Intervenção de enfermagem na prevenção e tratamento da mucosite da pessoa com doença oncológica em situação paliativa / Nursing intervention in the prevention and treatment of mucositis in people with oncological disease in a palliative situation

A mucosite provoca na pessoa com doença oncológica em situação paliativa dor e desconforto, com impacto negativo na sua vida. O enfermeiro desempenha um papel fundamental na prevenção e tratamento da mucosite do cliente com doença oncológica em situação paliativa, devendo para isso estar apto para usar ferramentas apropriadas para o diagnóstico, necessitando de conhecimento e competências para uma intervenção baseada na evidência. A partir da reflexão sobre a prática e da auscultação aos colegas do serviço onde desempenho funções de enfermagem com o objetivo de identificar as suas necessidades de formação, delineou-se como tema deste percurso Intervenção de enfermagem na prevenção e tratamento da mucosite da pessoa com doença oncológica em situação paliativa. Realizou-se um estágio em três contextos distintos: Unidade de Cuidados Paliativos (UCP), Serviço de Oncologia Médica e Serviço de Medicina. Foi efetuada pesquisa bibliográfica, elaborada uma revisão scoping, prestados cuidados na prevenção e tratamento da mucosite a pessoas com doença oncológica em situação paliativa, construídos documentos de apoio aos clientes e de apoio à prática dos enfermeiros e efetuada reflexão sobre a prática dos cuidados. O presente trabalho consiste no relatório no âmbito do 12º Mestrado em Enfermagem Médico-Cirúrgica, vertente Enfermagem Oncológica com o intuito de desenvolver competências comuns de Enfermeiro Especialista e específicas de Enfermeiro Especialista em pessoa em situação crónica e paliativa no domínio da intervenção de enfermagem na prevenção e tratamento da mucosite da pessoa com doença oncológica em situação paliativa, assim como promover a melhoria da qualidade dos cuidados no serviço em que trabalho. O presente trabalho consiste no relatório do estágio onde é refletido, analisado e discutindo os resultados e aprendizagens do percurso efetuado. Foi escolhida a Teoria do Conforto de Katharine Kolcaba enquanto referencial teórico no desenvolvimento do relatório. Ao longo do percurso foi possível desenvolver competências comuns e específicas de Enfermeiro Especialista, da European Oncology Nursing Society (EONS) e de Mestre, que são evidenciadas ao longo deste relatório, assim como contribuir para a melhoria dos cuidados à pessoa com doença oncológica em situação paliativa no serviço onde trabalho.

Mucositis trigger pain and discomfort in palliative cancer patients, with a negative impact on their lives. Nurses play a key role in the prevention and treatment of mucositis in palliative care patients with cancer disease and should be able to use appropriate diagnostic tools, knowledge and skills for an evidence-based intervention. Based on practice reflection and after consultation with colleagues in the service where I perform nursing functions with the purpose of identifying their training and knowledge needs, the subject of this study is Nursing intervention in the prevention and treatment of mucositis in palliative care patients with cancer. An internship was conducted in three different contexts: palliative care unit, medical oncology and medicine unit. A literature search was conducted, a scoping review was made, care was provided in the prevention and treatment of mucositis to patients with cancer disease in palliative situation, documents were created to support patients and nurses practice and reflection on the practice of care was accomplished. This study is a report within the scope of the 12th Master's Degree in Medical-Surgical Nursing in Oncology Nursing with the purpose of developing common and specific competencies of specialist nurses in chronic and palliative care situations in nurses' intervention in the prevention and treatment of mucositis in people with cancer disease in palliative situation, as well as promoting the improvement of the quality of care in the service where I work. This study consists of the internship report where the results and lessons learnt are reflected, analyzed, and discussed. Kolcaba's Theory of Comfort was chosen as a theoretical reference for the development of the report. Throughout the journey, it was possible to advance common and specific competencies of specialist nurses, the European Oncology Nursing Society (EONS) and the master's competencies, which are highlighted throughout this report, as well as contribute to improve the care provided to palliative cancer patients in the service where I work as a nurse.

Standardized nursing and clinical efficacy of OxyContin in reducing oral mucosal pain in patients with nasopharyngeal carcinoma: A randomized, double-blind, placebo-controlled study protocol.

