NURSING DIAGNOSIS: Risk for infection: opportunistic infection or sepsis

related to:

1.

2. 3. 4.

decreased resistance to infection associated with: A. cellular and humoral immune deficiencies present in HIV infection B. inadequate nutritional status C. depletion of immune mechanisms resulting from presenting infection and treatment with antimicrobial agents D. myelosuppression resulting from certain medications (e.g. zidovudine, antineoplastic agents, amphotericin, ganciclovir, pyrimathamine); stasis of respiratory secretions and/or urinary stasis if mobility is decreased; break in integrity of skin associated with frequent venipunctures or placement of a central venous catheter; impaired integrity of skin or mucous membranes if present.

Desired Outcome

The client will remain free of additional opportunistic infection and sepsis as evidenced by: 1. return of temperature toward client's normal range 2. decrease in episodes of chills and diaphoresis 3. blood pressure within normal limits and pulse returning toward normal range 4. normal or improved breath sounds 5. absence or resolution of dyspnea 6. stable or improved mental status 7. voiding clear urine without reports of frequency, urgency, and burning 8. absence or resolution of painful, pruritic skin lesions 9. stable or gradual increase in body weight 10. no reports of increased weakness and fatigue 11. absence of visual disturbances 12. absence or resolution of heat, pain, redness, swelling, and unusual drainage in any area 13. absence or resolution of oral mucous membrane irritation and ulceration 14. ability to swallow without difficulty 15. WBC and differential counts returning toward normal range 16. negative results of cultured specimens.
Nursing Actions and Selected Purposes/Rationales
1. Assess for and report signs and symptoms of additional opportunistic infection and sepsis (be alert to subtle changes in client since the signs of infection may be minimal as a result of immunosuppression; also be aware that some signs and

symptoms vary depending on the site of infection, the causative organism, and the age of the client): A. increase in temperature above client's usual level B. increase in episodes of chills and diaphoresis C. hypotension (a symptom of sepsis) D. increased pulse E. development or worsening of abnormal breath sounds F. development or worsening of dyspnea G. development or worsening of cough H. decline in mental status I. cloudy urine J. reports of frequency, urgency, or burning when urinating K. presence of bacteria, nitrites, or greater than 5 WBCs in urine L. vesicular lesions particularly on face, lips, and perianal area M. new or increased reports of pain in and/or itching of skin lesions and surrounding tissue N. further increase in weight loss, fatigue, or weakness O. visual disturbances P. new or increased heat, pain, redness, swelling, or unusual drainage in any area Q. new or increased irritation or ulceration of oral mucous membrane R. development of or increased dysphagia S. significant change in WBC count and/or differential T. positive results of cultured specimens (e.g. urine, vaginal drainage, stool, sputum, blood, drainage from lesions). 2. Implement measures to prevent further infection: A. administer the following medications if ordered: I. antiretroviral agents to reduce the rate of replication of HIV II. immunomodulating agents (e.g. interleukin-2, colony stimulating factors such as filgrastim and sargramostim) to stimulate production/enhance activity of the white blood cells III. antimicrobial agents to treat current infection or prevent additional opportunistic infection (prophylaxis for Pneumocystis carinii pneumonia, tuberculosis, toxoplasmosis, andMycobacterium avium complex is recommended for all patients with a CD4+ cell count below a critical level) B. maintain a fluid intake of at least 2500 ml/day unless contraindicated C. use good handwashing technique and encourage client to do the same D. protect client from others with infection E. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c) F. perform actions identified in this care plan to reduce stressors such as discomfort, dyspnea, and fear and anxiety in order to prevent an increase in secretion of cortisol (cortisol interferes with some immune responses) G. perform actions to prevent breakdown of oral mucous membrane and promote healing of existing lesions (see Diagnosis 6, action b) H. maintain sterile technique during all invasive procedures (e.g. urinary catheterization, venous and arterial punctures, injections) I. change peripheral intravenous line sites according to hospital policy J. anchor catheters/tubings (e.g. urinary, intravenous) securely in order to reduce trauma to the tissues and the risk for introduction of pathogens associated with the in-and-out movement of the tubing

K. change equipment, tubings, and solutions used for treatments such as intravenous infusions, respiratory care, irrigations, and enteral feedings according to hospital policy L. maintain a closed system for drains (e.g. urinary catheter) and intravenous infusions whenever possible M. encourage a low-microbe diet (e.g. thoroughly cooked foods, scrupulously cleaned fruits and vegetables) N. perform actions to prevent stasis of respiratory secretions (e.g. assist client to turn, cough, and deep breathe; increase activity as allowed and tolerated) O. perform actions to prevent or treat skin breakdown (see Diagnosis 7, actions c-e) P. perform actions to prevent urinary retention (e.g. instruct client to urinate when the urge is first felt, promote relaxation during voiding attempts) in order to prevent urinary stasis Q. instruct and assist client to perform good perineal care routinely and after each bowel movement R. if client has open lesions, perform actions to prevent wound infection (e.g. maintain sterile technique during wound care, instruct client to avoid touching wounds) S. if client has a central venous catheter, instruct and assist him/her with proper care of the exit site.

