainings for every position on the basis of local requirements. • She is responsible for familiarisation, training and education of all non-medical nursing workers. • Once a year she shall evaluate all her subordinate workers. • She shall see to the adherence of the prescribed procedures and trainings. • She shall archive all documentation. • She guarantees that all JACIE accreditation requirements concerning transplantations of haematogenous cells are included. • She organizes, leads and actively participates in seminars, publishes in professional magazines. • She organizes and leads nursing research. • She teaches students in her field. 3.2 Ward Nurse • She shall ensure training of personnel in all tasks concerning their work. • She shall ensure training and in-service training of new workers so that they obtain all information on obligations which will be delegated to them. • She shall ensure all documentation on trainings, in-service training, certificates, and compulsory regular trainings. • She evaluates in-service training of new workers. • Once a year she shall evaluate all her subordinate workers. • She shall archive all documentation. Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 2/37
  3. 3. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 • She organizes and actively participates in seminars, publishes in professional magazines. • She leads a nursing research. • She participates in the practical education of students. 3.3 New Personnel • They must be trained in all items and competences contained in their job description. • They shall only perform tasks in which they have been trained. 3.4 In-service Trained Personnel • They participate in regular trainings, seminars and continuously educate in the field and problems of transplantations of haematogenous cells. 4 Abbreviations and Definitions NELZP – non-medical health care occupations HS - Health and Safety at Work i.v. – intra venous 5 Devices and Material 6 Procedure 6.1 Basic Compulsory Entry Trainings All the nursing personnel • Fire fighting training • Evacuation Plan • HS • Work with chemical substances • Hygiene Rules General Nurses • Resuscitation • Peripheral venous access (cannulation) • Handling with and administration of cytostatic drugs • Administration of haematopoietic stem cells • All aspects of the nursing care for haematological-oncologic patients • High-dose chemotherapy and supportive treatment • Growth factors • Coping with infectious complications of immunosuppressed patients • Administration of blood products • Intensive nursing care 6.2 Regular Trainings • HS – a special training at the workplace once per 2 years (managing workers once per 3 years) • Peripheral venous cannulation once per 2 years • Resuscitation once a year • Handling with and administration of cytostatic drugs once a year • Regular trainings in the problems of haematological-oncologic patients twice a year 6.3 Publication, participation in nursing research, active and passive participation in haematological-oncology seminars. Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 3/37
  4. 4. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 7 Quality Control 8 Expected Results • All NEZLP working at HOU shall have the appropriate qualification • All NEZLP shall be trained according to the requirements of University hospital and JACIE • It will be possible to substantiate their competences for the performance of an activity. 9 Documentation University Hospital Directives Personal records of NEZLP – job descriptions, in-service training of a new worker, an evaluation of workers, syllabi of trainings and educations, attendance sheets. 10 Forms Attendance sheets for trainings Worker’s Evaluation 11 Related SOP 12 Miscellaneous • An agenda of trainings should correspond to the needs of the personnel. • It should be kept in all methods and styles – lectures, seminars, practice and self-study. • Every worker shall be provided an opportunity and is obliged to undergo such professional development and trainings as required by his/her profession. 13 References JACIE Recommendations Act No. 96/2004 Regulation No. 424/2004 Coll. Regulation No. 423/2004 Coll. CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 4/37
  5. 5. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/161/version01 Nursing Care in Hematopoietic Stem Cells Transplantation patients 4. Goal: To ensure the summary of all SOP defining procedures for the care of transplanted patients. 5. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides Rehabilitation workers, a dietician, coordinators 6. Competences and Responsibilities: Head nurse – the definition of nursing procedures and documentation, the inspections of adherence to the procedures, the care and settlement of mistakes Ward nurse – in-service training of new nurses and other personnel, the training of personnel, the assurance of appropriate aids and materials Nurse – the care for patients Auxiliary nurse – the nursing care and monitoring of patients Nurse´s aides – decontamination and cleaning of aids 7. Abbreviations and Definitions: SOP - Standard Operating Procedure 8. Devices and Material: They are specified in individual SOP 9. Procedure: The list of SOP defining individual procedures and problems of nursing: • Prevention and Infection Control Principles • Principles of Protective Isolation of Transplanted Patients • Monitoring of Patients and Environment during the Stem Cells Transplantation • Nutrition, Food Preparation and Diet Restrictions of Transplanted Patients • Assistance in Application, Treatment and Removal of Central Venous Catheter • Application of High-dose Chemotherapy – the Role of a Nurse • Nurse´s Assistance - Frozen Graft Transplantation • Nurse´s Assistance - Non-frozen Graft Transplantation • Oral Cavity care after High-dose Chemotherapy and Transplantation • Nausea and Vomiting management – the Role of a Nurse • Pain management – the Role of a Nurse • Administration of Immunosuppressive Drugs • Administration of Blood products 10. Quality Control: They are specified in individual SOP Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 5/37
  6. 6. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 11. Expected Results: Personnel will be familiarized with the summary of SOP on the care for transplanted patients. 12. Documentation: The nursing documentation of a patient in the clinical record 13. Forms: They are defined in individual SOP 14. Related SOP: Prevention and Infection Control Principles (162) Principles of Protective Isolation of Transplanted Patients (163) Monitoring of Patients and Environment during the Stem Cells Transplantation (164) Nutrition, Food Preparation and Diet Restrictions of Transplanted Patients (165) Assistance in Application, Treatment and Removal of Central Venous Catheter (165) Application of High–dose Chemotherapy – the Role of a Nurse (167) Nurse´s Assistance - Frozen Graft Transplantation (168) Nurse´s Assistance - Non-frozen Graft Transplantation (169) Oral Cavity care in Patients after High-dose Chemotherapy and Stem Cells Transplant (170) Nausea and Vomiting management – the Role of a Nurse (171) Pain management – the Role of a Nurse (172) Administration of Immunosuppressive Drugs (173) Administration of Transfusion Preparations (FN SLN / 001 / 01) 15. Miscellaneous: Mutual cooperation between nurses and other professions such as a dietician, a rehabilitation worker, a social worker, a transplantation coordinator is important. 16. References Requirements of the JACIE accreditation CHANGES/REVISIONS: Date: Reviewed/Approved by: Signature: Revision/change*: * Regular annual revisions marked bold Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 6/37
