Research for Queens Park common cases:
PATH-MED (Patient Assessment to Home Medicine)
> Common cases are related to musculoskeletal and neurovascular complications.
> Most of the patients in Queens Park comes from the Royal Columbian Hospital and Surrey Memorial
Hospital.Itismore of a rehabilitationcenterweremostof the patientstayforlongerperiodof time itcan
even rich to a month or longer.
> Every shift they have only 1 RN and all of them are LPN’s. My preceptor Irene Askew is an LPN. They
need to communicate withthe RN if there are nursing skills that are not belong in the scope of practice
What Are Fractures?
A fracture is the medical term for a broken bone.
There are many types of fractures,but the maincategories are displaced, non-displaced, open, andclosed.
Displaced and non-displaced fractures refer to the way the bone breaks.
Ina displacedfracture,thebonesnapsintotwoormore partsandmovessothatthe twoendsare notlined
up straight. If the bone is inmanypieces,it iscalleda comminuted fracture. Ina non-displaced fracture,the
bone cracks either part or all of the way through, but does move and maintains its proper alignment.
A closedfractureiswhenthebonebreaksbutthereisnopunctureor openwoundintheskin.Anopenfracture
isone inwhichthe bone breaksthroughtheskin;itmaythen recedebackintothe woundandnotbe visible
a risk of a deep bone infection.
Some fracture types are:
A transverse fracture is when the broken piece of bone is at a right angle to the bone's axis.
An oblique fracture is when the break has a curved or sloped pattern.
A comminuted fracture is when the bone breaks into several pieces.
This is commonly seen in arm fractures in children.
A pathologic fracture is caused by a disease that weakens the bones.
A stress fracture is a hairline crack.
The severity of a fracture depends upon its locationand the damage done to the bone and tissue near it.
Serious fracturescan have dangerouscomplications if not treated promptly; possible complications include
damage to blood vessels or nerves and infection of the bone (osteomyelitis) or surrounding tissue.
Recuperation time varies depending on the age and health of the patientand the type of fracture. A minor
What Are the Symptoms of a Broken Bone?
Signs and symptoms of a broken bone include:
Swelling or bruising over a bone
Deformity of an arm or leg
Pain in the injured area that gets worse when the area is moved or pressure is applied
Loss of function in the injured area
In open fractures, bone protruding from the skin
Fractures are usually caused by a fall, blow, or other traumatic event.
Pathologicfracturesarethose causedbydisease (suchas cancer)thatweakensthe bonesandcanoccurwith
littleornotrauma. Osteoporosis,adisorderinwhichthebonesthinandlose strengthastheyage,causes1.5
million fractures each year in the U.S. -- especially in the hip, wrist, and spine.
Fall prevention: Simple tips to prevent falls
1. Make an appointment with your doctor
Begin your fall-prevention plan by making an appointment with your doctor. Be prepared to answer
questions such as:
What medicationsare youtaking? Make a listof your prescriptionandover-the-countermedications
and supplements, or bring them with you to the appointment. Your doctor can review your
medications for side effects and interactions that may increase your risk of falling. To help with fall
prevention,yourdoctor may considerweaningyouoff certainmedications — such as sedativesand
some types of antidepressants.
Have youfallenbefore? Writedownthe details,includingwhen,whereand how youfell.Be prepared
to discuss instances when you almost fell but were caught by someone or managed to grab hold of
something just in time. Details such as these may help your doctor identify specific fall-prevention
Couldyourhealthconditionscause afall? Certaineye andeardisordersmayincreaseyourriskof falls.
Be prepared to discuss your health conditions and how comfortable you are when you walk — for
example,doyoufeel anydizziness,jointpain,numbnessorshortnessof breathwhenyouwalk?Your
doctor may evaluate your muscle strength, balance and walking style (gait) as well.
2. Keep moving
Physical activitycango a longway towardfall prevention.Withyourdoctor'sOK,consideractivitiessuch
as walking, water workouts or tai chi — a gentle exercise that involves slow and graceful dance-like
movements. Such activities reduce the risk of falls by improving strength, balance, coordination and
If you avoid physical activity because you're afraid it will make a fall more likely,tell your doctor. He or
she may recommend carefully monitored exercise programs or refer you to a physical therapist. The
physical therapist can create a custom exercise program aimed at improving your balance, flexibility,
muscle strength and gait.
3. Wear sensible shoes
with slick soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead wear
properly fitting, sturdy shoes with nonskid soles.
4. Remove home hazards
Take a look around your home. Your living room, kitchen, bedroom, bathroom, hallways and stairways
may be filled with hazards. To make your home safer:
Remove boxes, newspapers, electrical cords and phone cords from walkways.
Move coffee tables, magazine racks and plant stands from high-traffic areas.
