The Nursing Mucositis Challenge Essay

Internationally, the Oncology Nursing Society strives to guarantee that the footing of nursing pattern is on the most current grounds available to guarantee high quality, cost effectual patient attention. For OM, schemes suggested include an unwritten attention assessment tool, an unwritten attention protocol and patient instruction to assist keep patients ‘ functional position and quality of life ( Eilers and Million 2007 ) . Likewise, the National Comprehensive Cancer Network ( NCCN ) 2008, one of the universe ‘s prima malignant neoplastic disease Centres, recommends the same schemes. This Centre is committed to heightening the quality and effectivity of attention provided to malignant neoplastic disease patients. Furthermore, the World Health Organisation ( WHO ) and the National Cancer Institute ( NCI ) advocate assessment tools to rate the harm caused by mucositis ( WHO 1979, NCI 2003 ) . Other national general indexs for best pattern include the Department of Health ( DOH ) ( 2010 ) , benchmarking tool, Essence of Care. The Nursing Mucositis Challenge Essay These emphasis that pattern and attention should be grounds based and underpinned by research. The Kernel of Care benchmarks includes personal hygiene that constitutes mouth attention to guarantee that the unwritten pit is preserved in a healthy status. They besides outline that information should be available to do patients cognizant of peculiar hygiene demands that may be required as a consequence of specific interventions such as chemotherapy. Presently our administration is in the procedure of implementing benchmarking against criterions. However, locally in pattern no intercessions on minimising the hazard of mucositis exists despite the impact it can hold on malignant neoplastic disease patients.The Nursing Mucositis Challenge Essay

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Chemotherapy induced mucositis is a common side consequence of drug toxicity with up to 80 % of patients holding symptoms during their intervention ( Dodd et al 2000, Lalla and Patterson 2006 ) . Oral mucositis ( OM ) is defined as unwritten mucosal alterations secondary to malignant neoplastic disease therapies. It manifests foremost by the cutting of unwritten tissue taking to erythema. As the tissue continues to thin, ulceration finally occurs. Treister and Sonis ( 2007 ) allude to OM happening in four biological phases ( Table 1 )

Table 1: Adapted from Treister and Sonis ( 2007 )

Initiation

Cell exposure to chemotherapy causes DNA harm and generates reactive O species ( ROS ) , which are able to wound cells, tissues and blood vass.

Signing

ROS cause farther cell harm and stimulate look of written text factors that lead to weave hurt and cell decease.The Nursing Mucositis Challenge Essay

Ulcer

Painful ulcers form supplying an entry point for bacteriums, viruses and Fungis. Bacterial cell wall constituents can so bring on redness farther.

Mending

A signal from submucosal tissue allows renewed cellular proliferation and distinction reconstructing the liner of the unwritten mucous membrane.

The primary map of unwritten mucous membrane is to move as a barrier that protects the implicit in tissue and variety meats. The high turnover rate of the non – keratinized squamous epithelial tissues cells that make up the unwritten mucous membrane, every 10 to 14 yearss, increase the exposure of these cells to the effects of chemotherapy.The Nursing Mucositis Challenge Essay

Table 1:2 the clinical mark of mucositis includes ;

Erythema

Cracked lips

Trouble have oning dental plates and / or swallowing

Pain and / or hemorrhage

Ulcer

Dry oral cavity, accompanied by a decrease in the immune constituents of spit.

Despite the obvious clinical manifestation, OM presents a frustrating challenge for health care suppliers and a painful obstruction for patients.

The tissue injury and associated hurting of OM were identified as a major clinical job as far back as 1970. Among all the intervention side effects and complications that malignant neoplastic disease patients face, OM ranks as one of the most troublesome, doing important concern for the bulk of patients having chemotherapy. Bruce and Quinn ( 2007 ) highlighted the fact that patients consider OM to be the most hard intervention related toxicity to digest. This relates to the most common associated unwritten mucositis disfunction such as dysphagia, dry oral cavity and alterations in nutrient gustatory sensation. All these symptoms have a negative impact on patients ‘ day-to-day life and lifestyle ( Cheng and Chang 2003, Ohrn and Sjoden 2003 ) . Likewise, a 2008 study by the National Comprehensive Cancer Network stated that mucositis has emerged as the

‘Most important inauspicious symptom of malignant neoplastic disease therapy ‘ reported by patients.The Nursing Mucositis Challenge Essay

