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CarePartners Nursing Care Plan – Granulocyte Colony-Stimulating Factor (G-CSF)

Granulocyte Colony-Stimulating Factor Feb. 2017 Page 1 of 18

** If a CarePartners palliative care plan or oncology care plan is being used to guide the patient’s care, this Nursing Care Plan should be in addition to. **

Patient Name:

Date Initiated: Initials and Designation of Nurse Initiating Care Plan:

Initial Assessment Select the appropriate box according to the purpose of the G-CSF therapy.

Patient-Centred Goals SMART: Specific, Measureable, Attainable, Relevant and Time-related

Interventions/Teaching/Facilitating Self-Management/Discharge Planning

Include nursing procedures/delegated acts that will be taught to UCPs

Chemotherapy-induced Febrile Neutropenia

(Filgrastim)

Acute Myeloid Leukemia (Filgrastim)

Cancer Patients Receiving Bone Marrow Transplant (Filgrastim)

Peripheral Blood Progenitor Cell Collection

and Engraftment (Filgrastim). Refer to regional protocols from your area if you are administering Filgrastim for this purpose. Severe Chronic Neutropenia (Filgrastim)

Decrease the incidence of infection for patients receiving Myelosuppressive Chemotherapy (Filgrastim/Neulasta)

Hematopoietic Subsyndrome of Acute Radiation Syndrome (Filgrastim/Neulasta)

Patient/caregiver will: 1. Administer G-CSF as ordered

2. Be able to identify precautions associated

with G-CSF therapy and appropriately respond to complications

3. Be able to recognize signs of

myelosuppression including febrile

neutropenia and respond appropriately

Assessment: At each visit (document on flow sheet) 1. Adherence to medication regimen 2. Assess for side effects and signs of complications 3. Assess for signs of infection including: Fever higher than (38°C) Chills Cough or sore throat Severe constipation, loose stools, or diarrhea for more than 24 hours Mouth ulcers or sores in the throat or around the rectum Vomiting that continues 12 hours after treatment Painful or frequent urination, or inability to urinate for more than 4

hours Unusual vaginal discharge or itching Redness, swelling, or soreness of the skin around an implanted port Shortness of breath/chest pain Irregular or rapid heartbeat Blood in urine or stool

4. Complete assessment appropriate to care of oncology patients

Interventions (also refer to patient/caregiver teaching) 1. Measure vital signs at each visit (temp, pulse, BP, respirations) 2. Demonstrate, teach, assess administration of G-CSF as ordered,

document administration site (site rotation) 3. Teach signs of infection and prevention as well as complications. 4. Encourage client to verbalize concerns, signs of infection or

complications.

G-CSF Therapy

Filgrastim (Neupogen; Grastofil) (record start date, injection time, end date, dose, frequency and route) :

Neulasta (pegfilgrastim) (record start date, end date, dose, frequency and route). Neulasta is delivered once per cycle as a subcutaneous injection.

Other orders:

CarePartners Nursing Care Plan – Granulocyte Colony-Stimulating Factor (G-CSF)


Note: If a goal or intervention is no longer part of the care plan, cross out with one line and initial. When adding a goal or intervention to the initial plan, record the date and your initials beside the new entry.

(Nursing Care Plan Continued) Patient Name:

Patient/Caregiver Teaching Patient Response Date and initial/ designation

Medication dosage, actions, importance of taking at same time each day

*DO NOT ADMINISTER FILGRASTIM in the period of 24 hours before or after the administration of cytotoxic chemotherapy.*

*DO NOT ADMINISTER NEULASTA between 14 days before and 24 hours after administration of cytotoxic chemotherapy.*

Medication storage, safe handling and usage

Administration of G-CSF via subcutaneous injection (see handout), importance of site rotation and monitoring of injection site

Side effects of medication and response (see handout)

Monitor and record temperature twice a day

Signs and symptoms of infection and need to obtain medical help (i.e. temperature over 38°)

Steps and precautions to avoid infection

Review use of pager and 24/7 access if any concerns

Additional Teaching:

For more detailed information on Neupogen or Neulasta go to http://www.neupogen.com/ or http://www.neulastahcp.com/

Patient Safety Alert: Although Filgrastim and Neulasta are both G-CSF the dosing is significantly different. Ensure you are administering the correct dose and drug for the appropriate treatment regime.

Patient Safety Alert: Filgrastim dosing will vary based on the purpose of the therapy. Ensure you are following the appropriate treatment plan based on the purpose of the therapy.

