Haemathology-oncology practice - Assignment Example

?Haemato- Oncology Practice Identify and critically discuss/analyse one or two key patient issues, the care provided at the time and any factors thatmay have influenced the quality of the care provided Introduction The case under discussion is about a 16 years old female Ruth, patient’s name changed to preserve confidentiality as indicated in the NMC 2008 (Code of Professional Conduct). This essay will discuss neutropenic sepsis and the nursing care of the fatigue patient post diagnosis Acute Lymphoblastic Leukaemia (ALL). Case history Ruth was diagnosed in January 2010 with ALL. Initially, she presented to a General Practitioner (GP) with epistaxis and bruising on her legs who then conducted a few blood tests and referred her to Haematology Day Unit, where she underwent a diagnostic bone marrow aspiration. Based on the reports of that test, Ruth was informed that she has acute lymphatic leukemia (ALL) and will need to commence chemotherapy with Cyclophosphomide, Cytarabine and Mercaptoprine for which Hickman line was inserted and kept in situ. She received 4 cycles of chemotherapy until this admission when she got admitted for a complication, febrile neutropenia On this admission, the sixth one since her diagnosis, Ruth presented with fever. On examination, she was febrile, feeling unwell, tearful and anxious, and feeling hot and cold. Her temperature was 38.4C and heart rate 115 beats per minute. Neutrophil count was 0.3 percent, which is suggestive of severe neutropenia. Septic screen was done which included urine culture and sensitivity, stools culture and sensitivity, sputum examination and a full blood count. Chest x-ray and throat swab also was done. Intravenous fluids were commenced as per her weight and first line broad spectrum antibiotics as per hospital protocols were prescribed. Problem-1: Chemotherapy-related neutropenia Overview of the problem Ruth is diagnosed with febrile neutropenia. This is based on her absolute neutrophil count which is very low and that she has fever. Neutrophils are the most important type of white blood cells (WBC) in the blood and usually make up to 50-70% of circulating WBCs (Waugh and Grant, 2006). They serve as primary defense against infections by destroying bacteria in the blood; hence patients with neutropenia are more susceptible to infection (Hughes-Jones, 2009 and Waugh and Grant, 2006). Neutrophils are very important for innate immunity and comprise the first cellular component of any inflammatory response (Friese, 2006). Neutropenia is common adverse effect of cytotoxic chemotherapy (Brien et al, 2006). This condition typically occurs in the presence of other side effects and these concurrent events affect the quality of life of the patient. Other side effects include asthenia, anorexia, vomiting and dehydration. In addition to these events various precautions that are taken to minimise neutropenia also affect the quality of life. The degree of febrile neutropenia also influences the intensity of adverse events (Padilla and Ropka, 2005). The duration of chemotherapy induced neutropenia is typically 7-10 days (Friese, 2006). The blood culture of Ruth grew staphylococcus aureus. Urine and other cultures were negative. The staphyloccus aureus was resistant to vancomycin. Hence her antibiotics were changed to meropenem and gentamycin. Ruth was constantly monitored for improvement both through physical examination and laboratory tests. This is because, neutropenia is associated with significant morbidity and mortality because of the increased risk of developing infections that could be life threatening. The risk of infections correlates with drop 0f absolute neutrophil count and those with severe neutropenia (ANC < 0.5 ? 109/L) are at greatest risk of developing infections which are life threatening. In Ruth, the neutropenic count was 0.3 and she presented with only fever. More often than not, infection due to neutropenia manifests as just fever and hence presence of fever in neutropenic patients warrants close monitoring (Padilla and Ropka, 2005). Neutropenia, especially in the presence of other adverse events, affects the quality of life and in turn affects the outcomes of treatment. Ruth stayed in the hospital for one week during which time she underwent several blood tests and was given intravenous fluids and intravenous antibiotics. Her intravenous lines had to be changed frequently. Ruth was very upset that she had to undergo several tests and procedures which she found very distressing. She infact refused treatment several times. Poor quality of life during treatment may affect the willingness of the patient to continue treatment (Padilla and Ropka, 2005). According to a prospective study (cited in Padilla and Ropka, 2005), greater decline in absolute neutrophil count is associated with lower quality of life as measured by distress, social dysfunctioning, despair and general physical symptoms, as evident from Psychosocial Adjustment to Illness Scale. Neutropenia also contributes to increased treatment costs (Friese, 2006). Neutropenic sepsis remains an important cause for concern in haematology patients undergoing chemotherapy treatment: it can come on quite rapidly and may be life threatening if treatment is delayed (Kumer et al, 2006). Ruth presented with history of fever of one day and she was diagnosed with