Download 7-Case Care Plan, High Grade Urothelial Carcinoma

Case Care Plan
High Grade Urothelial Carcinoma
CC
Referred from Hamad general hospital with a diagnosis of high grade urothelial carcinoma
HPI
•
A.S is a 61 year old Qatari male patient with recent diagnosis at Hamad general hospital of
high grade urothelial carcinoma on Sep 21, 2011.
•
Admitted to Al Amal Hospital on Oct 7, 2011, first admission
•
Pt was taken to emergency room at Hamad general hospital because of having right leg
fracture; otherwise, the patient had no complaints
•
Later and two months back, the patient presented to Hamad with sever scapular and back
pain that interfered with his activities and was unable to work because of thigh pain
•
Had several images during period of his complains:
1. Rt side CT scan showed Rt hydronephrosis with urethral mass + lymphoadenopathy
(paraaortic, Rt renal hilum) + multiple lunge nodules, most likely mets + 12 rib osteolytic
lesion
2. MRI spin: illustrated metastatic deposit dorsal + lumbar + sacral vertebra + cord
compression at T7 level
•
Pt has metastatic disease: Spin T7 + Pelvic + Rt scapula + L.N (palpable) +Lung+
abdominal L.N, multiple mets
•
Pt admitted to hospital with nephrostomy tube inserted + floey's catheter inserted for the
hydronephrosis and underwent Rt femur internal fixation (September) surgically with postsurgical complications of Rt CFV DVT + PE
•
Pt arrived to AAH A/O X3, moving all limbs except Rt-lower limb
•
Received the therapeutic dose of Heparin. Drop in platelet count after heparin so inferior
vena cava filter inserted due to suspected HIT. Then, Heparin was resumed and platelet
count stabilized
•
Heparin infusion (40,000 IU) with aPTT (activated partial thromboplastin time) adjusted
according to protocol
•
Oct 12, D/C Heparin & start enoxaparine SC
•
Diagnosis explanation: explained to his sons, pt not aware of his diagnosis and not to be
informed as per his sons' request.
•
Expected length of stay: 2 weeks
•
Did not receive any chemotherapy with no plan for any chemotherapy in the future
•
The pt in general is bed bound, unable to move right leg because of fracture but moving
fingers and toes, conscious, oriented, corporative.
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
•
Pt on insulin sliding scale
•
Oct 12, D/C Tazocin, completed 9 days, started lower dose (2.25 gm IV then 4.5 gm IV
Q8hr, renal function)
•
Oct 14, pt is having fungal oral thrush and fluconazole 150 mg PO once was added
•
Oct 13, 14, and 15 pt is having abdominal pain and distention, did not pass stool, and vitals
are stable. Pt received stat fleet enema PR and passed motion
•
Currently, is seen by physiotherapist, however pt complaining of discomfort during
physiotherapy due to his scrotal edema
PMHx
•
DMII (>7 years)
•
HTN (>7 years)
•
Right leg fracture (September 2010)
•
PE
•
Rt DVT
Social History (SHx)
•
Married
•
Smokes and drinks alcohol
Allergies
•
NKDA
Patient Specific Characteristics
•
Weight & Height: unable to stand
Pain assessment
•
Pt in mild pain
Vitals (Oct 13, 2011)
•
Tem 36.8O C
•
BP 148/75 mmHg
•
Pulse (radial) 68 bpm and regular
•
RR 17 breaths/min
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Labs
Oct 2, intravascular catheter tip: no growth
Oct 2 & Sep 29, blood culture: negative
Cultures and
Microbiology
Sep 29, endotracheal secretions: Gramstain (no organism seen), Culture
(no growth)
Sep 16, Urine: organisms (Enterococcus faecalis & Eschaerichia coli), both
sensitive to Ampicillin and ciprofloxacin
Chemistries
(Oct 16-9)
BUN
Albumin
Scr
Na
(9.2 H, 9.8 H, 10.9
H, 11 H, 11 H, 9.4
H)
(33 L, 32 L, 32 L,
34 L, 33 L)
(82, 77, 75,
93, 82, 102)
(133 L, 131 L,
130 L, 133 L,
132 L, 135)
K
Mg
PO4
Ca
(4, 4, 4.4, 5.5 H,
4.6, 4.8, 4.9, 7.3,
5.2)
(0.77, 0.76, 0.78,