A figure of factors increase the hazard of infection which includes the loss of mucosal barrier unity. The cooperation of local and systematic unsusceptibility leads to the outgrowth of timeserving and acquired pathogens in the unwritten pit. Infections can be fungous, viral and bacterial in beginning ( Wojtaszek 2000 ) , doing direct tissue harm or increase harm already present due to mucositis. Symptoms vary from hurting and uncomfortableness to an inability to digest diet and fluids ( Silverman 2007 ) . Keeping equal nutrition and hydration can be hard if non impossible. Poor nutritionary position is known to interfere with mucosal regrowth as it decreases cellular migration and reclamation and therefore increases the consequence of mucositis through delayed healing ( Shih et al 2008 ) .The Nursing Mucositis Challenge Essay

In many instances excessively, the hurting can be terrible plenty to necessitate inmate attention and high dosage opoid anodynes ( Treiter and Sonsis 2007 ) . Opoid anodynes are associated with crippling side effects such as irregularity, hallucination and loss of mental watchfulness ( Bruce and Quinn 2007, Bellm et al 2000 ) . Continuous hurting and the inability to transport out simple unwritten undertakings such as get downing can hold a profound psychological consequence on patients, gnawing the feeling of well-being.

The experience of cancer patients overlaps with nursing care since the difficulties imposed by the disease and complications accruing from the therapy, such as oral mucositis, differentiate these patients who require specialized care.The Nursing Mucositis Challenge Essay

Mucositis is a toxic inflammatory response that affects the gastrointestinal tract mucosa, a sequel of radiotherapy and/or chemotherapy or bone marrow transplantation, resulting in intense pain and impaired verbal communication and eating(1). The occurrence of oral mucositis ranges from 40% to 76% in patients undergoing chemotherapy; 75% in individuals undergoing bone marrow transplantation; and may affect 90% of the patients undergoing radiation to the head or neck. These percentages increase when chemotherapy is associated with radiation(2).

Instruments to measure the degree of oral mucositis are important to determining patients’ self-care deficits and plan specific care actions. The instrument most frequently used is the scale presented by the World Health Organization (WHO) in 1979. It takes into account anatomical, functional and symptomatic aspects of muscositis and classifies them in degrees of 0, I, II, III, IV, which correspond to the absence of lesions up to lesions that impede the patient’s eating (3).The Nursing Mucositis Challenge Essay

In addition to using instruments, nurses must realize that care provided to cancer patients should be planned and that following the nursing process (NP) is crucial. The NP should be theoretically supported to guide data collection, the establishment of diagnoses, the planning of interventions and assessment of results(4). Three classifications are necessarily used by the third generation of NP: Diagnoses, Results and Interventions(5), according to specific taxonomies such as the North American Nursing Diagnosis Association (NANDA)(6), Nursing Interventions Classification (NIC)(7) and Nursing Outcomes Classification (NOC)(8).The Nursing Mucositis Challenge Essay

Theorists(9-11) support a concept of care in the dimension of human existence as a comprehensive, interactive and associative phenomenon that is generated between caregiver and recipients of care, aiming to generate comfort, help, promotion, and reestablishment of health, and relief of human suffering. From Heidegger’s perspective, caring is a key provision to deal with the world, that is, the relationship with another individual is manifested in the relationship between the being-here and the being-in-the-world, which is revealed not only by occupation, but also by pre-occupation, guided by tolerance and patience(12).

Therefore, the relevance of this study lies in the possibility of sensitizing and challenging nurses in regard to the problem of oral mucositis and encouraging professional autonomy in establishing more effective evidence-based practices. There are few studies in the nursing field addressing this problem, so it is expected to provide parameters to support practice. Understanding the experience of these patients is essential to developing technologies and planning nursing actions intended to alleviate the conditions that arise from treatments and optimize the quality of life of this population.The Nursing Mucositis Challenge Essay

Given the previous discussion, the objective was to characterize the sociodemographic and clinical profiles of cancer patients with oral mucositis and analyze the NP-based care provided to these patients.

METHOD

This descriptive, cross-sectional, and quantitative study was developed in two specialized cancer care centers, one philanthropic and one private facility, located in Teresina, PI, Brazil.

The population comprised all the patients admitted with an oral mucositis diagnosis or who developed the complication during data collection, cared for either by the outpatient clinic (chemotherapy and/or radiotherapy), or who were hospitalized. The accidental probability sample was composed of 213 patients, who expressed their consent to participate in the study by signing free and informed consent forms.

Data were collected between August 2011 and January 2012, in three stages. The first stage included the application of the form addressing the patients’ sociodemographic and clinical aspects and the situation of the nursing care provided. In regard to this last aspect, we asked about the presence or absence of nursing interventions implemented among the patients, which was important to detecting how the patients recognize the role of nurses or caregivers and verify whether there were failures in care delivery. The second stage of data collection was complementing data collected to that point with data from the patients’ medical records. In this stage, we verified which phases of NP had been implemented and the nature of the interventions performed for patients with oral mucositis. The third stage included physical assessment of oral mucositis by applying the WHO Oral Mucositis Grading Scale The Nursing Mucositis Challenge Essay

For this study, we stratified the severity of mucositis into two stages, mild and severe. Mild stages included 0, I, and II, in which the patient is able to maintain his/her routine diet despite mucosal erosion. The severe stage comprised degrees III and IV; in that stage, patients require either a change in their diet or are unable to eat.

