Michelle Lloid, RDH, BA, MS
Seattle , WA
mlloid@seattlecca.org

Oral mucositis causes significant complications for patients undergoing hematopoietic stem cell transplant (HSCT). The rapidly proliferating cells of the normal oral mucosa are extremely susceptible to damage caused by chemotherapy (single or multiple agent) and radiation utilized in preparative conditioning regimens. There are also a number of specific patient-related and treatment-related variables, which can influence the development of mucositis, including the type of transplant, patient age, disease, and pretreatment medical and dental conditions. Host defense mechanisms, mechanical and chemical barriers, and oral microbial flora also play a role; however, their interactions are not yet completely understood.

The toxicities associated with the preparative conditioning regimens are cumulative. Mucositis typically evolves during the first three to five days following completion of conditioning therapy and stem cell infusion and should resolve within three to four weeks. Mucosal tissues become significantly inflamed, causing atrophy, erythema, and edema. Ulcerations may develop, especially in areas more susceptible to trauma, such as the sides of the tongue or buccal mucosa. Mucositis can cause significant pain and oral hemorrhage, limit the ability to eat, drink, and talk, and increase the risk of local and systemic infection. The significant impact of oral mucositis on morbidity and mortality in patients receiving HSCT emphasizes the need for consistent evaluation, early diagnosis, and management.

An oral assessment provides a method for documenting the presence and measuring the severity of mucositis, infection, trauma, or graft-versus-host disease. An initial oral assessment should be performed prior to the initiation of HSCT therapy. This examination will identify existing oral conditions such as infection, abscess, or dental caries, which require stabilization prior to HSCT treatment. Clinicians also can identify other areas of concern that may impact the course of transplant or require close monitoring, such as oral manifestations of systemic disease (chloroma) and dental or prosthetic appliances. The initial examination should serve as the baseline to which subsequent exams are compared. The frequency with which transplant-associated oral assessments are performed is dependent on the oral condition prior to transplant, incidence, and severity of oral signs and symptoms and management needs. Mucositis assessments should be performed daily during the first three weeks after transplant or until resolution and at any time that new signs or symptoms are reported. Although the clinical signs and symptoms associated with oral complications can be nonspecific, their etiology is often multifactorial and may require additional diagnostic tests such as cultures or biopsy.

Complete oral assessment should include full oral examination, subjective patient complaints, such as pain and dryness, as well as oral hygiene practices. A number of oral assessment scales have been developed. The National Cancer Institute (NCI) and the World Health Organization (WHO) designed the two scales most commonly used in clinical trials. Many of the established scales grade the severity of mucositis using an assessment that combines clinical signs (erythema) and symptoms (pain) with functional capabilities (swallowing). However, there is no current evidence to suggest that any scale is better than another, and no single scale has been accepted as universally applicable. The assessment tool used should accurately record the clinical appearance and include all pertinent information needed to effectively manage the patient using an organized, efficient, and reliable approach. A consensus should be reached among clinicians about the type of assessment utilized and training provided to ensure accuracy and compliance.

Clinicians should develop a systematic, sequential method for examining the oral cavity. Elements of a complete oral examination include the upper and lower lips and labial mucosa, bilateral buccal mucosa, dorsal, lateral, and ventral surfaces of the tongue, floor of mouth, hard and soft palate, and gingival tissues. Prior to performing the exam, it may be helpful to have the patient use a bland rinse such as normal saline or saline/bicarbonate to moisten the tissues and remove surface debris. Topical anesthetics also may be used, if necessary, to enhance patient comfort and improve access and visibility. If tongue blades, cotton tip applicators, or gauze pads are needed to assist with an exam; moistening them with saline may help to avoid trauma. An adequate light source, such as an otoscope or penlight, should be used whenever possible. Light emitted from a flashlight can create a halo effect, which can obscure visibility or interfere with accurate interpretation of the extent or severity of signs such as atrophy and erythema.

Frequent oral assessment and patient monitoring will improve diagnosis and mucositis management, improve patient tolerance to therapy and quality of life by reducing pain and suffering, and reduce HSCT morbidity and mortality.

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Schubert, M.M. (2000). Oro-pharyngeal mucositis. In K. Atkinson (Ed.), Clinical bone marrow transplantation (2nd ed., pp. 812–820). Cambridge , UK : Cambridge University Press.

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Kate Castro, RN, MS, AOCN^®
Oak Hill, VA
castrok@mail.nih.gov

The Fall 2006 Advanced Practice Nursing (APN) Conference sponsored by ONS was a groundbreaking event. This was the first year that clinical nurse specialists (CNSs) were planning committee members, and the three-day course included content for both CNSs and nurse practitioners (NPs). The CNS and NP SIGs played important roles in helping to plan the conference, including having members represented on the planning committee.