0.75, 0.71)
(1.07, 1.13,
1.13, 1.19, 1)
(2.34, 2.33,
2.45, 2.41, 2.34)
Corrected
calcium
(2.48, 2.49, 2.61
H, 2.53, 2.48)
WBC (11.5, 13,
13.2, 12.6,10.7,
8.3)
Hgb (12, 11, 11.2,
10.7,11, 11)
Platelet (217,
248, 239, 209,
223, 215)
INR
PT
APTT
(1, 1.1, 1.1, 1.1,
1.1)
(12.8, 12, 11.3,
12.1)
(93.4, 29.5, 50, 78,124)
ALT/AST
HBA1C
Feb 1, Urinary albumin 137.8 (H)
(30/15, 35/27,
21/31)
10.7% (Mar 28),
10% (Mar 6), 11%
(Feb 1)
Lipid profile
Cholesterol
TG
HDL-C
LDL-C
(Mar 28, Mar
6, and Feb 1
(6.04, 4.9, 5.6)
(1.61, 2.74, 1.8)
(1.18, 0,86,
1.2)
(4.14, 2.81,
3.58)
CBC
(Oct 16-9)
INR, PT,
APTT
ALT/AST,
HBA1C,
Urinary
albumin,
Creatine
kinase
Neutrophils
(11.6, 11, 11)
40 u/l (N)
(Oct 16)
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Rx Medications
Active Mediations
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B-Sitosterol 0.25% ointment LA TID
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Panthenol 5% cream LA TID
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Solcoseryl 5% ointment LA TID
•
Insulin regular SC
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Insulin Isop/Reg 70/30 5 units SC BID
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Atenolol 100 mg PO once
•
Atorvastatin 20 mg PO HS
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Esomeprazole 40 mg PO QD
•
Fentanyl Transdermal 75 mg TD Q72hr
•
Tramadol 50 mg PO BID
•
Bisacodyl 10 mg PO TID
•
Enoxaparin 60 mg PFS SC Q12hr
•
Enoxaparin 40 mg PFS SC Q12hr
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Simethicone 84 mg PO TID
•
Lorazepam 1 mg PO HS
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Chlorhexidine gluconate LA TID
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Fluconazole 150 mg PO QD
Single Dose Mediations
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Fleet enema 1 tube PR (Oct 15)
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High cleansing enema 1 tube PR (Oct 15)
•
Fleet enema 1 tube PR (Oct 13)
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Lorazepam 1 mg PO (Oct 10)
•
50% dextrose 50 ml + 10 units of actrapid IV stat over 15 ml (Oct 9)
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Calcium gluconate 10%, 10 ml IV stat (Oct 9)
•
Salbutamol nebulizer 2:5 (Oct 9)
•
Calcium resonium 50 gm PO (Oct 9)
PRN Mediations
•
Paracetamol 1 gm IV TID for fever if ≥ 38OC
•
Lactulose syrup for constipation 30 ml PO BID
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Potential Issues and Assessment
•
Nephrostomy tube inserted, risk of re-infection & increased hospital stay with possible
nosocomial infections
•
Multiple lunge nodules, possible deterioration of pulmonary function
•
Cord compression at T7 level(as metastasis due to the disease), DVT and PE
complicated by Rt femur fracture, impaired pt QoL and interruption of normal daily
activities
•
Uurothelial carcinoma, cancer originated from renal system, possible re-deterioration
renal function & adjustment in DVT medication (use Heparin) increasing the pt length of
hospital stay
•
Scrotal edema? Could be because of several companied causes: low albumin, DVT,
bed bound & less movement, leg fracture, the disease itself. Reversal of some of the
possible causes might improve scrotal edema
•
Low Na and high BUN compained with high Scr, electrolyts imbalance caused by renal
impairment
•
Drug-Drug interaction: fungal oral thrush, possible breakthrough fungal infections: PPIs
(e.g. esomeprazole) decrease the absorption of azole antifungal, azoles require acidic
environment. Fluconazole
•
Drug-Drug interaction: fluconazole with atorvastatin. Generally avoid as
coadministration with potent inhibitors of cyp450 3a4 including azole antifungal agents
may significantly increase the plasma concentrations of HMG-COA reductase inhibitors.