The project was approved by the Institutional Review Boards at the care centers involved in the study and at the Federal University of Piauí, Brazil (CAAE: 0147.0.045.000-11).

After coding and developing the data dictionary, information collected was validated by double-entering data in Microsoft Excel spreadsheets. Afterwards, data were exported and analyzed in the Statistical Package for the Social Sciences (SPSS), version 17.0, and absolute and relative frequencies, as well as central tendencies and dispersion measures, were computed.The Nursing Mucositis Challenge Essay

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.The Nursing Mucositis Challenge Essay
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).The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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 Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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)The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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.The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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).The Nursing Mucositis Challenge Essay

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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There is considerable apprehensiveness associated with malignant neoplastic disease diagnosing, proportionately more than with other chronic disease such as bosom disease. Despite progresss in intervention and attention, there continues to be a great trade of anxiousness and fright associated with diagnosing of malignant neoplastic disease and intervention complications ( Lewis.,2004 ) . Therefore an of import function of the nurse in pull offing result is to acknowledge, intervene and supply support for the human response to populating with malignant neoplastic disease and malignant neoplastic disease intervention complications ( Sorrell, C. , 2005 ) .The Nursing Mucositis Challenge Essay

Cancer is one of the most important wellness jobs in the universe as a major cause of morbidity and mortality. Globally the load of new malignant neoplastic disease instances was estimated to be around 10 million with more than half of these instances arising from the developing universe population. Although estimations vary it is estimated that by the twelvemonth 2020 there will be about 20 million new instances. The magnitude of the job of malignant neoplastic disease in India, from the population nose count informations 609,000 new malignant neoplastic disease instances per twelvemonth were estimated to hold been diagnosed in the state ( Radhika, B. , 2008 ) .

Oral mucositis remain a major beginning of unwellness despite the usage of a assortment of agents to forestall them. Oral mucositis is defined as an redness and ulceration of the oral cavity mucous membrane with pseudo membrane formation. It is a possible beginning of infection which may take to decease. It manifests foremost by thinning of unwritten tissues taking to erythema and leads to ulcer formation. It is at this phase that the primary symptom is terrible enfeebling unwritten hurting ( Naidu, R. , 2004 ) .The Nursing Mucositis Challenge Essay

Incidence and badness of unwritten mucositis will change from patient to patient, and intervention to intervention. Approximately 400,000 patients per twelvemonth may develop ague or chronic unwritten complications during chemotherapy and radiation therapy. It is estimated that there is 40 per centum incidence of mucositis in patients treated with chemotherapy, patients having radiation have 30 to 60 per centum opportunity and patients having radiation therapy in peculiar to head and cervix have opportunity of 98 per centum ( Suman, A. , 2004 ) .

Severe mucositis is normally seen in patients who receive radiation therapy for malignant neoplastic disease of the unwritten pit and environing constructions. Oral mucositis besides occur secondary to chemotherapy for assorted solid tumours, the exact pathophysiology of development is non known, but it is thought to be divided into direct and indirect mucositis, chemotherapy or radiation therapy will interfere with the normal turnover of epithelial cells taking to mucosal hurt and besides occur due to indirect invasion of Gram-negative bacteriums and fungous species because most of the malignant neoplastic disease drugs will do alterations in blood counts ( Ramana, V.,2004 ) .The Nursing Mucositis Challenge Essay

The initial presentation of unwritten mucositis is erythema followed by white peel offing plaques, which are painful when touched. Epithelial crusting and a fibrin exudates result in a imposter membrane and ulceration, which is the more terrible signifier of mucositis and patients constantly ailment of hurting. Exposure of stromal connective tissue due to loss of epithelial cells is found in the most terrible signifier of mucositis. It normally develops seven to fourteen yearss after chemotherapy or radiation therapy is initiated ( Nathanial, S. , 2010 ) .