Secure loose rugs with double-faced tape, tacks or a slip-resistant backing — or remove loose rugs
from your home.
Repair loose, wooden floorboards and carpeting right away.
Store clothing, dishes, food and other necessities within easy reach.
Immediately clean spilled liquids, grease or food.
Use nonslip mats in your bathtub or shower.
5. Light up your living space
Keep your home brightly lit to avoid tripping on objects that are hard to see. Also:
Place night lights in your bedroom, bathroom and hallways.
Place a lamp within reach of your bed for middle-of-the-night needs.
Make clear paths to light switches that aren't near room entrances. Consider trading traditional
switches for glow-in-the-dark or illuminated switches.
Turn on the lights before going up or down stairs.
Store flashlights in easy-to-find places in case of power outages.
6. Use assistive devices
Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can
help, too. For example:
Hand rails for both sides of stairways
Nonslip treads for bare-wood steps
A raised toilet seat or one with armrests
Grab bars for the shower or tub
A sturdyplasticseatforthe showerortub — plusa hand-heldshowernozzleforbathingwhilesitting
If necessary,askyourdoctorforareferral toanoccupational therapist.He orshe canhelpyoubrainstorm
otherfall-preventionstrategies.Some solutionsare easilyinstalledandrelativelyinexpensive.Othersmay
require professional help or a larger investment. If you're concerned about the cost, remember that an
investment in fall prevention is an investment in your independence.
Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.
Memorylossisan example.Alzheimer'sisthe mostcommontype of dementia. Dementiaisnotaspecific
disease.It'sanoveralltermthatdescribesawide range of symptomsassociatedwithadeclineinmemory
or other thinking skills severe enough to reduce a person's ability to perform everyday activities.
Alzheimer'sdiseaseaccountsfor60to80percentof cases. Vasculardementia,whichoccursafterastroke,
isthe secondmostcommondementiatype.Butthereare manyotherconditionsthatcancause symptoms
of dementia, including some that are reversible, such as thyroid problems and vitamin deficiencies.
Dementia is often incorrectly referred to as "senility" or "senile dementia," which reflects the formerly
widespread but incorrect belief that serious mental decline is a normal part of aging.
While symptoms of dementia can vary greatly, at least two of the following core mental functionsmust
be significantly impaired to be considered dementia:
Communication and language
Ability to focus and pay attention
Reasoning and judgment
People withdementia may have problems withshort-term memory, keeping track of a purse or
Many dementiasare progressive,meaningsymptomsstartoutslowlyandgraduallygetworse.If
you or a loved one is experiencing memory difficulties or other changes in thinking skills, don't
ignore them. See a doctor soon to determine the cause. Professional evaluation may detect a
treatable condition.Andevenif symptomssuggestdementia,earlydiagnosisallowsa personto
getthe maximumbenefitfromavailabletreatmentsandprovidesanopportunityto volunteerfor
clinical trials or studies. It also provides time to plan for the future.
Dementia is caused by damage to brain cells. This damage interferes with the ability
of braincellstocommunicate witheachother.Whenbraincellscannotcommunicate
normally, thinking, behavior and feelings can be affected.
damaged, that region cannot carry out its functions normally.
Differenttypesof dementiaare associatedwithparticulartypesof braincell damage inparticularregions
of the brain.For example,inAlzheimer'sdisease,highlevelsof certainproteinsinside andoutside brain
cells make it hard for brain cells to stay healthy and to communicate with each other. The brain region
calledthe hippocampusisthecenterof learningandmemoryinthebrain,andthe braincellsinthisregion
are often the first to be damaged. That's why memory loss is often one of the earliest symptoms of
While mostchangesinthe brainthat cause dementiaare permanentandworsenovertime,thinkingand
memory problems caused by the following conditions may improve when the condition is treated or
Medication side effects
Excess use of alcohol
Diagnosis of dementia
There isnoone testtodetermineif someone hasdementia.Doctorsdiagnose Alzheimer'sandothertypes
of dementia based on a careful medical history, a physical examination, laboratory tests, and the
characteristic changes in thinking, day-to-day function and behavior associated with each type. Doctors
can determine thata personhasdementiawithahighlevel of certainty.Butit'sharderto determinethe
exact type of dementiabecause the symptomsandbrainchangesof differentdementiascan overlap.In
some cases,a doctor may diagnose "dementia"andnotspecifya type.If thisoccurs it may be necessary
to see a specialist such as a neurologist or gero-psychologist.
Dementia treatment and care
Treatment of dementia depends on its cause. In the case of most progressive dementias, including
Alzheimer'sdisease,there isnocure and no treatmentthatslowsor stopsits progression.Butthere are
drug treatments that may temporarily improve symptoms. The same medications used to treat
Alzheimer's are among the drugs sometimes prescribed to help with symptoms of other types of
dementias. Non-drug therapies can also alleviate some symptoms of dementia.
increased participation in clinical studies. Right now, volunteers are urgently needed to participate in
more than 180+actively enrolling clinical studies and trials about Alzheimer's and related dementias.
