This report critically discusses about the case study of a patient name Jenny Coste. She is an active 9 years old girl, who has recently complained about prolonged pain in legs. The prolonged pain in her legs is harming her quality of life as she could no longer go to school and take part in spots like her other siblings. On visiting a doctor and after sufficient tests, it was found that Jenny had been suffering from acute lymphoblastic leukemia (ALL) (Hunger and Mullighan 2015). It has been reported that after that Jenny struggled with a thorough treatment of long 18 months, after which she showed a brief remission from the disease, followed by a relapse. Her condition is found to deteriorate, and finally she was admitted to the hospital with fungal Pneumonia. It has been reported that her vital signs showed Blood pressure 90/60, Heart rate- 85, IVT- 0.9% NaCl with 55 dextrose at 60 mls/hr. O2 at 2L/min via nasal specs at O2 97%. It has been reported that while she was given the second dose of cefotaxime, she developed an anaphylaxis reaction and developed redness on her stomach.
The purpose of this paper is to discuss about Fungal Pneumonia, which Jenny had been suffering from after she had relapsed from the cancer. It has been critically discussed about the pathophysiology of the adverse drug reactions that has developed due to the application of cefotaxime. The report had critically discussed the signs and the symptoms, the pharmacological management of the clinical condition. The report also focuses on the nursing management protocols that are need to be served for a proper care. Reviews from literatures, as supporting evidence in order to explain the required care, has also been provided. This report also throws light up-on the psychosocial issues that jenny had to deal with in this case and have also discussed about the possible remedies that can be provided. It has also been discussed about the role of the interprofessional collaborations that are to be adopted in such a critical situation.
The following case study gives about idea about the fact that the girl was suffering from cancer and he underwent a treatment of long 18 months. Immunocompromised children suffering from cancer, have a constant risk of developing infections. The stage and the type of cancer, the type of the anticancer therapies and antibiotics used, integrity of the mucous membrane and the skin, the duration of the hospital stay, the patient’s vital status, nutritional status, all are responsible. Immuno compromised patients are susceptible to the risk of developing pulmonary infections, by pathogens such as bacteria, viruses and fungi. Infectious complications like Pneumonia are a major obstacle in immunocompromised children. Pulmonary infections mainly occur due to the aspiration of the pathogens from the upper airways. Opportunistic fungi can colonize and can cause fungal pneumonia (Sahbudak Bal 2015). Fungi like Aspergillus and Cryptococcus are responsible for Pneumonia. In this report we have come to know that Jenny had been given Cefotaxime to deal with the fungal Pneumonia. Cefotaxime is an antibiotic which is normally administered in case of bacterial infections. This drug belongs to the class of Cephalosporin antibiotics.
In addition to the required effects, Cefotaxime also can impose serious side effects and therefore require immediate medical attention. Normally the adverse effects that are caused are abdominal cramps, chills, chest pain, hives, itching, rashes on the skin and many more. In this case we can see that jenny has developed red abdominal rashes which directly link to the evidences provided (Aouam etal. 2012). Not all the side effects of Cefotaxime are reported, but when it comes to an immunocompromised child of just 9 years.
There are certain medicines that can interact with Cefotaxime to generate adverse drug reactions. Especially when a patient is under the medications of cancer, Cycloporins may cross react with the drug to give rise to anaphylactic reactions. Each and every person reacts to medicines differently. A drug suitable for one person may not be suitable for the other person. A person may develop rashes, hives or develop more serious adverse reactions; on the other hand another person may not show any such hypersensitive reactions (Carspecken et al. 2013). The immune system of the body reacts to drugs in many ways. For instance, if a body is allergic to a particular medicine, then the body identifies that particular drug as an allergen or an antigen, as in case of Jenny.
The immune system protects the body and fights against diseases and infections. During a hypersensitivity reaction the immune system reacts with the drugs, thinking it as a foreign invader. This immune response leads to inflammation causing rashes in Jenny, and since she is immunocompromised, the situations have turned more critical than it had been in any other patients (Carspecken et al.2013).
Hypersensitivity reactions due to drugs are mediated mainly by the IgE antibodies or T cells. The reaction mechanism of IgE is well investigated, but the mechanisms of T-cell-mediated drug hypersensitivity are not well understood (Lieberman 2012). Recent studies have mentioned about 2 concepts: the hapten/prohapten concept and the concept of interactions of the antibiotics with immune receptors (Adam, Pichler and Yerly 2012). In allergic drug reactions, mediated by the T cells, the specificity of the T-cell receptor that has been stimulated by the antibiotic may be directed to a cross-reactive major histocompatibility complex-peptide compound.