Patient Safety Alert: Neulasta is typically administered subcutaneous as a single dose injection once per chemotherapy cycle. Neulasta is NOT indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.

http://www.neupogen.com/

http://www.neulastahcp.com/


Patient Handout: Neupogen/Neulasta Administration Prefilled Syringe

**PLEASE NOTE These instructions are for both Neupogen (orange packaging) and Neulasta (blue packaging). The administration is the same, the appearance of the medication syringe is different as well as the dosing. If you have any questions please discuss them with your nursing team**

Step 1: Prepare A - Remove the prefilled syringe carton from the refrigerator. Put the original carton with any unused prefilled syringes back in the refrigerator.

Remove the syringe tray from the carton. On a clean, well-lit surface, place the syringe tray at room temperature for 30 minutes before you give an injection.

Do not use the prefilled syringe if the carton is damaged. Do not try to warm the prefilled syringe by using a heat source such as hot water or microwave. Do not leave the prefilled syringe in direct sunlight. Do not shake the prefilled syringe.

Open the tray by peeling away the cover. Grab the orange safety guard to remove the prefilled syringe from the tray. For safety reasons:

Do not grab the plunger rod. Do not grab the gray needle cap.

Grab Orange Safety Guard Grab Blue Safety Guard If you are administering Neupogen your If you are administering Neulasta your syringe syringe guard will be orange. guard will be blue.


B - Inspect the medicine and prefilled syringe.

Label and Medication Expiration date

Window with markings

Gray needle Cap

Clear Plunger Needle Safety Guard Gray Needle Cap Turn the prefilled syringe so you can see the medicine window and markings. Make sure the medicine in the prefilled syringe is clear and colorless.

Do not use the prefilled syringe if: o The medicine is cloudy or discolored or contains flakes or particles. o Any part appears cracked or broken. o The prefilled syringe has been dropped. o The gray needle cap is missing or not securely attached. o The expiration date printed on the label has passed.

In all cases, use a new prefilled syringe and call your healthcare provider.

C - Gather all materials needed for your injection. Wash your hands thoroughly with soap and water.

On a clean, well-lit work surface, place the:

Prefilled syringe Alcohol wipe Cotton ball or gauze pad Adhesive bandage Sharps disposal container

Neupogen Syringe

Neulasta Syringe


Step 2: Get ready D – Choose your injection site. Sites you can use are:

Upper arm

Outer area of upper arm (only if someone else is

giving the injection)

Stomach area (abdomen) **except for a 2-inch area right around your navel (belly button)

Upper Outer Buttocks (only if someone else is

giving the injection)

Thigh

Prepare and clean your injection site with an alcohol wipe.

Let your skin dry. Do not touch this area again before injecting.

If you want to use the same injection site, make sure it is not the same spot on the injection site area you used for a previous injection.

Do not inject into areas where the skin is tender, bruised, red, or hard. Avoid injecting into areas with scars or stretch marks.

E - Hold the prefilled syringe by the syringe barrel. Carefully pull the gray needle cap straight off and away from your body.

Syringe Barrel


Do not remove the gray needle cap from the prefilled syringe until you are ready to inject. Do not twist or bend the gray needle cap. Do not hold the prefilled syringe by the plunger rod. Do not put the gray needle cap back onto the prefilled syringe.

Important: Throw the gray needle cap into the sharps disposal container.

F -

Check your prescription before you inject your dose.

Your healthcare provider has prescribed either a “full” syringe dose or a “partial” syringe dose of NEUPOGEN or NEULASTA. • If you are prescribed a full dose, you will inject all of the medicine from your prefilled syringe. For a full dose, go directly to Step 3: Subcutaneous (under the skin) injection. • If you are prescribed a partial dose of NEUPOGEN or NEULASTA, start with Step G below.

G - Point the needle up and tap gently until the air rises to the top.


H - Slowly push the plunger rod up to the line on the syringe barrel that matches your prescribed dose.

Plunger prescribed to dose

Important: Do not slide the orange safety guard over the needle before you give the injection. This will “activate” or lock the orange safety guard. As you push the plunger rod up, air and extra medication is removed. Check to make sure the plunger lines up with the syringe markings for your prescribed dose. If you remove too much medicine, get a new prefilled syringe and start again at

Call your healthcare provider if you have problems measuring your prescribed dose.

Step 3: Subcutaneous (under the skin) injection

I - Pinch your injection site to create a firm surface.

Important: Keep skin pinched while injecting.


J - Hold the pinch. Insert the needle into the skin at 45 to 90 degrees

K - Using slow and constant pressure, push the plunger rod until it reaches the bottom.

Do not pull back the plunger rod while the needle is inserted. When done, gently pull the syringe off of your skin. Important: When you remove the syringe, if it looks like the medicine is still in the syringe barrel, this means you have not received a full dose. Call your healthcare provider right away.

