Non-Pharmacological Nursing Orders - Oncology ICU

ICU Consultant Standing Orders | System-Based Framework to Improve Patient Outcomes

OVERARCHING FRAMEWORK: THE ABCDEF LIBERATION BUNDLE

1. NEUROLOGICAL SYSTEM

Delirium Prevention & Cognitive Preservation

• CAM-ICU or ICDSC delirium screening every shift (document as positive, negative, or unarousable)
• Reorientation at every nursing interaction: state the date, time, location, and clinical situation
• Provide clock and calendar visible to patient; use whiteboard at bedside for daily orientation
• Maintain day/night lighting cycle: bright light during daytime (especially morning sunlight exposure), dim lights by 21:00 hrs
• Minimize nighttime interruptions: cluster nursing care; avoid routine vital signs between 23:00-05:00 unless clinically indicated
• Apply patient's personal hearing aids and glasses during waking hours
• Cognitive stimulation: familiar music, audiobooks, family photos at bedside
• Encourage family presence and family-led reorientation during daytime
• Document baseline cognitive status (pre-admission) to distinguish delirium from dementia
• Reduce unnecessary sedation: target RASS -1 to 0 unless contraindicated; perform daily SAT per protocol
• Avoid physical restraints unless imminent danger - reassess every 4 hrs; document indication

2. RESPIRATORY SYSTEM

Ventilator-Associated Events (VAE/VAP) Prevention & Oxygenation Optimization

• Head-of-bed (HOB) elevation: maintain 30-45 degrees at all times for all mechanically ventilated patients; document compliance
• Oral hygiene every 4 hours: chlorhexidine 0.12% oral rinse; tooth brushing twice daily; suction oral secretions before repositioning
• Subglottic secretion drainage: ensure subglottic drainage port is patent and draining
• Ventilator circuit: do not change circuits unless visibly soiled; drain condensate away from patient
• Cuff pressure check every 8 hours: maintain 20-30 cmH2O
• Spontaneous Breathing Trials (SBT): initiate per protocol every morning when SAT criteria met; document result
• Incentive spirometry / deep breathing exercises for non-ventilated patients every 2 hours while awake
• Encourage cough and huffing techniques post-surgery or during post-extubation period
• Nebulizer and MDI spacer hygiene: rinse and dry after each use; change every 24 hours
• Prone positioning: initiate per intensivist order for moderate-severe ARDS (P/F ratio <150); nurse trained proning team to document 16-hr prone cycles
• Monitor and document respiratory mechanics (plateau pressure, compliance) each shift if ventilated
• Tracheostomy care (if present): clean stoma with NS every 4-6 hrs; inner cannula change every 8 hrs; secure ties with 1-finger clearance

3. CARDIOVASCULAR SYSTEM

Hemodynamic Stability, DVT Prevention & Line Safety

• DVT prophylaxis:
  • Apply graduated compression stockings (GCS) to both legs unless contraindicated (severe peripheral arterial disease, active DVT)
  • Apply intermittent pneumatic compression (IPC) devices - ON for minimum 18 hrs/day; document compliance
  • Remove only during ambulation or skin assessment; reapply immediately after
• Central line care (CLABSI prevention):
  • Inspect insertion site every shift for signs of infection (erythema, purulence, tenderness)
  • Change dressing if soiled, wet, or non-occlusive; routine change every 7 days (transparent) or 2 days (gauze)
  • Scrub the hub with 70% alcohol for 15 seconds before every access ("Scrub the Hub")
  • Assess line necessity daily: remove all unnecessary central lines, arterial lines, and urinary catheters immediately
  • Strict sterile technique for all line accesses and infusion set changes
• Cardiac monitoring: continuous ECG monitoring; QTc assessment at baseline and every 48 hrs (high risk in oncology patients receiving targeted therapies, anthracyclines, anti-emetics)
• Fluid balance: strict hourly intake/output documentation; daily weight at same time each day
• Edema assessment: grade and document pitting edema; reposition dependent extremities; elevate edematous limbs on pillows

4. GASTROINTESTINAL SYSTEM

Nutrition, Gut Motility & Mucosal Protection

• Early enteral nutrition: initiate within 24-48 hrs of ICU admission if haemodynamically stable; do NOT withhold feeds for gastric residual volumes <500 mL
• Check gastric residual volumes every 4 hrs if feeding; document and escalate if >500 mL x 2 consecutive readings
• Post-pyloric feeding (NJ tube): consider if aspiration risk is high or repeated high residuals
• Constipation prevention: monitor for bowel movements daily; if no bowel movement for 3 days, escalate per protocol; positioning (left lateral, knee-flex) for bedpan use
• Oral feeding assessment: assess swallowing safety (modified bedside swallow test) before resuming oral diet post-extubation; involve speech therapy
• Mucositis care (chemotherapy-related): oral assessment every shift using WHO or Oral Mucositis Assessment Scale (OMAS); oral rinses with saline/sodium bicarbonate every 2-4 hrs; avoid lemon glycerine swabs
• Nausea monitoring: use CTCAE grading; use non-pharmacological measures (positioning, cold packs to forehead, aromatherapy per protocol, acupressure wrist bands) before escalating to pharmacology
• Abdominal assessment: bowel sounds, distension, and tenderness every shift; document accurately