In the given case study it has been found that Jenny after getting a treatment of prolonged18 months, have been found to develop Pneumonia, and we can see that her condition is gradually deteriorating. This deterioration might have caused by the side effects shown by the antifungal drugs (Jesenak et al. 2014).
The selection of the type of therapy of these kinds of patients depends on the type of immune suppression in the patient and other factors such as the presence of the central venous lines. Antifungal therapies are there for the children with cancer (Skidmore-Roth 2013). In case of adverse drug reaction caused by the cephalosporin class of antibiotics, medicines like antihistamines and oral or intravenous corticosteroids or intramuscular or subcutaneous epinephrine can also be applied. To reduce the chance of fungal pneumonia, the following interventions can be taken up for Jenny, prophylactic antibiotic can be given, haematopoetic growth factors can also be given in a prophylactic strategy (Groll et al. 2014).
There are several risks associated with giving prophylactic antibiotics, especially when it is just a child of 9 years. Furthermore, recent researches have found that prophylactic antibiotics given to the patients undergoing chemotherapy have helped to develop resistant organisms that can cause infection later on during the course of the treatment. Care should be taken while administrating the drugs as these can have adverse effects in the patients whose immunity is compromised as in case of this case study. The antifungal might cross react and give rise to allergic reactions. Infusion related reactions may occur like it may give rise to rash fever, chills (Smyth et al. 2012). Before administration of the antifungal the clinicians should monitor the blood urea nitrogen, serum creatinine, live function, serum electrolytes before the administration of the antivirals. It can be said that the pharmacist should be aware of the recommended doses for each patient, especially when it comes to children. He should be well aware of the drug-drug interactions and the general side effects while prescribing these antifungal agents.
Elements of care required
From the given case study we have come to know that Jenny has been hospitalized for few days with fungal Pneumonia, after which she had been diagnosed with adverse drug reactions after which she had been discharged home with a palliative care team and home care support. Extra precaution should be taken as Jenny has also relapsed from cancer and, even a small hypersensitive reaction can be fatal for her. In case of respiratory distress, arising out of the adverse drug reactions, she can be given aggressive respiratory measures like administration of high concentration of oxygen, mechanical ventilation, endo-tracheal intubation (Laschinger and Smith 2013). Antihistamines and corticosteroids can be administered, keeping the health status of Jenny in mind. The palliative care team for Jenny should contain highly skilled multidisciplinary team of specialized doctors and nurses, which would focus on the holistic care of the patient with a progressive illness. The early integration of a palliative care not only affects the physical domains of the illness but also caters to the patient’s psychological, spiritual, developmental wellness (Jacobsen and Wagner 2012).
Nursing care plan
- Recognition of the early signs and the symptoms of acute hypersensitivity reactions.
- Administration of the Epinephrine by consulting with the specialist.
- Should avoid the triggering of allergen as much as possible.
- Looking after the vital signs of Jenny and would try specific allergen therapy to prevent the adverse reactions.
- Asses the rate and the depth of the respiration and the chest movements.
- Application of the intravenous body fluids as per the condition of the vital status of Jenny.
- Communication with the patient’s family regarding what measures should be taken in case of a future drug reaction, as the patient is immunocompromised.
- One should teach the patient to carry out the necessary exercises as deep breathing and exercises would bring about expansion in the chest.
- Frequent monitoring of the chest X-Ray, pulse oximetry readings, for detecting any improvement or deterioration.
- Would maintain proper nutritional charts, fluids containing electrolytes, beverages that are nutrition enriched.
Interprofessional collaboration is the key to provide a proper healthcare to some clinical complications. Such collaborations improve the health outcome of the patients by reducing the effects of the adverse drug reactions, and lessen the rate of mortality and morbidity. It helps in the optimization of the medical dosage (Falk 2016; Reeves et al. 2013). Team work is always found to be suitable for better outcomes. The interprofessional collaboration that has been adopted in case of Jenny is as follows:-
Role clarity is required in order to attain a successful palliative team of medical experts. In case of Jenny, the palliative team should contain a medicine specialist, a pedriatric specialist, one oncologist (as she has just relapsed from cancer), a pulmonary specialist, a hematologist and a group of efficiently trained nurses. Each expert having specializations in their individual domains should try their best to manage the adverse reactions caused by the drug and should assure prevention of the recurrence of the adverse drug reactions (Russell 2013).