Dementia risk and prevention
Some riskfactorsfordementia,suchas age andgenetics,cannotbe changed.Butresearcherscontinue to
explore the impact of other risk factors on brain health and prevention of dementia. Some of the most
active areas of research in risk reductionand prevention include cardiovascular factors, physical fitness,
Cardiovascular risk factors: Your brain is nourished by one of your body's richest networks of blood
vessels. Anything that damages blood vesselsanywhere in your body can damage blood vessels in your
brain,deprivingbraincellsofvitalfoodandoxygen.Bloodvessel changesinthe brainare linkedtovascular
dementia. They often are present along with changes caused by other types of dementia, including
Alzheimer'sdisease anddementiawithLewybodies.These changesmayinteractto cause fasterdecline
or make impairmentsmore severe.Youcanhelpprotectyourbrainwithsome of the samestrategiesthat
protect your heart – don't smoke; take steps to keep your blood pressure, cholesterol and blood sugar
within recommended limits; and maintain a healthy weight.
Physical exercise:Regularphysical exercise mayhelplowerthe riskof some typesof dementia.Evidence
suggests exercise may directly benefit brain cells by increasing blood and oxygen flow to the brain.
Diet: What you eat may have its greatest impact on brain health throughits effect on heart health. The
best current evidence suggests that heart-healthy eating patterns,such as the Mediterraneandiet,also
mayhelpprotectthe brain.A Mediterraneandietincludesrelativelylittleredmeatandemphasizeswhole
grains, fruits and vegetables, fish and shellfish, and nuts, olive oil and other healthy fats.
a. What isParkinson’s diseaseandwhatcausesit?
Parkinson's disease is a chronic, degenerative neurological disorder that affects one in 100 people over
age 60. While the average age at onset is 60, some people are diagnosed at 40 or younger. There is no
objective test, or biomarker, for Parkinson's disease, so the rate of misdiagnosis can be relatively high,
especiallywhenthe diagnosisismade by a non-specialist.Estimatesof the numberof people livingwith
the disease therefore vary, but recent research indicates that at least one million people in the United
States, and more than five million worldwide, have Parkinson's disease. Parkinson's disease was first
characterized extensively by an English doctor, James Parkinson, in 1817. Today, we understand
Parkinson's disease to be a disorder of the central nervous system that results from the loss of cells in
various parts of the brain, including a region called the substantia nigra. The substantia nigra cells
produce dopamine,achemical messengerresponsiblefortransmittingsignalswithinthe brainthatallow
for coordinationof movement.Lossof dopamine causesneuronsto fire withoutnormal control,leaving
patients less able to direct or control their movement. Parkinson's disease is one of several diseases
categorized by clinicians as movement disorders. The exact cause of Parkinson's disease is unknown,
although research points to a combination ofgenetic and environmental factors.If a continuum existed,
with exclusively genetic causes at one end and exclusivelyenvironmental causes at the other, different
Parkinson'spatientswouldlikelyfallatmanydifferentplacesalongthatcontinuum. Inthe past 10 years,
researchers have identifieda number of rare instances where Parkinson's disease appears to be caused
by a single geneticmutation.Inthese cases,the mutatedgene is passedfromgenerationto generation,
resultingina great numberof Parkinson'sdisease caseswithinanextendedfamily.Onthe opposite end
of the continuum, in the early 1980s, a group of heroin users in California took drugs from a batch
contaminated with a substance called MPTP. After ingesting this chemical,the drug users were stricken
with a form of Parkinson's disease that was primarily, if not exclusively, "environmental" in origin. For
most Parkinson's patients, the cause lies somewhere in the middle. While many Parkinson's patients
reportone or more familymemberswiththe disease,itisnotalwaysclear that one or several genesare
the cause. Similarly, while some patients suspect that exposure to one or another chemical or
environmental toxincausedtheirParkinson'sdisease,thisalsocannot be conclusivelyproved.Scientists
currently believe that in the majority of cases, genetic and environmental factors interact to cause
it is generally impossible to determine what specifically caused an individual's Parkinson's disease.
b. What are the riskfactors forParkinson’sdisease?Isthere anythingthatcan be done to reduce the
Because the causes of Parkinson's disease are unknown, there is no scientifically validatedpreventive
course to reduce the risk of its onset. The single biggest risk factor for Parkinson's disease is advancing
age. Men have a somewhat higher risk than women.
That being said, a number of studies have highlighted factors that are associated with either greater or
lesserriskof Parkinson's disease.Forexample,smokingandcaffeine consumptionhave beenassociated
with lower rates of Parkinson's disease, while head injury and pesticide exposure have been associated
or another, they highlight areas where further research may guide us to risk-prevention or treatment
c. How isParkinson’sdiseasediagnosed?
