Case study: Pediatric Oncology Patient

Significance of the Laboratory Findings

Nicole’s la results reflect the adverse side effects of the chemotherapy. The most prevalent form of the adverse effect of the chemotherapy is myelosuppression. Antineoplastic are known to attack the fast growing cells such as erythrocytes, leukocytes, and platelets. This leads to anemia, thrombocytopenia and neutropenia. Among the effects of this reduce tissue perfusion, greater risks of infection, and more possibility of bleeding. The lab results highlights presence of these three problems. It can observed that Nicole has anemia which is said to occur when the hematocrit value fall below 28%. The normal white blood cells count for Nicole should be 4100-10800/mm3 compared to 2000/mm3 indicated in the lab results pointing to a possibility of neutrophils where the neutrophil count is <500 cells/mm3. The low platelet level of 50,000 indicates that Nicole is at a high risk of bleeding. Thrombocytopenia occurs when the platelet count is less than 50000 cells/mm3 which denoted an increased risk for bleeding. 

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Other Useful Assessment Data

To make better diagnoses, the following assessment data would be important; urine specific gravity, urine for blood, hemoccult of stool, assessment of central venous access device, urine culture and  sensitivity, chest x-ray, oxygen saturation using pulse oximetry, and peripheral blood cultures. 

Priorities of Care for Nicole on Admission

Upon admission, the following aspect should be highly prioritized with care offered to deal with them; low immunity due based on the neutrophil count, the elevated risk of bleeding due to low platelet count, high risk of ineffective tissue perfusion as evident in the hemoglobin and hemacrit values, Impaired oral mucous membrane, acute pain due to mucositis, and risk of nausea as a side effect of chemotherapy on gastrointestinal mucosa.

Common complications of Chemotherapy

The chemotherapy drugs are used to kill the rapidly growing cancer cells but may end up also harming the healthy cells thereby causing some side effect. The severity of these side effects I dependent on general health, age, and the specific chemotherapy used. The most common side effects of chemotherapy include general weakness, fatigue, pain, nausea, hair loss, and vomiting. These side effects are indicated to be experienced by more than 70% of the patients. Other prevalent side effects include mouth sores, dry mouth and numbness, and memory impairment. 

Nursing Actions Required to Address Adverse Effects Resulting from Chemotherapy

To address Nausea, it is important to pre-medicate the patient with antiemetic prior to the administering the chemotherapy, administer the required proton pump inhibitors every four hours for 24 hours after the chemotherapy, provide lorazepam for breakthrough nausea, and to curb offensive odors in the surroundings.

To deal with pain, pain medication may be issued, assessing the baseline pain level and carrying out hourly assessment to point out the effectiveness of the prescribed pain medication, encourage the intake of cool liquid during acute phase. 

Use of Cyclophosphamide Intravenously

Cyclophosphamide is an alkylating neoplastic that has a mode of action by inhibiting DNA synthesis that are utilized in all the phases of cell cycle. It is noted to be most effective in the S cycle and causes shifts in the acid-base balance in the cell. It is a commonly found to makeup various chemotherapy regimen used for acute and chronic leukemia on children. Alkylating agents are known to lead to myelosuppression which largely affects the production of leukocytes leading to condition of neutropenia. The action of these agents are to the rapidly growing cells with makes the hair follicle cells to get destroyed thereby leading to alopecia. The toxic action on the epithelium of the gastrointestinal tract causes nausea and vomiting. The agents requires detoxification at the liver and may finally lead to impaired hepatic function. Due to its effect on causing extravasation, a nursing intervention that may be administered is cyclophosphamide through the CVAD. Before the administering of cyclophosphamide, antiemetic, ondansetron and dexamethasone should be administered. Medication for nausea and vomiting should be provided. An important nursing action will be to closely monitor the laboratory values for a period of 24 hour after administering. 

CVAD Line Infection

Despite the protective aspect of the CVAD catheters through the use of antibacterial filter, line infection still poses a major threat to CVAD. The main origin of the line infection I the pathogenic organism growing at the proximal end of the catheter and enhanced by the fibrin formation that grows at this site. Fibrin offers necessary conditions for proliferation of bacterial growth. The lack of ensuring the right pressure at the proximal end of the catheter causes increased risk to the infection. The risk is boosted with the presence of the myelosuppression.

Nicole’s Refusal to See Friend

The reason that Nicole issues for not wanting to see her friends, which is to minimize the risk of exposure infection, is both plausible and convincing. However, it can be observed that the refusal is motivated by other factors. One of the reasons may be failing to adjust to her new status caused by hair loss. This has clearly affected her appearance, which is among the most treasured aspect by adolescent girl. This is likely to have a negative impact on the elf-esteem of Nicole as she will hold the feelings that her friends won’t approve her new appearance. 

Sore Throat and Mouth

Among the side effect of the chemotherapy is mucositis, which is a painful condition that is caused by the destruction of oral normal flora. It is important for the nurse to have physician prescribe products such as nystatin swish and spit and intravenous morphine sulfate, as they have been noted to be effective in dealing with mucositis. Another helpful nursing action will be to keep her hydrated using intravenous fluids up to a point where her pain is controlled. The patient can be offered with supplements of high protein and high-carbohydrate drinks. The nurse should ensure that the patient avoid eating citrus fruits whose acidity would cause irritation to the sores. 

Agents for Treating Line Infection

The intravenous antibiotic infection prescribed to treat the line infection is the gentamicine sulfate. Vancomycin hydrochloride, and cefoxitin. Gentamine sulphate is an aminoglycoside that functions as an antimicrobial that prevents protein synthesis in the bacterial cell wall, thereby causing the cell to die, a situation refeed to as ototoxicity. Vancomycin hydrochloride is categorized as a miscellaneous antimicrobial or tricyclic glycopeptide, which is an antimicrobial used to treat different gram-positive infections that have resisted other forms of toxic agents. This drug may lead to an adverse effect of renal failure. Cefoxitin is a form of cephalosporin that mainly fights against the gram-positive bacteria through causing interference with cell wall synthesis. The use of this medication may lead to allergic reaction which may case anaphylaxis. It can be note that for these three drugs, all the dosages prescribed are within the safe range for Nicole’s status. 

Pharmacy Schedule

The prescribed schedule is ideal and can be utilized as it is. However, some minor changes may be introduced to make it even more workable. A shift in the cefoxiticin schedule to 0100-0700 1300-1900 may be effective in removing the possible overlap of drug administration. 

Rates of Administration through a Volumetric Intravenous Infusion pump

Formula: Time1 /volume1=Time1/ volume1

Gentamicin hourly rate = 200 mg/hr.

30 minutes /100 mL= 60minute / x

30x = 60 X 100

Therefore, the hourly rate of gentamicin= 200ml/Hour

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