Download Details Case Study - Acute (Oncology) Placement June 2011

Clinical Practice 2 (HCNUR2943): Case Study
Case Summary
Name: Lady Gaga
DOB: 26/12/1935
Sex: Female
Presenting problem/Diagnosis
Acopia
Bone Pain
Dehydration
Hypoxia
Decreased Mobility
Lost 8kg’s in the last 3 months
Associated Comorbidities
Non Small Cell Lung Cancer (Stage IV) – Pancoast Tumour (squamous cell carcinoma)
Bone Metastasis
Emphysema
Comprehensive Health History
Ex smoker - 1996
Frequent episodes of constipation in the last 2 months
Frequent episodes of nausea
Abdominal pain
Decreased appetite
Fatigue+++ last 2 months
Decreased sensation in feet that started approximately 6 weeks ago
Patient reports getting sweats and fever at night
Non productive cough
Very short of breath, worse on exertion
Hypothyroidism
Osteoarthritis
Current Medications
At home: Oxycodone
Metoclopramide
Nilstat
Endone
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Clinical Practice 2 (HCNUR2943): Case Study
Movicol
Panadol Osteo
In Hospital: Thyroxine
Panadol Osteo
Endone
Enoxaparin
Coloxyl and Senna
Metoclopramide
Oxycontin
Ondansetron Wafer
Movicol
Spiriva
Seritide
Salbutemol
Clinical management plan
Admit to oncology
Regular Analgesia – Syringe Driver and Breakthrough
Oxygen via nasal prongs when required or O2Sa < 92%
Regular aperients
Allied Health – Physio, OT, Dietician
Hospice Involvement
DVT Prophylaxis
Diet and Fluid
Liaise with BAROC house re: Palliative Radiotherapy
Orthopaedic Review
Relevant diagnostic tests and procedures
CT Chest Abdomen and Pelvis: Os acetabuli
Full Blood Examination
Urinalysis
Right Leg Imaging
Bone Scan
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Relevant Pathophysiology
Non-Small Cell Lung Cancer:
Cigarette smoke contains over 30 carcinogens and causes 80 – 90% of lung cancers.
Those carcinogens, along with probable genetic predispositions to cancers results in genetic
abnormalities in bronchial cells including; deletion of chromosomes, activation of oncogenes
and inactivation of tumour suppressor genes (Craft, Gordon & Tiziani, 2011). Once lung
caner is initiated by the carcinogenic-induced mutations further tumour development is
promoted by growth factors.
Non-small cell lung cancer includes three subtypes; Squamous cell carcinoma – occurs most
frequently in the central zone, clinical manifestations may be airway obstruction and
hypocalcaemia. Adenocarcinoma tumours are peripheral in origin with a clinical
manifestation of pleural effusion. Large cell carcinomas are diagnosed by exclusion as none
of the histological findings of Squamous cell carcinoma or adenocarcinoma. Large cell
carcinoma cells have lost all evidence of differentiation. Clinical manifestations can be
cough, chest pain, airway obstruction and wheezing (Yoder, 2006).
Emphysema:
Inhaled oxidants in tobacco smoke and pollution stimulate inflammation, which over time
causes alveolar destruction and loses its normal elastic recoil. The Destruction of alveolar
tissue means a loss of respiratory membrane where gases are exchanged between air and
the blood. This loss then causes a ventilation-perfusion mismatch, which leads to hypoxia.
Due to the loss of normal elastic recoil large air spaces are created in the lung tissue. This
loss of normal recoil also reduces the volume of air that can be expired passively and
expiration becomes very difficult. This air trapping causes an increase in expansion of the
chest, which puts mechanical ventilation muscles at a significant disadvantage. The
workload of breathing is drastically increased (Craft, Gordon & Tiziani, 2011).
Bone Metastasis and related pain:
Metastasis is the spread of cancer cells from the site of the original tumour to separate
areas. Cancer cells acquire invasive behaviour characteristics. The cancer cells break
away and they poses the ability to survive for a period of time independently from other cells.
Metastasis formation occurs in three steps; cells invade blood or lymph vessels, move by
mechanical means and then lodge and grow in a new location. Metastasis can contribute
significantly to a patients pain and discomfort levels, as can be seen in Mrs Gaga. Pain
associated with cancer is usually due to complications rather than the actual tumour.
Pressure, obstruction, stretching and inflammation could all possibly cause pain in cancer
Clinical Practice 2 (HCNUR2943): Case Study
patients. This pain may possibly be influenced strongly by; fear, anxiety, fatigue or
deterioration (Williams & Hopper, 2007).
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Evaluation of Health Assessment and Clinical Management Plan
Admission to Oncology: As Mrs Gaga has a lot of uncontrolled pain at the moment
admission on to ward for further investigation would be the best way in order to make her
feel more comfortable. On the oncology ward she has direct access to oncology doctors,
oncology nurses and is around other patients who may be going to through a similar
experience.