The cardinal symptoms of Parkinson's disease are resting tremor, slowness of movement (bradykinesia)
andrigidity.Manypeoplealsoexperience balanceproblems(postural instability).These symptoms,which
often appear gradually and with increasing severity over time, are usually what first bring patients to
a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the
otherside. Thereisnoobjectivetest(suchas abloodtest,brainscanorEEG) tomake adefinitivediagnosis
of Parkinson's disease. Instead, a doctor takes a careful medical history and performs a thorough
neurological examination, looking in particular for two or more of the cardinal signs to be present.
Frequently, the doctor will also look for responsiveness to Parkinson's diseasemedications as further
evidence thatParkinson'sisthe correct diagnosis.(However,startingonmedicationrightawaycan limit
your ability to participate in clinical trials that urgently need newly-diagnosed Parkinson's patients.) In
2011, the Foodand Drug Administration(FDA) approvedaspecializedimagingtechnique calledDaTscan
that allowsdoctorsto capture detailedpicturesof the dopamine systeminyourbrain.It is the first FDA-
approved diagnostic imaging technique for the assessment of movement disorders such as Parkinson's
disease. DaTscan alone can't diagnose Parkinson's disease by itself, but it can help confirm a physician's
clinical diagnosis -- something that has never been possible before. Unfortunately, because there is no
definitive testforParkinson'sdisease,andbecause Parkinson'sdisease symptomsare similartothose of
other neurological conditions, the misdiagnosis rate remains significant. It is worthwhile to consider a
second opinion, and to reach out to a neurologist with specific expertise in movement disorders.
d. What are the range of symptomsforParkinson’sdisease?
People are generally most familiar with the motor symptoms of Parkinson's disease, since they are the
mostexternallynoticeable.Thesesymptoms,which are alsocalledthe"cardinal"symptomsof Parkinson's
disease,are restingtremor,slownessof movement(bradykinesia),postural instability(balanceproblems)
and rigidity.Some otherphysical symptomssuch asgait problemsandreducedfacial expressionare also
of note. These are due to the same discoordination of movement that causes the better-knowntremor
and slowness. There is also increasing recognition of the importance of other Parkinson's disease
symptomsthatare sometimescalled"non-motor"or"dopamine-non-responsive."While neitherof these
terms is ideal, these symptoms are common and can have a major impact on Parkinson's patients.For
example, cognitiveimpairment, rangingfrommildmemorydifficultiesto dementia,andmooddisorders,
such as depression and anxiety, occur frequently. Also common are sleep difficulties, loss of sense of
when standing. Parkinson's disease symptoms manifest differently in different patients. Many patients
experience some symptomsandnotothers,andeventhe pace at whichthe disease worsensvariesfrom
person to person.
e.Will I die fromParkinson’sdisease?
Most doctors say that Parkinson's disease itself is not fatal. You die with Parkinson's disease, not from it.
However, as symptoms worsen they can cause incidents that result in death. For example, in advanced
cases, difficulty swallowing can cause Parkinson's patients to aspirate food into the lungs, leading to
pneumonia or other pulmonary conditions. Loss of balance can cause falls that result in serious injuries or
death. The seriousness of these incidents depends greatly on the patient's age, overall health and disease
f. How can I help speed a cure?
A Parkinson's disease diagnosis is life changing, and at times, it can feel as if things are spinning out of
control. One way to regain control is to get involved in the search for a cure by volunteering for clinical
research.Volunteersare vitallyneededforclinical studies,whichare the lastandcritical stage of research
before new treatments are brought to market. There is a particular need for newly-diagnosed patients
and for people who don't have Parkinson's disease (referred to as "controls"). Additionally, learn
aboutPPMI (Parkinson'sProgressionMarkersInitiative),aclinical studytofindbiomarkersof Parkinson's
disease.Currently,yourdoctordependsonthe descriptionyouprovide of yoursymptomsandtheirown
markertheycoulduse instead,muchlike aglucose measurementinthe managementof diabetes.That's
the goal of PPMI. Whetheryouyourselfare facingthe challenge of Parkinson'sdisease,orare touchedby
the disease inanotherway,everysingle personcan playa role in the search for a cure.The answeris in
all of us.
4. Hepatitis C
What Is Hepatitis C?
This infectionof the liveriscausedby the hepatitisCvirus.About3.5 millionpeople inthe U.S.have the
disease. But it causes few symptoms, so most of them don't know.
There are many formsof the hepatitisC virus.The mostcommoninthe U.S.istype1.None ismore serious
than any other, but they respond differently to treatment.
What Are the Symptoms?
