Sharing on Lymphodema training 淋巴水腫之學習篇

December 22nd, 2016 in Reflection

Author: Lam Choi Hung, Carol

Affiliations: Breast Cancer Case Manager, Pamela Youde Nethersole Eastern Hospital, Hong Kong

曾經是外科乳科護士的我,現為腫瘤科乳癌個案護士,一直抱著學海無涯的心態,希望通過不斷學習和實踐,盡力理解乳癌病人的身心需要,努力為病者及其身邊人提供更為適切的護理和照顧 。

 

乳癌病者從確診、手術、輔助治療、以至步入康復階段,心情上不免經歷高低起伏,照顧上更有着不同的需要。身為護理專業的我們有着重要的角色去盡力明白、理解、協助並與病者同心同行去面對疾病及接受治療。

 

大部分乳癌病者都會有擔憂或面對淋巴水腫的困擾,其普遍性及對病者的影響正是我期望有機會可以深入學習和鑽硏的護理課題。

 

淋巴水腫主要是由於手術及電療所引發的後遺症,可於治療或康復階段發生。雖然現今的前哨淋巴切除技術已經大大減少了淋巴水腫的出現,但病者擔憂受其影響的情緒卻沒有因此而減少 。護士在處理淋巴水腫的角色上,主要是教育、評估、輔導及轉介為主,包括:向病者講解淋巴水腫的成因;教授如何調整在生活細節中的護理以減低水腫出現的機會;提供適切和及時的評估;以及轉介病者進行相關的物理或職業治療。

 

今年二月承蒙部門主管及同事的支持,讓我有機會遠赴澳洲坎培拉由淺入深學習處理淋巴水腫。課程為期三週,除了學習基本的病理成因,此行最重要的目標是學習淋巴水腫治療方法及技巧。

 

我們的學習小組共有14人,學員當中有五位是護士、兩位物理治療師、其餘的都是按摩治療師。在澳洲當地,對淋巴水腫護理的服務需求與日俱增,已經不是醫院可以單方面能應付得來,由社區護理服務給病者提供支援的模式遂應運而生。如何可以在醫院平台提供改善病人這方面的護理需要,這正是作為護士及有關機構值得深思的問題!

 

在三週的學習過程,與來自不同專業背景的海外同學一起集思互動,讓我獲益良多,大家的目標都是希望為淋巴水腫患者提供最為合宜的護理照顧。要成為一位合資格的淋巴水腫治療師,當然要過五關斬六將的完成評核及考試。有志者事竟成,我終於不負眾望取得了澳洲當地的認可治療師資格。

 

回到工作崗位,我一直思索如何學以致用幫助病人施行人手淋巴引流按摩治療,由於醫院實際工作安排真的不容抽身,要把這個想法付諸實行絕對是一個挑戰。 最後唯有嘗試簡化整套人手淋巴引流按摩治療法,以教導病者自己在家施行。意想不到的是,教導了五位有初期淋巴水腫徵狀的病者後,當中有四位都興奮地回覆這簡化版淋巴引流按摩有著明顯的紓緩果效,這鼓舞了我繼續思考如何在醫院平台上多走一步,在病者等候轉介的期間可推廣有關淋巴引流按摩。雖然仍有許多不足及有待改善之處,但初步成績已大大加強了自己的信心,並進一步滿足病者的護理需要。

 

practical-assessment

Practical Assessment

The 25th Multinational Association of Supportive Care in Cancer (MASCC) Meeting

August 11th, 2016 in Reflection

Author: Gillian Blanchard

Affiliations: Conjoint Lecturer School of Nursing and Midwifery, University of Newcastle, Australia 

MASCC 2016 brought together over 1070 delegates from 50 counties to Adelaide, South Australia.