Trust and cooperation
Trust and cooperation between the members of a care team is important for successful treatments. Collaboration between the team members, Jenny and her family can bring about a positive outcome in the treatment and would promote fast recovery in Jenny (Falk 2016).
Ability to overcome adverse conditions
The team of medical experts should be prompt in dealing with the deteriorating conditions. In adverse times team collaboration becomes very necessary. Jenny is suffering from a very critical condition; therefore she needs a care that is exclusively patient centered and a lot of expertise. So, the team should be confident enough to manage the difficult situations. It is not always an easy task to get along well with the team members. An adverse situation cannot be overcome if there is no unity between the professionals. The professionals also should be able to communicate freely with Jenny’s family (Eijzenga et al. 2013).
As we are talking about a palliative team, therefore we should focus on the collective care provided by a team. Collective leaderships reduce the pressure from an individual member in a team (Falk 2016; Laschinger and Smith 2013).
Jenny is just a child of 9 years, and within this only she has become the victim of the curse called Cancer, therefore it is very natural that she should be suffering from some psychosocial issues. Normally children who suffer from cancer go through emotional turmoil. Therefore they demand special approaches to operationalize the issues that they face during that phase. These psychosocial effects may bring about depressions in the child, which may lead to her widrawal from the loved ones, which is again detrimental for her mental as well as her physical health (Bellizzi et al. 2012).
Jenny has been detected with a deadly disease in such an early phase of her life, followed by another infection; she is encountered with traumatic thoughts, palpitations that lead to chronic psychosocial issues in her.
Impact of the psychosocial issues
The principle concern focuses on the impact of the disease on the physical domain. ALL directly impairs the development of the child. Emotional distress and anxiety would leave no room for improvement in the patient (Eijzenga et al. 2013).
ALL followed by the Pneumonia, which is again followed by an adverse drug reaction can have a devastating impact on the brain of a child of just 9 years. She had already suffered from the pain of the chemotherapies and radiations. The brief period of remission would have brought a new ray of hope within her, but the recurrence of the discomfort, pain would have shattered mentally.
Impact on the loved ones
Parents and the loved ones are the most affected and face severe challenges in coping up with the situations. Parents suffer from severe anxiety, trauma and it often becomes difficult for them to assess the situation and take proper action (Wiener et al. 2015). As we can see from the case study that jenny is suffering from post traumatic stress. A comprehensive assessment of the psychosocial issues is required to lessen the depression in the family as well as the child (Marcus 2012).
Possible remedies to improve the quality of life
In order to deal with the quality of life Jenny and her family needs to register under certain family programs. Programs like social platforms and camps where Jenny could mix with more children like her and get motivated. Play therapies can reduce the emotional turmoil taking place in Jenny, and overcome the impact of the infection (Jacobsen and Wagner 2012).
Evidence based care for Jenny
Assessment of the risk factors, physical examination and diagnostic evaluation are the ways by which nurses can identify the patients who are likely to become immunocompromised. Safety and care in pediatric patients are dynamic and complex. In some cases the health care professionals knowledge might not be enough, to ensure safe and proper therapeutic regimen to the patient. In such cases it is recommended to go through the case histories of the ADRs. It should be always kept in mind that poor monitoring is worst than poor prescribing. It is the duty of the nurses to monitor the ADRs and report them to the physicians while helping them (James 2013). In case of Jenny, a proper monitoring at the time of administration of the drug and preventive measures could have resisted this condition. Depending on the need the palliative care can be coordinated by a community nurse. Volunteers can provide practical and emotional support. One should have a regular appointment with the health professionals, so that they can monitor any progress or deterioration.
Therefore it can be concluded that an immunocompromised patient like Jenny can easily fall prey to infections, and improper management of therapeutic can lead to severe drug reactions. These drug reactions can be prevented by applying evidence based practice, interprofessional collaborations among the healthcare professionals. The report also focuses on the fact that, since Jenny is suffering from several psychosocial issues; it is the duty of the caregivers and the family to provide her with a holistic approach of care and sufficient mental support
Aouam, K., Chaabane, A., Toumi, A., Fredj, N.B., Romdhane, F.B., Boughattas, N.A. and Chakroun, M., 2012. Drug rash with eosinophilia and systemic symptoms (DRESS) probably induced by cefotaxime: a report of two cases. Clinical medicine & research, 10(1), pp.32-35.