Assorted agents are used in order to cut down the incidence and badness of unwritten mucositis. Chlorhexidine gluconate is an anti microbic agent that appears to be effectual in commanding infection. Povidone I is an antibiotic agent besides appears to be good in commanding radiation or chemotherapy induced unwritten mucositis. An ideal unwritten rinse for patients with radiation or chemotherapy induced unwritten mucositis should cut down the unwritten microflora, promote reepithelization of soft tissue lesion, normalise the pH of unwritten fluids and be nontoxic. 1 % of povidone I gargle and 0.12 % chlorhexidine gargle have all these qualities. Patients with radiation or chemotherapy induced unwritten mucositis rinse their oral cavity with 10 milliliters of gargle, twice a twenty-four hours for healing of unwritten mucositis ( Goodman.M,2006 ) .The Nursing Mucositis Challenge Essay

1.1 Need for the Survey: In patients undergoing malignant neoplastic disease intervention, unwritten mucositis is reported as the most debilitating facet of their intervention. Ulcer may move as a site for local infection and a portal of entry for all unwritten vegetations that in some case may increase the hazard for developing blood poisoning. In add-on to direct morbidity, unwritten mucositis contribute indirectly to increased length of hospitalization and increased cost of intervention.

Oral mucositis affects upto 40 per centum of patients who receive radiation therapy. Severe mucositis interrupt the direction of malignant neoplastic disease which can compromise remedy rate. Patients with terrible unwritten mucositis demand hospitalization because of terrible hurting and lose ability to take anything by oral cavity and necessitate parentral nutrition ( Lieberman, A.,2003 ) .

Many different gargles are commercially available, patients and wellness professionals struggle to choose the most appropriate merchandise for a peculiar demand. Normally used gargle for unwritten mucositis are chlorhexidine gargle and povidone I gargle. Many of the literature shows that both gargles have an consequence on radiation or chemotherapy induced unwritten mucositis. Mucositis may be terrible as to detain intervention and so restrict the effectivity of malignant neoplastic disease therapy. Patient with damaged unwritten mucous membrane and decreased unsusceptibility ensuing from chemotherapy and radiation therapy are besides prone to timeserving infections in the oral cavity. It is hence highly of import that mucositis should be treated and to forestall related complications. Advancement in the bar and direction of mucositis will better quality of life, cut down cost of attention and facilitate completion of more intensive malignant neoplastic disease chemotherapy and radiation therapy protocols. Improved direction of mucositis that is usage of povidone I gargle may let execution of malignant neoplastic disease intervention protocols efficaciously ( Dodd. , 2003 ) .The Nursing Mucositis Challenge Essay

Nurses play a critical function in the appraisal and direction of unwritten mucositis. However, nurses face several important challenges in efficaciously pull offing unwritten mucositis. First, the appraisal and direction of unwritten mucositis is inconsistent. Second, available intervention options are mostly uneffective, aimed at palliation of symptoms, and do non aim the implicit in pathophysiology. Nursing attention has focused chiefly on symptom direction and hurting control. With recent progresss in the apprehension of the pathophysiology of unwritten mucositis and the development of intercessions, it is hoped that the quality of attention provided to patients will better dramatically as new agents such as povidone I gargle should let the end of direction to switch from symptom alleviation to protection and bar. Nurses should be educated about these novel options for the direction of unwritten mucositis ( Bavier, A. , 1990 ) .

The research worker during the clinical experience come across malignant neoplastic disease patients with radiation or chemotherapy induced unwritten mucositis and steps to advance healing of unwritten mucositis have been found uneffective. From the findings of literature besides the research worker realized that it is necessary to carry on a survey for comparing of povidone I gargle and chlorhexidine gargle in cut downing radiation or chemotherapy induced unwritten mucositis. This motivated the research worker to happen out the most effectual gargle for radiation or chemotherapy induced unwritten mucositis.The Nursing Mucositis Challenge Essay

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1.2 Statement of the job
A COMPARATIVE STUDY TO ASSESS THE EFFECTIVENESS OF POVIDONE IODINE MOUTHWASH VERSUS CHLORHEXIDINE MOUTHWASH ON RADIATION OR CHEMOTHERAPY INDUCED ORAL MUCOSITIS AMONG CANCER PATIENTS IN CARITAS HOSPITAL, KOTTAYAM.

1.3 Aims
Assess the radiation or chemotherapy induced unwritten mucositis in malignant neoplastic disease Patients.

Assess the effectivity of povidone I oral cavity wash on radiation or chemotherapy induced unwritten mucositis in malignant neoplastic disease patients.

Assess the effectivity of chlorhexidine gargle on radiation or chemotherapy induced unwritten mucositis in malignant neoplastic disease patients

Compare the effectivity of povidone I and chlorhexidine oral cavity wash on radiation or chemotherapy induced unwritten mucositis in malignant neoplastic disease patients.

1.4 Premise
Radiation therapy or chemotherapy will do unwritten mucositis.

Povidone I gargle and chlorhexidine gargle helps in healing of unwritten mucositis.

The usage of povidone I oral cavity wash is more effectual than chlorhexidine oral cavity wash on healing of radiation or chemotherapy induced unwritten mucositis in malignant neoplastic disease patients.

1.5 Hypothesis
1.5.1 There will be important difference between pretest and posttest class of radiation or chemotherapy induced unwritten mucositis in a group utilizing povidone I gargle.

