your shift
Im admitting a patient for Blinatumomab- what are my resources, what will be different about my admit prep?
Blina nursing tip sheet on teams, you will use the CADD pump delivered by homecare (hopefully the day before), you will have pre-primed tubing, no fluid requirements,
it is up to you , the admitting nurse to communicate nothing to be run with blina, no trifuse, no bifuse unless needing NS, educate the family so they can stop errors before they happen.
Your patient receiving dinutuximab is refusing to take their tylenol q4. What do you do?
educate family, use child life, assess patient, address this in BMT rounds if 7L, watch for fevers, tachycardia, can it be skipped per the team? does it need to be changed to IV, do they need an ng tube? Bring this discussion to the team while they are in house, dont wait for them to start it.
My patient is coming in for their first dose of Dinutuximab, the parent asks why they are starting on a PCA (they only ever had one during stem cell transplant). What do you tell them?
GD2 is on a nuroblast and a nerve cell. Dinutuximab helps find these markers like a lock and key for their immune system to attack. It is painful when it happens on a nerve cell.
what resources can you give parents? What can you give kids?
You are paging about assessment concerns about a patient receiving immunotherapy. what must you have for adequate paging etiquette.
a full recent and document set of vs
i & o
focused assessment about your concerns
sbar ready- what do you want to get out of the page?
Don't forget to provider document every discussion!
you have an unexpected drug reaction. What do you chart and where?
Infusion Chemo Infusion Reaction
provider noficication
Im hanging my dose of dinutuximab, walk through the process from PPE to programming the pump.
check the hd/ list- follow the instructions. What if your drug isnt listed, who do you ask?
double check bsa, dose, paper orders (for now), make sure you are caught up on all your meds, your bolus and chemos (if on salvage) are given
check for blood return, program pump with double check, double check the pre-primed tubing are all connections secure?
smart pump program-
STAR moment- slow down.
change the VTBI to 70.. why?
change the rate to 5.
note the time to start your q15 min vs and when to increase the rate to 10.
When i go to change my blina there is still drug left in the bag at hour 24. what do i do?
This is on purpose! There is overfill to cover for unexpected delays so the patient gets the full 28 days of infusion. Unlike other medications, you will change- remember overfill is noted on the label and you should be changing volume in the MAW when scanning.
your patient receiving immunotherapy is hypotensive and has chills. They are afebrile. what will you do? what will happen next.
Full vs
focused assessment, cap refill, neuro, pulses
pause pump (unless blina), call team
infusion reaction vs other side effect- what will the team do?
You have a ndx ALL with no fluid orders. The resident hasn't rounded, the team doesn't bring this up in rounds. What do you do? Why is this important?
Fluids. 1.5x MIVF , no K, we want to support the body through tumor lysis, flush the kidneys, dilute the electrolytes.
IV + PO orders are not safe for a patient at risk for TLS (also always question IV +PO for general F/N admits as well- )
Anytime you chat with a provider you should what...
provider notification !
draw and explain how you will set up your pump for a patient being admitted for salvage therapy for neuroblastoma? You have them day 1 and 2. what is different.
lets chat!
You have to give IVIG - how do you know how fast to run it. Where are your resources?
IVIG calculation tool in pharmacy homepage
Lippincott
Up to date
I am admitting a patient for fevers who received Kymriah 3 days ago. What will my assessment be focused on. Why?
vs, neuro, perfusion,
this can be multiple things at once:
Cytokine response from the T Cell activation- hypotension, tachycardia, angioedema,
Tumor Lysis from B-Cell destruction- lab monitoring, uop, cardiac function
Capillary Leak- immune response from T cell, and from tumor lysis-
A sepsis alert fires on your dinutuximab patient overnight, you and the CN determine the patient looks bad and activate a huddle. Who do you page?
You will have the CN activate a RRT, you will also page the BMT APP on call so they are aware.
you are changing your continuous rate on your PCA. You have the order and change it on the pump, where in iCentra do you need to document the dose change?
in Advanced pain modalities and in MAR
your patient and parent are fighting off morning vitals and weights for your 0800 deadline. what are options you can give them to get these done?
you can get a dry weight- post void, post diaper change anytime after 0400, next time they are up to bathroom grab scale, you can get AM vitals from 0700-0800 but 0600 does not count for AM vitals
These have been discussed before admit with the team, but is often forgotten
You have a patient who received Kymriah and are admitted for fevers. They are tachycardic with softer BP. Your provider orders a 20/kg bolus, labs, abx, - what are you watching for, do you question anything. What would be your expected plan of care.
question the 20/kg bolus, what if they are having capillary leak with their CRS? what is the plan if the fluid doesn't work? When does the APP want to be notified?
What could be a contributing factor to so many AML count recovery patients having such intense nose bleeds?
Gemtuzumab. A late effect of this is nasal hemorrhage.
When working with your PCT for a patient on the BMT team, getting unituxin, getting blina or kymriah.. what can you delegate to them, what can you teach them to look out for?
vs frequency, when to notify you,- any vs change,
decreased uop , rash, coughing, confusion, looking or acting different. Strict i&o. real time charting.
Any parameter- bp max
Where do I document my discharge bag of blinatumomab?
Pediatric Infusion-Oncology band- Chemotherapy Verification.
Why do we need to chart this here?
what about NDX in general? Unituxin? What documentation is required?
Journey board, binder, central line book, unituxin orange book, skivolo story book, NBL calendar from care coordinator. (document on ad hoc- ndx teaching and in patient education in iView)
GMCSF- make sure they know how to give SQ shots- ad hoc form )
Meds- do they know how to take retinoic acid.
Your patient getting unituxin is having uncontrolled pain. what are your options?
up the pca, clinician bolus, change the drug, ketamine? do they need lidocaine in picu until disease has debulked?
I am giving Rituximab. after your second ramp you patient gets chills, mottled, tachycardic. What do you do? What is a likely cause?
Stop the pump, do a focused assessment and full VS, page the team.
You will need to know the rate of prior setting before this most recent ramping.
Decrease to prior rate and if directed restart at lower rate for remainder of infusion.
You have a lahey patient getting chemo or a BMT/chemo patient with a PICU fellow on at night- what is your chain of command for chemo clarifying questions. What is urgent/what can wait?
Lahey patients getting chemo-- oncology fellow (can even have a conference call w/ fellow and resident). Chemo/BMT protocol specific questions- can they wait? Ask the provider on call, then suggest ARCC and calling the attending if its urgent.
you have uop orders per void.. where do you document, where do you review in handoff?
Bonus: your unituxin patient has LOW urine output. what is going on? what do you expect to see throughout the 24 hours?
Bonus Bonus: Your Kymriah patient has LOW urine output. What is going on?
Bonus X 3: your NDX ALL has LOW urine output. You are watching the trends over your shift and the shift before you. What is going on?
BONUS Q/A - lets discuss~