Bellizzi, K.M., Smith, A., Schmidt, S., Keegan, T.H., Zebrack, B., Lynch, C.F., Deapen, D., Shnorhavorian, M., Tompkins, B.J. and Simon, M., 2012. Positive and negative psychosocial impact of being diagnosed with cancer as an adolescent or young adult. Cancer, 118(20), pp.5155-5162.
Carspecken, C.W., Sharek, P.J., Longhurst, C. and Pageler, N.M., 2013. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics, 131(6), pp.e1970-e1973.
Eijzenga, W., Aaronson, N.K., Hahn, D.E., Sidharta, G.N., van der Kolk, L.E., Velthuizen, M.E., Ausems, M.G. and Bleiker, E.M., 2014. Effect of routine assessment of specific psychosocial problems on personalized communication, counselors' awareness, and distress levels in cancer genetic counseling practice: a randomized controlled trial. Journal of Clinical Oncology, 32(27), pp.2998-3004.
Falk, A. L. (2016). Interprofessional Collaboration in Health Care. Link?ping University Electronic Press.
Groll, A.H., Castagnola, E., Cesaro, S., Dalle, J.H., Engelhard, D., Hope, W., Roilides, E., Styczynski, J., Warris, A. and Lehrnbecher, T., 2014. Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis, prevention, and treatment of invasive fungal diseases in paediatric patients with cancer or allogeneic haemopoietic stem-cell transplantation. The Lancet Oncology, 15(8), pp.e327-e340.
Hunger, S.P. and Mullighan, C.G., 2015. Acute lymphoblastic leukemia in children. New England Journal of Medicine, 373(16), pp.1541-1552.
Jacobsen, P. B., & Wagner, L. I. (2012). A new quality standard: the integration of psychosocial care into routine cancer care. Journal of Clinical Oncology, 30(11), 1154-1159.
James, J.T., 2013. A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety, 9(3), pp.122-128.
Jesenak, M., Banovcin, P., Jesenakova, B. and Babusikova, E., 2014. Pulmonary manifestations of primary immunodeficiency disorders in children. Frontiers in pediatrics, 2.
Laschinger, H. K., & Smith, L. M. (2013). The influence of authentic leadership and empowerment on new-graduate nurses’ perceptions of interprofessional collaboration. Journal of Nursing Administration, 43(1), 24-29.
Marcum, Z.A., Amuan, M.E., Hanlon, J.T., Aspinall, S.L., Handler, S.M., Ruby, C.M. and Pugh, M.J.V., 2012. Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans. Journal of the American Geriatrics Society, 60(1), pp.34-41.
Marcus, J. (2012). Psychosocial issues in pediatric oncology. The Ochsner Journal, 12(3), 211-215.
Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: effects on professional practice and healthcare outcomes (update). The Cochrane Library.
Russell, P.S., 2013. Clinical approach to infection in the compromised host. Springer.
Sahbudak Bal, Z., Yilmaz Karapinar, D., Karadas, N., Sen, S., Onder Sivis, Z., Akinci, A.B., Balkan, C., Kavakli, K., Vardar, F. and Aydinok, Y., 2015. Proven and probable invasive fungal infections in children with acute lymphoblastic leukaemia: results from an university hospital, 2005–2013. Mycoses, 58(4), pp.225-232.
Sims, S., Hewitt, G. and Harris, R., 2015. Evidence of collaboration, pooling of resources, learning and role blurring in interprofessional healthcare teams: a realist synthesis. Journal of Interprofessional care, 29(1), pp.20-25.
Skidmore-Roth, L., 2013. Mosby's 2014 nursing drug reference. Elsevier Health Sciences.
Smith, J.A. and Kauffman, C.A., 2012. Pulmonary fungal infections. Respirology, 17(6), pp.913-926.
Smyth, R.M.D., Gargon, E., Kirkham, J., Cresswell, L., Golder, S., Smyth, R. and Williamson, P., 2012. Adverse drug reactions in children—a systematic review. PloS one, 7(3), p.e24061.
Wiener, L., Kazak, A. E., Noll, R. B., Patenaude, A. F., & Kupst, M. J. (2015). Standards for the psychosocial care of children with cancer and their families: an introduction to the special issue. Pediatric blood & cancer, 62(S5).