The meeting’s motto is “supportive care makes excellent cancer care possible” and was held over 4 days from the 22nd to the 24th of June. It featured a pre-conference cancer nurse practitioner workshop and patient seminar; six pre-conference Study Group workshops (mucositis research, nutritional care in advanced cancer, supportive care and immunotherapy, end of life, cancer related cognitive impairment and sleep, drowsiness and fatigue), plenary sessions on survivorship, gastrointestinal toxicity, and the future of supportive care, a patient seminar, e-posters, and a parallel paper session for each MASCC Study Group.

ISNCC hosted a display at the conference; this provided Australian ISNCC members an opportunity to promote the work of ISNCC and the benefits of membership.

The Cancer Nurse Practitioner pre- conference workshop was organized by the Cancer Nurses Society of Australia Nurse Practitioner Specialist Practice Network (CNSA CNP SPN). This event was designed for Cancer Nurse Practitioners and Advanced Clinicians. The program incorporated plenary presentations and Supportive Care Interactive Learning Sets (SCILS) and was attended by 53 delegates.

The plenary sessions featured local and international speakers Prof Dorothy Keefe: Supportive care challenges, Dr Karen Mustian: Exercise oncology from behavior to biology – Treating cancer-related fatigue, Tracey Doherty: The role of the nurse in supportive care and Prof Lawrence Einhorn: Controversies in management of chemotherapy-induced nausea and vomiting.

The SCILS workshops focused on Breathlessness and persistent cough, Anxiety and Depression, Clots and novel anticoagulants and Oral health, mucositis and osteonecrosis of the jaw. Overall the workshop provided a great opportunity for networking and updating one’s skills and knowledge in the area of advanced practice nursing.

Prof Larry Einhorn presented ‘Nausea is the New Black’.  Prof Einhorn proposed that in 2016, nausea not vomiting is the main element of toxicity for Chemotherapy Induced Nausea and Vomiting (CINV) and that Olanzapine, an anti-psychotic, may be the most promising drug for mitigating nausea.  Indeed in 1974 when Prof Einhorn began using Cisplatin chemotherapy in testicular cancer patients they could experience up to 10 episodes of emesis a day and now the number is closer to zero.

Karen Mustian, an exercise physiologist and researcher spoke about the optimal dose of exercise for cancer related fatigue.  She advised health care professionals (HCP’s) need to become aware of our patients limitations and as such exercise should be individually tailored.  Karen emphasized that the bottom line is to avoid inactivity by starting slow and increase both intensity and duration of physical activity. Exercise interventions, it seems, are better than pharmaceuticals at reducing cancer related fatigue.

There were many other presentations that used improving patient engagement and partnering with others eg. Pharma, NGO’s and other HCP’s to meet the supportive care needs of our patients.  As clinicians we must be better at toxicity management as reported by patients, including managing both the physical and psychosocial burden these toxicities cause.

The MASCC guidelines and assessment tools can be found on their website at www.mascc.org

A Case Sharing- An Exceptional Challenging Cancer Patient

July 14th, 2016 in Reflection

Annda LumAuthor: Annda Lum

Affiliations: Pamela Youde Nethersole Eastern Hospital, Hong Kong

[Special acknowledgement to Dr Kwok Sing Ng, CP Mr Victor Kong, SWA Ms Christy Lee]

Case Background

Ms X was a 50 years old lady having hormonal-responsive, HER-2 positive breast cancer with multiple metastases in Feb 2013. She was initially managed in Hospital A, with chemotherapy and radiotherapy given, later defaulted follow-up. Afterwards, she had started to receive Tamoxifen and Herceptin since Mar 2014 in our Unit, eventually passed away in Dec 2015.

Characteristic Exceptions Demonstrated by Ms X

Throughout her treatment process, she demonstrated several characteristic exceptions.

Exceptional keen for hospitalization- prolonged stay in our Orthopedic unit for 537 days and 215 days in our unit without clinical indication.

Exceptional plan for hospitalization- after discharge from Hospital A, Ms X went to different hospitals and requested admissions.

Exceptionally being refused- because of Ms X’s violent behavior, several hospitals marked ALERT not to admit her.

