RESEARCH ARTICLES

Systematization of nursing care applied to a teenager hospitalized with paracoccidioidomycosis

Eugenio Fuentes Pérez Júnior^I; Ariane da Silva Pires^II; Rafael Tavares Jomar^III; Ellen Peres^IV; Antonio Marcos Tosoli Gomes^V; Antonio Carlos Rocha^VI

^I Nurse. PhD Student in Nursing and Assistant Professor of Medical-Surgical Nursing Department of the State University of Rio de Janeiro. Brazil. E-mail: eugenioperezjunior@gmail.com
^II Nurse. Occupational and Stoma Therapist Nurse. PhD Student in Nursing and Assistant Professor at the Medical-Surgical Nursing Department of the State University of Rio de Janeiro. Brazil. E-mail: arianepires@oi.com.br
^III Nurse. PhD Student in Public Health and Assistant Professor of Medical-Surgical Nursing Department of the State University of Rio de Janeiro. Brazil. E-mail: rafaeljomar@yahoo.com.br
^IV Nurse. PhD in Community Health and Associate Professor of Medical-Surgical Nursing Department of the State University of Rio de Janeiro. Brazil. E-mail: ellenperes@globo.com
^V Nurse. PhD in Nursing. Professor of the Medical-Surgical Nursing Department and Coordinator of the Postgraduate Program in Nursing at the State University of Rio de Janeiro. Brazil. E-mail: mtosoli@gmail.com
^VI Nurse. Nursing Coordinator of Parasitic Infectious Diseases Unit of Pedro Ernesto University Hospital. Rio de Janeiro. Brazil. E-mail: startonirj@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.18764

ABSTRACT

This descriptive, clinical, case study examined the treatment and nursing care given to a teenager hospitalized with Paracoccidioidomycosis, as systematized in five steps: history, diagnosis, planning, intervention and evaluation. The study was conducted at a university hospital in Rio de Janeiro City from April to May 2015. The results revealed the following diagnoses: anxiety; unbalanced nutrition; disturbed body image; nausea; risk for ineffective renal perfusion; and willingness to improve self-control of health. As applied to the teenager, the systematization was safe, of good quality and contributed greatly to his hospital discharge, with a good prognosis, following remission of the symptoms that led to the hospitalization.

Keywords: Paracoccidioidomycosis; communicable diseases; nursing process; nursing research.

INTRODUCTION

The object of this paper is the care and the systematization of nursing care (SNC) to a teenager hospitalized with paracoccidioidomycosis. Paracoccidioidomycosis is a fungal disease with high prevalence in tropical countries in South America, and Brazil is an endemic center¹. A juvenile form of this infection has rapid evolution, with impairment of vital organs, leading to the need for hospitalization for clinical treatment ². The main complications of juvenile paracoccidioidomycosis are accented weight loss with nutritional deficits, pulmonary lesions, neurological manifestations and evidence of adrenal impairment².

Therefore, the nursing care provided to hospitalized patients with acute form of infection caused by Paracoccidioides brasiliensis requires from nurses cognitive, technical, ethical and humanistic skills. It is worth mentioning the SNC, method by which the nurse organizes the assistance, from a collection of data that allows him to identify problems aiming to plan and implement of nursing interventions. In summary, SNC consists in the adoption of a scientific method that gives the nurse conditions to plan and execute safe and quality interventions aimed at meeting the patient's needs ³.

The SNC is the mark of the nurse's role in the application of his technical and scientific knowledge for the realization of a stand-alone and quality service in health assistance. The application of SNC in the context of nurses' professional practice gives them an emblematic direction to their practice of formulator, promoter and care provider, aimed at technical and academic legitimacy. This perspective allows them the investigative resolution of problems and their determinants, as well as the design or the development of a focused action plan to overcome these obstacles.

The aim of this manuscript was to analyze the application of SNC a teenager hospitalized for juvenile paracoccidioidomycosis. Since it is a rare situation in the hospital environment to provide nursing assistance to a patient affected by the acute and juvenile form of paracoccidioidomycosis, a case study may contribute to the development of the nursing body of knowledge from a real situation observed⁴.