There were many opportunities to share practice concerns for both of the APN groups. Participants were able to discuss practice similarities and build upon the knowledge that each group has gained from years of experience. A variety of content was offered, from evidence-based clinical content to discussions surrounding mentoring both in the CNS and NP roles. Several forums provided opportunities to discuss advocacy for the APN and the issues surrounding APN practice. The doctorate of nursing practice (DNP) degree along with the variation in state nurse practice acts regarding APN roles were discussed in numerous sessions. Attendees expressed concern that fewer nurses may pursue advanced degrees in nursing if the DPN is required because of the increased time commitment to complete the curriculums and increased costs. Some states offer the CNS limited prescriptive privileges, whereas other states do not recognize the AOCN^® certification as an APN certification. All attendees, especially CNSs, were strongly encouraged to keep current with their state boards and to take an active part in ensuring oncology CNS practice is recognized. ONS is continuously monitoring legislation that may affect oncology APNs, but each member should be knowledgeable about legislation.

The conference was an excellent opportunity to network with colleagues from a variety of practice backgrounds. The sessions offered ample time for attendees to bring questions forward or share experiences from their centers. The APN role in oncology is as varied as the patients we care for. In the area of stem cell transplantation, the APN role must be recognized. At many centers, APNs perform the majority of long-term post-BMT care, and as healthcare continues to change, so does the role of the APN.

Margaret Bevans RN, PhD, AOCN^®
Bethesda, MD
Mbevans@cc.nih.gov

A regional reporter is a volunteer identified within a specific region of the country to increase the communication between the BMT SIG and various areas/centers. The goal is to have regional reporters gather practice issues from their center and other centers in their region, to be shared through the SIG newsletter or virtual community (Web site). In addition, it would give the regional reporters (and their contacts in their respective region) an opportunity to share practice strategies, unit issues, patient/caregiver issues, education issues, etc.

Please consider sharing the issues and best practice from your center throughout the nation by connecting with your regional contact! It is only through networking and sharing of best practices that we can ensure the highest level of care to ALL BMT patients and families!

New England Region:
Jeanne Eskander
Beth Israel Deaconess Medical Center, Boston, MA
Jeskande@bidmc.harvard.edu

Mid-Atlantic Region:
Rebecca Babb
National Cancer Institute, National Institutes of Health, Bethesda , MD
babbr@cc.nih.gov

Tracy Douglas
Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
dougltr@jhmi.edu

Midwest Region:
Jan Sirilla
Ohio State University James Cancer Hospital, Columbus, Ohio
jan.sirilla@osumc.edu

The BMSCT SIG continues its efforts to highlight the varying HSCT programs both nationally and internationally. This quarter's “spotlight” is on The Beth Israel Deaconess Medical Center , Boston , MA , and the H. Lee Moffitt Cancer Center and Research Institute, Tampa . FL. Please feel free to contact the respective authors with any questions you may have regarding their programs. A big thanks to Jeanne and Terry for their contributions.

Jeanne A. Eskander, RN, CRNI, OCN^®
Boston , MA
jeskande@bidmc.harvard.edu

The Beth Israel Deaconess Medical Center , Boston , MA , has a hematopoietic stem cell transplantation (HSCT) program that is actively involved in research protocols to improve the success of the treatment. The HSCT program follows patients from diagnosis, induction chemotherapy, and throughout the transplant and post-transplant care periods. The HSCT program treats patients with a variety of hematologic malignancies and disorders. The patient population is adults, and HSCT types performed are autologous, syngeneic- and allogeneic- (myeloablative and nonmyeloablative) matched sibling, and unrelated donors through the National Marrow Donor Program. The source of HSCT product collection is primarily peripheral but is patient specific, and bone marrow may be harvested if indicated.

The HSCT unit works on a primary nursing model so patients and families become familiar with one group of nurses who care for them throughout the varied admissions required, from diagnosis through the post-transplant recovery phases. After discharge following a HSCT, the patient initially returns for follow-up visits to a clinic, which is part of the HSCT unit, and this allows him or her continued contact with the nurses that have been with them throughout a significant part of their treatment. Later, the patient will transition over to the BMT clinic in the outpatient center; however, close communication continues between these nurses and the ones who cared for the patient during their inpatient stay.

The nursing team has been growing rapidly. The inpatient beds have doubled in less than three years, with the blending of many new oncology nurses with those who have years of experience, and the team work provides all patients with high-quality nursing care. Patient satisfaction surveys keep our unit ranked as one of the top nursing teams when benchmarked against other oncology/BMT units of similar institutions. The nursing experience at BIDMC provides an excellent learning environment with opportunities to advance in the field of oncology nursing.

Terry Sylvanus, MSN, APRN-BC, AOCN^®
H. Lee Moffitt Cancer Center
SylvanTL@moffitt.usf.edu

At Stanford Hospital and Clinics and Lucile Packard Children's Hospital, state-of-the-art medical technology and an outstanding level of compassionate care come together to create an extraordinary experience for patients and professionals alike. Here, you'll discover the exceptional training, technology and expertise you'd expect from a world-renowned medical institution and an internationally recognized pediatric and perinatal facility that consistently rank high on U.S. News & World Report's prestigious honor roll of " America 's Best Hospitals." We invite nurses who share our dedication to growth and development to join our team in one of the following opportunities:

• BMT Staff Nurses


• Clinic BMT Coordinator


• Pediatric, Unrelated BMT Coordinator


• Infusion Center RNs

For access to the full-text versions of these and other CJON articles, visit the Publications area of the ONS Web site.

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