  7. 7. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Standard Operating Procedure (SOP) SZN HOO/162/version01 Prevention and Infection Control Principles 17. Goal: To eliminate risks of infections in patients after the Stem cells transplantation 18. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides Cleaning personnel 19. Competences and Responsibilities Head and ward nurses – the definition of the correct procedures and their observation, the compilation of a Hygiene Plan, the creation of educational materials, inspection Nurse – education of patients and their visitors, taking care of patients Auxiliary nurse – nursing care for patients Nurse´s aide – cleaning and disinfection of surfaces according to the Hygiene Rules of the station, handling with laundry Cleaning personnel – cleaning and disinfection of floors according to the Hygiene Rules of the station 20. Abbreviations and Definitions: No 21. Devices and Material: No 6. Procedure: The list of SOP defining individual procedures and principles of prevention and coping with infections and the problems of nursing: • Principles of Protective Isolation of Transplanted Patients • Monitoring of Patients and Environment during the Stem Cells Transplantation • Nutrition, Food Preparation and Diet Restrictions of Transplanted Patients • Assistance in Application, Treatment and Removal of Central Venous Catheter 7. Quality Control: Monitoring of the occurrence of infectious complications 8. Expected Results: Minimum occurrence of infectious complications 9. Documentation: They are defined in individual SOP 10. Forms They are defined in individual SOP 11. Related SOP Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 7/37
  8. 8. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Principles of Protective Isolation of Transplanted Patients (163) Monitoring of Patients and Environment during the Stem Cells Transplantation (164) Nutrition, Food Preparation and Diet Restrictions of Transplanted Patients (165) Assistance in Application, Treatment and Removal of Central Venous Catheter (165) 12. Miscellaneous: No 13. References 1. Vokurka Samuel et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005 2. Adams R., Herold C.E.: Sestra pro akutní stavy od A – Z, Grada, 2002 3. Educational materials by EDIPO CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation * Regular annual revisions marked bold Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 8/37
  9. 9. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Standard Operating Procedure (SOP) SZN HOO/163/version01 Principles of Protective Isolation 22. Goal: To define the environment for the treatment of patients treated by the Stem cells transplantation. 23. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides Cleaning personnel 24. Competences and Responsibilities: Head and ward nurses - the definition of the correct procedures and their observation, the compilation of a Hygiene Plan, the creation of educational materials, inspection Nurse - education of patients and their visitors, taking care of patients Auxiliary nurse - nursing care for patients, the preparation of food Nurse´s aide - cleaning and disinfection of surfaces according to the Hygiene Rules of the station, handling with laundry Cleaning personnel - cleaning and disinfection of floors according to the Hygiene Rules of the station 25. Abbreviations and Definitions: CVC – central venous catheter 26. Devices and Material: No 6. Procedure A patient for transplantation is only hospitalized in a room of the transplantation unit. Make the patient familiar with the hygiene regime – see Annex No. 1 below. Make the patient familiar with the regime of cleanings in the room according to the Hygiene Rules of the University hospital and the Department. Make the patient familiar with the regime of the food preparation and diet restrictions according to SOP (165). Make the patient familiar with the rules for regular monitoring according to SOP (164). A patient may only be treated or visited by persons without symptoms of an infectious disease. Upon entry to the room, personnel shall use a mask and gloves disinfected by a solution situated in front of the entrance door. Personnel shall use a gown at allogeneic transplantations at the time of preparation and neutropenia and in specific cases to prevent spreading of infections of the affected patient. Visitors shall enter with gloves, mask, in a gown and shoe covers. Persons close to the patient cooperating in his/her regular nursing and staying for a long time in the room of the patient may be allowed an individual regime upon agreement with Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 9/37
  10. 10. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 possible provision of clean nursing clothes, slippers, a mask and gloves need not be used if a careful hygiene of hands by disinfection is ensured (gloves are necessary for the direct treatment and hygiene of a patient). Visits of children are only allowed upon an express consent of a physician. There is a ban on the location of fresh or dried flowers and plants in the room. In case an examination outside the transplantation unit is necessary, a patient must be equipped with protective aids – a gown, a mask, a cap, gloves, shoe covers. 27. Quality Control: Monitoring of the occurrence of infectious complications. 28. Expected Results: Minimum occurrence of infectious complications. 29. Documentation: The nursing part of the clinical record of a patient The Cleaning Log-book 30. Forms: No 31. Related SOP: 1. Monitoring of Patients and Environment during the Stem Cells Transplantation (164) 2. Nutrition, Food Preparation and Diet Restrictions of Transplanted Patients (165) 32. Miscellaneous: No 33. References: 1. Vokurka Samuel et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005 3. Adams R., Herold C.E.: Sestra pro akutní stavy od A – Z, Grada, 2002 3. Educational materials by EDIPO CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 10/37
  11. 11. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Annex No. 1 Hygiene Regime of a Patient in the Room with Reverse Isolation • Total body hygiene – once a day with a disinfection soap and shampoo • Higher hygiene of hands – a disinfection soap + a disinfection solution - use of disposable gloves in case of need for toilet • Assurance of hygiene in the area of head and face by means of packed potable water • Care for the buccal cavity, nasal cavity, external auditory canal, soles and nails: Unless otherwise prescribed, the following applies: Buccal cavity – rinsing with Skinsept mucoza and packed potable water Nasal cavity – Mukoseptonex gtt. External auditory canal - Otosporin gtt. Soles and nails - Clotrimazol AL 1% spray • Personal clothes – daily replacement • Bed clothes – Daily replacement at granulocytes <1.0x109 /l, - Replacement three times a week at granulocytes > 1.0x109 /l - According to individual needs of a patient • Disposable hygiene aids – towels, wash cloths, handkerchiefs, underwear, covers • Daily replacement of disinfection solutions and glass in the room of a patient – a beaker with a mercury thermometer, a glass for rinsing the mouth, a glass with 3% solution of hydrogen peroxide for keeping a toothbrush, a drinking glass. • Daily drain off water from all water faucets in the room of a patient (the prevention of Legionella) • Observe a special preparation of food for patients – heating of all food in a microwave oven, re-baking of bread and rolls for the patients with a sterile regime (granulocytes <1.0x109 /l) • Daily check food in the fridge in the room of a patient and remove any remains of food within 24 hours • Daily replacement of tea and all packed drinks in the room of a patient Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 11/37