THEORETICAL FRAMEWORK

Paracoccidioidomycosis is defined as a systemic infection caused by Paracoccidioides brasiliensis fungus. Acute disseminated form is considered by many studies as rare and affects children and adolescents^1,2,5,6,7. Because it is a common disorder in childhood and adolescence, the early diagnosis becomes difficult ⁷, which contributes to the occurrence of complications such as those involving the lymphatic system from the superficial lymph nodes, followed by others that can harm liver, spleen, skin, bones and articulations¹ resulting in the need for hospitalization and treatment, requiring from the nursing team a specialized and individualized assistance.

In developing the specialized and individualized nursing care, it is necessary that nurses refer to SNC for the production of care based on technical and scientific knowledge, in order to solve the problems presented by the client. Systematizing assistance is an intellectual activity that requires from nurses clinical reasoning skills to identify care needs presented by the client, those priorities, the most appropriate interventions, and the results to be achieved with the implementation of planned care^8,9.

Clinical reasoning is present in all actions and care decisions of nurses, for example, in the survey and interpretations of the signs and symptoms of problems presented by the client. Other contributions of these professionals are linked to the diagnosis of care needs and their seriousness and impact in planning and choosing the best interventions to meet the needs presented and in defining the results to be achieved¹⁰.

It is noteworthy that the SNC, though not always adopted, has been the main instrument used by nurses to organize, scientifically, the care grounded in critical clinical reasoning ¹¹. In this respect, it is worth emphasizing the importance and necessity of students and nursing teachers to implement the SNC in the context of health care, as well as of exercising thought from the case discussion and exchange of experiences in order to provide individualized, safe and quality care.

METHODOLOGY

This is a descriptive study of clinical case, in which the SNC was applied in its five steps: history, diagnosis, planning, intervention and evaluation. The case study uses qualitative research strategies to map, describe and analyze the context, relations, phenomena or episodes in question, generating knowledge about the studied event, as well as interventions and changes occurred¹². This type of study is appropriate to the practice of nursing care in order to conduct a thorough analysis of the problems and needs of patients, enabling to develop strategies to address them¹³.

To develop the clinical history, data was collected through interviews and consultation of medical records. Then, the collected data were submitted to the clinical trial of two nurses, based on the related factors and their defining characteristics for the formulation of nursing diagnoses. The analysis of the problems identified was determined by clinical judgment and diagnostic reasoning established as the grouping of evidence in patterns, inferences or hypotheses. Then, the diagnosis itself was established, structurally defined by the nomenclature of the diagnosis or medical condition inferred by nurses through the related or etiologic factor and the defining characteristics, which are the objective and subjective data grouped to evidencing nursing diagnoses¹⁴.

For the development of diagnostics, it was adopted the Taxonomy II of North American Nursing Diagnosis Association (NANDA), since this is the basis for selection of interventions and therapeutic results, according to the taxonomies Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC)¹⁵. The proposed interventions were a consensus between the two nurses, with reference to the proposals adopted by the NIC.

This case study was approved by the Plataforma Brasil, under number 46753515.1.0000.5259, observing the ethical principles of research and developed in the inpatient unit of infectious and parasitic diseases of a university hospital, located in the city of Rio de Janeiro, from April to May 2015.

RESULTS AND DISCUSSION

Nursing history

The case study refers to the 15-year-old male student, spiritualist religion, resident in the city of Tres Rios, in the Mid-South of the Rio de Janeiro State. He lives with his parents in a brick house with treated water and sewage network. He has daily contact with domestic animals (dog and chickens) and has a dove as a pet. He denies use of tobacco, alcohol, and other psychoactive drugs and having started sexual practices.

Until the onset of symptoms that led him to hospitalization, the teenager was healthy, with full immunization coverage. Regarding the common childhood diseases, he reported having had chickenpox at 5 years old. He was admitted on 3.11.2015, in a municipal health unit of Tres Rios, complaining of diffuse and constant abdominal pain and loss of about 10 kg. In the unit, he was treated with Albendazole, without clinical improvement, which evolved with increased abdominal size and jaundice, without presenting choluria or acholic stools. Simultaneously, there was cervical mass emergence painless to palpation and without phlogosis signals. Abdominal ultrasound showed a conglomerate compressing adjacent structures. Laparotomy for lymph node biopsy was performed, which revealed nonspecific lymphadenitis, ruling out the diagnosis of lymphoma. In 03.24.2015, the patient underwent supraclavicular node biopsy, which revealed chronic granulomatous inflammatory process compatible with fungal infection.