NURSING DIAGNOSIS: Fear/Anxiety

related to unfamiliar environment; lack of understanding of diagnosis, diagnostic tests, and treatments; financial concerns; and feelings of confinement.

Desired Outcome

The client will experience a reduction in fear and anxiety as evidenced by: 1. 2. 3. 4. 5. verbalization of feeling less anxious usual sleep pattern relaxed facial expression and body movements stable vital signs usual perceptual ability and interactions with others.

Nursing Actions and Selected Purposes/Rationales

1. Assess client for signs and symptoms of fear and anxiety (e.g. verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness, diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors). 2. Implement measures to reduce fear and anxiety: A. orient client to environment, equipment, and routines; explain the purpose for and operation of a kinetic bed if indicated B. introduce client to staff who will be participating in care; if possible, maintain consistency in staff assigned to his/her care C. assure client that staff members are nearby; respond to call signal as soon as possible D. keep door and curtains open as much as possible to reduce feeling of confinement E. maintain a calm, supportive, confident manner when interacting with client F. encourage verbalization of fear and anxiety; provide feedback G. reinforce physician's explanations and clarify misconceptions client has about the diagnosis, treatment plan, and prognosis H. explain all diagnostic tests I. provide a calm, restful environment J. instruct client in relaxation techniques and encourage participation in diversional activities K. assist client to identify specific stressors and ways to cope with them L. initiate social service referral and/or assist client to identify and contact appropriate community resources if indicated M. provide information based on current needs of client at a level he/she can understand; encourage questions and clarification of information provided N. encourage significant others to project a caring, concerned attitude without obvious anxiousness O. include significant others in orientation and teaching sessions and encourage their continued support of the client P. administer prescribed antianxiety agents if indicated. 3. Consult appropriate health care provider if above actions fail to control fear and anxiety.

Situational Low Self-Esteem

May be related to

Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain

Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety

Possibly evidenced by

Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness, hopelessness, powerlessness

Preoccupation with change or loss Not taking responsibility for self-care, lack of follow-through Change in self-perception/others perception of role

Desired Outcomes

Verbalize understanding of body changes, acceptance of self in situation. Begin to develop coping mechanisms to deal effectively with problems. Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.

Nursing Interventions

Rationale

Discuss with patient/SO how the diagnosis and treatment are affecting the patients personal life/home and work activities.

Aids in defining concerns to begin problem-solving process.

Review anticipated side effects associated with a particular treatment, including possible effects on sexual activity and sense of attractiveness/desirability, e.g., alopecia, disfiguring surgery. Tell patient that not all side effects occur, and others may be minimized/controlled.

Anticipatory guidance can help patient/SO begin the process of adaptation to new state and to prepare for some side effects, e.g., buy a wig before radiation, schedule time off from work as indicated.

Encourage discussion of/problem-solve concerns about effects of cancer/treatments on role as homemaker, wage earner, parent, and so forth.

May help reduce problems that interfere with acceptance of treatment or stimulate progression of disease.

Acknowledge difficulties patient may be experiencing. Give

Validates reality of patients feelings

information that counseling is often necessary and important in the adaptation process.

and gives permission to take whatever measures are necessary to cope with what is happening.

Evaluate support structures available to and used by patient/SO.

Helps with planning for care while hospitalized and after discharge.

Provide emotional support for patient/SO during diagnostic tests and treatment phase.

Although some patients adapt/adjust to cancer effects or side effects of therapy, many need additional support during this period.

Use touch during interactions, if acceptable to patient, and maintain eye contact.

Affirmation of individuality and acceptance is important in reducing patients feelings of insecurity and selfdoubt.

Refer for professional counseling as indicated.

May be necessary to regain and maintain a positive psychosocial structure if patient/SO support systems are deteriorating.