Many people with Hepatitis have no symptoms. But you could notice these:
Jaundice (a condition that causes yellow eyes and skin, as well as dark urine)
Loss of appetite
How Do You Get It?
The virus spreads through the blood or body fluids of an infected person.
You can catch it from:
Sharing drugs and needles
Having sex, especially if you have an STD, an HIV infection, several partners, or have rough sex
Being stuck by infected needles
Birth -- a mother can pass it to a child
Hepatitis C isn’t spread through food, water, or by casual contact.
Who Gets It?
The CDC recommends you get tested for the disease if you:
Received blood from a donor who had the disease.
Have ever injected drugs.
Had a blood transfusion or an organ transplant before July 1992.
Received a blood product used to treat clotting problems before 1987.
Were born between 1945 and 1965.
Have been on long-term kidney dialysis.
Were born to a mother with hepatitis C.
How Is It Diagnosed?
You can get a blood test to see if you have the hepatitis C virus.
Are There Any Long-Term Effects?
Yes. About75% to 85% of people whohave it developalong-terminfectioncalled chronichepatitisC.It
can leadto conditionslikelivercancerandcirrhosis,orscarringof the liver.Thisisone of the topreasons
people get liver transplants.
How Is It Treated?
Hepatitis C treatments have changed a lot in recent years. In January 2016, the FDA gave approval to a
once-daily pill combinationof elbasvir and grazoprevir called Zepatier. It has been shown to have the
ability to cure the disease in almost 100% of those treated. It follows the success of another once-daily
treatment called Harvoni that cures the disease in most people in 8-12 weeks. Harvoni combines two
drugs: sofosbuvir (Sovaldi) and ledipasvir. In clinical trials, the most common side effects in both drugs
were fatigue and headache.
How Is It Treated? continued...
recent drugs are ombitasvir-paritaprevir-dasabuvir-ritonavir(Viekira Pak), ombitasvir-paritaprevir-
ritonavir(Technivie)anddaclastasvir(Daklinza) whichdonotrequire interferonandcure more people in
lesstime. Ombitasvir-paritaprevir-dasabuvir-ritonavirandombitasvir-paritaprevir-ritonavircarryan FDA
warning of severe liver injury if given to someone with underlying severe liver disease. All of these
medicines are quite expensive.
Instead, your doctor could recommend a combination of boceprevir(Victrelis), simeprevir (Olysio),
sofosbuvir (Sovaldi), or ), or telaprevir (Incivek) with interferon (which you take by injection),
and ribavirin(which comes as a liquid, tablet, or capsule).
Interferon and ribavirin used to be the main treatments for hepatitis C. They can have side effects
like fatigue, flu-like symptoms, anemia, skin rash, mild anxiety, depression,nausea, and diarrhea.
Your treatmentwill dependonmanythingsincludingwhattype of hepatitisCvirusyouhave. Inthe U.S.,
the mostcommontype isgenotype 1,followedbygenotypes2and3. Genotypes4,5,and 6 are veryrare
in the U.S. Your doctor will help you figure out what's right for you, based on your medical needs
and insurance coverage.
What Are the Side Effects?
The most common effects of hep C drugs are:
Low blood counts
Can You Prevent Hepatitis C Infection?
There’s no vaccine to prevent hepatitis C. To avoiding getting the virus:
Use a latex condom every time you have sex.
Don't share personal items like razors.
Be careful if yougeta tattoo,bodypiercingor manicure.The equipmentmayhave someone else'sblood
Don't donate blood or tissue if you’re infected.
5. Cytotoxic Precaution (Antineoplastic Drugs)
What are cytotoxic drugs?
Cytotoxicdrugsinhibitorpreventthe functionof cells.Cytotoxicdrugsare primarilyusedtotreatcancer,
frequently as part of a chemotherapy regime. Recently, their uses have expanded to treat certain skin
conditions (e.g., psoriasis),rheumatoid and juvenile rheumatoid arthritis, and steroid-resistant muscle
conditions. The most common forms of cytotoxic drugs are known as antineoplastic. The terms
‘antineoplastic’ and ‘cytotoxic’ are often used interchangeably.
Cytotoxicdrugscanpreventthe rapidgrowthanddivisionof cancercells.Theycanalsoaffectthe growth
of otherquickdividingcellsinthe body,like hairfolliclesandthe liningof the digestivesystem.Asaresult
of the treatment, many normal cells are damaged along with the cancer cells.
There are no exposure limits set for cytotoxic drugs. CUPE’s position is that even low-level exposure to
cytotoxicdrugsshouldbe avoided.The onlysafeoccupational exposure tocytotoxicdrugsisno exposure.
What are the risks of occupational exposure to cytotoxic drugs?