Laboratory tests revealed leukocytosis without left bypass, negative serology for hepatitis and Human Immunodeficiency Virus (HIV), non-reactive purified protein derivative (PPD), echocardiogram and chest x-ray without changes. The results of the neck tomography revealed increased cervical lymph nodes in the chains II, III and IV, and the largest were located in the left jugular topography measuring 2.0 by 1.1 cm, and in the right, measuring 1.7 by 1.1 cm with signs of internal necrosis. On 03.27.2015, he was discharged from the municipal unit and returned to his city, remaining stable at home, without weight gain, but with right cervical adenopathy in progressive increase.

On 04.10.2015, the patient was admitted to the hospital, the infectious diseases service, for diagnostic research and treatment of cervical adenopathy. During the exam he was lucid, oriented, accompanied by his mother, reporting concern about the presence of cervical mass and worry due to hospitalization and the condition of removal from his family, social and school life. Skin and mucous membranes were intact, with preserved elasticity and turgor, afebrile, acyanotic, anicteric. There was presence of right cervical adenopathy measuring approximately 5 cm, fibroelastic, painless on palpation and no signs of phlogosis. Clinical examination revealed palpable adenopathies in the chest with supraclavicular chains. Pulmonary auscultation showed universally audible murmurs without adventitious sounds; during cardiac auscultation, it was identified regular heart rhythm in two stages, with normal sounds. Abdomen was flat, flaccid; there was peristalsis, surgical scar of approximately 4 cm in the right hypochondrium, painless to superficial and deep palpation, and there were no palpable masses or visceromegalies. The genitourinary system was in appropriate pubertal development and with no abnormalities. Lower limbs had no edema or other abnormalities.

During hospitalization, routine lab tests were performed, as well as revision of cervical adenopathy biopsy blade and blood serology for Paracoccidioides brasiliensis. After confirming the diagnosis of acute disseminated juvenile paracoccidioidomycosis by biopsy and blood serology, it was started intravenous treatment with liposomal amphotericin B with daily clinical and laboratory monitoring.

During evolution, the customer showed gastric intolerance to antifungal infusion with nausea and vomiting per- and post-infusion, which was controlled with pre-infusion and maintenance of antiemetic and pro-kinetic. After the completion of 20 days of treatment, the teenager showed clinical improvement of lymphadenopathy, but with increased blood urea and creatinine rates, pointing to nephrotoxicity to liposomal amphotericin B. Thus, the infusion of the antifungal treatment was suspended and continued with sulfametazol and oral trimethoprim until the day 05/28/2015, when he was discharged, with general improvement, significant weight gain and decreased of lymphadenopathy from 5 cm to 1.5 cm, and referral for continuity of outpatient treatment.

Diagnoses, interventions and results

The following describes the diagnoses and respective interventions and results, for the case study.

Based on the data described above, it proceeded to the development of nursing diagnoses, phase in which the nurse performs the analysis, judgment, perception and interpretation of clinical data obtained that show situations that require intervention. The nursing diagnoses are based both on real problems as on the potential problems, i.e., those that may arise in the future as complications¹⁵.

First diagnosis

The first nursing diagnosis was the anxiety related to hospitalization, characterized by concern about the removal of their social and school activities. As interventions, it was established a therapeutic relationship to convey empathy and unconditional respect, being available to listen and talk to the patient, providing accurate information about their situation and providing physical contact to alleviate their fears and provide confidence. The expected/obtained results were self-control of anxiety, facilitating treatment adherence.

Thus, with regard to this diagnosis, it is worth noting some factors related to hospitalization that can generate anxiety¹⁶, such as the inability to carry out their activities outside the hospital, the stay outside their home and away from their comfort environment, the fear of suffering related to therapeutic measures, tests and procedures, the invasion of their privacy and exposure of their body and insecurity related to their future in face of the disease.