Step 5: Finish

L -

Before you finish! For your safety, pull the orange safety guard until it clicks and covers the needle.

Once extended, the orange safety guard will lock into position and will not slide back over the needle. Keep your hands away from the needle at all times. GRAB HERE


M - Discard (throw away) the used prefilled syringe.

Put the used prefilled syringe in a FDA-cleared sharps disposal container right away after use.

Do not throw away (dispose of) the prefilled syringe in your household trash. If you do not have a FDA-cleared sharps disposal container, you may use a household container that is:

o made of a heavy-duty plastic, o can be closed with a tight-fitting, puncture-resistant lid, securing sharps inside, o upright and stable during use, o leak-resistant, and o properly labeled to warn of hazardous waste inside the container.

When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. Do not reuse the prefilled syringe. Do not recycle the prefilled syringe or sharps disposal container or throw them into household trash. Important: Always keep the sharps disposal container out of the reach of children.

N - Examine the injection site.

If there is blood, press a cotton ball or gauze on your injection site. DO NOT rub the injection site. Apply an adhesive bandage if needed.


Patient Handout: Filgrastim Administration Single-Dose Vial

Step 1: Prepare A - Remove the vial from the refrigerator.

On a clean, well-lit surface, place the vial at room temperature for 30 minutes before you give an injection.

Do not try to warm the vial by using a heat source such as hot water or microwave. Do not leave the vial in direct sunlight. Do not shake the vial. Use the vial only 1 time.

Vial

B - Inspect the vial.

Make sure the medicine in the vial is clear and colorless. Do not use the vial if:

o The medicine is cloudy or discolored or contains flakes or particles. o The expiration date printed on the label has passed.

In all cases, use a new vial and call your healthcare provider.

Disposable Syringe Plunger Needle Cap

Syringe barrel with markings

C - Gather all materials needed for your injection.

Wash your hands thoroughly with soap and water. On a clean, well-lit work surface, place the:

Vial Disposable syringe and needle 2 alcohol wipes Cotton ball or gauze pad Adhesive bandage Sharps disposal container

Only use the disposable syringes and needles that your healthcare provider prescribes. Only use the syringes and needles 1 time. Discard (throw away) any used syringes and needles. You should only use a syringe that is marked in tenths of milliliters (mL).

Your healthcare provider will show you how to measure the correct dose of FILGRASTIM. This dose will be measured in milliliters (mL).


Step 2: Get Ready

D - Take the cap off the vial. Clean the rubber stopper with one alcohol wipe.

E - Check the carton containing the syringe. If the carton has been opened or damaged, do not use that syringe. Dispose of (throw away) that syringe in the

sharps disposal container.

F - Hold the syringe by the barrel with the needle cap pointing up. Carefully pull the needle cap straight off and away from your body.

Pull back on the plunger and draw air into the syringe that is the same amount (mL) as the dose of FILGRASTIM that your healthcare provider prescribed. Important: Throw the needle cap into the sharps disposal container.

G - Keep the vial on the flat working surface and insert the needle straight down through the rubber stopper. Do not insert the needle through the rubber

stopper more than 1 time.


H - Push the plunger down and inject all the air from the syringe into the vial of FILGRASTIM.

I - Keep the needle in the vial and turn the vial upside down. Make sure that the FILGRASTIM liquid is covering the tip of the needle.

J - Keep the vial upside down and slowly pull back on the plunger to fill the syringe barrel with FILGRASTIM to the correct marking amount (mL) of medicine that

matches the dose your healthcare provider prescribed.

K - Keep the needle in the vial and check for air bubbles in the syringe. If there are air bubbles, gently tap the syringe barrel with your finger until the air bubbles

rise to the top. Slowly push the plunger up to push the air bubbles out of the syringe.


L - Keep the tip of the needle in the liquid and again pull the plunger back to the number on the syringe barrel that matches your dose. Check again for air

bubbles. The air in the syringe will not hurt you, but too large an air bubble can reduce your dose of FILGRASTIM. If there are still air bubbles, repeat the steps above to remove them.

M - Check again to make sure that you have the correct dose in the syringe. It is important that you use the exact dose prescribed by your healthcare provider.

Do not remove the needle from the vial. Lay the vial down on its side with the needle still in the vial.

Step 3: Get ready N – Choose your injection site. Sites you can use are:

Upper arm

Outer area of upper arm

(only if someone else is giving the injection)

Stomach area (abdomen) **except for a 2-inch area right around your navel (belly button)

Upper Outer Buttocks

(only if someone else is giving the injection)

Thigh

Prepare and clean your injection site with an alcohol wipe. Let your skin dry. Do not touch this area again before injecting. If you want to use the same injection site, make sure it is not the same spot on the injection site area you used for a previous injection. Do not inject into areas where the skin is tender, bruised, red, or hard. Avoid injecting into areas with scars or stretch marks.