L-asparaginase

Generic name: Asparaginase Trade names: Elspar, Kidrolase Other names: Erwinia L-asparaginase Chemocare.com uses generic names in all descriptions of drugs. Kidrolase and Elspar are trade names for asparaginase. L-asparaginase or erwinia l-asparaginase are other names for asparaginase. In some cases, health care professionals may use the trade names elspar or kidrolase or other names l-asparaginase or erwinia l-asparaginase when referring to the generic drug name asparaginase. Drug type: L-asparaginase is an anti-cancer ("antineoplastic" or "cytotoxic") chemotherapy drug. This medication is classified as an "enzyme." (For more detail, see "How this drug works" section below). What this drug is used for:

Acute lymphocytic leukemia (ALL) Note: If a drug has been approved for one use, physicians may elect to use this same drug for other problems if they believe it may be helpful. How this drug is given:

Aspariginase is given as an injection into a large muscle (intramuscular or IM). Depending on your dose, the medication may need to be divided into two injections. Also may be given into the vein as an infusion (intravenous or IV). This method has higher risk of allergic reaction so often a test dose is given first. There is no pill form of aspariginase. The amount of aspariginase that you will receive, and how it is given, depends on many factors, including your height and weight, your general health or other health problems, and the type of cancer or condition being treated. Your doctor will determine your dose and schedule. Side effects: Important things to remember about the side effects of asparaginase:

Most people do not experience all of the side effects listed.

Side effects are often predictable in terms of their onset and duration. Side effects are almost always reversible and will go away after treatment is complete. There are many options to help minimize or prevent side effects. There is no relationship between the presence or severity of side effects and the effectiveness of the medication. The following side effects are common (occurring in greater than 30%) for patients taking asparaginase:

Fever, chills (see flu like symptoms) Nausea and vomiting Allergic reaction, (sudden onset of wheezing, itching, rash, face swelling, agitation, low blood pressure). You will be monitored closely for this reaction. Poor appetite Stomach cramping Central neurotoxicity: excessive sleepiness, depression, hallucinations, agitation, disorientation or seizure. Less commonly seen stupor, confusion and/or coma. These side effects are less common (occurring in about 10-29%) of patients receiving asparaginase:

Mouth sores Pancreatitis (inflammation of the pancreas) in up to 10% of patients. Mainly noted in blood tests that return to normal after therapy is discontinued. Rarely may be severe causing symptoms. Symptoms of acute pancreatitis include: (pain in the upper abdomen that worsens with eating, swollen and tender abdomen, nausea, vomiting, fever, and rapid pulse). Blood test abnormalities (Increased blood glucose level - some refer to this as "sugar"). Increases in blood tests measuring liver function. These return to normal once treatment is discontinued (see liver problems). Blood clotting disorders, increases risk of both bleeding and clotting. Not all side effects are listed above. Some that are rare (occurring in less than 10% of patients) are not listed here. However, you should always inform your health care provider if you experience any unusual symptoms. When to contact your doctor or health care provider: Contact your health care provider immediately, day or night, if you should experience any of the following symptoms:

Fever of 100.4 F (38 C) or higher, chills (possible signs of infection).

The following symptoms require medical attention, but are not an emergency. Contact your health care provider within 24 hours of noticing any of the following:

Nausea (interferes with ability to eat and unrelieved with prescribed medication) Vomiting (vomiting more than 4-5 times in a 24 hour period) Persistant upper abdominal pain or pain that worsens with eating Abdominal swelling Diarrhea (4-6 episodes in a 24-hour period) Unusual bleeding or bruising Swelling, redness and/or pain in one leg or arm and not the other Extreme fatigue (unable to carry on self-care activities) Yellowing of the skin or eyes Unusual thirst, need to urinate frequently Confusion, excessive sleepiness, hallucinations (seeing, hearing or feeling things that are not there), agitation, or disorientation (not able to recognize familiar surroundings) Always inform your health care provider if you experience any unusual symptoms. Precautions:

Before starting asparaginase treatment, make sure you tell your doctor about any other medications you are taking (including prescription, over-the-counter, vitamins, herbal remedies, etc.). Do not take aspirin, products containing aspirin unless your doctor specifically permits this. Do not receive any kind of immunization or vaccination without your doctor's approval while taking asparaginase. Asparaginase may be inadvisable if you have had a hypersensitivity (allergic) reaction to asparaginase. If you have had a reaction to Elspar, Erwinia L-asparaginase may be used with caution. Inform your health care professional if you are pregnant or may be pregnant prior to starting this treatment. Pregnancy category C (use in pregnancy only when benefit to the mother outweighs risk to the fetus). For both men and women: Do not conceive a child (get pregnant) while taking asparaginase. Barrier methods of contraception, such as condoms, are recommended. Discuss with your doctor when you may safely become pregnant or conceive a child after therapy. Do not breast feed while taking this medication. Those who have a history of pancreatitis (inflammation of the pancreas) should not be treated with asparaginase. Self-care tips:

Drink at least two to three quarts of fluid every 24 hours, unless you are instructed otherwise.

