Integrating Theory and Practice for Patient Situation

Critical reflection is an essential characteristic to achieve competence in health care. Incorporation of this skill in professional practice helps in analyzing patient situation and taking better health care divisions. This paper particularly analyzes the health condition of 9 year old patient Jenny who has been diagnosed with acute lymphoblastic leukaemia (ALL). She complained of pain in her legs initially and felt lethargic. She was diagnosed with leukaemia which became evident from her blood test. She was admitted to hospital for first cycle of chemotherapy, but after 18 months of treatment her condition again declined and she developed pneumonia. This report explains the theoretical perspective related to pathophysiology, relevant pharmacology, interprofessional role in patient centered care and lifespan and psychosocial issues in dealing with a patient with acute lymphoblastic leukaemia. Integrating Theory and Practice for Patient Situation.

Pathophysiology

Acute Lymphoblastic Leukaemia (ALL) is a malignant condition of the bone marrow in which the hematopoietic cells of the bone marrow is replaced by early lymphoid precursors. It is a cancer of the white blood cells which originates in the bone marrow (Inaba, Greaves, & Mullighan 2013, pp.1943-1955). The disease is classified into four types according the type of white blood cells affected and the rate at it which develops. These are Acute lymphocytic leukaemia, Acute myeloid leukaemia, Chronic lymphocytic leukaemia and Chronic myeloid leukaemia.

It is the most common form of cancer in children in the United States. Among all the types of leukaemia, chronic lymphocytic leukaemia is the most common type leukemia diagnosed in Australia with about 1161 people diagnosed in 2012. In 2013, bout 1367 death were caused by all the four types of leukaemia in Australia and acute leukaemia caused the maximum number of deaths (Australia 2016). Jenny was also diagnosed with ALL and so it is necessary to know the cause of this disease.

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Lymphoid cells are derived from the stepwise maturation of hematopioetic stem cell in the bone marrow. The maturation of lymphoid in the bone marrow is controlled by the activation of transcription factors and selection through functional signal transduction. ALL develops due to the malignancy of lymphoid cells occurring due to genetic alterations. It is characterized by chromosomal abnormalities like hyperdiploidy or hypoploidy, translocation and rearrangement. It blocks lymphoid differentiation and lead to uncontrolled cell proliferation (Pui et al. 2012, pp.1165-1174). In the early stage of development, malignant lymphoid precursor cells are arrested due to the abnormal expression of gene following chromosomal translocation. It is a serious condition as this lymphoblast replaces normal bone marrow elements and leads to decrease in the production of normal blood cells. The proliferation takes place in other organs too such as liver, spleen and lymph nodes (Van Vlierberghe & Ferrando 2012, pp.3398-3406).

As it is a life threatening malignant disease, it requires sophisticated diagnostics and complex therapy. That is why emergency admission to the oncology center for treatment is highly recommended. Integrating Theory and Practice for Patient Situation. After Jenny was examined by Dr. Brown, she was ordered for a number of test like hemoglobin, white blood cell count, urea, electrolytes and C-reactive proteins and mid-stream specimen of urine. After confirmation of ALL, bone marrow analysis is essential to determine the level of leukemic infiltration. It helps to clearly understand the severity of the condition. Lumbar puncture test is done to monitor if spinal fluid contains any malignant leukaemia cells (Maurizi et al. 2014, pp.173-177). Thus after diagnosis of ALL, Jenny was immediately transferred to the oncology clinic for bone marrow biopsy and lumber puncture. These tests are important to identify the precise type of leukeamia that Jenny had She became very pale and febrile and her respiratory rate was also elevated. Jenny also felt tired lethargic due to reduction in the number of normal blood cells and aneamia in children (Levinsen 2014, pp.1416-1421). Children with leukemia have more chance of infection due to reduction in the number of normal white blood cells (de Morais et al. 2014, pp.78-85). That is why Jenny had elevated respiratory rate due to severe upper respiratory infection. Her immune system has weakened and the high-intensity chemotherapy also has made Jenny very weak. Due to these abnormalities in the body, Jenny may be complaining of aches and pain in her legs. Thus analysis of pathophysiology of ALL and its link with Jenny’s condition suggest that prevention of infection should be major priority for nurses and medical staff caring for Jenny.

Pharmacology

ALL requires immediate pharmacological intervention to manage patient’s condition. Jenny treatment was also pacing at a rapid rate. The aim of this intervention is to destroy leukaemia cell and enable bone marrow to work normally. The relevant pharmacological interventions that Jenny will require are as follows:

Induction therapy- The main goal of induction therapy is to achieve complete remission for long-term survival or care. In this phase intensive treatment is given which last for 4-6 weeks. Patients like Jenny are given dexamethasone and cyclophosphamide to prevent tumor lysis syndrome.  Integrating Theory and Practice for Patient Situation.This therapy is also useful to induce a mild cell reduction. The medications given in induction therapy have specific mechanism of action and spectrum of adverse effects. Under pegylated aspariginase therapy, monitoring liver parameters, glucose, pancreatic enzymes and coagulation factor is also necessary. If remission control is not achieved in this phase, such patients are regarded as high risk patients. In that case the therapy is intensified by increasing the dosage. At the end of this phase, it is checked whether child has leukemia or not (Kalwinsky et al. 2013, October, p. 149). This test will also be necessary for Jenny to determine whether she is in remission or not.

