Assessment helps identify risks
Questions provide guide for screening clinician
Questionnaires can help identify people’s risk for certain types of cancer. At St. Joseph’s Hospital of Atlanta, a cancer screening program called Canscreen uses a 70-question risk assessment with yes and no answers. It is divided into components for determining several types of cancer. Categories include skin, head and neck, lungs, digestive system, kidney and bladder, occupational and environmental exposure, breasts, female reproductive, male reproductive, diet, and nutrition.
The questionnaires are mailed to all people who schedule a screening appointment, and they bring them with them when they come for the screening.
"It provides a quick guide as to what some of their risk factors may be and who in their family may have had cancer that may increase their chances of developing something," says Peggy Watson, RN, OCN, Canscreen clinician at St. Joseph’s.
Watson uses the questionnaire to help tailor her education to individuals. She discusses their risk factors and what they can do to lower their risk for certain types of cancer. Following are the questions for the breast component:
• Do you have pain in the breasts for which you do not know the reason?
• Have you noticed a lump in either breast?
• Have you noticed any change in your breast or nipples?
• Have you noticed any discharge, bleeding, or scaling of the nipples?
• Have you noticed any change in the skin of your breasts such as dimpling, puckering, or color change?
• Have any of your blood relatives had cancer of the breast?
• Are you over the age of 30 and have never had a baby or had your first baby after 30 years of age? (female only)
• Are you over the age of 50?
Mastectomy pre-op teaching offers details
Education lays foundation for successful recovery
Comprehensive education is the key to the success of the outpatient mastectomy program at Johns Hopkins Hospital in Baltimore. The 21¼2 hour pre-op teaching session is full of details. Women are told exactly how they will feel when they wake up in the recovery room. They are also told how they might feel a week, two weeks, and a month after surgery.
"The more women know, the less anxiety they have. They told us this," says Mary Donnelly-Strozzo, CRNP, MPH, MS, nurse practitioner in the Breast Center at Johns Hopkins.
The pre-op mastectomy program was gradually shaped by the type of surgery, the questions women ask, and a seven-page questionnaire given to patients six months following surgery. The questionnaire has been particularly helpful in uncovering gaps in the program.
For example, staff thought they were meeting the patient’s psychological needs, but the information gathered on questionnaires showed that patients were not satisfied. Now the nurse practitioner has the patient fill out a brief symptom inventory questionnaire during the education session to determine if she should see a counselor.
Even if the patient does not need immediate counseling, she receives a list of support services. The list includes such services as Reach to Recovery sponsored by the Atlanta-based American Cancer Society, which pairs breast cancer survivors with newly diagnosed breast cancer patients. The list also includes signs they should look for that could signal emotional problems, such as a strained relationship with loved ones. (For more information on using a questionnaire for ongoing program evaluation, see story, p. 153.)
The detailed pre-op education session also helps women decide whether they want to go home following their surgery or be admitted to the hospital. "Most women have decided by the time they come for pre-op teaching, but if they have not, I tell them to wait until we’ve gone through all the information that explains what they will need to do. Then we talk about whether they want to stay overnight or go home," says Donnelly-Strozzo. Women can make the final decision while in the recovery room.
Critical pathway orchestrates teaching
To ensure that all details are covered, the nurse practitioner doing the pre-op teaching follows the education portion of a critical pathway. The teaching portion is started at the pre-op session and either finished by the discharge nurse, if the patient is admitted to the hospital or the home health nurse if the patient goes home after surgery. The patient spends 11¼2 hours with the nurse practitioner and an hour with an occupational therapist during the teaching session. (To learn more about triggering patient education via a critical pathway, see story, p. 154.)
Following is a brief outline of the educational portion of the pathway:
• Demographic information.
This part of the pre-op education is more fact-finding than education. The nurse practitioner gets details on where the woman will be staying following surgery so arrangements can be made for visits from a home health nurse. Patients who opt to stay in the hospital overnight also receive two home care visits following discharge. Information is gathered on family members who can provide care at home or whether the woman has made other arrangements for care.
• Support services.
Each patient receives a sheet that lists the support services available at Johns Hopkins. The list describes the service and provides information on when to access the services. For example, a patient might want to seek help from social services if she is having problems managing stress, is preoccupied with health concerns, or her job performance is suffering.
• Specifics on surgery.
Pre-op instructions such as what medicines to take the morning of surgery are covered. Also covered are details of the surgery such as what it will be like when they are waking up, how pain and nausea will be controlled in the recovery room, and what sensations they will feel in their breast, chest, and arm.
• Drain care.
The patient and a family caregiver are instructed on drain care. They not only learn how to clean the drain site but also what the drainage will look like. Often people think something is wrong when they see blood clots, although that is normal. The nurse practitioner also shows the caregiver how to monitor the daily drainage and track it on a sheet so the nurse practitioner will know when it can be removed. "I call them on a daily basis to talk to them about the drain and how it is flowing," says Donnelly-Strozzo.
• Discharge instructions.
If the patient is going home after surgery, she receives discharge instructions during her pre-op teaching. Information on diet, activity, and medications is reviewed.
• Occupational therapy.
The patient spends an hour with the occupational therapist who discusses temporary restrictions such as lifting, driving, and showering and other issues such as scar management. The therapist also teaches the patient a set of exercises they will need to do during recovery.
Know your family history
Patients and their relatives who have a family history of cancer can be referred to the Breast Ovarian Surveillance Clinic within the Breast Center for genetic counseling. Those who come for counseling are asked to complete a 20-page form that asks details on family history and gives information the patient is seeking, such as whether they should have a mastectomy to help prevent cancer.
"Genetic counseling is for sorting out family history issues and deciding on genetic testing. Many women rate their risk of breast cancer higher than it actually is," says Barbara Ashley, RN, MSN, CRNP, adult nurse practitioner at the Johns Hopkins Breast Ovarian Surveillance Clinic.
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