  12. 12. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Standard Operating Procedure (SOP) SZN HOO/164/version01 Monitoring of Patients and Environment during the Stem Cells Transplantation 34. Goal: To eliminate the risks of complications and ensure a safe environment for the stay of transplanted patients 35. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses 36. Competences and Responsibilities Head and ward nurse – correct procedures, their observation and performance of audits Ward nurse – training of personnel, the assurance of aids and materials Nurse – monitoring of a patient, keeping the documentation Auxiliary nurse – the nursing care and monitoring of a patient 37. Abbreviations and Definitions: ALO-JIP – the transplantation unit for allogeneic transplantations 38. Devices and Material: No 6. Procedure: • Observe the below-given instructions, unless otherwise individually recommended: o After the admission to the transplantation unit: 1. Smears for microbiological and cultivation examination - the skin around the central venous catheter insertion, groin, vagina, prepuce, rectum, nose, throat, oral cavity, urine. • Daily – 3 times: 1. Body temperature 2. Blood pressure and pulse • Daily - 1 time: 1. Weight and the balance of liquids (uptake and release of liquids); 2. Waist circumference (ALO-JIP); 3. Check of the central venous catheter, its coverage and the place of puncture; 4. Central venous pressure (ALO-JIP); 5. Vomiting and nausea (the number, quantity, smell, colour, traces); 6. Faecal discharge (the number, quantity, smell, colour, consistency and traces); 7. Bleeding – skin, epistaxis, haematemesis, melaena, enterorrhagia, menses, etc. 8. Skin condition and the intensity of sweating 9. Condition of the oral cavity mucosa according to WHO 10. Uptake of food and liquids Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 12/37
  13. 13. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 11. Pain of a patient according to VAS 12. Blood taking for the blood count examination • At the re-bandaging of the central venous catheter: A smear for cultivation before the skin disinfection • Once a week: 1. Smears for microbiological and cultivation examination – rectum, node, throat, oral cavity, urine 2. Taking of the Aspergilla antigen in blood (ALO-JIP) • 4 times a year and according to the need of the transplantation unit: 1. Hygiene-epidemiologic monitoring – scrapings, air, water 14. Quality Control: Hygiene controls Monitoring of the occurrence of potential infectious complications. 15. Expected Results: Minimum occurrence of infectious complications. 16. Documentation: The nursing part of the clinical record of a patient 17. Forms: Monitoring sheets of the nursing documentation Records on the uptake/release of liquids 18. Related SOP: No 19. Miscellaneous: No 20. References: No CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 13/37
  14. 14. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/165/version01 Nutrition, Food Preparation and Diet Restrictions in Transplanted Patients 1. Goal: 1. To ensure an adequate uptake of food 2. To ensure a low-bacterial food and to minimize the risk of transfer of an infection 2. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides A nutrition therapist 3. Competences and Responsibilities A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of aids and materials Nurse – the checks of food, the monitoring of the food intake, the education of a patient and visitors Nutrition therapist – the selection of suitable food, additions, nutrition supplements, the monitoring and evaluation of nutrition parameters of a patient, the education of a patient and visitors Auxiliary nurse – the preparation and serving of food Nurse´s aides - decontamination and cleaning of aids 4. Abbreviations and Definitions: BMI – body mass index GIT – gastrointestinal tract 5. Devices and Material: No 6. Procedure: Observe the below-given instructions: • At the admission of a patient: 1. Determine the weight and height of a patient and BMI according to the table 2. Select a potential diet regime with regard to the accompanying diseases of a patient – diabetes mellitus, renal failure, obesity, food allergies 3. Find out about special requirements of a patient – vegetarianism, religious orders 4. Instruct a patient on the possibility of an uptake failure in case of mucositis of the oral cavity and nausea. 5. Instruct a patient on his/her diet restrictions and bans at the time of transplantation: ⇒ Fresh fruit or vegetable which was not thermally treated Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 14/37
  15. 15. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 ⇒ Dried fruit ⇒ Mayonnaise and products containing mayonnaise ⇒ Blue cheese ⇒ Cakes and sweets containing cream and custard ⇒ Sweet frozen products ⇒ Domestic juices ⇒ Chocolate products and all sweets ⇒ Alcohol ⇒ Sour fish ⇒ Salt pastry – crisps, chips, all kinds of nuts, sticks, etc. ⇒ Non-boiled milk ⇒ Hamburgers, very spicy food ⇒ Instant food • During the hospitalisation: 1. Observe the instructions related to the preparation and serving of food to patients (below) 2. Daily monitor and record the uptake of food and liquids 3. Daily monitor the weight of a patient 4. Monitor complications limiting the uptake of food (nausea, vomiting, oral mucositis) 5. Offer energy and nutrition food supplements to a patient e.g. Nutridrink, Resource. 6. Regularly consult nutrition parameters and the condition of a patient with a physician and/or a nutrition therapist 7. Cooperate in the assurance and application of alternative nutrition regimes (feeding by a nasogastric/nasojejunal tube, parenteral feeding by the “all in one” system) After the discharge of a patient: 1. Give instructions to a patient on the feeding regime - given in the Recommendations for the Patients after the Bone Marrow Transplantation Rules for the food preparation: 1. Re-bake bread and rolls in a hot-air oven 2. Re-bake ham, unless vacuum-packed, packed in an AL kitchen foil 3. Sterilize warm food in a microwave oven – liquids for 3 minutes, solid food for 2 minutes • Serving of food: Handle the food in a disposable apron, gloves and with a head cover Use the dishes and trays of the transplantation unit Wash the dishes in a dishwasher – 2 hours at 60°C Disinfect trays according to the schedule in the Hygiene Plan Store the clean dishes in a designated cabinets daily cleaned by 0.5% Persteril and cover them with a sterile cloth The crossing of private dishes of patients and personnel with hospital dishes must not occur. Liquids and food in the original packages must be used within 24 hours after opening. Observe the rules of the Hygiene Plan of the University Hospital. 7. Quality Control: Inspection of the occurrence of infectious complications. 8. Expected Results: A patient has no complications in relation to the food serving. 9. Documentation: A patients clinical record – the monitoring card Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 15/37
  16. 16. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 10. Forms: No 11. Related SOP 1. The Hygiene Plan of the University Hospital 12. Miscellaneous: No 13. References: No CHANGES/REVISIONS: Date: Reviewed/Approved Signature: Revision/change*: * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/166/version01 Assistance in Application, Treatment and Removal of Central Venous Catheter 39. Goal: To minimize the risk of harm to a patient in relation to the central venous catheter. 40. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 41. Competences and Responsibilities A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of aids and materials Nurse – the preparation of a patient, aids, giving instructions to a patient, the assurance of examinations. Auxiliary nurse and a nurse´s aide – the decontamination and cleaning of aids. 42. Abbreviations and Definitions FR – physiological solution (Normal Saline inf.) 43. Devices and Material: They are defined at individual performances in the procedure below. 6.1 Procedure: Assistance in the cannulation of the central venous catheter suitably inform a patient about the process of the performance; Review potential allergy of a patient ; Prepare aids: Sterile aids: • Tampons, squares, a mask • Gloves • Straight pair of scissors Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 16/37