Exceptional treatment refusal- Ms X refused most management as planned for her.

Exceptionally irritable- she attacked staff and generated ward conflicts multiple times. She was diagnosed having adjustment disorder, delusion disorder and personality difficulties.

Family Background and Psychosocial Formulation

Ms X had no contact with family after quarrel at her adolescence. She was an ex-jewelry saleslady. Lived alone in a public housing unit and a Comprehensive Social Security Assistance (CSSA) recipient. Ms X was discriminated by her neighbors too. After onset of her illness, she refused home. Ms X was defensive and hostile towards hospital staff. Nevertheless, she was nice and helpful towards other patients. For instance, she shared pizza with other patients in ward and assisted daily task of another elder in ward.

Ms X was referred to clinical psychologist for illness coping. Rapport building turned out to be a challenging task, as she appeared interpreting any assessment as an attempt to label her as mentally ill. Due to Ms X’s defensiveness and downhill physical condition, intensive psychotherapy targeting delusional beliefs or personality issues was not a realistic option. Instead, psychological intervention focused on providing emotional support and problem solving on her immediate concerns. Efforts were made to facilitate insight regarding how her cognitions affected emotions and medical treatment.

Last Journey and Team Reflection

When Ms X was very weak, she still did not disclose any after-death business. Our team paid much effort to find if Ms X had self-arranged her funeral matter before. Multiple NGOs were contacted and ultimately our social worker was able to identify one to address Ms X’s final need. During the last moments of Ms X, chaplain was invited to see her, our staff and social worker accompanied her at bedside. Conveyable comforts words like “let go” through her ears were done to enhance her spiritual peace. Ms X’s last wish of funeral concern was addressed and fulfilled at her final moment. She rested in peace without lingering time.

Even though Ms X was an exceptional challenging patient to care, we still tried our best to preserve her dignity and the humanity. Our team awareness was increased after debriefing was done regarding to our own emotions and feeling towards Ms X’s care. Mutual staff support with good team spirit was vital for this kind of challenge.

 

 

跨專業團隊合作新模式

May 27th, 2016 in Reflection

Author: Choy Yin Ping, NC (ONC), KWC

Affiliations: Nurse Consultant., Princess Margaret Hospital, Hong Kong

去年,我有幸代表我的團隊到首爾參加第二屆亞洲腫瘤科護理會議(AONS 2015 Conference),發表了有關跨專業團隊合作診治新服務模式的學術報告。很高興這份報告被大會評審為大會最佳報告之一。

所謂跨專業團隊合作診治新服務模式,是病人接受抗癌治療期間,除了醫生的診症外,我們會定期加入腫瘤科護士和其他專業團隊(如臨床藥劑師)的診症服務。這種服務模式最大的優點是各專業團隊可以發揮其專業所長,相互協作,為病人和家屬提供更有效率和更全面的服務。

腫瘤科護士可透過對病人的診症、評估、教育與輔導,發揮全人護理中「身、心、社、靈」的理念,提升了腫瘤科護士在癌症治療中的重要角色。這種嶄新的護理模式深得病人和其家屬的肯定,在每一次的病人滿意程度調查中,我們的護理診症服務都被給予很高的評價,實在令人鼓舞。

隨著癌症治療科學日新月異的發展,各種癌症的治愈機會愈來愈高,病人的壽命亦得以大大延長。病人和其家屬在治癌以至復康的漫長過程中所需的支援便愈來愈多。身為腫瘤科護士的我們肩負的任務將會愈加重大,但我深信這是我們專業發展中必須前進的路向,而這種跨專業團隊服務的模式相信亦是醫療發展的方向之一。

 

Choy Yin Ping

A new tool for the prediction of complications associated with febrile neutropenia

April 28th, 2016 in Reflection

Authors: Matthew Fowler, RN, B (Nurs) PGDip

Affiliations: Heart of England NHS Foundation Trust

This piece of work is adapted from an original article submitted by Matthew Fowler as follows:

Fowler, M., (2015) Management of Patients with Low-Risk Febrile Neutropenia. Cancer Nursing Practice, 14, (5), pp16-21.

