Patient Encounter 1 Part 3 Create a Care Plan

Create a care plan while KM is receiving INF therapy. Your plan should include: (a) the goal of therapy with INF, and (b) a plan related to dealing with the side effects to expect from this therapy.

What supportive measures should be used to minimize side effects? What laboratory parameters need to be monitored? What are the indications to discontinue or hold therapy? When may the therapy be restarted after the doses were held?

What are the pharmacologic and nonpharmacologic recommendations for managing side effects?

How frequently should KM be monitored while on therapy? Be able to discuss with the patient the following for INF:

• The differences between acute and chronic side effects

• The side effects that the patient will develop tolerance to

• The best time of the day to administer the drug

• The importance of keeping regular follow-up appointments to monitor for long-term side effects of the therapy and draw blood for routine lab tests

• Reassure the patient that therapy may be stopped at any time if side effects are intolerable

• What is the follow-up plan for KM after he has completed therapy with interferon-a2b?

After diagnosis and treatment of skin cancer, the next crucial step in management is monitoring for recurrence. Most recurrences materialize in the first 5 years, and the majority appears within the first 2 to 3 years following treatment.19 The site of recurrence can be at the original site of the disease or in a different, distant anatomic location. Early detection of tumor recurrence is crucial because response rate is decreased significantly with tumor relapse.18 Recurrences are found equally by physicians and patients, and one study demonstrated that 94% of recurrences were detected by the

patient. Thus it is imperative to educate patients on how to perform a total skin self-examination appropriately. Additionally, patients need to understand the importance of scheduling regular follow-up visits with the oncologist or dermatologist after the diagnosis and treatment of skin cancer.

There is no universal guideline for follow-up care for MM. The National Comprehensive Cancer Network recommends annual skin examination for all patients.44 Educate patients with stage IA disease to have a history and physical examination every 3 to 12 months as clinically indicated and an annual skin examination for life. For stages IB to III disease, schedule a history and physical examination every 3 to 6 months for 3 years, every 4 to 12 months for 2 years, and then annually as indicated. It is optional to obtain a chest x-ray, LDH, CBC, and liver function tests (LFTs) every 3 to 12 months. CT scan can be obtained as indicated clinically.44

Patients who received immunotherapy after stage III or IV MM may experience fatigue and other chronic side effects. Develop a plan to order laboratory tests such as LFTs, thyroid-stimulating hormone, and white blood cell count at baseline and on a weekly or monthly basis as indicated. Monitor and evaluate patients for side effects of IL-2 or IFN, and educate patients on what to expect and how the side effects will be managed. Assess the patients' psychological, physical, and social functioning. Counsel patients to contact the hospital's social service department or the American Cancer Society for assistance in dealing with the disease emotionally, and recommend that patients consider attending support group meetings or talking to a counselor if or before they become overwhelmed with the diagnosis.

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