1.5.2 There will be important difference between pretest and posttest class of radiation or chemotherapy induced unwritten mucositis in a group utilizing chlorhexidine gargle.The Nursing Mucositis Challenge Essay

1.5.3 There will be a important difference between class of radiation or chemotherapy induced unwritten mucositis in group utilizing povidone I gargle and chlorhexidine oral cavity wash.

1.6 Operational definition
1.6.1 Effectiveness: It is the result of usage of povidone I gargle and chlorhexidine gargle on radiation or chemotherapy induced unwritten mucositis

1.6.2 Mucositis: Radiation or chemotherapy induced redness of unwritten mucose membrane which will be graded by utilizing unwritten mucositis appraisal graduated table.

1.6.3 Mouth washes:
1.6.3. a ) Povidone iodine gargle: 1 % of povidone I gargle is a antibiotic solution used to handle radiation or chemotherapy induced unwritten mucositis

1.6.3. B ) Chlorhexidine gargle: 0.12 % chlorhexidine gargle is a antimicrobic solution used to handle radiation or chemotherapy induced unwritten mucositis

1.7 General system theoretical account: The conceptual frame work of this survey derived from General System Theory. Harmonizing to General system theoretical account input, throughput, end product explains pre appraisal of radiation or chemotherapy induced unwritten mucositis, supplying povidone I and chlorhexidine gargle and station appraisal of unwritten mucositis. Input represents the pre appraisal of unwritten pit which includes presence of ulcers, erythema, hydrops, bleeding, and strength of hurting, presence of enteric or parental eating. Throughput represents the disposal of povidone I gargle for povidone I group and chlorhexidine gargle for chlorhexidine group. Output represents the station appraisal of unwritten pit of both groups which brings that there is important difference in povidone I gargle and chlorhexidine gargle in cut downing radiation or chemotherapy induced unwritten mucositis

The world is constantly changing as the future draws nearer. By being a nurse, I have the ability to change lives and make major impacts on the lives of people and the world in a medical aspect. I know in my heart that it is my calling to become a nurse, to lead this world into the future. Being a nurse will be a challenge, but I am ready for that challenge. I have been ready for a long time to take on my role as a world changer, a listener, a healer, and a friend to those with needs, a nurse. I have chosen to pursue a career in nursing because it fits my essence of being, will allow me to accomplish my professional goals, and will allow me to practice a career with which I am irreversibly enthralled. The Nursing Mucositis Challenge Essay
Since I possess these two qualities, I know in my heart that I am honest with myself and dedicated to the goals I have set for myself. When I set goals for myself, I accomplish them. I have always been passionate and deeply devoted to achieving my goals. When I first began to learn how to tumble, the only tumbling pass I was able to do was a cartwheel. The first day I stepped into my competitive cheerleading gym for practice, I made myself a goal to be able to do a round-off back-handspring tuck, and I achieved it. After much hard work, practice, sweat, and tears, I took myself from a level one cheerleader to a level four cheerleader in only two years of doing competitive cheerleading. My team ranked World Champions two years in a row in the Senior Coed Division, and we were undefeated the entire time I cheered on that competitive cheerleading team.

Many patients besides experience emotional side effects including anxiousness, hurt and depression. A survey by Dodd et Al ( 2001 ) highlighted the impact mucositis had on patients ‘ quality of life during chemotherapy intervention. They noted that temper perturbation, choler and depression doubled in patients who suffered with mucositis. Severe mucositis can besides greatly perplex the direction of malignant neoplastic disease. It frequently leads to a hold in intervention rhythms, dose restricting complications and hence compromise remedy rates ( Lalla and Peterson 2005 ) . As unwritten complications chiefly are associated with uncomfortableness and intervention with unwritten map in patients who are besides immunosuppressed, these complications can go life endangering.

Economically, mucositis becomes a load when patients require drawn-out hospitalization or unplanned admittances to hospital. This is governed by the demand for prophylaxis antibiotic therapy to cut down the hazard of systemic infection, hurting direction and parenteral nutrition to optimise a positive clinical result ( Avritscher et al 2004, Bhatt et al 2010 ) . This is an illustration of one patient ‘s experience of mucositis ;The Nursing Mucositis Challenge Essay