Pain Management: Pain is a significant symptom of cancer. Understanding this experience
in relation to pain management is important in out nursing care. Research has found a
strong relation between bone metastasis and higher pain scores (Rustoen, Gaardsrud,
Leegaard and Wabl. 2009). The first response from health care providers when trying to
manage pain is strong opioid analgesia such as morphine, pethidine, endone, etc. Mrs
Gaga arrived already on OxyContin, which was unsuccessfully managing her pain at home.
On admission to the oncology ward Mrs Gaga was prescribed prn endone and prn morphine
for any pain that she may need it for. When it came time to evaluate Mrs Gaga’s progress in
relation to her pain management it was clear by the amount of time that she needed the prn
break through pain medication on top of her regular analgesia was not suffice for amount of
pain that she was experiencing. At this point it was decided that it would be best to put Mrs
Gaga on a syringe driver with Morphine and Metroclopramide in it. A syringe driver is a
small infusion pump witch will administer a constant dose of a desired drug, in this case
morphine for the pain and Metroclopramide as a prophylaxis for nausea and vomiting. Mrs
Gaga found this method to be most useful in managing her pain. Yau et al 2004 also stated
that unmanaged pain in cancer patients should be referred on for palliative radiotherapy,
which will be discussed later on in considerations for future care. As nurses we can also help
patients help gain control, firstly we can make a plan with them. Help them to decide on
what is an ‘acceptable’ level of pain and what we can do now to try and get them there by
discussing things such as; what exacerbates the pain? When is the pain at its worse? Is
there any new pain? What sort of pain is it? Then we can work out appropriate strategies to
deal with the pain, i.e. showers in the afternoon instead of morning, ensuring pain relief is
given before procedures, etc. (Williams & Hopper, 2007).
We also need to monitor for adverse effects of the opioids such as; sedation and respiratory
depression. If any of these are occurring the doctors should be notified and perhaps the
dose may be decreased or medications changed.
In addition to her regular pain Mrs Gaga has explained that she also has abdominal pain and
has had frequent episodes of constipation, which now due to her immobility could possibly
be exacerbated.
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Constipation Management: Mrs Gaga has been prescribed regular coloxyl and senna and
movicol to assist her bowels to start moving. A problem that could arise with this is
overdosing on aperients and experiencing diarrhoea. This is a perfect example of why
aperients administration should be closely monitored. As Mrs Gaga is already dehydrated
and malnourished developing diarrhoea runs the risk of escalating these problems.
Allied Health Involvement:
Physiotherapy: A referral to a physiotherapist is not only a great idea to help Mrs Gaga with
her mobility issues but also to help her with the issues she is having with her emphysema.
Physiotherapists use a range of techniques to improve ventilation, reduce work of breathing
and increasing respiratory function. Chest physiotherapy may include positioning, breathing
exercising and whole-body exercises to improve strength and function. An important aim of
chest physical therapy is to maximise exercise tolerance to help keep people as ambulant as
possible (Garrod & Lasserson 2007).
Occupational Therapy: An occupational therapist can come and assess Mrs Gaga to help
her with self-care deficits such as; showering, toileting and moving around. The
occupational therapist is also an integral part in planning for future care. They can ensure
that the patient’s home is suitable for them to return to and that the patient is well equipped
with the skills to manage themselves as much as possible. The occupational therapist can
also teach someone like Mrs Gaga energy conservation techniques to help alleviate the
fatigue that she is feeling. They can also help her re-engage in leisure activities and
community involvement. Another aspect that they would be able to help Mrs Gaga with is
bone protection techniques when participating in daily activities (Lemoignan, Chasen &
Bhargava, 2010).
Dietician: As Mrs Gaga has not only been constipated the past two months, she also stated
that she has lost 8kgs in the past two months. These two facts alone increase her risk of
becoming malnourished and dehydrated. Sampson (2008) states that nutritional support
can reduce hospital readmission occurrences by more than 29%. A dietician will be able to
correctly assess Mrs Gaga, educate her and will liaise with her other carers.
Deep Vein Thrombosis Prophylaxis: Deep vein thrombosis (DVT) risk is increased by many
factors for example; increased age, obesity, immobility and previously history of deep vein
thrombosis. When being admitting to hospital most patients are screened for their risk of
developing a DVT and prophylactic medications are usually administered on a daily basis, in
Mrs Gaga’s case she has a daily subcutaneous injection of enoxaparin. Studies have found
that screening for DVT and DVT prophylaxis measures can reduce the instances of DVT’s
more than 50% (Piazza et al, 2009).
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Prioritisation of Care
1.) Pain management: This should be the first line of action due to the fact that Mrs
Gaga is extremely uncomfortable and has presented with new pain. Different
investigative measures need to be taken to find out what pain management is going
to be most effective and what could be causing this new pain
2.) PRN Oxygen: As Mrs Gaga has emphysema her work of breathing may be increased
and she gets short of breath very easily. It is important to note though that she
should not be given too much oxygen as she may be a CO2 retainer. This means
that her body has gotten used to having such a high level of carbon dioxide in her
system that her mechanism to breathe is low oxygen levels. This means that if she is
given too much oxygen this can take away her stimulus to breathe (Williams &
Hopper, 2007).