The toxicityof cytotoxicdrugscan make themdangerousto people whohandle them.Healtheffectsare
well documented.Studiesshowfrequentlydetectablelevelsof cytotoxicdrugsinthe airof hospital areas
where the drugs are prepared without proper biological safety cabinets. Health care workers preparing
the drugs without adequate precautions have tested positive for cytotoxic drugs in their urine.
Exposure to cytotoxicdrugs has beenreportedto cause increasedfrequencyof chromosome damage in
Theycan cause acute skin, eye,and mucous membrane irritations, as well as nausea,
headaches, and dizziness.
Cytotoxic drugs have also been associatedwith negative health effects for developing fetuses,including
higher incidences of spontaneous abortions, congenital malformations, low birth weight, and infertility.
As part of any cytotoxicexposure reductionplan,protective reassignmentfora workerwho ispregnant,
breastfeeding or intends to conceive a child must be put in place.
Repeated long-term occupational exposure to small amounts of cytotoxic drugs has not been identified
to cause of cancer. However, many cytotoxic drugs are known to be:
Genotoxic: a substance that damages DNA. Such damage can lead to the growth of a
Carcinogenetic: a substance that may cause mutations leading to the developmentof tumors in
otherwise healthy cells.
Mutagenic: a substance that alters the DNA of a living being, increasing the likelihood of
Who is at risk?
Anyone who works withpatients receiving cytotoxic drugs is at risk of exposure,and must be protected
while working withcytotoxic drugs. Exposure may occur when preparing,administering, or transporting
drugs, handling patient waste, transporting and disposing of waste, or cleaning spills.
If at any time there is skincontact withany cytotoxicdrug, the affectedworkershouldthoroughlywash
the affectedareawithsoap and water.The workershouldnotscrape or abrade the skinbyusinga scrub
brushas thiscouldincrease exposure.If eyecontacthasoccurred,flushthe affectedeye(s),while holding
back the eyelid(s),withcopiousamountsof waterforatleast15 minutes.Afteranytype of exposure,itis
always recommended to seek a medical evaluation by a physician.
Training and information
All staff whomay handle cytotoxicdrugsor waste by-productscreatedbytheiruse,includingphysicians,
nurses, assistants, pharmacists, stores and receiving personnel, housekeeping and maintenance staff
should receive training. Management and the health and safety committee should develop specific pre-
employmentworkertrainingproceduresforthe properhandling,mixing,anddisposal of cytotoxicdrugs
and waste by-products. These training procedures should:
Be written, posted, and available to all employees.
Explain how training is developed, delivered, and evaluated.
Describe the roles of supervisors to ensure proper regulations are followed.
A complete training program should cover the following topics:
Hazards of cytotoxic drugs
Methods of preparation
Use and disposal procedures
Proper use of protective equipment
Maintenance of the facilities and equipment
The department responsible for cytotoxic drugs should maintain a record of information on toxicity,
exposure treatment procedures,solubility, stability, and general descriptions of the appearance of all
cytotoxicdrugs that are used in the facility.Thisrecord shouldbe easilyaccessible andavailable tostaff
who may come into contact with cytotoxic drugs.
Drug preparation and reconstitution
Cytotoxicdrugsshouldonlybe preparedbypersonnel withthe propertraininginacentralizeddedicated
location. The hierarchy of hazard control should be put into effect to control the hazard as much
1. Engineering controls
The followingengineeringcontrolsshouldbe put in place where cytotoxic medications are being used:
1. A minimum of a Class II biological safety cabinet with HEPA filter exhaust systemsthat does not
allowairto be circulatedback intothe room shouldbe usedwhilemanipulatingcytotoxic drugs.
2. The preparation area within the cabinet should be covered with a plastic backed, absorbent
material to reduce dispersion and facilitate the clean-up of any spilled medication.
3. Medicationsshouldbe isolatedandlockedoutinsucha mannerthat onlythose properlytrained
have access to the storage location.
4. CSA approved,puncture proof containersforthe disposal of needles,syringesandvialsmustbe
provided. Labelled,sealable refuse bagsforthe puncture proofcontainersshouldalsobe available
inthe preparationarea.Contaminatedneedles,syringes,andvialsshouldbe disposed of intact.
5. Negative pressure rooms that prevent any spilled medication from leaving the room are
2. Personal Protective Equipment (PPE)
While handling any cytotoxic drugs, workers should use:
1. Protective gloves made of vinyl or nitrile rubber. Gloves should be changed frequently, or
immediatelyif punctured,cut,or torn. It is alsorecommendedthatworkerswear two pairs at a
time for additional protection.
2. A moisture resistant, long sleeved gown with elastic cuffs.
3. Chemical splash goggles, and if necessary, full-face protection.
4. Incaseswhere there isapossibility of the medicationbecomingairborne,apoweredairpurifying
respirator is recommended.