A patient ‘s narrative
Mia, a 45-year-old adult female was admitted with neutropenic sepsis. Mia was diagnosed with chest malignant neoplastic disease three months ago and is presently holding chemotherapy. The primary focal point on admittance was to pull off and handle the episode of sepsis, a life endangering status. The initial nursing appraisal did non foreground any important physical complications associated with her cytotoxic therapy. As this was Mia ‘s first admittance with Neutropenic sepsis, she was evidently dying about the infection and the possibility that her following rhythm of chemotherapy would necessitate to be delayed or postponed. Four yearss on, nursing staff noted that Mia had become withdrawn. Her dietetic and unstable consumption had decreased plenty to do concern. Mia admitted that she was happening it hard to get down, eat and drink as her oral cavity was really painful. Mia described the hurting as “ intolerable ” at times. An scrutiny highlighted redness in the mucosal membrane with patchy ulceration throughout the unwritten pit. Mia ‘s symptoms were straitening for her as she associated a good dietetic consumption with recovery. Mia admitted that she had anticipated some side effects but felt unprepared for the longer-term side effects of altered gustatory sensation, trouble in get downing, dry oral cavity and loss of appetency. Nursing staff were concerned about the hazard of farther infection. Mia spent an excess four yearss in infirmary, required opoid analgesia to pull off her hurting, endovenous fluid therapy to keep hydration, drugs and oral cavity washes to relieve the ulceration and redness The Nursing Mucositis Challenge Essay

In 1997 the WHO defined Quality of life as

“ an person ‘s perceptual experience of their place in life in the context of the civilization and values systems in which they live and in relation to their ends, outlooks, criterions and concerns. ”

Neutropenic patients are the most vulnerable of malignant neoplastic disease patients due to their inability to contend infection, and hence are more susceptible to timeserving infection. These immunosuppressed patients are besides at increased hazard of developing OM and hence should have a standardized unwritten attention government as an on-going constituent of their attention. Patients with OM and neutropenia have an increased hazard of sepsis more than four times than that of patients with neutropenia merely ( Treister 2010 ) . The potency of systemic infections associated with chemotherapy induced mucosal harm could diminish every bit could tie in morbidity and mortality, if mucosal harm could be prevented or treated earlier.The Nursing Mucositis Challenge Essay

Much of the literature sing this topic relates to the medical direction such as effectual drug interventions to handle mucositis. My involvement is to concentrate on the nursing intercessions that could minimise the hazard of developing mucositis in the first case. Cawley and Benson ( 2005 ) claim that effectual unwritten hygiene can cut down hurting, hemorrhage and prevent infection. However, McGuire ( 2003 ) found that unwritten attention was frequently set aside when nursing work loads were inordinate. Meanwhile, Quinn ( 2009 ) points out that it is non ever a precedence until jobs arise taking to unneeded hurt for the patient and could potentially take to more serious clinical effects. This is a true contemplation of what happens in current pattern, as mucositis is non straight addressed unless patients complain of hurting or are observed holding jobs eating and imbibing.The Nursing Mucositis Challenge Essay

Locally in pattern, there is no scheme in topographic point to cut down the hazard of OM in this patient group, despite overpowering grounds that OM has a negative impact on patients ‘ quality of life and intervention results. Cheng ( 2007 ) advises that increased attending to unwritten disfunction is paramount for the early sensing of mucositis and alleviation of hurt. Nursing these patients gives us the chance to hold a positive impact on their attention, through persevering attending mucositis can be identified early leting for intervention intercessions before the job intensifies.The Nursing Mucositis Challenge Essay

To organize a determination sing the best possible clinical intercession for this identified pattern job it seems logical to change over the issue into a individual answerable inquiry ( Colyer & A ; Kamath 1999 ) . Several writers have identified that the usage of models to inform the development of the clinical inquiry, provides the practician with a systematic procedure of explicating an answerable inquiry ( Sackett et al 2005, Ridsdale 1998 ) .

Therefore to turn to the focal point of my question, I utilised the four phase procedure model, identified by the acronym PICO ( Sackett et al 2005 ) .

Patient or Population

Adult patients with chemotherapy induced neutropenia.

Intervention or Index

Effective nursing intercessions The Nursing Mucositis Challenge Essay

Comparison or command

Current pattern

Result

To minimise the effects of mucositis

Hence, the development of the inquiry ;

“ What does the grounds suggest is effectual nursing intercessions to minimise the hazard of mucositis in grownup patients with chemotherapy induced neutropenia? ”
Having read loosely literature refering to OM and using PICO to explicate the inquiry, this will help me to develop a hunt scheme and take me to research relevant grounds to reply the inquiry.