3.) Aperients for constipation: As Mrs Gaga has stated she is also experiencing
abdominal pain and that she has been having frequent episodes of constipation.
These frequent episodes could lead to complications such as faecal impaction or
haemorrhoids.
4.) DVT Prophylaxis: As Mrs Gaga is in the high-risk category for developing a DVT
prophylaxis is a high priority.
5.) Diagnostic Tests: CT scans, full blood examination, urinalysis, bone scan and x-ray
of her right leg. Which is important to get done soon to find out where her pain is
coming from. It is also important, as Mrs Gaga could have developed more
metastasis.
6.) Nutrition and Hydration: As Mrs Gaga has presented with weight loss and
dehydration, getting on top of these things before she goes home will allow for her to
have a better quality of life. In hospital she will have hydration of normal saline
through a drip to start with and being closely monitored with a fluid balance chart.
Once her hydration levels seems satisfactory she will be taken off the normal saline
but still monitored with a fluid balance chart to ensure that her intake is sufficient. As
she has lost 8kgs in the past 2 months she will be on a daily weight and a food chart.
Regular antiemetics will be given to help with nausea that may be caused by her pain
medication.
7.) Allied Health Involvement: Dietician and Physiotherapy are both services that should
be utilised while in hospital with a possible view for referral to someone closer to
home when she is discharged. Occupational Therapist involvement is something
that may be considered closer to Mrs Gaga’s time of discharge and will be mentioned
in consideration for future care.
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Considerations for Future Care
Radiotherapy: Local field radiotherapy is commonly used to treat localised bone metastasis
to help relieve pain (Lin & Ray, 2006). Radiotherapy can be used for; complete cure,
temporary relief, symptom relief or as an adjuvant therapy. In Mrs Gaga’s case it would be
used a symptom relief for her pain that she is experiencing. Lin and Ray (2006) explain that
treatment of pain from bone metastasis with radiotherapy can give the patient additional
quality of life and also slightly improve their quantity of life as well.
Occupation Therapy: As Mrs Gaga presented with acopia at home it is clear that it is not
wise to send he home to the exact environment that she was not coping with. The
occupation therapist (OT) would be able to go through her home, finding where she is having
trouble and ways that she may be able to overcome them. The OT will be able to teach Mrs
Gaga coping strategies with her fatigue and decreased mobility. The OT is also able to offer
advice on being able to become more mobile and develop exercises that would suit Mrs
Gaga. Hammond (2004) explains that the role of the OT is not only capable in implementing
physical intervention but also psychological interventions. They can provide counselling,
relaxation and stress management programmes.
Hospice Involvement: Hospice is a palliative care service offered in Ballarat. Hospice offers
connection to a range of services, for example; nursing services, pastoral care services,
social work services, medical services and grief/loss and bereavement services. Hospice
will make a care plan with the patient and/or the patient’s family, which will be ongoing and
constantly reassessed as situations change. This service could be very helpful to Mrs Gaga
as she would have constant support and monitoring in her own home, which would perhaps
reduce her risk of readmission for the same problems.
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References
Craft, J., Gordon, C., & Tiziani, A. (2011). Understanding Pathophysiology. Chatswood,
NSW, Australia: Elsevier.
Garrod, R., & Lasserson, T. (2007). Role of physiotherapy in the management of chronic
lung diseases: An overview of the systematic reviews. Respiratory Medicine,
101(12), 2429 – 2436.
Hammond, A. (2004). What is the role of the occupational therapist? Best Practice and
Research Clinical Rheumatology, 18(4), 491 – 505.
Lemoignan, J., Chasen, M., & Bhargava, R. (2010). A retrospective study of the role of an
occupational therapist in the cancer nutrition rehabilitation program. Support Cancer
Care, 18, 1589 – 1596.
Lin, A. & Ray, M. (2006). Targeted and systematic radiotherapy in the treatment of bone
metastasis. Cancer Metastasis Review, 25, 669 – 675.
Piazza, G., Rosenbaum, E., Pendergast, W., Jacobson, J., Pendleton, R., McLaren, G.,
Elliott, G., Stevens, S., Patton, W., Dabbagh, O., Paterno, M., Catapane, E., Li, A. &
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Rustoen, T., Gaardsrud, T., Leegaard, M. & Wahl, A. (2009). Nursing Pain Management –
A Qualitative Interview Study of Patients with Pain, Hospitalised for Cancer
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Sampson, G. (2009). Weight loss and malnutrition in the elderly – The shared role of GP’s
and APD’s. Australian Family Physician, 38(7), 507 – 510.
Williams, L.S, & Hopper, P.D. (2007). Understanding Medical Surgical Nursing (3rd Ed).
Philadelphia, PA: F.A. David Company.
Yau, V., Chow, E., Davis, L., Holden, L., Schuller, & Danjoux, C. (2004). Pain
Management in Cancer Patients with Bone Metastasis Remains a Challenge.
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Yoder, L. (2006). An Overview of Lung Cancer Symptoms, Pathophysiology and
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