MANAGING CINV: PRACTICAL NURSING ISSUES
Guideline-based treatment can often prevent nausea and vomiting, which improves both patient satisfaction and caregivers’ experiences.4 The oncology nurse’s role can include evaluating patient risk factors for CINV and communicating that information to oncologists.2,3 Oncology nurses can advocate for appropriate treatment by using treatment guideline recommendations to suggest changes to non-guideline-adherent orders.13
The patient’s risk factors for CINV should be assessed before chemotherapy begins.9 Online resources, such as Oncology Nursing Society’s Clinical Practice resource, can provide helpful information. In general, patients who are more likely to experience CINV can be identified by several factors.
Female patients are at elevated risk, as are those who are young, have a history of low alcohol intake, experienced emesis during pregnancy, have an impaired quality of life, or have previously experienced chemotherapy.6,14,15 Currently, specific prophylaxis is not generally based on patient risk factors but rather on the emetogenicity of the chemotherapy administered, though considering a combination of the two has been suggested.2,6,14 In addition to patient evaluation for risk factors, concomitant medications are an important aspect of the nursing assessment. These should be considered both as a risk factor for nausea and vomiting and for potential interactions with CINV prophylactic agents.3
Challenges in the effective management of CINV include underestimation of its prevalence by health care providers.16 Prevalence of CINV may be under-reported for many reasons.17 Chemotherapy agents are divided into low, moderate, and high risk of emetogenicity, with ranges of risks reported. Those ranges are likely to be both overestimations and underestimations of the true risk for CINV, which vary from patient to patient. In addition, the ranges are based on acute CINV and do not take into account either anticipatory or delayed CINV.
Despite their potential benefits, oral chemotherapies also pose particular challenges in terms of ensuring adherence and managing side effects.18 The use of outpatient facilities to administer chemotherapy creates a barrier to direct observation of CINV symptoms, in particular the delayed type, by health care personnel in general and oncology nurses specifically.17,18 Other potential reasons for the underestimated prevalence of CINV are patients’ desire to avoid complaining to their physicians and physician assumption that patients will recognize CINV as a problem that should be reported. Overall, delayed CINV may be more common than acute CINV as it is less likely to be reported, and therefore also less likely to be treated effectively.17,19
Ample evidence exists to show that adherence to antiemetic guideline recommendations can improve clinical outcomes.6,20 In general, adherence rates for prophylactic treatment of delayed CINV are substantially lower than for acute CINV. One study revealed adherence to antiemetic guidelines for acute CINV was 75.5%, whereas adherence to antiemetic guidelines for delayed CINV ranged from 36.4% for HECs to 90.0% for those with lower emetogenic potential.21 In addition, although adherence to antiemetic guidelines did not reduce acute CINV rates, adherence was associated with a significant reduction in delayed CINV.21
A study by Gilmore and colleagues found that 57.3% of patients received guideline-consistent CINV prophylaxis, and the no-CINV rate was higher in these patients compared with those whose prophylaxis treatment was inconsistent with guidelines (P<.001).22 Another study found that, in the absence of intervention, guideline-adherent antiemesis for MEC was 100% in the acute period but only 6.6% in the delayed period.23 For those patients who received an intervention designed to increase guideline-adherent antiemesis (89%), their care was indeed more adherent with guidelines, and 20% more patients achieved complete protection from CINV compared with the nonintervention group.23 Overall, a relationship between adherence to antiemetic guidelines and reductions in CINV is supported.22,23
Evaluating the success of antiemesis procedures is crucial to effective patient treatment. A follow-up phone call or administering a patient reporting tool to better examine the true incidence of CINV in your practice is recommended.17