Caner care and the complications of chemotherapy have always created concerns in the nursing profession. Arguments have been that these complications are preventable since evidence based research has discovered strategies to limit burns and other adverse effects of the treatment. The following pages of this document present a case study of a patient suffering from chemotherapy complication. A synthesis of evidence based research interventions that have been recommended as prophylactic measures will be advanced as an appropriate nursing care is designed for this patient.
Mr. John was diagnosed with colorectal cancer and agreed to surgery. Adjuvant Chemotherapy was prescribed after surgery and he agreed to the treatment, which contained Fluorouracil (Joensuu, 2008). After his third cycle of chemotherapy he reported a sore in his mouth accompanied by difficulty in eating. Upon examination Mr. John’s mouth appeared red and ulcerated. The ulcers were estimated to be about 5mm in diameter.
Fluorouracil is responsible for this side effect because initially some patients’ bodies do not contain the genetic component to synthesize this drug. Therefore, micrositis is one way it affects the body from a central nervous system reaction. Apart from this reaction the drug is folic acid; purine and pyrimidine antagonists as well as an Adenosine deaminase inhibitor (Longley et.al, 2003). However, these side effects are preventable. As such, this document will focus on developing one medical prevention strategy that could have been implemented on the onset of therapy; one pharmacology intervention and one non-pharmacological.
One prevention strategy prior to chemotherapy
One prevention strategy that can be applied in addressing Mr. John‘s mouth ulcers due to chemotherapy is mouth care. Studies conducted by MD Anderson Center revealed that patients receiving chemotherapy ought to be mindful of mouth care as a preventative measure. Precisely, research has shown it is one of the most common complications which have associating discomforts. These include sores in the mouth or throat (ulcers); painful mouth and/or gums; infection; burning, peeling, or swelling of the tongue; changes in saliva consistency or dry mouth; taste alteration and difficulty in eating (Anderson MD Center, 2009).
Further, studies have revealed that in preventing mouth sores the person receiving chemotherapy ought to eat only foods which can be tolerated by the integrity of the mouth. Often patients may eat foods containing acids that can be irritating. Also, hot or too cold food may pain the teeth or be discomforting to the gums. Foods containing such puddings, gelatin milkshakes, moderately cooked cereals and bars can be very beneficial to the maintaining the mucous lining integrity and preventing breakdown ( Anderson MD Center, 2009).
Specialists have advised from research findings that a very useful technique for mouth care in chemotherapy patients is to avoid eating very hot food then immediately switch to a cold one. This can create friction to the teeth and gums initiating mucous membrane breakdown to an already sensitive lining. Therefore, incorporating chewing techniques during mouth care can be a beneficial prevention strategy. Patients are advised to take smaller portions into the mouth when chewing food and masticate it properly before swallowing. Between amounts liquid should be sipped slowly. These can consist of drinks, juices, decaffeinated and non-acidic fluids (Lee.al, 2010).
In cases where the patient has gum issues such as bleeding gums, dentures that are irritating or very sensitive gums care should be taken when brushing the teeth. Tooth brushes that have soft bristles ought to be used instead of those with harsh ones. It is always best to remove dentures in when brushing the teeth ( Hofmann et.al, 2005). .
Studies conducted by Cheung (2001) and his counterparts established a protocol for mouth care as a prophylactic measure in patients receiving chemotherapy. The study was conducted for eight months on 42 children aged 8- 17 years old. Oral care protocol embodied tooth brushing with ‘ 0.2% chlorhexidine mouth rinse and 0.9% saline rinse.’ ( Cheng et.al, 2001). Subjects were separated into two groups. Twice weekly evaluations were conducted for three weeks. Incidences of ulcerative lesions, severity of oral mucositis and the related pain intensity were the main variables used in predicting the outcomes. 38% reduction in the incidence of ulcerative mucositis was discovered among subjects using the oral care protocol compared with those in the control group (Cheng et.al, 2001).
The American Dental Association has recommended after conducting their studies that a thorough oral evaluation should be done at least two weeks prior to commencement of treatment. Oral care specifics should be prescribed by the dentist for each patient distinctively depending on the particular predisposing factors. While chemotherapy is being administered steps should
One pharmacological priority intervention
Many types of toxicities have been discovered besides the one manifested in Mr. John’s case. Dr. Ambili Remesh (2012) confirmed that pharmacological intervention varies with the stage of the disease and particular side effect manifested. Mr. John shows signs of mucositis.
This might have been the manifestation of another underlying toxicity, which would surface later. As such, the recommendation is to take a broad-spectrum pharmacological approach towards treating Mr. John’s mucositis. The drug therapy of choice advocated by Dr. Remesh (2012) is administration of analgesics (Remesh, 2012).
Groups of healing and coating analgesics were suggested. They include Sucralfate, Vitamine E, Antacids, Allopurinol, Lidocaine, Benzocaine, Diclomine hydrochloride.
Systemic analgesics; and if the pain is severe, NSAID Narcotic analgesics can be used. Dr. Remesh (2012) further emphasized that since this condition insidiously develops with 5-16 days of the first administration and can lead to infection and subsequently death, immediate intervention is imperative ( Remesh,2012).
Similar studies conducted by Debra Harris (2006) supports Dr. Remesh’s (2012) preposition that analgesic therapy is the most effective pharmacological intervention for treatment of mucositis in patients enduring chemotherapy side effects. Her study aimed at effective pain management and confirmed that in selecting appropriate analgesic therapy considerations related to predisposing underlying biological factors ought to be perceived. Her drug of choice falls in the topical analgesic category which includes viscous Lidocaine which can be administered as in mouth washes (Harris, 2006).