Chapter 2

With the focal point of the thesis now determined, what does the grounds suggest are the nursing intercessions required to understate the hazard of unwritten mucositis in chemotherapy induced neutropenic patients. This chapter will show the systematic procedure used to detect, select and pull out the best possible grounds from the literature to reply the research inquiry.The Nursing Mucositis Challenge Essay

Clinical pattern is non ever grounds based and, hence, may non optimize patient results. I considered utilizing pattern question to research my cognition and analyze current pattern within the infirmary on the chosen subject. Current pattern could be considered ritualistic, as attention is frequently carried out without believing it through in a job – work outing logical manner. Harmonizing to Philipin ( 2002 ) ritualistic pattern can be irrational, unscientific, insistent and hence, insecure. Furthermore, Strange ( 2001 ) perceives ritual pattern as economically underproductive and crude which presents a disapproving position of such attention. Soon, there is no policy or guidelines in topographic point for pull offing OM in chemotherapy induced neutropenic patients within my administration. Meanwhile, I felt evidence-based pattern ( EBP ) was the best option to reply the inquiry as it allows nurses to develop realistic intercessions that are more efficacious for the identified patient group. Throughout the procedure, I will measure theories and patterns, with the purpose of using the cognition obtained to future pattern. The outgrowth of ( EBP ) in the early 1990 ‘s has placed accent on guaranting that the best available grounds determines determinations in health care ( Evans 2003 ) . The public assume and patients expect that attention received be based on the best clinical cognition that has been tested and verified. Harmonizing to Fineout – Overholt et Al ( 2005 ) , health care that is grounds based and conducted in a lovingness environment leads to heighten clinical determinations and patient results. Sackett et Al ( 1996 ) concur, saying The Nursing Mucositis Challenge Essay

“ EBP aims to advance clinical and cost effectual attention through the explicit, painstaking and wise usage of the current available best grounds from research to steer determinations ” .

Practitioners are progressively required to oppugn their ain pattern ( Towler, 2001 ) and to present attention based on current grounds and, if applicable, on validated research ( Nursing and Midwifery Council ( NMC ) 2004 ) . This research based or EBP as it is known ( Meijet et al 2003 ) , is the painstaking usage of current best grounds in doing determinations about patient attention ( Sackett et al 2000 ) .Furthermore, this includes actions and interactions ensuing in clinically appropriate and cost effectual intercessions and results for clients ( Polit et al 2001 ) . Silverman ( 2005 ) proposes that research is a tool for developing the quality of nursing determinations, prescriptions and actions. As nurses, we have a research duty ; disregard of that duty could be classified as professional disregard.The Nursing Mucositis Challenge Essay

Research Approach and Design
Research is a systematic procedure used to analyze, verify or filtrate bing cognition and to research new thoughts about issues associating to nursing pattern ( Borbasi et al 2008 ) .

Nursing research falls within two wide universe positions, the rationalist and the realistic paradigms ( Houser 2008 ) . Both have contrasting premises about pragmatism and position of the universe. Positivists believes that a individual world exists, which can be calculated. Whereas, the realistic paradigm believes in legion worlds, that continually alteration and hence, can non be measured. Further premises are outlined below.

Table 2
Postivist Paradigm
Naturilistic Paradigm
One world – measurable

Numerous worlds.

Can non be guarded or predicted.

A degree of apprehension can be

achieved.

The research worker and the survey participants remain independent of each other and hence do non act upon each other.

The research worker and survey participants communicate and hence, influence each other

The results from the research can be indiscriminate from the survey sample to the larger mark population The Nursing Mucositis Challenge Essay

Findingss can non be generalised outside the survey sample.

Knowledge gained from the survey is in the signifier of a “ on the job hypothesis ”

Cause and consequence relationships can be tested

The multiple worlds are continuously altering.

Impossible to separate causes from consequence therefore, cause / consequence relationship can non be tested.

The research can be carried out objectively.

Value free

Research is subjective

Value bound- influenced by the research workers own values

( Adapted from Jones & A ; Bartlett )

Research methodological analysiss include qualitative, quantative, and assorted method theoretical accounts that provide specific way for processs in a research design. Research design is a logical and adept procedure ( Jolley 2010 ) to depict how, when and where information is to be collected and analysed ( Parahoo 2006 ) .The Nursing Mucositis Challenge Essay

Qualitative research is a wide term used to depict research that is focused chiefly on human experience through researching attitudes, beliefs, values and experiences ( Whitehead 2007 ) . It is used to research wellness related or illness related experiences or groups where small is known, or when the current apprehension seems unequal ( Richards & A ; Morse 2007 ) . Qualitative research is based on a figure of methodological analysiss including phenomenology, grounded theory and descriptive anthropology. The research method most normally used in this procedure is interviews, instance surveies and descriptive anthropology, the procedure of detecting an integral cultural group over a long period roll uping chiefly, experimental and interview informations ( Creswell 2007 ) . Therefore, qualitative research workers will reason that it is more indepth and holistic, bring forthing rich stuff on which to establish the findings of a piece of research ( Polit and Beck 2010 ) . Qualitative research plays a critical function in supplying grounds for pattern in nursing and is deriving greater credence within medical specialty ( Bailey and Tilley 2002 ) .The Nursing Mucositis Challenge Essay