staphylococcus blood infection, which is a life threatening infection. Infact, chemotherapy induced neutropenia is the most serious adverse effect related to hematology in cancer chemotherapy. The neutropenia predisposes the cancer patients like Ruth to life-threatening infections, especially, gram positive cocci, gram negative bacilli and fungi by suppressing the production of neutrophils and by causing cytotoxic effects on the gastrointestinal tract (Friese, 2006). Nursing management On admission, I took an elaborate history of the patient and conducted a detailed physical examination. During physical examination, the main focus was on examination of the chest, skin and mucous membranes, venous access devices, perianal region, urinary tract and gastrointestinal tract. Investigations were followed up on emergency basis. This is because; delay in the diagnosis and management of neutropenia can result in increased mortality rates (Begbie et al, 2000). Several preventive measures were taken for febrile neutropenia in case of Ruth and they are avoidance of ill persons in to the patient's room, thorough and regular hand washing, administration of CSF as an when required based on neutrophil count monitoring, frequent temperature checks and complete blood picture checks (Friese, 2006; Mank et al, 2003). The nurse taking care of Ruth took all aseptic measures. Cross contamination was avoided strictly. Skin and mucous membrane was assessed during every shift. Even intravenous sites and central venous access sites were assessed during every shift. Rectal medication and insertion of indwelling catheter were not be done until required. Plants or cut flowers in standing water were not allowed in the room. Other sources of stagnant water like denture cups, water jugs, and respiratory therapy equipment were avoided as far as possible. The visitors were screened for illnesses. Visitors were encouraged to wash hands before coming in contact with the patient. Ruth was started on ceftazidime and gentamycin initially. After the blood culture grew staphylococcus, ceftazidime was changed to meropenem. It is recommended that intravenous antibiotics be instituted within half-an-hour of presentation of the patient to emergency department. Antibiotics were initiated only after collection of blood cultures. Intravenous fluids were started immediately and vital signs were checked atleast every four hours and any changes were documented and reported. Ruth was started on Granulocyte colony stimulating factor or G-CSF which is an endogenously produced factor by the monocytes, endothelial cells and fibroblasts that has profound effects on the stimulation of hematopoietic cells of neutrophil lineage. The non-endogenously produced forms have similar actions and are derived from escherichia coli and Chinese hamster ovary cell (Ghalaut et al, 2008). G-CSF is thus a major regulator of innate immune system and hematopoiesis. It influences the proliferation, survival and differentiation of all the cells of the neutrophil lineage right from stem cells to mature neutrophils. It also influences the functioning of mature neutrophils (Friese, 2006). The reason why G-CSF was started in Ruth was because many clinical trials in the past decade have investigated the potential benefits of G-CSF in the amelioration and prevention of profound neutropenia following cytotoxic chemotherapy in patients with hemotological cancers and also to ascertain the impact of G-CSF on the infections, duration of fever and duration of hospitalisation. According to a study by Ghalaut et al (2008), administration of G-CSF to patients 24 hours after developing chemotherapy induced neutropenia, decreased the incidence and duration of fever, decreased the duration of hospitalisation and decreased the median time for absolute neutrophil time recovery. Several randomised controlled trials have demonstrated the efficacy and tolerance of G-CSF (filgrastim) in the prophylactic role in chemotherapy induced neutropenia for reducing the incidence, severity and duration of grade- 4 neutropenia, for reducing the risk of febrile neutropenia, for reducing the depth of neutrophil nadir and also for reducing antibiotic use, duration of stay in the hospital and cost of treatment to the patient and health care system. Both pegfilgrastim and filgrastim are equally efficient. The advantage of the former over the latter is that it is a one-per-cycle dosing and thus simplifies the management of chemotherapy induced neutropenia (Royal Children’s Hospital, 2005; Shelton, 2003). It can also contribute to improvement in quality of life because of fewer injections, fewer clinic visits, decreased chances of dosage or drug administration errors and decreased disruptions of various activities of the patient (Friese, 2006). According to the American Society of Clinical Oncology, primary G-CSF must be provided to all patients with 40 percent or increased risk of developing febrile neutropenia. However, in view of cost factors, it is not recommended in those with lower risk status (Friese, 2006). Problem-2: Fatigue Overview of the problem Fatigue is feeling of lack of energy, unusual excessive whole-body tiredness, not relieved by sleep. Fatigue has been commonly described as “tiredness, exhaustion, depression, feeling unwell, loss of motivation and limitations of mental state" (Iop, 2004).It can also be described as “a