To prevent the spread of medication, protective clothing should not be worn outside of the
3. Additional controls
Special controls are required for the housekeeping and custodial staff regarding the potential hazards
involved in handling laundry or other materials that may be contaminated with biological fluids
contaminated with cytotoxic drugs.
Safe work procedures for handling these materials should be developedand taught to all affected staff.
Proper signage informing all employees of the presence of cytotoxic drugs and their hazards must be
developed and displayed in highly visible locations. Eating, drinking,smoking, applying makeup and the
storage of food should be completely prohibited in the preparation area.
Safety while caring for patients
Personal care workerswhocouldbe exposedtobiological fluidfromapatientwhohasreceivedcytotoxic
drugs within the previous 48 hours, and workers handling potentially contaminated linen should wear
protective gloves and disposable gowns that are discarded after use. It is up to management to ensure
that all staff are informedastowhenandwhere cytotoxicdrugsare beingusedsoappropriate measures
can be taken.
Plasticbags that are at least2mm thick (if polypropylene) or4mm thick (if polyethylene) shouldbe used
to collect potentiallycontaminated materials.Bags should be color-coded and labelled with a cytotoxic
warning label. All sharps should be placed in puncture proof containers before bagging. All workplaces
should have a policy for segregating waste materials resulting from cytotoxic drug preparation and
Housekeepingstaffshouldwearprotective gloveswhilehandlingwastecontainers.Cytotoxicwaste must
be handleddifferentlythanregulargarbage and mustbe disposedaccordingtoprovincial regulations.In
caseswhere the waste istobe incinerated,itshouldbe notedthatcompletelysealed(airtight)containers
that could build pressure and explode must be avoided. Temperatures of 1,000°C to 1,600°C should be
used to render the cytotoxic drugs harmless.
1. Spill kit
A clearly labelled cytotoxic spill kit should be kept wherever cytotoxic medications are being prepared,
stored, administered or received (shipping). The kit should contain:
Fit tested NIOSH certified respirators for any one that would be working in these areas
At least two sets of surgical gloves
Disposable eye protection
Scoop and scraper
Two large plastic disposal bags (minimum of 4mm thick)
Decontamination agent (i.e. a basic detergent of pH 8-9 and water)
Puncture and leak resistant waste container
Two sheets of absorbent material at least 30cm square
A spill needstobe cleanedbymembersof the staff thathave receivedthe appropriatetrainingandhave
the appropriate protective equipment; others should vacate the area as soon as it is safe to do so until
the spill is cleaned. All spills should be immediately marked with a warning sign to prevent exposure to
others. Glass should never be handled by hand; always use a scoop. The cleanup should be done by as
few people as feasible, but there should be at least two people involved.
2. Small spill cleanup
Small spills (less than 5ml or 5mg) that occur outside of a biological safety cabinet should be cleaned
immediately by personnel wearing gowns, doubled protective gloves and eye protection.
Small amounts of liquid should be wipedwith absorbent pads, while solids should be wiped witha wet
absorbentgauze.Spill areasshouldbe cleanedatleastthree timeswiththe detergent(describedabove).
Broken glass should be placed in a small container and placed in the disposal bags. All contaminated
materials should also be placed in the garbage bags.
Unbrokenglassware orreusableitemsthathave beencontaminatedshouldbe placedinaplasticbagand
washed, following the procedures for cleaning reusable items that have been developed for
3. Large spill cleanup
For spillsthatare larger than 5ml or 5mg, the cleaner’sinitial concern(afterpersonal protection) should
be limitingthespreadof cytotoxicdrugsthroughtheworkenvironment.Coverthe spill withanabsorbent
sheet or spill control pads. If the drug is in powder form, a wet or damp cloth should be used. For large
spills, protective clothing should be worn with the addition of the respirator to protect against any
airborne powder or aerosols. The use of chemical inactivates is not recommendedas they may create a
hazardousby-product.Aswithsmall spills,all contaminatedareasshouldbe cleanedaminimumof three
times, and all contaminated products and equipment should be disposed of or cleaned in an
4. Spills in a biological safety cabinet
Afterthe proceduresdescribedabove are followed,the interiorof the hoodmay alsorequire cleaning.If
the HEPA filterhasbeencontaminated,the unitmustbe labelled“Contaminated, DONOTUSE”.The filter
must then be changed and disposed of as soon as possible by trained personnel who are wearing the
appropriate protectiveclothing.Protective goggles(if notdisposedof) should be thoroughlycleanedwith
an alcohol wipe after cleanup.
Storing and transport
Areas where cytotoxic drugs are stored should be separated from regular storage, and clearly marked.