Meanwhile, the footing for the quantitative research procedure is the paradigm of logical positivism. This focuses on results for patients, which are mensurable. It is a more formal, nonsubjective, deductive attack to job work outing. The quantitative paradigm is considered more dominant and is normally associated with the so – called “ scientific method ” . Generally, statistics gathered through several methods, for illustration a study questionnaire, is utilized for this procedure ( Parahoo 1997 ) . Furthermore, roll uping informations in numeral signifier and stressing precise measuring of variables is frequently conducted in the signifier of strictly controlled surveies. Basically, quantitative research provides strong, nonsubjective grounds that can be statistically analysed and interpreted. Extra characteristics of the qualitative and quantitative research methodological analysiss are outlined below.The Nursing Mucositis Challenge Essay

Table 2:1
Qualitative
Quantitative
Less scientific

Firm scientific discipline

Subjective

Aim

Inductive logical thinking used to mix facts

Deductive logical thinking used to mix facts

Focus – intricate and wide

Focus – succinct and narrow

Develops theory

Trials theory

Footing of cognizing – significance, find

Footing of cognizing – cause and consequence relationships

Basic component of survey – words, narrative

Basic component of survey – Numberss and statistical analysis

Multiple worlds that continuously change with each reading

A individual world – can be calculated and generalised.

( Adapted from Houser 2008 )

Evidence – based nursing and clinical administration presuppose research, without it grounds will stay obscure and no creditability will be given to clinicians who base their work on everyday and tradition entirely ( Lawton et al 2000 ) . To heighten patient results now and in the hereafter, it is critical that the grounds – based attack to nursing attention is integrated into clinical pattern scenes. Effective development of EBP depends on the accomplishment of happening and analyzing informations, critically analyzing consequences and using the appropriate intercession to make the coveted result ( Dickerson 2010 ) .The Nursing Mucositis Challenge Essay

Search Scheme
A well-formulated hunt scheme is an indispensable constituent in garnering appropriate grounds ( Hewitt-Taylor 2002 ) . By comprehensively reexamining all types of surveies and consequences, future service developments can avoid doing the same errors and be ethically more feasible ( Arnd-Caddigan & A ; Pozzato 2006 ) . Sackett et Al ( 2000 ) , propose the undermentioned scheme for the EBP procedure ;

Table 2:2
Measure 1: Convert the demand for information into an answerable inquiry.

Measure 2: Search the best grounds with which to reply the inquiry.

Measure 3: Critically appraise the grounds for its cogency, impact and pertinence.

Measure 4: Integrate the critical assessment with clinical expertness, patient ‘s alone biological science, values and fortunes.

Measure 5: Measure the effectivity and efficiency in put to deathing Stairss 1 through 4 and seek ways to better them both.

Literature Search

Conn et Al ( 2003 ) propose that a good – defined literature hunt scheme is critical for heightening the cogency of reappraisals as, uncomplete and colored hunts can ensue in insufficient databases taking to possible inaccurate consequences. However, there is now such a wealth of research that it can be hard to turn up and spot what is relevant. Therefore, the hunt scheme will be devised from the framed EBP inquiry. As nurses are encouraged to work within the multidisciplinary squad, researching multiple databases is advised to pull out the best grounds ( Polit and Hungler 1997 ) . For the intent of this thesis, the hunt for grounds will research electronic databases. Identifying the cardinal databases associating to Health and Social Care directed the initial hunt. Subsequently Ebsco Host provided entree to databases such as Cochrane Library, Cinahl, Medline and Ovid.The Nursing Mucositis Challenge Essay

Key words within hunt footings

Keyword hunts are the most common method of placing literature ( Ely and Scott 2007 ) . Careful consideration was given to the keywords in order to choose footings that would bring forth the informations being sought. Furthermore, some alternate keywords can be found utilizing the database synonym finder ( Hek and Moule 2006 ) . Specific footings to the capable headers within the proposed inquiry were focused on for this ground. Harvard ( 2007 ) highlighted the significance of placing the hunt standards prior to get downing the information hunt. For the intent if this thesis the cardinal words found utilizing the inquiry being asked were ;

Oral mucositis

Infection

Nursing attention intercessions

The Boolean hunt methods rely strongly on cardinal words hence, it was critical to guarantee the defined footings unwritten mucositis, infection and nursing attention intercessions were appropriate and non open to misunderstanding. Medical Sub Headings ( MESH ) is a standardized list of footings densed by the National Library of Medicine in America. The usage of MESH footings increases the likeliness of a successful hunt ( Lambrou 2004 ) . However, trouble in turn uping suited capable headers and rawness in usage can impact hunt returns ( Conn et al 2003 ) . Consequently, I did non use any MESH footings to my hunt within the chosen hunt engines The Nursing Mucositis Challenge Essay