PICO Clinical Question1

PICO Clinical Question1

PICO Clinical Question

TiffiniSchnur

Ferris State University

Abstract

When nurses identify an area of improvement and perform research to attempt in improving patient outcomes, this is called nursing research. The question that this author chose to research is Chinese related techniques to relieve chemotherapy-induced nausea and vomiting. The interventions researched includes progressive muscle relaxation, acupuncture, and Chinese herbs. Each of these remedies revealed positive effects on the patients, but some more than others.

Introduction

Chemotherapy-induced nausea and vomiting is a pestering side effects for many cancer patients. Reducing this side effect would lead to a better quality of life and allow the patient to recover more effectively after treatment. Many medications are used to assist in this process, but those also come with risks and may cause further side effects. Non-pharmaceutical interventions to relieve this nausea and vomiting has been researched and positive results have been reported.

Clinical Question

Chemotherapy-induced nausea and vomiting (CINV) can lead to harmful effects to the patient. Many times antiemetic medications are given before, during, and after treatment, but they do not always work. Nursing researchers have researched non-pharmaceutical interventions that can assist in relieving CINV. The PICO question that this author has chosen to research is: Does non-pharmacological interventions (specifically Chinese medicine related techniques) reduce chemotherapy-induced nausea compared to medications alone in patients post receiving chemotherapy?
The acronym PICO stands for patient/population, intervention, comparison, and outcome (Lansing Community College, 2014). In the question above, the patient/population is patients who had recently received chemotherapy. The interventions are non-pharmacological interventions, focusing on Chinese medicine related techniques. The comparison is between patients receiving Chinese medicine techniques along with antiemetic medication versus antiemetic medications alone. Lastly, the outcome would be reduced CINV.

By answering this question and determining additional ways to reduce CINV, it will lead to improved patient quality and safety. When an individual experience prolonged nausea and vomiting, they often become malnourished and dehydrated. This causes more medical problems, on top of the cancer diagnosis they already have. Dehydration can lead to electrolyte imbalances, irregular heart rhythms, constipation, infection, renal failure, weakness, and many other adverse effects (Mayo Clinic, 2014). Being malnourished and dehydrated does not allow the body to optimally recover from the treatment regimen.

Methodology

When performing research to find answers to the PICO question, nursing research from academic and peer reviewed articles was used. Online databases via Ferris State University’s library were used. The databases included CINAHL, PubMed, and Crochane Reviews. Only nursing research that was pertinent to the PICO question was evaluated.

Nursing research was chosen because it “provides the scientific basis for the practice of the profession,” (American Associated of Colleges of Nursing, 2014). Nursing research provides evidence-based practice findings to improve patient outcomes and meet patient’s goals. In finding answers to the PICO question, the nurse can assist the patient in exploring non-pharmaceutical interventions to assist in relieving CINV when medications are lacking. As a registered nurse providing bedside nursing patient care, nursing research is the most useful and relevant.

When researching articles, the credibility must be questioned. One way to assess the credibility is by identifying the level of evidence. The levels range from level I to level VII. Level VII represents the lowest quality of evidence and is classified as an expert’s opinion. Level I is the highest quality of evidence represents systemic reviews of the topic. Each article that assisted in answering the PICO question was graded an acceptable level of evidence, and will be discussed further in the next section.

Discussion of Literature

To attempt in finding an answer to the PICO question, three references were evaluated. Each article contains research that was performed. The data obtained from that research was assessed and graded on level of evidence and applicability to nursing practice was identified.

Article One

The first article was “The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a randomized controlled trial.” In this research trial there were 38 individuals in experimental group, 33 individuals in control group, all of which have been diagnosed with breast cancer.The Morrow Assessment of Nausea and Vomiting was used to evaluate level of nausea and vomiting and was asked via questionnaire (2001). The groups are appropriate and ethical as the experiment had minimal risks and the participants were aware of the study. Results revealed that experimental subjects reported fewer times when they felt nauseas than the control subjects. The difference was most significant in the first 4 days after chemotherapy (2001).

In critiquing this article, the purpose of this study was clear, and easy to identify as it was in the title of the article. The literature was appropriately reviewed and it was published by the Department of Nursing at Chinese University of Hong Kong. This article is level 2 evidence, as is contained one or more randomized controlled trials. This study collected data that was ordinal level of measurement because nausea/vomiting level were ranked.