  17. 17. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 • A needle-holder and a sewing material • Needles – black (22G), pink (18G) • Syringes 20 ml 3 pieces • A kit for cannulation according to the physician’s choice Other aids: • Vomit bowls • A disinfection solution for the surgery disinfection • A local anaesthetic • FR • A three-way stopcock with tubing • A cover foil (occlusive dressing) • A mask, a cap, a gown (an open sterile shirt), an apron Prepare the place of puncture (shave, etc.) and adjust the patient´s position lying on the back; Prepare a local anaesthetic and further assist according to the needs of a physician; If not made by a physician, cover the place of the input of the central venous catheter by a sterile occlusal foil; Review the catheter is closed; Upon agreement with a physician organize an X-ray check of the central venous catheter position in the patient; With the knowledge of X-ray check results and upon consulting a physician start administrations to the central venous catheter; Make a record in the nursing documentation of a patient. 6.2 Procedure: Re-bandaging of the central venous catheter 6. Daily check and record the state of the central venous catheter to the treatment documentation: • The surrounding of the puncture and skin changes according to the WHO scale – see below • Pain according to the VAS scale 1 - 5 • The function of the catheter Evaluation of skin changes according to WHO grade 0 1 2 3 4 Finding No effect Erythema Erythema with itching Separation of the skin, ulceration Separation of the derma, necroses 7. Re-bandage the central venous catheter covered by an occlusal foil once a week on a specified day (usually on Tuesdays) In case of complication (a detachment of the foil, swelling of the place of puncture, erythema, etc.) treat and re-bandage the central venous catheter immediately 8. Prepare aids and materials: Sterile • Gloves • Squares, small brushes • The system of infusion lines (according to the unit) • A transparent cover foil Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 17/37
  18. 18. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Non-sterile • A disinfection for the surgery disinfection • A vomit bowl • 2 pieces of masks, a disposable PVC apron • 2 pieces of sterile tampons for scrapping from the surrounding of the puncture of the central venous catheter (before and after the disinfection for cultivation) 9. Inform the patient about the procedure; 10. Put on the mask to a patient and ensure suitable position – turn the head away from the place of puncture of the central venous catheter; 11. Take a mask and a disposable apron; 12. Carefully remove the old foil; 13. Take the first scrapping of the skin for microbiology; 14. Put on sterile gloves; 15. Perform disinfection and wait until it takes an effect; 16. Take the second scrapping of the skin for microbiology; 17. Apply a new sterile occlusal foil – the distance between the place of puncture and the edge of the foil must be at least 2 cm; 18. Replace infusion lines twice a week; 19. Underlay individual entries by a sterile cloth; 20. Assemble individual infusion lines on a sterile stand; 21. Close individual lumens of the central venous catheter; 22. Connect the filled infusion lines after the previous disinfection of entries of the central venous catheter. 6.3 Procedure: Removal of the central venous catheter 1. Remove the central venous catheter after the instruction given by a physician 2. Prepare aids and materials: A sterile stand • 1 pair of sterile gloves • Sterile squares • 2 pairs of surgical scissors • 1 piece of an anatomic tweezers • Fixation material – a transparent sterile cover foil A non-sterile stand: • A disinfection agent according to the Hygiene Plan • A sterile cloth • A vomit bowl • Fixation material – a sterile cover foil, an anti-allergic plaster • An envelope with sterile pitchforks • A sterile absorptive Gelaspon gelatine sponge - to stop bleeding • A sterile test tube + an identification label of the patient • A light source, a lamp, if needed • A gown of a disposable apron, a mask, gloves • Marked and filled in travellers for microbiological examinations (the end of the catheter) 3. Inform the patient about the procedure; 4. Put the mask on to a patient and ensure suitable position – turn the head away from the central venous catheter; 5. Take a mask and a disposable apron; Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 18/37
  19. 19. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 6. Carefully remove the old foil; 7. Put on sterile gloves using the correct technique; 8. Disinfect the area using sterile squares and observe the exposition time; 9. Release and remove all fixation stitches using tweezers and scissors; 10. Gradually take out the central venous catheter (by a sterile glove or tweezers) and at the same time apply the sterile square by which consequently press the place of puncture; 11. After the removal cut the end of the catheter away by the non-used sterile scissors to the marked sterile test tube; 12. Cover the place of puncture by a square and a plaster; 13. Send the taken samples to the microbiological unit; 14. Dispose of the residual material and aids according to the valid instructions; 15. Make an entry to the documentation of the patient. 7. Quality Control: Monitoring of an occurrence of related complications 8. Expected Results: Minimum occurrence of complications related to the central venous catheter 9. Documentation: The treatment documentation of a patient and monitoring sheets The Hygiene Rules of the University Hospital 10. Forms: The nursing part of the clinical record of a patient 11. Related SOP: SLN HOO/131A – Central Venous Catheter SNL/DOS/SOP/ 010/02 – University Hospital 12. Miscellaneous: No 13. References • Vokurka Samuel et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005 • Adams R., Herold C.E.: Sestra pro akutní stavy od A – Z, Grada, 2002 • J. Drábková. : Medicína naléhavých a kritických stavů, IDV Brno • Educational materials by EDIPO CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 19/37
  20. 20. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/167/version01 High–dose Chemotherapy Administration – the role of a Nurse 44. Goal: A safe application of high-dose chemotherapy 45. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 46. Competences and Responsibilities: A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of appropriate aids and materials Nurse – the preparation and monitoring of a patient, the preparation of aids, the application of cytostatics, documentation Auxiliary nurse - the nursing care and monitoring of patients Nurse´s aides - decontamination and cleaning of aids 47. Abbreviations and Definitions: OOPP - Personal Protective Equipment 48. Devices and Material: OOPP – Personal Protective Equipment 49. Procedure: 1. Accept from a physician only a precise treatment with a legible record containing: - The name of a cytostatic agent and the size of the dose - The kind and volume of a solvent - The manner and time of application 2. The treatment of a physician must be recorded and documented in: - The daily treatment card of a patient (a daily record on the disease development) - Form FN 3102-3110 Application of the Preparatory Regime before the Haematogenous Cells Transplantation Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 20/37