Consolidation phase- The purpose of this therapy is to maintain complete remission in patients. The consideration for consolidation therapy may differ in different oncological clinics of the world. In this step, oncologists specially try to prevent the spread of leukemia cells in brain and spinal cord. Though there are different methods of treatment in this phase, evidence based research have shown that cyclic consolidation therapy along with the application of methotrexate and asparaginase is highly effective. Timely application of drugs is critical and drugs like methotrexate injected directly into the spinal fluid during a lumbar puncture. For this purpose only, Jenny was also operated on for a lumbar puncture surgery. It is followed by interim recovery period where more drugs are given to keep the leukemia in remission. Further dose of chemotherapy kills leukemia cells (Neu et al. 2014, 104-113).

Maintenance treatment- The maintenance phase in children and adults may last for two-three years. In this phase, it is also necessary for Jenny to continue taking her daily medications, weekly tablets and maintain monthly chemotherapy sessions. After the successful completion of this phase, Jenny can take part in daily life activities and attend her school.

Bone marrow transplantation- After 18 months of treatment, Jenny’s ALL relapsed. In such situation, bone marrow transplant is immediately needed (Krentz et al. 2013, pp.295-304). Integrating Theory and Practice for Patient Situation.

Inter-professional role in patient-centered care

The diagnosis of acute leukemia requires intensive and immediate treatment. Thus collaboration of interprofessional team member is extremely important to properly manage medications and treatment. The range of treatment for patients with ALL includes chemotherapy, bone marrow transplantation, radiotherapy, daily oral tablets and immunotherapy. To address the complex needs of Jenny also, effort of more than one discipline is needed to improve her health status. Interprofessional collaboration allows sharing of expertise to develop a common goal for improving health outcome in patients. Patient centered care revolves around the needs and preference of patient. In such case, different inter-professional team member work for the better health outcome of all such patients (Bernabeo & Holmboe 2013, pp.250-258.).

In case of Jenny, different health care disciplines may work together to improve her condition. Different members divide the work according to their scope of practice. For example in case of Jenny a hematologist, pathologist, oncologist, radiologist, nurse, dietitian and many other work together to treat Jenny at different stage of her illness. Any collaborative approach becomes successful only when patient and family members are also included in decision making. In case of Jenny also it was seen that doctors spent a lot of time with Jenny’s parent and answered all their queries regarding the disease. This is essential because it is very important that patients and family member understand the cause of illness and the rational for proposed treatment in such cases. This practice helps build therapeutic relationship with team members and also help in adherence to treatment protocol (Liberati et al. 2015, pp.45-52). Since Jenny was to young to get involved in her health care decision, it was necessary that her parents took part in decision making. A number of health professional were present at the oncology center to talk to her parents and explain them the current health status of Jenny. The main purpose of interprofessional health care team is to prevent relapse of condition in Jenny after chemotherapy and maintain the continued improvement as far as possible.

Lifespan and psyhosocial issues

Apart from the pain and physical distress in patients with acute lymphoblastic leukemia, lifespan and psychosocial issues also increase mental distress in such patients. A child like Jenny may face several coping problem sue to the stress and pain involved during chemotherapy, radiation and surgery. Psychosocial issues may vary in children depending on the support they get from family members.Integrating Theory and Practice for Patient Situation.  Apart from this, children or adult have different needs in life related to education, family relationship, career commitment, social participation and body image. A diagnosis of cancer takes away patients independence in life (Jones et al. 2015, pp.142-162). Jenny’s pain in leg became so acute that she was unable to stand erect. She complained of tiredness and did not wished to accompany her siblings in athletics. She became pale and was not interested in her usual food too. After the diagnosis of ALL, Jenny missed all her daily life activities like going to school, taking part in athletics, playing with her siblings and interest in food like ice creams or doughnut.

Apart from mental trauma caused to patients, it also significantly affects patient’s family member. Jenny’ parent was also concerned and worried about the health of their child. Throughout patient lifespan, patient’s physical level of functioning is also severely affected. Their body image is also affected post chemotherapy due to the adverse effect of chemotherapy drugs and injection on patients (Pailler et al. 2015, pp.163-177). Most patients lose hairs and become pale and unpleasant to look. Such patient lose all hope and they do not wish to interact or take part in social gathering, Due to the harsh procedure of chemotherapy, children like Jenny also develops fear and suffer in each chemotherapy session. In case of children, cancer also has affected on their cognitive development. Although a 9 year old child like Jenny may not be able to fully understand the illness, but they face difficulty in accepting the disfiguring treatment. Mostly children diagnosed with cancer have difficulty coping with treatment regimen and they develop anxiety. Apart from this parents of such children also show great level of distress and grief. Jenny’s parent also felt guilty that they could not detect the symptoms in the beginning. Thus, it is necessary that health professionals dealing with such patients teach them coping strategies and support their parents to deal with diagnosis and treatment effects. Comprehensive assessment in addressing the familial psychosocial issues is also necessary to improve family functioning. It is necessary that patient’s family have increases morale to support and encourage their child to heal properly. Integrating Theory and Practice for Patient Situation.

Conclusion

Thus from the analysis of Jenny’s condition, we can conclude that Acute Lymphoblastic leukemia is a life threatening condition which requires immediate treatment to prevent serious outcome in patients. This report gave detail on the pathogenesis of ALL and explained how Jenny’s problem is related to ALL. It gave explanation about the possible pharmacological intervention that is generally given to such patients and highlighted the rational for each treatment. Finally it brought into focus the role of interprofessional health care team in managing such patients and highlighted their psychosocial issue those cancer patients face.

Reference

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Cancer Council Australia 2016, Leukaemia , viewed 5^th September 2016,

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