ONCOLOGY
CHEMOTHERAPY
TEACHING
FLOW SHEET PATIENT IDENTIFICATION
SPECIAL LEARNING NEEDS: Language Barrier Emotional State Cultural / Religious Differences
Hearing / Visual Impairments Ability to Comprehend None
EDUCATION GOALS:
Patient will be prepared for administration of chemotherapy: Minimal Moderate High
will be able to cite drug & method of administration:
Patient will describe 3 side effects secondary to Chemotherapy Minimal Moderate High
Plan of care discussed with patient: Yes No with family: Yes No
Initial / Date
Learning Knowledge Method Response Date / Need Met
CONTENT / FOCUS
Needs Level Initial Date / Init'l
1. Disease Process: A. Specific Disease:
B. Treatment Plan (specific cycle)
2. Treatment Process: A. Definition
B. Mechanism of Action
C. Specific Drugs:
3. Side Effects of A. Myelosuppression
Chemotherapy:
B. Neutropenia
C. Anemia
D. Thrombocytopenia
E. Anorexia / Taste Changes
F. Mucositis / Mouth Care
G. Nausea & Vomiting
H. Alopecia
I. Skin Changes
J. Infiltration / Extravasation
K. Hemorrhagic Cystitis
L. Constipation
M. Diarrhea
N. Fatigue / Weakness
O. Sexual Dysfunction / Infertility
P. Organ Toxicity
Q. Other:
*CODE FOR CODE FOR METHOD RESPONSE CODES
KNOWLEDGE LEVEL V = Video PT = PATIENT TAUGHT 5. Verbalized Recall of
R = Role Play New Knowledge
FT = FAMILY TAUGHT
G = Good E = Explain 6. Demonstrated Ability /
F = Fair D = Demonstration 1. Poor Attention Span Recall
P = Poor H = Handout / Manual 2. Refusal 7. Anxious
TV = Closed Circuit 3. Asked Questions 8. Needs Follow-Up
P = Poster / Flip Chart 4. Partial Comprehension Reinforcement
PART OF THE MEDICAL RECORD
8850477 Rev. 05/05 Chemotherapy Teaching Flow Sheet_ONCOLOGY_NURSING PAGE 1 of 3
ONCOLOGY - Chemotherapy Teaching Flow Sheet
Learning Knowledge Method Response Need Met DATE /
Needs
CONTENT / FOCUS Level Date / Init'l INITIAL
4. General Self-Care: A. Nutrition / Fluid Intake / Adequate Rest:
B. Psycho social / Spiritual Support / Referrals:
5. Hazards of Exposure A. Hand washing after toilet
to Chemotherapy:
drugs:
B. Flush toilet twice after each use
C. Call RN if there are any spills, drips or leaks
6. Supportive Services A A. Oncology Social Worker
Available:
B. Nutritional Care
C. Ostomy, Wound, and Continence Nurse
D. Pastoral Care / Palliative Care
E. Rehabilitative Services (Physical Therapy,
F. Speech Therapy & Occupational Therapy
F. Oncology Case Management Coordinator
F. (Home Care Needs)
7. Written Materials A. Chemotherapy and You
given:
B. What you need to know about:
C. Taking Time
D. Oral Hygiene
E. Chemotherapy Fact Sheets:
F. American Cancer Society Resource Guide
F. & Programs
G. Look Good Feel Better Program Support
F. Group Brochure & Flyer with PH Schedule
H. Information / Brochure on other Support
F. Groups (if available)
I. Eating Hints
J. Videos:
K. Other:
PART OF THE MEDICAL RECORD
8850477 Rev. 05/05 Chemotherapy Teaching Flow Sheet_ONCOLOGY_NURSING PAGE 2 of 3
ONCOLOGY
CHEMOTHERAPY
TEACHING
FLOW SHEET PATIENT IDENTIFICATION
INITIALS CLINICIAN'S SIGNATURE / TITLE INITIALS CLINICIAN'S SIGNATURE / TITLE
PART OF THE MEDICAL RECORD
8850477 Rev. 05/05 Chemotherapy Teaching Flow Sheet_ONCOLOGY_NURSING PAGE 3 of 3