Anti-cancer chemotherapy is well documented to cause a plethora of toxicities, however by far one of the most serious complications is that of febrile neutropenia (Innes et al 2003). As a practising ANP (Advanced Nurse Practitioner) for oncology and haematology I am frequently involved with the care and management of patients presenting with febrile neutropenia and was curious as to if length of stay could be reduced for this group of patients.

The NICE guidelines (2012) advocate that patients classified as Low Risk Febrile Neutropenia (LRFN) should be considered for management in the community setting and the tool most widely utilised to identify LRFN patients is the Multinational Association of Supportive Care of Cancer (MASCC) Risk Index which was devised by Klastersky et al (2000) and is demonstrated in Table 1 below

Teuffel et al (2010) have also identified a cohort of patients identified as LRFN in accordance with the MASCC risk index who unfortunately go on to develop complications necessitating hospital admission; this further substantiates the case for initial admission to hospital for a period of observation for LRFN patients. In response to some of the concerns raised about the MASCC risk index, Carmona-Bayonas et al (2011) devised the CISNE (Clinical Index of Stable Febrile Neutropenia) (see Table 2) tool to identify patients who are at low risk of developing complications of FN who can be discharged home after 24 hours if their CISNE score is 0.

Table 2 CISNE tool (Carmona-Bayonas et al 2011)

Characteristic Score
Performance Status >2 2
Stress Induced Hyperglycaemia 2
COPD 1
Chronic cardiovascular disease 1
Mucositis grade >2 1
Monocytes <0.2 1

 

Use of the CISNE tool has the potential to revolutionise the way in which patients with LRFN are cared for. There is potential for patients with LRFN to be discharged home after 24 hours with oral antibiotics and robust patient education. In my own area of practice, I am in the process of working with the consultant microbiologists, general physicians and oncologists to devise a robust pathway for early discharge of patients with LRFN using the CISNE tool.

This clearly has fundamental and far-reaching implications for both the healthcare economy and most importantly the cancer patient journey. This is the beginning of an exciting development and it is proposed that once this change in practice is embedded that we can begin researching a truly ambulatory model for management of patients with LRFN.

References

Carmona-Bayonas, A., Gomez, J., Gonzalez-Billalabeitia, E., Canteras, M., Navarrete, A., Gonzalvez, M. L., Vicente, V. and Ayala de la Pena, F. (2011) Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients. British Journal of Cancer, 105 (5): 612-617.

Innes, H.E., Smith, D.B., O’Reilly, S.M., Clark, P.I., Kelly, V. & Marshall, E. (2003) Oral antibiotics with early hospital discharge compared with in-patient intravenous antibiotics for low-risk febrile neutropenia in patients with cancer: a prospective randomised controlled single centre study. British Journal of Cancer, 89 (1): 43-49.

Klastersky, J., Paesmans, M., Rubenstein, E. B., Boyer, M., Elting, L., Feld, R., Gallagher, J., Herrstedt, J., Rapoport, B., Rolston, K., and Talcott, J. (2000) The Multinational Association for Supportive Care in Cancer Risk Index: A Multinational Scoring System for Identifying Low-Risk Febrile Neutropenic Cancer Patients. Journal of Clinical Oncology, 18 (16): 3038-3051.

National Institute for Health and Care Excellence (2012) Neutropenic Sepsis: prevention and management of neutropenic sepsis in cancer patients (CG51) London: National Institute for Health and Care Excellence.

Teuffel, O., Amir, E., Sung, L. & Alibhai, S. M. (2010) Treatment strategies for low-risk febrile neutropenia in adult cancer patients: A cost-utility analysis. (2010) Journal of Clinical Oncology, 28:15s, (suppl; abstr 6102)

 

 

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