BACKGROUND: Pain caused by oral mucositis (OM) is the main problem in the process of concurrent chemoradiotherapy for the nasopharyngeal carcinoma (NPC). This protocol aims to explore the standardized nursing and therapeutic effect of OxyContin on OM pain in the patients with NPC undergoing the concurrent chemoradiotherapy. METHODS: The experiment is a randomized clinical research, which was granted through the Research Ethics Committee of Shandong Provincial Third Hospital (No.20200802097). In this research, 90 NPC patients with OM induced by chemotherapy are enrolled, and the score of visual analogue >5 and the grade of OM >1 are evaluated. Patients with known allergy to OxyContin, the opioid abuse history, or major organ dysfunction, for instance, hepatic insufficiency, renal failure, and respiratory and heart failure, as well as a series of severe mental illness are excluded from our research. Patients in study groups receive standardized nursing and oral OxyContin. Patients in control groups only receive oral OxyContin. The analgesic effect could be assessed with the comparison of the visual analogue scale after and before the treatment. Safety evaluations contain the assessment of the vital signs, laboratory tests, as well as adverse events. The Karnofsky performance status standards of the International Cancer Control Union is utilized to evaluate the quality of life. RESULTS: The comparison of outcomes after taking OxyContin in both groups will be shown in .(Table is included in full-text article.) CONCLUSION:: The combination of OxyContin and standardized nursing care appears to improve the analgesic efficacy and life quality in NPC patients. TRIAL REGISTRATION: We registered this protocol in Research Registry (researchregistry6098).

Data-Driven Precision Implementation Approach.

: This is the third article in a new series about evidence-based practice (EBP) that builds on AJN's awardwinning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series features exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

Evidence-based interventions for cancer treatment-related mucositis: putting evidence into practice.

Mucositis is an inflammatory process that can involve the mucosal epithelial cells from the mouth to the rectum. Historically, mucositis and stomatitis were used interchangeably, but momentum has increased toward more specific terminology since the 2000s. Stomatitis refers to inflammatory diseases of the mouth, including the mucosa, dentition, periapices, and periodontium, whereas mucositis refers more globally to an inflammatory process involving the mucous membranes of the oral cavity and the gastrointestinal tract. In addition, differentiation is needed regarding mucositis involving the oral cavity and the remainder of the gastrointestinal tract that require use of a scope-type device for close examination. As a result, oral cavity mucositis has been the focus of the majority of the studies reported to date. The mucous membranes beyond the oral cavity are more challenging to view, so the mouth has been presented as revealing potential changes in the gastrointestinal tract. However, because of the variation in morphology, function of different locations, and risks associated with procedures to validate that speculation, evidence is limited. The purpose of this article is to review evidence-based interventions for mucositis, particularly in the oral cavity, and provide clinicians with guidelines for nursing interventions.

Outcomes evaluation of a weekly nurse practitioner-managed symptom management clinic for patients with head and neck cancer treated with chemoradiotherapy.

PURPOSE/OBJECTIVES: To determine whether improved monitoring through close follow-up with a nurse practitioner (NP) could enhance treatment compliance and decrease frequency of hospitalizations. DESIGN: Retrospective chart review. SETTING: An academic National Cancer Institute-designated comprehensive cancer center. SAMPLE: 151 patients aged 45-65 years diagnosed with stage III or IV oropharyngeal cancer. METHODS: Patients were nonrandomized to one of two groups: a prechemotherapy clinic group and a weekly NP-led clinic group. After examination of descriptive statistics, multiple linear and logistic regressions were used to compare groups across patient outcomes. MAIN RESEARCH VARIABLES: Hospitalization, chemotherapy dose deviations, and chemotherapy treatment completion. FINDINGS: The average number of visits during traditional treatment was three and, after initiation of the NP-led clinic, the number was six. The hospitalization rate was 28% in the traditional clinic group compared to 12% in the NP-led group. The rate of chemotherapy dose deviations was 48% in the traditional clinic group compared to 6% in the NP-led clinic group. Forty-six percent of patients in the traditional clinic group received the full seven scheduled doses of chemotherapy compared to 90% of patients seen in the NP-led clinic group. CONCLUSIONS: A weekly NP-led symptom management clinic reduces rates of hospitalization and chemotherapy dose deviations and increases chemotherapy completion in patients receiving intensive chemoradiotherapy for oropharyngeal cancer. IMPLICATIONS FOR NURSING: Patients receiving chemoradiotherapy benefit from close monitoring for toxicities by NPs to successfully complete their treatment and avoid hospitalization. KNOWLEDGE TRANSLATION: Early interventions to manage toxicities in patients with head and neck cancer can improve outcomes. NPs are in a key position to manage these toxicities and, when symptoms are controlled, costs are reduced.

Strategies for assessing and managing the adverse events of sorafenib and other targeted therapies in the treatment of renal cell and hepatocellular carcinoma: recommendations from a European nursing task group.