  21. 21. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 3. In case of any ambiguity in the record, consult the physician 4. Verify, whether the patient has been informed and prepared for the application of chemotherapy 5. When preparing and handling with cytostatics, use OOPP and observe instructions given in the respective nursing procedure and the FN directive called Preparation, Application and Handling with Cytostatics. 6. The prepared cytostatics shall be checked before application by another qualified person (a nurse, a physician) 7. Use an infusion pump for the administration of cytostatics to the central venous catheter 8. During the application monitor the condition and reactions of a patient 9. Repeat checking the speed of infusion and the appearance of cytostatics 10. In case of development of complications, inform a physician 11. Rinse each kind of a cytostatic agent with the solution of FR 12. After finishing the administration, confirm the application of the cytostatic agent by your signature in: - The daily nursing card of a patient (a daily record on the disease development) - Form FN SLN 3102-310 Application of the Preparatory Regime before the Stem Cells Transplant 13. Make a record on the application and procedure to a summary chronic card of a patient and the nursing documentation. 14. Dispose of the residues of cytostatics and aids according to the valid standards in FN 50. Quality Control: No 51. Expected Results: Precise application without complications 52. Documentation: The application of a cytostatic agent is documented in a total of 4 documents: A record in FN SLN 3102–3110- Application of the Preparatory Regime before the Stem Cells Transplantation A record in the daily nursing card of a patient (a daily record on the disease development) A record in the chronic card of a patient A record in the nursing documentation of nurses 53. Forms: FN SLN 3102-3110 Application of the Preparatory Regime before the Stem Cells Transplantation The daily nursing card of a patient (a daily record on the disease development) A chronic card of a patient The nursing documentation of nurses 54. Related SOP: The Rules for Application of the Preparatory Regime before the Stem Cells Transplantation (conditioning) – 111A The Nursing Care for Patients Treated by the Transplantation of Hematogenous Cells – 160 55. Miscellaneous: No 56. References: No CHANGES/REVISIONS: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 21/37
  22. 22. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/168/version01 Nurse Assistance - Frozen Haematopoietic Cells Graft administration 57. Goal: To specify the requirements for safe administration of a transplant to a patient 58. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 59. Competences and Responsibilities: A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of aids and materials Nurse – the preparation of a patient, the application of drugs, the fulfilment of the treatment prescribed by a physician, the preparation of aids, the assurance of necessary examinations Auxiliary nurse and a nurse´s aide - the decontamination and cleaning of aids. 4. Abbreviations and Definitions: Autologous transplant – the donor of cells is the patient himself CŽK – central venous catheter FR – physiological solution HPC – haemopoetic progenitor cells TK – blood pressure P – pulse TT – body temperature 5. Devices and Material: • A thermal bath with distilled water heated to 37°C • Resuscitation trolley • A tonometer, a stethoscope • A disinfection solution • A vomit bowl • A sterile cloth and sterile squares • Transfusion sets according to the number of bags with a transplant • A three-way stopcock with tubing for infusion therapy Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 22/37
  23. 23. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 • Syringes 50 ml and 5 ml • EDTA blood sample tube 2 ml (violet) • Sterile test tubes for microbiology sampling • An infusion bottle of the FR with a needle with an anti-bacterial filter (Mini Spike) • Syringes with pre-medication (unless otherwise prescribed) see no. 7 in the Procedure below 6. Procedure: 1. Unless other procedures is prescribed for the specific patient, the following applies: 2. Instruct the patient – he/she shall not eat and drink since the midnight before the performance 3. Unless otherwise prescribed, 2 hours before the transfer of the transplant start hyperhydratation of the patient by the infusion of Glucose 5% at the speed of 250ml/hour i. v. 4. Prepare aids and materials 5. Accept the transplant transported in a box, check the identification data in the traveller and confirm the acceptance and inform the physician 6. Inform the patient – recommend going to the toilet 7. Unless otherwise specified, apply pre-medication 15 minutes before the transfer of cells: - Hydrocortison 100 mg i.v., Dithiaden 1 mg i.v., Calcium gluconicum 10 ml i.v. 8. Ensure a suitable position of the patient in medium sitting position on the bed 9. Measure and record TK, P, TT. 10. Put a sterile cloth under the three-way stopcock with tubing with inputs and the infusion lines 11. Assist the physician according to his instructions in the process of defrosting of the transplant and prepare disinfection for the treatment of input ports of the bag with the defrosted transplant 12. Connect the three-way stopcock with tubing to the transfusion set 13. Pass the transfusion set to the physician to connect it to the disinfected port of the bag 14. After filling the set, take a sample of 1.5ml of a graft with a syringe connected to a three-way stopcock with tubing and divide: 2x 0.5 ml to sterile bottles for the HOU laboratory for the cultivation examination and 1x 0.5 ml to the EDTA test tube for the examination of the graft cells life time 15. Assist the physician in the connection of the set to the three-way stopcock and in the connection of a 50ml syringe 16. A physician shall start the transfer – the speed is governed by the condition of the patient, if possible within 30 minutes after defrosting 17. Record the time of the start of the transfer of cells, TK, P, TT and during the process and at the end 18. After applying each bag with the transplant, rinse the three-way stopcock with tubing with FR. 19. Check the condition of the patient after the transfer, measure and record TK, P, TT: - 4x after 15 minutes, 4x after 30 minutes, 4x after 60 minutes 20. After finishing the whole transfer rinse the cannula by FR 21. Replace the infusion line and unless otherwise prescribed, connect again the infusion with Glucose 5% at the speed of 250 ml /hour for the period of 3 hours after the transfer. 22. Store the empty bags in a designated fridge for the period of 24 hours 23. After 8 hours after the transfer take samples for the examination of ions of blood and urine + sedimentation 7. Quality Control: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 23/37