multidimensional phenomenon which evolves over time, compromising physical energy, mental capacity and the psychological condition of the patient with cancer" (Iop, 2004). It has been demonstrated in the literature that "fatigue reduces the individual resources of patients, influences their nutritional state, increases morbidity and can negatively affect the dose intensity of some forms of oncology therapy (Iop, 2004). It can be acute or chronic and can impact the ability of the person to function appropriately. It also affects the quality of life. Cancer related fatigue is very common and is one of the distressing side effects of cancer related chemotherapy (Curt et al, 2000; Messias et al, 1997). It comes suddenly, not related to exertion or activity and is not relieved by rest or sleep. The exact cause for fatigue is unknown. It may be related to chemotherapy or the cancer disease itself. Factors which contribute to fatigue include anemia, combination cytotoxic chemotherapy, tumor-induced hyper-metabolic state and decreased nutrition due to various complications like loss of appetite, nausea and vomiting, altered taste sensation, diarrhea, mouth sores and heart burn. Other contributing factors include hypothyroidsm, medications used to treat various side effects, stress and depression. The main cause for Ruth's fatigue was decreased food intake due to mucositis. Mucositis in cancer patients like Ruth occurs because of the damage to mucosa that occurs as a result of interference of normal epithelial cell turn over subsequent to cancer therapy. The incidence and severity of mucositis varies from patient to patient and treatment to treatment. The incidence of mucositis is high and can occur upto 40 percent in those on standard chemotherapy. In those with high doses of chemotherapy or combination of radiotherapy and chemotherapy, the chances of procuring mucositis is as high as 76 percent (Naidu et al, 2004). Though mucositis is not a life threatening condition, it is a distressing condition and increases the number of treatment cycles. Thus nurses have a major role to play to prevent mucositis and detect mucositis in early stages (Eilers and million, 2007) so that appropriate interventions to prevent the progression of the disease can be instituted. There are several interventions to prevent and detect mucositis in early stages. There are several grading systems for mucositis, of which, the WHO grading is the most widely used (Naidu et al, 2004). According to the World Health Organization, mucositis is graded from 0-4. "If the patient has no signs and symptoms, it is graded as 0. If the patient has painless ulcers, edema, or mild soreness, it is graded as 1. If there is painful erythema, edema, or ulcers but able to eat, it is graded as 2. If there is painful erythema, edema, or ulcers but unable eat, it is graded as 3. If there a requirement for parenteral or enteral support, it is graded as 4" (Wilkes, 1998). In Ruth, the mucositis was of grade-2. Nursing management Cancer-related fatigue in patients like Ruth can be combated by conservation of energy, exercise, stress management and intake of appropriate nutrition (Hamilton, 2005). Important strategies for treating cancer-related fatigue in Ruth include correction of metabolic disorders, changing the therapeutic regime of the patient, treatment of insomnia and changing exercise regimen. Other non-pharmacological approaches include cognitive therapy, behavioural therapy, rest, alteration of sleep rhythm and nutritional support (Mock et al, 2001). Important pharmacological interventions include corticosteroids and stimulants. The nursing plan for fatigue in Ruth was mainly based on the physical and mental needs of Ruth and this was developed after discussion with various members of the team, with the main coordinator being physician (Otto, 2001). The family members were also involved in drawing up the nursing care plan. Nurses played an important role in the management of fatigue of Ruth. Since they closely work with her, they were in a position to provide constant personal, emotional and spiritual support. They gave her diet which she found tasty. They helped her sleep on time and take adequate rest. They told her age-appropriate stories and made her laugh. They also played an important role in the assessment and monitoring of her pain and other symptoms which contributed to fatigue. Nurses were the first persons to evaluate pain and advised the treating physician whether the pain remedy advocated was appropriate. Nurses taking care of cancer patients must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When Ruth reported side effects like abdominal pain, the nurses recorded, managed and monitored the symptoms and guided the physician about the condition of the patient thereby suggesting when to change the step in the analgesic ladder. Thus, nurses have an important role in acting as coordinators of different specialties, thereby tacking various distressing problems of the patients. Fatigue in Ruth was thus reduced through various approaches and team work. Conclusion The main outcomes of this discussion are awareness of risk, diagnosis, monitoring and management of febrile neutropenia in hemato-oncology patients receiving cytotoxic cancer therapy. Another common problem among this population, fatigue, was also discussed. 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