It is important to reflect that, given the customer's low age and insecurity to face adverse conditions caused by the hospitalization, anxiety can be enhanced and should primarily be addressed as a problem for nursing. This concern is closely linked to the high potential to interfere in treatment adherence, by episodes of anxiety manifested by crying spells, aggression, denial and panic when performing procedures.

Second diagnosis

The second nursing diagnosis was unbalanced nutrition, less than the body needs, considered the abdominal pain or colic and weight loss of 10 kg in three months. The adopted measures were talking with the client about the dietary habits, food preferences and aversions to be observed to stimulate appetite, evaluating the motility of the gastrointestinal tract and eliminations, evaluating serum levels of protein, vitamins, electrolytes and trace elements to accompany the evolution of the general state and administering prescribed drugs, if necessary, to reduce pain and abdominal cramping. The expected results were progressive weight gain to achieve the target goal.

The problem characterized by progressive and rapid weight loss in a short period of time suggests lower caloric intake, which is accompanied by weakness of the general condition and asthenia, and is considered the main manifestation of juvenile paracoccidioidomycosis^2,5,6,10,16. Thus, an accurate observation of the nursing team during meals is essential in order to identify food preferences, dialoguing with nutrition service so that it promotes the necessary adjustments (preferred food, feeding time...). It is emphasized that the administration of medication to minimize abdominal cramps and nausea, when prescribed, must precede the time of feeding, in order to provide a better acceptance of diet and consequent contribution of nutritional table.

Nausea and cramps are common manifestations of paracoccidioidomycosis and come in two conditions that affect patients, in general. The first, by the dysfunction of the gastrointestinal system, primarily due to the impairment of lymphatic network, which may cause biliary obstruction and compression due to the formation of abdominal lymph nodes^2,6,7, as occurred with the teenager of this study. And the other, by compression of the stomach and intestine by other structures, such as in hepatosplenomegaly.

Third diagnosis

The third nursing diagnosis was disorder of body image related to the cervical fungal lymphadenopathy and lymph node biopsy, characterized by visible and palpable cervical node to the right, with 5 cm, and surgical scar on right hypochondrium. The interventions used were the guidance regarding the pathophysiology of the disease and the transience of the body change, recognition of behaviors indicative of excessive concern with body image, guidance to the patient on how to handle with the changes in his body image, the establishment of a therapeutic relationship, demonstrating a welcoming attitude. The obtained/expected results were the recognition and incorporation of change of image to his self-concept accurately, without voiding the self-esteem.

The lymphadenopathies, mainly cervical, submandibular and supraclavicular, are common manifestations of paracoccidioidomycosis ^2,6,7 that appeared in this case in the form of ganglion, measuring 5 cm located in the right dorsal region, featuring a misshapen body image. Its presence was felt and perceived by the teenager as a deformation on his body and this affected, to a large extent, his self-image and self-esteem, producing anxiety, sadness, shame and isolation.

It is noteworthy that, especially in adolescents, body image is linked to emotional satisfaction, so that changes in body image emotionally affect adolescents, promoting behavioral, emotional and affective changes ¹⁷. In this context, nursing intervention must focus on information and clarification on the transience of changes caused by the disease and, in cases of irreversibility of the changes, patients should be encouraged to deal with the changes, not allowing that these contribute to a low on self-esteem.

Fourth diagnosis

The fourth nursing diagnosis refers to nausea related to treatment with intravenous infusion of Amphotericin B and lipid complex, characterized by complaints, nausea and emetic episodes during and after infusion of the drug. Interventions adopted were administration of prescribed anti-emetic drugs prior to infusion of the antifungal agent, scheduling the antifungal dose so as not to interfere with the feeding, guidance on food intake in small quantities and with greater frequency to avoid excessive gastric filling, enhancement of oral hygiene, especially after emetic episodes to minimize the disagreeable sensation and stimulation of crushed ice use in the oral cavity during infusion of the drug to minimize nausea. The expected result was obtained with the control of nausea and vomiting.

Nausea are manifestations of paracoccidioidomycosis in the gastrointestinal system that may be aggravated by the use of Amphotericin B, whose main immediate complications are the occurrence of nausea during infusion^18,19. It is therefore up to the nursing professional to identify which factors are related to nausea and intervene, minimizing risk factors. Examples of effective nursing interventions in order to avoid or minimize the occurrence of nausea are programmed infusions of amphotericin B away from mealtimes, administration of antiemetics sufficiently in advance, when prescribed, and fractionation of food intake to avoid excessive gastric filling.