  24. 24. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Quality of the record of monitoring of physiological functions of a patient Quality of recording complications 8. Expected Results: The nursing personnel know the procedure of the performance and are able to cooperate with a physician. 9. Documentation: The nursing and the medical part of the clinical record of a patient 10. Forms: Accompanying sheets: Cryopreserved autologous HPC from aphaeresis Cryopreserved donor´s lymphocytes Protocol: The Transport of a Graft within the University Hospital 11. Related SOP: 115A – The Transplantation of the Cryopreserved Graft 12. Miscellaneous: Annex – Complications at the Transfer and Coping with Them 13. References: No CHANGES/REVISIONS: Date: Reviewed/Approved Signature: Revision/change*: SOP implementation * Regular annual revisions marked bold Annex – SOP SZN HOO/168 Complications at the Transfer and Coping with Them: 1) Toxic symptoms of the preservative solution: Nausea up to vomiting, irritation to cough, a foul taste in the mouth, shivers, increase and decrease of TT, P, TK, cramp like pains of abdomen up to diarrhoea Procedure: Slow down or stop the transfer and further according to the physician ´s instructions 2) Blood circulation overload: Cough, dyspnoea Procedure: Sitting position, oxygen, diuretics according to the physician´s instructions 3) Allergic reaction: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 24/37
  25. 25. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Nettle rash, skin itching, dyspnoea Procedure: The application of a corticoid, anti-histaminics according to the physician´s instructions 4) Acute infectious complications: Fever and ague, fever, heavy hypotension Procedure: The transfer must be suspended – the treatment of the infection according to the physician´s instructions Standard Operating Procedure (SOP) SZN HOO/169/version01 Nurse Assistance - Non-frozen Graft administration 60. Goal: To specify the requirements for safe transfer of a haematogenous cells to a patient 61. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 62. Competences and Responsibilities: A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of aids and materials Nurse - the preparation of a patient, the application of drugs, the fulfilment of the treatment prescribed by a physician, the preparation of aids, the assurance of necessary examinations Auxiliary nurse and a nurse´s aide - the decontamination and cleaning of aids. 4. Abbreviations and Definitions: Autologous transplant – the donor of cells is the patient himself CŽK – central venous catheter FR – physiological solution HPC – haemopoetic progenitor cells TK – blood pressure P – pulse TT – body temperature 5. Devices and Material: • Resuscitation trolley • A tonometer, a stethoscope • A trolley • A disinfection solution • A vomit bowl • A sterile cloth and sterile squares • Transfusion sets according to the number of bags with a transplant • A three-way stopcock with tubing Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 25/37
  26. 26. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 • Syringes 50 ml and 5 ml • EDTA test sampling tube 2 ml (violet) • Sterile test tubes for microbiology samples • An infusion bottle of the FR solution with a needle with an anti-bacterial filter (Mini Spike) • Syringes with pre-medication – unless otherwise prescribed – see items no. 7-8 in the Procedure below • The ABO transfusion kit at the transfer of marrow 6. Procedure: 1. Unless other procedures are prescribed for the specific patient, the following applies: 2. Instruct the patient – he/she shall not eat and drink before the performance. 3. Unless otherwise prescribed, 2 hours before the transfer start hyperhydratation of the patient by the infusion of the Ringer solution at the amount of 250ml /hour i.v. 4. Prepare aids and materials. 5. Accept the transplant, check the identification data in the traveller, confirm the acceptance and inform the physician. 6. Inform the patient – recommend going to the toilet 7. One hour before the transfer administer Paracetanol 500 mg per.os. 8. Unless otherwise prescribed, administer further pre-medication before the transfer: Hydrocortison 100 mg i.v., Dithiaden 1 mg i.v., Calcium gluconicum 10 ml i.v. 9. Prepare the patient to the medium sitting position on the bed. 10. Measure and record TK, P, TT, D. 11. Put a sterile cloth under infusion lines. 12. After disinfecting the input ports of the bag with a graft, insert the transfusion set with a three-way stopcock with tubing. 13. Review after filling the KS set of the donor by the security test – only applies to marrow 14. Re-connect the hyperhydratation from the yellow line to the white one 15. After checking the data connect the bag with the graft and start the transfer of cells according to the instructions of a physician (CAUTION Not by overpressure, 1-2 hours, 60-80 drops per minute, in case of KS non-conformity the initial speed shall be slower). 16. Record the time of the start of the transfer, TK, P, TT, D to the patient´s documentation 17. Check the condition of the patient during and after the transfer - TK, P, TT, D: - 4x after 15 minutes, 4x after 20 minutes, 4x after 60 minutes 18. After finishing the transfer rinse the cannula with a physiological solution and record the time. 19. Remove the infusion line and connect again the infusion with the Ringer solution for 3 hours. 20. Store the empty bags in a designated fridge for the period of 24 hours. 21. After 8 hours after the transfer take samples for the examination of ions in serum and urine + sedimentation 7. Quality Control: Quality of the record of monitoring of physiological functions of a patient Quality of recording complications 8. Expected Results: The nursing personnel know the procedure at the transfer of a transplant. 9. Documentation: The nursing and medical part of the clinical record of a patient 10. Forms: Accompanying sheets: Allogene HPC from aphaeresis Allogene bone marrow Donor lymphocytes Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 26/37
  27. 27. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Protocol: The Transport of a Graft within FN 11. Related SOP: 116A – The Transplantation of an Allogene Graft 12. Miscellaneous: Annex – Complications at the Transfer and Coping with Them 13. References: No CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation * Regular annual revisions marked bold Annex – SOP SZN HOO/169 Complications at the Transfer and Coping with Them: 5) Haemolytic reaction: Pain in chest, head, back, cyanosis, dyspnoea, tachycardia, hypotension, restlessness, shock Procedure: Stop the transfer and further treatment of the shock according to the physician´s instructions 6) Febrile non-haemolytic reaction: Shivers, ague, quick increase of TT Procedure: Suspend the transfer if it still persists and administer anti-pyretic drugs according to the physician´s instructions 7) Blood circulation overload: Cough, dyspnoea Procedure: Sitting position, oxygen, diuretics according to the physician´s prescription 8) Allergic reaction: Nettle rash, skin itching, dyspnoea Procedure: The application of a corticoid, anti-histaminics according to the Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 27/37
  28. 28. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 physician´s instructions 9) Acute infectious complications: Fever and ague, fever, heavy hypotension Procedure: The transfer must be suspended – the treatment of the infection according to the physician´s instructions Standard Operating Procedure (SOP) SZN HOO/170/version01 Oral Cavity care in Patients after High-dose Chemotherapy and Stem Cells Transplantation 63. Goal: To minimize complications associated with the harm of the mucosa of the oral cavity . 64. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 65. Competences and Responsibilities: A head nurse – the definition of correct procedures and their observation Ward nurse - training of personnel, the assurance of aids and materials Nurse – the monitoring of the patient´s condition, the administration of drugs and preparations, the fulfilment of a physician´s prescriptions. Auxiliary nurse and a nurse´s aide - the decontamination and cleaning of aids. 66. Abbreviations and Definitions: OM – oral cavity mucositis (a specific affection of mucosa after chemotherapy) 67. Devices and Material: A torch and Tongue depressor 68. Procedure: 1. After the admission of a patient instruct him/her about the risk of OM development. 2. Recommend to the patient the following basic care for teeth and the oral cavity: • Ordinary cleaning of teeth with a soft toothbrush, unless there is strong bleeding, otherwise rinsing with selected solutions and wiping the teeth with small brushes dipped in a solution. • Cleaning of artificial denture and its removal for night and during the day in case of OM. • Rinse the buccal cavity with solutions which shall be non-irritating, non-toxic and pleasant for the patient always after eating or as he/she likes, but at least 3 times a day Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 28/37