5. RENAL SYSTEM & FLUID MANAGEMENT

AKI Prevention & Urinary Catheter Safety

• CAUTI prevention:
  • Assess catheter necessity daily - remove urinary catheter as soon as possible; document indication at each shift
  • Maintain closed drainage system at all times; keep drainage bag below bladder level
  • Periurethral hygiene every 8 hrs with soap and water; after every bowel movement
  • Secure catheter to thigh with minimal tension
• Hourly urine output monitoring in haemodynamically unstable or post-operative patients; report UO <0.5 mL/kg/hr x 2 hrs to intensivist immediately
• Strict fluid balance: daily net balance; cumulative balance calculation every 24 hrs
• Nephrotoxin avoidance checklist: alert team before giving contrast, aminoglycosides, NSAIDs, or high-dose ifosfamide/cisplatin in patients with creatinine trending up
• Foley care documentation: daily catheter care log; date of insertion visible on catheter label

6. INTEGUMENTARY SYSTEM

Pressure Injury Prevention & Wound Care

• Pressure injury risk assessment: Braden Scale on admission and every 24 hrs; score ≤18 = high risk
• Repositioning schedule: turn every 2 hours strictly; use a turning clock at bedside
  • 30-degree lateral tilt preferred over 90-degree; alternate right/left/supine
  • Document position, skin integrity, and time in nursing notes
• Heel offloading: apply foam heel protectors or elevate heels off mattress using pillows at all times for immobile patients
• Pressure-redistributing mattress: activate dynamic/alternating pressure mattress for Braden score ≤16
• Skin assessment: head-to-toe skin inspection with every repositioning; document any Stage I-IV wounds, suspected deep tissue injury (SDTI), or medical device-related pressure injuries (MDRPI)
• Device rotation: rotate pulse oximetry probes every 2-4 hrs; reposition oxygen masks/nasal prongs hourly; check behind ears, bridge of nose, and occiput every shift
• Moisture management: keep skin dry; apply barrier cream to perineal area for patients with incontinence
• Chemotherapy extravasation protocol: for all peripheral IV sites - assess patency before each infusion; monitor every 15 mins for vesicant/irritant infusions; document site, gauge, and insertion date
• Nutrition link: report albumin <2.5 g/dL and weight loss >10% to dietitian - escalate to high-protein, high-calorie plan

7. MUSCULOSKELETAL SYSTEM

Early Mobility & Rehabilitation

• Mobility assessment: daily physiotherapy/nursing mobility assessment using ICU Mobility Scale (IMS 0-10)
• Early progressive mobilization protocol:
  • Level 1 (bed-bound): passive range of motion (PROM) to all limbs 3x daily; wrist/ankle circles, quad sets
  • Level 2 (awakening): active-assisted ROM; bed exercises; deep breathing
  • Level 3 (sitting): dangle at edge of bed; progressive sitting in chair once haemodynamically stable
  • Level 4 (standing/walking): stand at bedside with support; ambulate in room with physiotherapist
• Document functional status at admission (pre-hospital) and daily in ICU to set rehabilitation goals
• Physiotherapy referral within 24 hrs of admission for all oncology ICU patients
• Avoid prolonged bed rest >24 hrs unless absolute contraindication (hemodynamic instability, active bleeding, unstable fractures)
• Foot drop prevention: use foot boards or anti-foot-drop boots for comatose/sedated patients
• Anti-contracture positioning: maintain joints in neutral position; document ROM limitations

8. NEUROPSYCHOLOGICAL / MENTAL HEALTH SYSTEM

Anxiety, Sleep, and Psychological Support

• Sleep bundle (implement every night after 21:00):
  • Dim all lights to minimum necessary
  • Reduce monitor alarm volumes (adjust alarm thresholds appropriately)
  • Cluster nursing interventions to allow 90-120 min uninterrupted sleep windows
  • Offer ear plugs and eye masks nightly
  • Avoid non-urgent lab draws, imaging, or procedures between 23:00-06:00
• Anxiety and distress screening: screen using HADS or ESAS (Edmonton Symptom Assessment Scale) every 24 hrs
• Non-pharmacological anxiety management:
  • Guided imagery or relaxation breathing instruction at bedside
  • Music therapy (patient preferred genre, 30-min sessions twice daily)
  • Therapeutic touch and presence
  • Clear communication: explain every procedure before performing; narrate care activities
• Chaplaincy and spiritual care: refer to chaplaincy/pastoral care team within 48 hrs of admission for all oncology ICU patients; document spiritual needs
• ICU diaries: nurses and family to write daily entries; shown to reduce PTSD post-ICU (evidence-based)
• Psychological support referral: palliative care and oncology psychologist referral for all patients with new/worsening cancer diagnosis, poor prognosis, or family distress