Fifth diagnosis

The fifth nursing diagnosis was the risk of ineffective renal perfusion related to the use of amphotericin B, characterized by elevated blood levels of urea and creatinine. The interventions adopted were controlling eliminated and administered fluids; evaluation of lung auscultation to detect early signs of pulmonary congestion; monitoring of urea and creatinine serums and chest X-ray to assess the level of electrolyte imbalance and signs of pulmonary congestion; assessment of changes in tensor levels and the presence or evolution and ends edemas; administration of diuretics, when prescribed, infusion of Anfotecina B in at least 4 hours, and administration of saline solutions when prescribed to minimize the risk of nephrotoxicity. The expected/obtained results were control of renal function with normalization of levels of urea and creatinine.

Regarding the use of Amphotericin B, lipid complex as the drug chosen for treatment of paracoccidioidomycosis. Renal nephrotoxicity, caused by Amphotericin B, is the most worrisome complication for the possibility of taking the patient to an irreversible loss of kidney function. This is due to vasoconstriction of the afferent artery of the renal tubules, resulting in the loss of glomerular function and increased creatinine¹⁸ and is also associated with cumulative doses in long term treatment, as in this case study. Studies describe the relationship between time of infusion and nephrotoxicity related to Amphotericin B. Thus, infusion in times less than in 4 hours of duration is associated with higher rates of glomerular injury^18,19.

Monitoring of serum levels of markers of renal function; performing water control; strict control of time of infusion of saline pre-infusion, when prescribed, to minimize the toxic effect of amphotericin B on the renal parenchyma^18,19; and daily assessment of fluid overload signals on the cardiovascular and respiratory system, are essential to care of the customer in use of Amphotericin B.

Sixth diagnosis

The sixth nursing diagnosis refers to improved willingness for self-control of health, related to fungal infection and characterized by the desire to heal and resume his usual activities. As interventions, the nursing team sought to identify the client's vulnerabilities conditions; set a lifestyle change plan to be adopted to minimize the vulnerabilities related to pathology; advise the client about the risk factors related to pathology and guide him and his family about the importance of treatment adherence and continuity of it to the control and cure of disease; guidance about the early signs and symptoms of complications due to prescribed therapy and the evolution of the disease and guide them on the importance of periodic review of the client, as an outpatient, in the post-discharge period. As expected results, the nursing team aims a behavior related to the pursuit of health.

The diagnosis of improved willingness for self-control of health is related to the proactive attitude of the adolescent and his family members towards seeking ways to obtain the cure or control of the disease picture, whose treatment is long, lasting on average 6 to 24 months. Treatment adherence is the determining factor for the cure or relapse of the disease²⁰.

It is therefore up to the nurse to identify, during hospitalization, the patient's weaknesses and plan with him and his family individual and collective strategies for post-discharge care, working as a facilitator²¹, in order to encourage him to deal with the new activities that the treatment requires and hence encourage him to improve or enhance his adherence to outpatient treatment avoiding thereby relapses and complications, as well as new admissions.

CONCLUSION

In the presented study, the hospitalization of the adolescent affected by paracoccidioidomycosis provided a unique opportunity to systematize nursing care and to provide to the patient an individualized, safe and quality care, which contributed to a faster hospital discharge, with remission of a substantive part of symptoms, especially cervical lymphadenopathy, and a positive prognosis.

Moreover, this experience provided the exercise of critical clinical reasoning adopted in the context of professional practice. The expertise of each step of the scientific methodology content produces an effective empowerment for planning, implementation and evaluation of nursing care.

It is worth mentioning that although the production of knowledge of nurses about care to the teenager affected by paracoccidioidomycosis is scarce, partly because the disease is rare and by the scope of generalization of findings in the context of a clinical case study if of small spectrum, it can be recommended that more studies are implemented. Similarly, it is suggested that the experience of SNC, reported here, is considered as a starting point for further research to be carried out, contributing thereby to promote the development and spread of knowledge that will contribute to a safe and quality health practice.

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