Engineeringcontrols(locks,limitedaccesskeycard systems) shouldbe in place to preventunauthorized
personnel fromenteringthe storage area.Aninventoryof the cytotoxicdrugsthatisfrequentlyreviewed
shouldbe keptinthe room,alongwithinstructionsforcleaningspills.Wherepossible,otherdrugsshould
notbe storedwithcytotoxicdrugs.Clearwarninglabelsshouldbe usedtoidentifythe cytotoxicdrugsand
pointouttheirhazards.Shelvesshouldalsobe fittedwithaliporbackslope thatpreventsthe drugsfrom
falling to the floor.
Whena damagedcontainerisfound,itshouldonlybe handledbytrainedpersonnelwithpersonal
shouldall be placedinthe appropriate puncture proof containeranddisposedof
as cytotoxicbiological waste.
Cytotoxic drugs should be securely capped and sealed and should be packed in impervious packing
material.Labelsof all boxes,containersandvialsshould indicate that the substance is a cytotoxic drug.
6. Bypass Graft
What isfemoral poplitealbypass surgeryandpercutaneous transluminalangioplasty (PTA)of the femoral
Femoral popliteal bypasssurgery isusedtotreatblocked femoral artery. The femoralartery isthe largest
artery in the thigh. It supplies oxygen-rich blood to the leg. Blockage is due to plaque buildup or
atherosclerosis. Atherosclerosis in the leg arteriescauses peripheral vascular disease. The same process
causes heart disease and stroke.
There are two methods used to treat a blockage of the femoral arteries.
Femoral poplitealbypass. The healthcare provideraccessesthe femoralartery throughalarge incision
inthe upperleg. A veintakenfromanotherareainyourlegisattachedabove andbelowthe blockage.
This is called a graft. The blood is rerouted through the graft around the blockage. In some cases, a
man-made graft may be used, rather than a vein graft.
Percutaneous transluminal angioplasty (PTA) of the femoral arteries. Percutaneous transluminal
angioplasty is a minimally invasive. That means it’s done without a large incision. Instead, the
healthcare providerusesalong hollow tube (catheter) insertedintothe femoral artery and guidesit
to the narrowed area. There, atiny balloon atthe cathetertipisinflated compressingthe fatty tissue.
This makes a larger opening in the artery for better blood flow. A tiny, expandable metal mesh coil
(stent) maybe putinthe newly opened areaof the artery. Ithelpskeepthe arteryfromnarrowingor
Why might I need a femoral popliteal bypass surgery?
You may need a femoral popliteal bypass surgery for:
Lifestyle changes and medicine have not improved symptoms, or symptoms are worse
Leg pain that interferes with daily life or ability to work)
Infection or gangrene
Leg pain at rest
Danger of losing the limb due to decreased blood flow
There maybe otherreasons foryourhealthcareprovidertorecommendfemoral poplitealbypasssurgery.
What are the risks of the femoral popliteal bypass surgery?
Some possible complications may include:
Irregular heart beats
Swelling of the leg
Blood clot in the leg
Fluid in the lungs
Bleeding where the catheter is put in after the procedure
Blood clot or damage to the blood vessel where the catheter is put in
Blockage in the graft used in bypass surgery
There may be other risksbasedon your condition. Be sure to discuss any concerns withyour healthcare
provider before the procedure.
What happens after femoral popliteal bypass?
In the hospital—femoral popliteal bypass
After the procedure, you will be taken to the recovery room and watched. Once your blood pressure,
pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or
your hospital room.
Your healthcare provider will check your pulsesbelow the surgical site often to check blood flow to the
limb.He orshe will alsowatchyourlegforcolor(paleorpink),warmth,sensationsof pain,andmovement.
The incision may be tender or sore for several days after the procedure. Take a pain reliever as
recommended by your doctor.
You may be on special IV medicine to help your blood pressure and your heart, and to control any
problems with bleeding. As you stabilize, your provider will gradually decrease, and then stop,
You can return to eating solid foods as you are able to handle them.
When your healthcare team determines that you are ready, you will be moved from the ICU to a
postsurgical nursingunit.Yourrecoverywill continue.Youcan graduallyincrease youractivityasyouget
out of bed and walk around for longer periods.
Arrange for a follow-up visit with your healthcare provider.
In the hospital—PTA of the femoral artery
Afterthe procedure,youwillbe takentothe recoveryroomatwatched.Once yourbloodpressure,pulse,
and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your
Tell yournurse rightawayif youfeel anychestpainor tightness,oranyother pain,aswell asanyfeelings
of warmth, bleeding, or pain at the insertion site.
The nurse will helpyouthe firsttime yougetup.Move slowlywhengettingupfromthe bedsoyoudon’t
You may be given pain medicine for pain or discomfort where the catheter was insertedor from having
to lie flat and still for a long period.
You can start to eat solid foods as you can handle them.
Your hospital staywill dependonyour conditionandthe resultsof your procedure.You will getdetailed
instructions for your discharge and recovery period.
Arrange for your follow-up visit with your healthcare provider.