  29. 29. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 (it is not necessary to stick to the use of anti-microbial solutions, unless a clearly infectious affection is concerned and unless there is no other reason for their application - see item 4 below). 3. In case of the OM development, recommend continuing with the ordinary care specified above but with regard to individual tolerance of the patient. 4. In case of an ulcerous form of OM, the development of the infection in the area of the buccal cavity or in case of bleeding, rather use anti-microbial solutions for rinsing (e.g. preparations with the content of chlorhexidine, povidon-iodine, benzydamine), but always with regard to the tolerance by the patient – the goal is to ensure any regular and careful rinsing of the buccal cavity. 5. In case of pains of mucosae, agree with the physician on an efficient treatment by parenteral analgetics (e.g. tramadol) and opiates. You may also offer solutions with a local anaesthetic for testing (e.g. mesocain) or protective gels (e.g. Gelclair), but think of the possibility of absorption of mesocain, its overall effect with toxicity and limitations of the ability of swallowing. 6. Ask the patient daily on the feelings in the oral cavity, the ability to eat and drink. 7. Daily evaluate the development in OM by viewing by means of a torch and a tongue depressor (always carefully with regard to the patient´s condition), monitor individual areas of the buccal cavity (see the figure below) and evaluate the state of affection of the buccal cavity according to the WHO criteria and the pain according to VAS (see the table below) 8. In case of suspicion that the infection in the buccal cavity develops, inform the physician and carefully take a smear for microbiological and mycological examination. ORAL CAVITY I Soft and hard palate II Palatine ridge III Tongue IV Tonsils V Uvula WHO criteria of the seriousness of OM affection Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Not present Discomfort and light pain, flare of mucosae Defects of mucosae, Food can be accepted without limitations Defects of mucosae, only liquids can be accepted Impossibility to accept food and liquids (a table is possible) VAS - Visual Analogue Scale – Evaluation of Pain at OM Pain intensity: 0 = no pain, 5 = unbearable pain A patient shall mark the intensity of pain on the segment and express by a number. 0-------------5 69. Quality Control: Quality of keeping of documentation 70. Expected Results: Ordinary process of OM without the development of infectious complications. 71. Documentation: The nursing part of the clinical record of a patient 72. Forms: The nursing part of the clinical record of a patient 73. Related SOP: Physicians /140A – The Oral cavity care Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 29/37
  30. 30. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 74. References: 1. Vokurka Samuel et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005 2. Educational materials by EDIPO CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/171/version01 Nausea and Vomiting management – the Role of a Nurse 1. Goal: The suppression of nausea and vomiting in patients and associated complications 2. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses 3. Competences and Responsibilities: Head and ward nurse - correct procedures, their observation and performance of audits Ward nurse – the training of personnel Nurse – monitoring of a patient, the fulfilment of a physician´s instructions, the keeping of documentation. Auxiliary nurse – the nursing care and monitoring of a patient 4. Abbreviations and Definitions: No 5. Devices and Material: No 6. Procedure: 1. Instruct the patient on the risk of nausea and vomiting during transplantation 2. Never disparage nausea felt by the patient 3. Recommend basic measures for decreasing the feeling of nausea: - The selection of food and drinks with regard to the taste and wishes, unless there is another restriction - Easy to digest, non-irritating and rather cool food - Eat more often but by smaller portions - Rather exclude warm food and sparkling drinks Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 30/37
  31. 31. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 - Drink rather after meals or only small sips during the meal - Chew a gum after the meal according to your taste 4. Daily ask the patient about his/her feelings of nausea and vomiting 5. Monitor and record the intensity of problems – the number of individual vomiting and the difficulty of nausea on the visual analogous scale with the intensity from 0 to 10, where 10 is the highest degree of suffering for a patient and 0 is the condition without nausea. 6. Inform the physician about the problems of a patient and consider the introduction or adjustment of an anti-emetic treatment, 7. Administer anti-vomiting drugs according to a physician´s prescription. 8. Monitor the development of problems of the patient and the effect of the treatment. 11. Monitor the intake and output of liquids. 7. Quality Control: Audits of the nursing documentation. 8. Expected Results: A patient has no nausea or does not vomit or they decrease to a bearable level. 9. Documentation: The nursing part of the clinical record of a patient 10. Forms: NO The nursing part of the clinical record of a patient 11. Related SOP: Physicians /142A Management of Nausea and Vomiting 12. Miscellaneous: NO 13. References 1. Kris M. et al. ASCO Guideline for Antiemetics in Oncology: update 2005. 2. Vokurka S. et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005. CHANGES/REVISIONS: Date: Reviewed/Approv: Signature: Revision/change*: * Regular annual revisions marked bold Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 31/37
  32. 32. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Standard Operating Procedure (SOP) SZN HOO/171/version01 Pain management – the Role of a Nurse 75. Goal: To specify tasks in the monitoring and relief of pain. 76. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses Physiotherapists 77. Competences and Responsibilities: Head and ward nurse - correct procedures, their observation and performance of audits Ward nurse - training of personnel, the assurance of aids and materials Nurse - monitoring of a patient, the fulfilment of a physician´s instructions, the keeping of documentation. Physiotherapist – an adequate rehabilitation of a patient Auxiliary nurse – the nursing care and monitoring of a patient 78. Abbreviations and Definitions: CNS – the central nervous system 79. Devices and Material: No 80. Procedure: 1. Monitor the patient continuously and ask him/her about pain. 2. Find out its: locations start and duration of pain Intensity of pain according to the scale: VAS - Visual Analogue Scale – Evaluation of Pain Intensity Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 32/37