Article Two

The second article, “Evaluation of acupuncture for cancer symptomsin cancer institute in Brazil,” (2012) was also beneficial to answering the PICO question. In this research 183 patients whom were enrolled in outpatient acupuncture at the State of Sao Paulo Cancer Institute for treatment of chronic pain, nausea, vomiting, and zerostomia due to cancer or cancer-related therapies. The participants ranked their nausea level on a scale from 0-10 (10 being the worst) before and after acupuncture. Results showed initial (before acupuncture) the average score was 7.04 (p. 25). After acupuncture the average score was 2.56, showing a drastic improvement on symptom intensity (p. 25)

This article is level 6 on the hierarchy of evidence. This study was observational with no control group. The question statement was easy to identify and the results were clearly stated. Using a ranking scale is appropriate, but may have caused some barriers because individuals may interpret the scale differently. This data is also ordinal level of measurement, due to being based on a ranking.

Article Three

The last article “Chinese medicinal herbs to treat the side-effects of chemotherapy in breast cancer patients,” (2007) focused on Chinese herbs. The purpose of this research was to determine if the use of Chinese medical herbs reduce toxicity-related conditions (ex: nausea/vomiting) in patients receiving chemotherapy. Like the previous research, the results were based on numerical ranking. Scores were analyzed after six weeks of treatment and there was a 1.8% decrease in vomiting in patients receiving the herbal capsule (Zhang, Liu, Li, He, Tripathy, 2007, p. 1).

The goal of the research was clear. The research consisted of 58 participants. Some participants were given the Chinese herbs, while others were given placebo pills with starch. This may lead to ethical issues because those receiving the placebo pills were unaware that it was not the Chinese herbs. This is level 2 evidence. Participants were chosen via random selection and there were no determinants as to who received placebo and who received the herbs. The data collected was nominal level of measurement because the number of vomiting episodes was the determining factor.

Significance to Nursing

Nurses work closely along with patients before, during, and after receiving chemotherapy. Managing side effects of chemotherapy can be one of the most difficult tasks. There are many medications and anti-emetics available, but unfortunately, they do not work well for everybody. By researching other interventions to relieve CINV, the nurse can explore these options with the patients to improve their symptoms and quality of life. By performing researchand evaluating other research, nurses provide the best care because they are using evidence-based practice. Nurses have the skills to “use health research methods and processes, alone or in partnership with scientists, to generate new knowledge for practice,” (QSEN Institute, 2014).

Evidence-based practice is the most respected set of standards and is supported by the American Nurses Association Scope and Standards of Practice. “Evidence based practice is a scholarly and systematic problem-solving paradigm that results in delivery of high-quality health care,” (American Nurses Association, 2010, p. 16). Research is used to achieve the best patient outcomes forindividuals, groups, populations, and healthcare systems (p. 16).

Acupuncture and muscle relaxation therapy is a realistic therapy that patients in this area have access to. The Chinese herbs may be less realistic. Identifying and learning non-pharmaceutical interventions to control symptoms is safer for the patient because medication side effects and errors are no longer a risk. Educating the patients on these regimens may make a huge difference in how well they recover after chemotherapy.

Conclusion

The research has proven that Chinese related non-pharmacological remedies can assist in relieving nausea and vomiting after receiving chemotherapy. By exploring these options with the patients, it can lead to improved patient outcomes and increase patient safety. Nursing research develops evidence-based care and allows the patient to have the highest quality of care to improve their health and meet their goals.

Reference:

American Association of Colleges of Nursing. (2014). Nursing research. Retrieved from

American Nurses Association. (2010). Nursing:Scope and standards of practice. (2nd ed). Silver Spring, MD: Nursesbooks.org.

D’Alessandro, E., de Brito, C., Cecatto, R., Saul, M., Atta, J. A., An Lin, C. (2012). Evaluation of acupuncture for cancer symptoms in a cancer institute in Brazil. Acupunt Med. 31: 23-26. doi: 10.1136/acupmed-2012-010206

Lansing Community College. (2014). What is PICOT? Retrieved from

Mayo Clinic. (2014). Dehydration. Retrieved from

Molassiotis A., Yung H..P, Yam B.M., Chan F.Y., Mok T.S. (2001). The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a randomized controlled trial. Support Care Cancer. 10(3):237-46

QSEN Institute. (2014). Graduate KSAS: evidence-based practice. Retrieved from

Zhang, M., Liu, X., Li, J., He, L., Tripathy, D. (2007). Chinese medicinal herbs to treat the side-effects of chemotherapy in breast cancer patients. DOI: 10.1002/14651858.CD004921.pub2