Step 4: Subcutaneous (under the skin) injection

O - Remove the prepared syringe and needle from the vial.

P - Pinch your injection site to create a firm surface.

Important: Keep skin pinched while injecting.

Q - Hold the pinch. Insert the needle into the skin at 45 to 90 degrees

R - Using slow and constant pressure, push the plunger rod until it reaches the bottom.

Do not pull back the plunger rod while the needle is inserted. When done, gently pull the syringe off of your skin. Important: When you remove the syringe, if it looks like the medicine is still in the syringe barrel, this means you have not received a full dose. Call your healthcare provider right away.


Step 5: Finish

S -

Before you finish! For your safety, pull the orange safety guard until it clicks and covers the needle.

Once extended, the orange safety guard will lock into position and will not slide back over the needle. Keep your hands away from the needle at all times. GRAB HERE

T - Discard (throw away) the used prefilled syringe.

Put the used prefilled syringe in a FDA-cleared sharps disposal container right away after use.

Do not throw away (dispose of) the prefilled syringe in your household trash. If you do not have a FDA-cleared sharps disposal container, you may use a household container that is:

o made of a heavy-duty plastic, o can be closed with a tight-fitting, puncture-resistant lid, securing sharps inside, o upright and stable during use, o leak-resistant, and o properly labeled to warn of hazardous waste inside the container.

When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. Do not reuse the prefilled syringe. Do not recycle the prefilled syringe or sharps disposal container or throw them into household trash. Important: Always keep the sharps disposal container out of the reach of children.

U - Examine the injection site.

If there is blood, press a cotton ball or gauze on your injection site. DO NOT rub the injection site. Apply an adhesive bandage if needed.


Goals for Self-Administering Subcutaneous Injections

Choose at least 1-2 strategies that you or your caregiver feel confident you can follow and work on them for a period of a week. Use your personal action plan to help guide you. Once you feel confident that you are managing these goals, select at least 1-2 more.

I will call my Homecare

Nurse or Physician if I need help.

I will keep an updated list of all the medications I take and bring the list with me when I see my doctor.

I will give my injection around the same time each day. I will remind myself by: ___________________ __________________________

I will choose the injection site that I would prefer to use for the injection. (avoiding 2” around belly button, scars, stretch marks, bruises, etc.)

I will prepare the syringe by removing from the box, checking the label for accuracy, and gathering the supplies needed.

I will clean the site with an alcohol swab.

I will pinch the skin and hold it until the injection is finished being given.

I will administer the injection with the help of my nurse.

To avoid bruising I will hold firm pressure (no rubbing) over the site of injection for 3-5 minutes after the injection is given.

I will discard the used syringe into a proper sharps container immediately after the injection is given.

I will purchase a thermometer and I will monitor and record my temperature twice a day.

Everyday I will monitor for any signs of infection, side effects or other concerns and report them to my health care provider.


Personal Action Plan

Today’s Date: _______________ Name: _______________________ 1. Goals: Something you WANT to do:

2. Describe your plan:

How?

Where?

What?

When?

How often?

3. Barriers (what is standing in the way of meeting your goals?):

4. How can you overcome barriers?

5. Importance of achieving goal: 0 1 2 3 4 5 6 7 8 9 10

6. Confidence in achieving goal: 0 1 2 3 4 5 6 7 8 9 10

7. Follow-Up (Date that I will reassess my goal and progress?):

PAP v2 10Sept2014

SAMPLE Personal Action Plan

Today’s Date: Monday September 8th Name: Jane Doe

1. Goals: Something you WANT to do: Administer own injections

2. Describe your action plan:

How? Learn to do with help from nurse

Where? At home – kitchen table

What? Start with 1-2 steps first

When? Next nursing visit

How often? everyday

3. Barriers (what is standing in the way of meeting your goals?): 1. I am very nervous that I will make a mistake

2. Fear that it will hurt

4. How can you overcome barriers? 1. Have the nurse watch me and write down the steps

2. Remember that it hurts the same whether I do it or someone else does

5. Importance of achieving goal: 0 1 2 3 4 5 6 7 8 9 10

6. Confidence in achieving goal: 0 1 2 3 4 5 6 7 8 9 10

7. Follow-Up (Date that I will reassess my goal and progress?): Will try with every injection this time and add steps each time so that by the last one I am

doing it by myself – then review it with the nurse.

Documents

CarePartners Nursing Care Plan Granulocyte Colony ... Nursing Resources... · Severe constipation, ... Complete assessment appropriate to care of oncology patients ... – CarePartners