PURPOSE: As a group of European nurses familiar with treating patients with renal cell carcinoma (RCC) and hepatocellular carcinoma (HCC) using targeted/chemo- therapies, we aimed to review strategies for managing adverse events (AEs) associated with one targeted therapy, sorafenib. METHOD: Focusing on the AEs we considered the most difficult to manage (hand-foot skin reaction [HFSR], diarrhoea, fatigue and mucositis/stomatitis), we reviewed the literature to identify strategies relevant to sorafenib. Given the paucity of published work, this included strategies concerning targeted agents in general. This information was supplemented by considering the wider literature relating to management of these AEs in other tumour types and similar toxicities experienced during conventional anti-cancer therapy. Together with our own experience, this information was used to compile an AE management guide to assist nurses caring for patients receiving sorafenib. RESULTS: Our collated experience suggests the most commonly reported AEs with sorafenib and other targeted agents are HFSR, diarrhoea, fatigue, rash and mucositis/stomatitis; these generally have an acute (appearing at ∼0-1 months) or delayed onset (appearing at ∼3 months). Most management strategies in the literature were experience-based rather than arising from controlled studies. However, strategies based on controlled studies are available for HFSR and mucositis/stomatitis. CONCLUSIONS: Evidence, especially from controlled studies, is sparse concerning management of AEs associated with sorafenib and other targeted agents in RCC/HCC. However, recommendations can be made based on the literature and clinical experience that encompasses targeted and conventional therapies, particularly in the case of non-specific toxicities e.g. diarrhoea and fatigue.

Supportive care treatment guidelines: value, limitations, and opportunities.

Evidence-based guidelines in clinical oncology practice are now prominent, with emphasis on clinical, health outcome and economic perspectives. Given the complexity of cancer management, a multidisciplinary approach is essential. Evidence-based guidelines to address supportive cancer care have merged expert opinion, systematic evaluation of clinical and research data, and meta-analyses of clinical trials. Production of supportive care guidelines by the interdisciplinary team is dependent on sufficient high-quality research studies. Once published, it is essential they be customized at institutional and national levels. Implementation in clinical practice is perhaps the greatest challenge. Optimal management occurs through integration of country-specific issues, including care access, healthcare resources, information technology, and national coordination of healthcare practices. The purpose of this article is to: (1) provide an overview of interdisciplinary cancer management using evidence-based guidelines; (2) delineate the theory and practice of guideline dissemination, utilization and outcome assessment; and (3) recommend future research strategies to maximize guidelines use in clinical practice.

Nurse led electronic toxicity scoring in head and neck radiotherapy.

PURPOSE OF THE STUDY: In order to improve 'adherence' to a course of treatment for head and neck radiotherapy, patients need to be managed frequently. In order to achieve this in a busy clinical environment streamlined electronic tools must be utilised. By providing nursing teams with the capacity to conduct electronic toxicity scoring on a bi-weekly basis, adherence can be improved and closer attention paid to head and neck radiotherapy toxicities. METHODS AND MATERIALS: A convenience sample of 20 patients undergoing head and neck radiotherapy was analysed. Each of these patients had electronic toxicity data recorded on a bi-weekly basis for dysphagia, mucositis, skin reaction and weight loss. This information was then extracted from the ARIA™ patient information system and analysed. Additionally the time taken for the nursing team to undertake each patient review was also extracted from ARIA™. RESULTS: The efficiencies offered by an electronic medical record allow comprehensive toxicity data to be recorded and analysed effortlessly. The average time taken to review these patients on a bi-weekly basis was 6.97 min and contained on average 60 words of toxicity description and action. CONCLUSION: Electronic toxicity scoring offers many advantages to the radiation oncology nurse, increased efficiency allows more frequent patient interaction which will in turn aid adherence. In order to better manage the treatment course of head and neck radiotherapy patients, nurses must be provided with streamlined and efficient electronic means of recording data. In this way it is possible to review head and neck radiotherapy patients bi-weekly.

Mucosite oral: patobiologia, prevenção e tratamento / Oral mucositis: pathobiology, prevention and treatment

A mucosite representa a alteração bucal mais comum nos pacientes que se submetem à radioterapia de cabeça e pescoço e representa um importante fator de risco para infecções de ordem sistêmica. O mapeamento dos genes de expressão desta afecção foi feito, podendo-se identificar cinco fases da mucosite, as quais especifi cam características peculiares patobiológicas a cada uma delas.

Mucositis represents the more common buccal alterationin the patients who submit x-ray of head and neck and representsan important risk factor for infections of sistemic order. The mappingof the gens of expression of the affection was fact, being able itself toidentify fi ve phases of the mucositis, which specify pathobiology characteristics to each one of them.