In her systemic review she cited studies showing immense improvements in oral integrity of patients with mucositis due to Fluorouracil incorporated chemotherapy. These investigations tested mouthwashes containing ‘125 ml (100 mg) diphenhydramine, one ampule of 2% (100 mg) lidocaine, and two ampules of 8.4% sodium bicarbonate to 1000 ml of sterile saline’ (Harris, 2006). She confirmed that this mixture was easy to prepare from a pharmacological perspective and inexpensive economically (Harris, 2006)
A sample of 31 (n=31) clients were recruited for the study. The methodology consisted of instructing them to swish 20 mL of solution inside their mouths then spitting it out at 2-3 hours interval based on their pain. Data using Scores were recorded for’ mucositis, bleeding, white blood cells, infection, taste, and metabolism according to the CALGB expanded common toxicity criteria’ (Harris, 2006).
Harris (2006) admitted that there were no group control and the sample was small for this case study. However, these 31 patients showed marked improvements in tolerance to pain after using the solution as was prescribed. After reviewing studies where systemic analgesics were administered she concluded they should be the second line of treatment after mouth washes fail to relieve pain (Harris, 2006).
Likewise Ling and Larsson (2011) conducted studies regarding the pharmacological treatment of patients with mucositis due to chemotherapy to conclude that systemic analgesics were insufficient to treat the condition. They recommended that more studies regarding a more effective pharmacological intervention is impending (Ling & Larsson, 2011).
The study aimed at investigating pharmacological response to pain in patients with head and neck cancer who developed mucositis. When systemic analgesics were administered at its highest potency patients claimed that pain was not relived ( Ling & Larsson,2011) This study supports Dr. Remesh’s (2006) assumption that the success of pharmacological intervention is related to the type of cancer and the stage of the disease ( Remesh, 2006).
More revealing evidenced based data was made available by Rajesh Lalla (2008) and associates who admit that the first line of relief in patients suffering from chemotherapy induced mucositis to relieve pain. They contend that pain affects patients in various ways therefore; measures to bring relief must be considered urgent. Recommended analgesic pharmacological interventions include ‘saline mouth rinses, ice chips and topical mouth rinses containing an anesthetic such as 2% viscous lidocaine’ (Lalla et.al, 2008).
It was further advised that lidocaine could be mixed with diphenhydramine and Maalox as recommended by Novartis Consumer Health, Inc., Fremont. Kaopectate could also be added on the advice of pharmaceutical agencies such as Chattem, Inc and Chattanooga, TN. These must be mixed in in equal portions. The researchers cautioned that this pharmacological cocktail offers temporary relief, but systemic analgesics can be added to the intervention based on the Primary care physician’s practice style (Lalla et.al, 2008).
In Mr. John’s mucositis evidence based studies have shown that the pharmacological intervention is analgesic therapy. It can be administered through topical applications depending on severity of pain and also through system routes. Lidocaine seems to be the analgesic of preference from the studies referenced often being mixed to be used as topical applications in mouth rinses (Hampton, 2011).
One non-pharmacological priority intervention
Pharmacological intervention is aimed mainly at relieving pain, but non pharmacological priority is managing not the condition itself, but the complications that can arise from mucositis. Already Mr. John has expressed that he has difficulty eating. Therefore, the non-pharmacological intervention requiring immediate attention is his nutrition.
Lalla (2008) research on the management of mucositis confirmed that along with pharmacological intervention nutrion is the next important aspect of care ought to be addressed. This is important from two perspectives. Mr. John could be losing appetite due to pain as well as taste. In assessing nutritional status according to Lalla (2008) and his counterparts weight management is important. Precisely, Mr. John ought to be monitored by a dietician or experienced care giver knowledgeable in proper nutritional practices. They recommend a soft diet/ liquid diet supplements can be tolerated by the individual. In severe cases a nasogastric feedings recommended (Lalla et.al, 2008).
Keefe (2007) and others conducted studies to develop nutritional strategies in treating patients with mucositis because it was discovered that there were many studies related to mucositis which did not address the condition from a chemotherapy induced perspective. They concluded that was ‘difficult to establish a definite link between nutritional status, nutritional interventions and mucositis’ (Keefe, 2007).
It meant that while clearly there is evidence based intervention supporting the need for nutrion management in mucositis there were no studies defining specifically the types of food or categories of nutrients best for the diet of a cancer patients. Speculations have been based on studies conducted with rats that there may be a folic acid deficiency (Tucker et.al, 2002).
However, Margaret Crawley and Laura Benson (2005) advanced theories to confirm that there are new approaches to nutritional management in patients with chemotherapy induced mucositis. While there is no specific intervention and more nurse ought to proactive in conducting such research a protocol for treatment of the complication ought to be established. This must encompass a nutrion component of care (Crawley & Benson, 2007).
Conclusion
The foregoing evidence based analysis of Mr. John’s case study outlined prophylactic strategies which could have been taken to eliminate mucositis as a chemotherapy complication and pharmacological as well as non-pharmacological interventions when the condition has occurred. As a prophylactic strategy prescreening for mouth care intervention techniques was advocated and a number of studies cited showing how mouth care has saved many lives. Mouth care has been proven very useful in preventing ulcers and other dental issues occurring due to to chemotherapy (Ciccolini et.al, 2010).
In relation to pharmacological intervention the method recommended was pain management through analgesic therapy. Combinations of topical and systemic drugs were recommended by the studies cited. Even when using mouth care as a prophylactic intervention pain is always a challenge because chemotherapy sometimes induces pain all over the body. The non-pharmacological approach was cited as proper nutrion. However, there are no existing evidence based studies relating specific nutritional practices to chemotherapy induced mucositis. It is recommended that nutritionists, chemotherapy doctors and cancer research be promote studies on how nutritional practices can be improved to help patient suffering from chemotherapy induced mucositis.
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