  33. 33. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 Pain intensity: 0 = no pain, 10 = unbearable pain A patient shall mark the intensity of pain on the segment and express by a number. 0-------------5-------------10 Quality of pain – a sharp, dull, burning, cutting, colicky pain Worsening factors (e.g. it is worse after movements, breathing in, etc.) Relieving factors (e.g. a relief position) 3. Record the data and inform the physician. 4. Try to influence the pain of a patient in a nursing way: • Distract his/her attention (e.g. telling a story, striking). • Find out whether the application of cold bandages or heat causes relief to a patient. 5. Cooperate in the further procedure specified by a physician, apply the prescribed medicines. 6. Monitor further development of the condition of a patient. 81. Quality Control Audits of the nursing documentation. 82. Expected Results Relief from pain. 83. Documentation Admission anamnesis in the clinical record of a patient. The nursing part of the clinical record of a patient 84. Forms: No The nursing part of the clinical record of a patient 85. Related SOP: SOP Physicians - /141A – Management of Pain SOP University Hospital - 015/01 - Control of Pain 86. Miscellaneous: Pain is what the patient says and exists when the patient feels it (Mc. Caffery 1983) Websites on the management of pain: www.algos.cz, www.pain.cz, www.linkaprotibolesti.cz 87. References B. Sofaer: Bolest, příručka pro zdravotní sestry, Grada, 1997 Vokurka Samuel et al.: Ošetřovatelské problémy a základy hemoterapie, Galén, 2005 Collective of authors: Vše o léčbě bolesti, příručka pro sestry, Grada, 2006 CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 33/37
  34. 34. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Standard Operating Procedure (SOP) SZN HOO/173/version01 Administration of Immunosuppressive Drugs 88. Goals: Safe and unified administration of immunosuppressive drugs 89. Scope of Application: A head nurse, ward nurses, general nurses, auxiliary nurses, nurse´s aides 90. Competences and Responsibilities: Head and ward nurse – the education of the nursing personnel, the verification of knowledge, audits Nurse – the application of immunosuppressive drugs, monitoring and education of a patient Auxiliary nurse – the monitoring of a patient, the measurement of blood pressure, pulse and temperature 91. Abbreviations and Definitions: Immunosuppressive drugs suppress a patient´s immune system to ensure the tolerance of the applied transplant and the prevention or treatment of the graft-versus-host disease (GvHD). ATG – anti-thymocyte globulin CyA – cyclosporin A (Sandimmun, Equoral, Consupren) FR – physiological solution 1:1 (0.9% of NaCl) MTX – Methotrexate OOPP – personal protective equipment 92. Devices and Material: OOPP, infusion solutions, infusion pumps and sets 93. Procedure for the most frequently used drugs: Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 34/37
  35. 35. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 7.1 CYCLOSPORIN A (CyA) e.g. Sandimmun, Equoral, Consupren 1. Remember – the risk is a nephrotoxicity, the elevation in liver tests, an arterial hypertension, neurotoxicity and shivers of limbs, hirsutismus (higher hairiness). 2. A dose of CyA is determined by a physician most frequently according to the levels of the drug in blood (the effective level is 100-300 ug/l). 3. Blood taking for the CyA level is performed from a different i.v. line than the one which is used for the administration of CyA. In case of one-way central venous catheters, the sample must be taken from peripheral blood (CyA persists in lines for a long time). 4. Intravenous application: day –1 to day + 3 after transplantation: 24-hour infusion or distributed to two doses after 12 hours (e.g. 8:00 a.m. to 8:00 p.m. and 8:00 p.m. to 8:00 a.m.), dilute in 500ml of FR or 5% glucose, administer through a separate i.v. line! From day +4 on: Dilute the dose in 50ml of FR or 5% glucose, administer twice a day for 3 hours (e.g. 8:00 a.m. to 11:00 a.m. and 8:00 p.m. - 11:00 p.m.) 5. Per oral administration: Commonly twice a day, a capsule or an oil suspension diluted in a drink – preferably in warm milk or cocoa, a different drink is possible, but never a grapefruit juice (the drub is not absorbed!). 7.2 METHYLPREDNISOLON - Solu-Medrol, Medrol 1. Remember – the risk is diabetes, skin atrophy, vessel fragility, osteoporoses and fractures. 2. A dose is determined by a physician. 3. After the i.v. application, dilute the dose in 20ml of FR and administer as a slow bolus. 7.3 METHOTREXATE (MTX) 1. Remember – the risk is the mucositis of buccal cavity, stomach and intestines, a skin damage and hepatotoxicity and to reduce the toxicity folic acid is administered (ac.folicum, Leucovorin). 2. A dose of MTX is determined by a physician. 3. After the i.v. application, dilute the dose in 20ml of FR and administer as a slow bolus. 4. For intrathecal (i.t.) application at the lumbar puncture dilute in Aqua for injection (usually 2-3ml after the agreement with a physician). 7.4 ANTI-THYMOCYTE GLOBULIN (ATG) - ATG Fresenius 1. Remember – it is produced from the rabbit serum and the risk is an allergic reaction (anaphylactic) during or shortly after the administration of ATG or so called serum disease with the pain of joints, temperatures and skin rash after 1 - 2 weeks upon administration. 2. Remember – to eliminate risks of an allergic reaction the intra-dermal test, pre- medication and careful monitoring of a patient is used. 3. Before the administration of the first ATG dose, ensure the intra-dermal test: - Apply intradermally 0.05ml of ATG on the right forearm - Apply the same quantity 0.05 ml of FR on the left forearm - Monitor the patient and the place of puncture every 15 minutes for the period of 1 hour Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 35/37
  36. 36. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 - In case of complications, inform the physician - The test is positive at the development of the local reaction with flare of 10mm and more, with a swell and itching on the forearm at the place of ATG administration - inform the physician! 4. Pre-medication: - As standard before ATG: Dithiaden 1 ampoule i.v., Calcium 1 ampoule slowly i.v., Solu-Medrol 80mg i.v. - As standard during the ATG infusion: Accompanying infusion of Solu-Medrol 80mg to 250ml of 5% glucose, administer i.v. by an infusion pump for the whole period of ATG infusion and 2 hours more 5. Intravenous administration of ATG: - Dilute the dose recommended by a physician in 500ml of FR - Verify once more the result of the intra-dermal test and the assurance of pre- medication - Administer by an infusion pump, usually for 4 hours 6. During and after the ATG administration carefully monitor the patient every 30 minutes - TK, P, temperature and breathing 8. Quality Control: Audits of the nursing documentation. 9. Expected Results: No harm to a patient or personnel due to the unprofessional administration of drugs. 10. Documentation: The nursing and medical part of the clinical record of a patient 11. Forms: No 12. Related SOP: No 13. Miscellaneous: No 14. References: Protocols of preparatory regimes of transplantations Manufacturer’s recommendation for the administration of individual drugs CHANGES/REVISIONS: Date: Reviewed/Approve d by: Signature: Revision/change*: SOP implementation Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 36/37
  37. 37. Haematological-Oncology Unit Clinical Unit No.: ...version01 copy: 1 * Regular annual revisions marked bold Processed by: XXXXXX Date: 20 November 2007 Reviewed by: XXXXXXXXXX Date: 25 November 2007 Approved by: XXXXXX Date: 5 December 2007 Valid from: 1 January 2008 Page: 37/37

×