9. INFECTIOUS DISEASE / INFECTION CONTROL SYSTEM

Sepsis Prevention in Immunocompromised Oncology Patients

• Hand hygiene compliance: perform 5 moments of hand hygiene (WHO protocol) before and after every patient interaction; use ABHR (alcohol-based hand rub) or soap and water if C. difficile suspected
• Neutropenic precautions (ANC <500/mm³):
  • Private room with positive pressure if available; single-occupancy minimum
  • Visitors: limit to 2 at a time; no one with active infection or recent live vaccination
  • No fresh flowers, plants, or standing water in room
  • Strict food safety: avoid raw fruits and vegetables unless washed per protocol
  • Daily body temperature monitoring minimum every 4 hrs; report fever ≥38°C IMMEDIATELY
• Catheter site monitoring: all line sites inspected every shift; document for redness, tracking, or discharge
• Isolation adherence: standard precautions for all patients; contact/droplet/airborne precautions as clinically indicated and labelled on door
• Blood culture technique: ensure aseptic technique (chlorhexidine, allow to dry 30 sec) before every blood culture draw
• Device audit: daily "line rounds" - document justification for every invasive device (CVC, arterial line, urinary catheter, chest tube, nasogastric tube)

10. PAIN MANAGEMENT (NON-PHARMACOLOGICAL)

Comfort and Procedural Pain

• Pain assessment every 2-4 hrs using:
  • NRS (Numeric Rating Scale 0-10) for conscious, communicative patients
  • BPS or CPOT for sedated/non-verbal patients
  • Document pain type: nociceptive, neuropathic, visceral, procedural
• Non-pharmacological pain strategies before escalating medication:
  • Repositioning for comfort; pillow splinting post-operative incisions
  • Cold/warm packs (cold for acute inflammation; warm for muscle/joint pain - not over radiation sites)
  • Distraction techniques during procedures (music, focused breathing, counting)
  • Pre-procedure: notify patient 2 minutes before any painful intervention; allow patient to signal readiness
  • TENS (transcutaneous electrical nerve stimulation) for chronic/neuropathic components where available
  • Massage therapy (light effleurage) to non-affected extremities for relaxation

11. COMMUNICATION & FAMILY-CENTRED CARE

Family Engagement

• Structured family meetings: intensivist-led family conference within 48-72 hrs of admission and every 72 hrs thereafter; nursing to attend and document
• Open visiting policy: allow family presence 24 hrs (at patient's consent) unless infection control contraindicated
• Family education: nurse to teach family members hand hygiene, repositioning assistance, and comfort care techniques within 24 hrs of admission
• Designated bedside communication board: display patient name, care team, daily goals, and orientation information
• Goals of Care documentation: nursing to ensure goals of care discussion is documented and visible; escalate if undocumented in first 24 hrs for ICU admissions >72 hrs expected
• Palliative care integration: early palliative care consult for all oncology ICU patients; nursing to advocate for comfort measures alignment with patient-expressed values

12. SAFETY & FALL PREVENTION

• Fall risk assessment: Morse Fall Scale on admission, with each transfer, and after any fall
• High-fall-risk patients:
  • Bed in lowest position, brakes locked at all times
  • Call bell within reach; educate on use
  • Non-slip footwear on at all times during ambulation
  • Bed/chair exit alarms activated
  • Hourly rounding documented (pain, position, personal needs, proximity of call bell)
• No siderails up without patient consent - use as positional aids, not restraints

MONITORING & DOCUMENTATION STANDARDS (All Systems)

KEY EVIDENCE REFERENCES

• Kang J et al. Non-pharmacological interventions for sleep and delirium prevention in critically ill patients: systematic review and meta-analysis. Aust Crit Care. 2023 [PMID: 35718628]
• Barr J et al. ABCDEF Bundle implementation across large healthcare system. Crit Care Explor. 2024 [PMID: 38250248]
• Kieswick S, Gibbison B. Critical care delirium: prevention, identification and management. Anaesthesia. 2026 [PMID: 41808494]
• SCCM PADIS Guidelines 2018 (Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption)
• WHO 5 Moments of Hand Hygiene

Consultant Note: These orders are to be reviewed jointly with the oncology attending, bedside nurse, physiotherapist, dietitian, and palliative care team at daily multidisciplinary rounds. Oncology ICU patients carry unique risks from cytopenia, mucositis, immunosuppression, and treatment toxicities - every system-based intervention above must be cross-referenced with current blood counts, chemotherapy received, and the patient's expressed goals of care.