For flu-like symptoms, keep warm with blankets and drink plenty of liquids. There are medications that can help reduce the discomfort caused by chills. You may be at risk of infection so try to avoid crowds or people with colds, and report fever or any other signs of infection immediately to your health care provider. Wash your hands often. To help treat/prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda and/or 1/2 to 1 teaspoon of salt mixed with 8 ounces of water. Use an electric razor and a soft toothbrush to minimize bleeding. Avoid contact sports or activities that could cause injury. To reduce nausea, take anti-nausea medications as prescribed by your doctor, and eat small, frequent meals. Avoid driving and tasks that require being alert until your response to this drug is well understood. Avoid sun exposure. Wear SPF 15 (or higher) sunblock and protective clothing. In general, drinking alcoholic beverages should be kept to a minimum or avoided completely. You should discuss this with your doctor. Get plenty of rest. Maintain good nutrition. If you experience symptoms or side effects, be sure to discuss them with your health care team. They can prescribe medications and/or offer other suggestions that are effective in managing such problems. Monitoring and testing: You will be checked regularly by your doctor while you are taking asparaginase, to monitor side effects and check your response to therapy. Periodic blood work to monitor your complete blood count (CBC), blood clotting factors, pancreatic enzymes, blood sugar as well as the function of other organs (such as your kidneys and liver) will also be ordered by your doctor. How this drug works: All cells need a chemical called asparagine to stay alive. Normal cells can make this chemical for themselves, while cancer cells cannot. Asparaginase breaks down asparagine in the body. Since the cancer cells cannot make more asparagine, they die. When asparaginase breaks down asparagine it is broken down into 2 chemicals, aspartic acid and ammonia. The neurologic side effects seen with asparaginase (such as, confusion, excessive sleepiness, agitation, disorientation, or coma) are related to increased levels of these chemicals circulating in the body.

Note: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice. Elspar is indicated as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia(ALL).

DOSAGE AND ADMINISTRATION

Recommended Dose The recommended dose of Elspar is 6,000 International Units/m intramuscularly (IM) or intravenously (IV) three times a week. Instructions for Administration W hen Elspar is administered IM, the volume at a single injection site should be limited to 2 mL. If a volume greater than 2 mL is to be administered, two injection sites should be used. Discard unused portion. W hen administered IV, give Elspar over a period of not less than thirty minutes through the side arm of an infusion of Sodium Chloride Injection orDextrose Injection 5% (D5W). Discard unused portion. Preparation and Handling Precautions For IM administration, reconstitute Elspar by adding 2 mL Sodium Chloride Injection to the 10,000 unit vial. W ithdraw volume of reconstituted Elspar containing calculated dose into sterile syringe. The reconstituted solution contains 5,000 international units (IU)/mL. For IV administration, reconstitute Elspar by adding 5 mL Sterile W ater for Injection or Sodium Chloride Injection to the 10,000 unit vial. W ithdraw volume of reconstituted Elspar containing calculated dose into sterile syringe. The reconstituted solution contains 2,000 IU/mL. Use reconstituted Elspar within eight hours. Parenteral drug products should be inspected visually for particulate matter, cloudiness or discoloration prior to administration, whenever solution and container permit. If any of these are present, discard the solution. However, occasionally, a very small number of gelatinous fiber-like particles may develop on standing. Filtration through a 5.0 micron filter during administration will remove the particles with no resultant loss in potency.

HOW SUPPLIED
Dosage Forms And Strengths 10,000 International Units as lyophilized powder in single-use vial. Dosage Form NDC 67386-411-51 10,000 International Units as lyophilized powder in single dose vial individually packaged in a carton. Storage and Handling Keep vials refrigerated at 2-8C (36-46F).

Elspar does not contain a preservative. Store unused, reconstituted solution at 2-8C (36-46F) and discard after eight hours, or sooner if it becomes cloudy.

CONTRAINDICATIONS

Serious allergic reactions to Elspar or other Escherichia coli-derived L-asparaginases Serious thrombosis with prior L-asparaginase therapy Pancreatitis with prior L-asparaginase therapy Serious hemorrhagic events with prior L-asparaginase therapy Mechanism of Action The mechanism of action of Elspar is thought to be based on selective killing of leukemic cells due to depletion of plasma asparagine. Some leukemic cells are unable to synthesize asparagine due to a lack of asparagine synthetase and are dependent on an exogenous source of asparagine for survival. Depletion of asparagine, which results from treatment with the enzyme Lasparaginase, kills the leukemic cells. Normal cells, however, are less affected by the depletion due to their ability to synthesize asparagine.