Prevention and management of oral mucositis in patients with cancer.

OBJECTIVES: To review current evidence that applies to the development of a nursing plan of care for the prevention and treatment of oral mucositis related to cytotoxic therapy. DATA SOURCES: Research studies, review articles, evidence-based guidelines, web-based material, and clinical experience. CONCLUSION: Although high-level research evidence regarding mucositis is limited, use of multiple types of evidence in developing a structured plan of care facilitates improved patient outcomes and the advancement of the current body of knowledge. IMPLICATIONS FOR NURSING PRACTICE: Nurses play a key role in the identification and use of evidence to guide the care of patients at risk for cytotoxic therapy-related oral mucositis.

Ensuring accurate oral mucositis assessment in the European Group for Blood and Marrow Transplantation Prospective Oral Mucositis Audit.

Oral mucositis (OM) has substantial negative clinical, quality-of-life, and economic consequences for patients with haematologic malignancies who require myeloablative chemotherapy or radiotherapy. Uniform training in OM assessment is infrequent in clinical practice, so the true incidence and duration of OM are unknown. Nurses and physicians from the European Group for Blood and Marrow Transplantation recently undertook an audit of 214 patients (197 evaluable patients) treated at 25 centres, the Prospective Oral Mucositis Audit (POMA), to determine the incidence, severity, and duration of OM. To standardise the assessment of OM severity, the World Health Organization (WHO) Oral Toxicity Scale was used across centres. This article focuses on the quality control analyses that were conducted to ensure that OM was accurately assessed across all 25 centres. Twenty-two trainers, who received comprehensive training about POMA study design, pathobiology of OM, and endpoint assessment, educated staff at the 25 transplantation centres about OM assessment. The trained staff collected data by completing daily worksheets for each patient. Three quality control analyses, of 82, 1949, and 4111 worksheets respectively, showed a nurse assessment accuracy rate of 74%, 90%, and 90%. The most common errors were in assigning WHO grade 0 or 1. This analysis shows that training of nursing staff had a positive effect on assessment of OM severity, which should ultimately lead to improvement in the quality of supportive care.

Palifermin for patients with haematological malignancies: shifting nursing practice from symptom relief to prevention of oral mucositis.

Oral mucositis (OM) is an extremely debilitating side effect of certain high-dose chemotherapy and radiotherapy regimens. It is especially prevalent in patients with haematological malignancies who undergo myeloablative therapy and autologous haematopoietic stem cell transplantation (HSCT). Severe erosion of the lining of the oral cavity can make patients' everyday activities, including eating, drinking, swallowing, and talking, difficult or even impossible. Palifermin (Kepivance) was approved in Europe in 2005 for both prevention and treatment of this painful condition. It works at the epithelial level to help protect cells in the mouth and throat from the damage caused by chemotherapy and radiation, and to stimulate growth and development of new epithelial cells to build up the mucosal barrier. In the pivotal clinical trial, palifermin reduced the incidence, severity, and duration of severe OM. Palifermin was also well-tolerated; common adverse reactions reported included rash, pruritus, erythema, edema, pain, fever, arthralgia, mouth or tongue disorders, and taste alteration. In this article, nurses who are skilled in caring for patients undergoing HSCT review their clinical experience with palifermin, sharing practical advice about its reconstitution, dosing, and administration. By familiarising themselves with the use of palifermin, nurses can influence a shift in clinical practice away from OM symptom management to the more satisfactory situation of protecting patients against severe OM.

Management of oral mucositis at European transplantation centres.

Oral mucositis (OM), which occurs in many patients with hematologic malignancies treated with high-dose therapy and stem cell transplantation, is associated with substantial clinical, economic, and quality-of-life (QOL) consequences. It has been associated with an increased need for total parenteral nutrition and opioid analgesics, prolonged hospital stays, and increased risk of infection. The research subgroup of the European Group for Blood and Marrow Transplantation Nurses Group surveyed nurses at transplantation centres for their thoughts about the clinical, QOL, and economic consequences of OM; tools for assessing OM; strategies for preventing and treating OM; and the need for the development and implementation of treatment guidelines. The responses from 46 centres, in 16 countries, indicated that most nurses (91%) believe OM has a large effect on patients' QOL. Nurses are not highly satisfied with current treatments for OM, but they believe the discomfort is reduced with oral care protocols and mouthwashes. Oral mucositis is routinely and frequently assessed, however there are inconsistencies in how it is managed. Most centres used unpublished, centre-specific guidelines, and the survey found that most nurses agreed that published national guidelines would be valuable for standardising the assessment and management of OM.