This is associated with an increased risk of musculoskeletal toxicity. myopathy
manifested as muscle pain and/or weakness associated with grossly elevated creatine
kinase
•
Pt's prognosis, poor prognosis: does he need atorvastatin?
•
Constipation, not relieved by current laxatives, required enema to relief constipation on
two incidences.
•
Ca metastatic disease, which requires management
Therapeutic Alternatives
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Constipation therapeutic alternatives:
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Fiber supplementation and bulk forming laxatives
•
Stool softener: docusate
•
Saline laxatives: Mg Hydroxide
•
Stimulant laxatives: senna, bisacodyl
•
Osmotic laxatives: lactulose
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Treatment or Interventions: Pharmacological & Non-pharmacological recommendations
with Justifications of Treatments or Interventions
High grade urothelial carcinoma
Constipation:
Mg Hydroxide 15 ml PO BID (pt already on a stimulant and osmotic agent, might benefit from
adding salin laxative)
Drug-Drug interaction (fluconazole with atorvastatin)
D/C Atorvastain, no need for dyslipidemia treatment, poor prognosis because of the metastatic
disease with short life expectancy
Might consider using Pravastatin 40 mg po once, safer alternative, not metabolized by CYP450
3A4
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Drugs to be Avoided
•
Drugs that increase constipation (antimotility agents), loperamide.
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Drugs that can cause constipation as side effect: opioids, this is not possible as the pt is
in pain with poor prognosis, want the pt to be conformable
•
Breakthrough fungal infections, oral thrush: avoid itraconazole and ketoconazole
•
Proton pump inhibitors may decrease the gastrointestinal absorption of the azole
antifungal agents, itraconazole and ketoconazole, both of which require an acidic
environment for dissolution.
Goals of Therapy
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Surgery. The goal of surgery is to remove the tumor from the urethra, while leaving as
much of the urethra as possible intact.
•
Radiation therapy. The goal of radiation is to kill cancer cells by using high energy xrays. This treatment is sometimes used to shrink a tumor before surgery or to treat any
remaining cancer cells after surgery. If surgery is not possible, radiation may be used
alone to treat the symptoms of urethral cancer.
•
Chemotherapy. The goal of chemotherapy is to shrink the cancer when it has spread to
other parts of the body. Occasionally, it may be used to reduce the size of a urethral
cancer before surgery.
Desired Clinical Outcomes (pt specific)
•
Prolong survival by stabilizing the pt (vitals and labs)
•
Improve the symptoms by giving the best supportive care, pain management
•
Minimize and prevent adverse drug reaction of therapy
•
Improve functional status with physiotherapy
•
Optimize overall QoL
Therapeutic Monitoring Plan
Safety and efficacy:
Safety
Efficacy
Time to
Follow-up
Atenolol
Bradyarrhythmia, cold
extremities, hypotension,
dizziness, monitor BG,
liver and renal function
blood pressure; standing
and supine
Baseline,
within one
week, then q
4 weeks
Esomeprazole
CBC
Prevention of abdominal
and gastroesophageal
discomfort
After 1 week,
q 4 wks
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Fentanyl
Transdermal
Tramadol
Flushing, pruritus,
constipation, N/V,
Xerostomia, dizziness,
headache, insomnia,
somnolence
pain reduction,
improvement in ability to
move
Baseline,
after 2472hr of
imitation,
then q week
Decreased abdominal
discomfort and pain
Within 60
min of
therapy
initiation,
then after 24
hr, later q
week
hypoventilation during
first 24 to 72 hours after
initiation
Bisacodyl
Diarrhea or abdominal
pain, discomfort, and
cramping
having bowel movement
within 15 to 60 min after
initiation
if rectal bleeding or no
bowel movement after
laxative (D/C therapy)
Lactulose
Bloating symptom,
Diarrhea, epigastric pain,
flatulence, N/V, cramp
Serum electrolytes
(Hypernatremia,
Hypokalemia) in elderly
or debilitated patients on
long term therapy ≥ 6
months
Mg Hydroxide
Photosensitivity, myalgia,
clostridium difficile
diarrhea, hepatotoxicity,
Improvement of signs
and symptoms of
constipation such as the
number and the
consistency of bowel
movements
Baseline,
symptoms
improvement
s within 24
hrs, q week
symptomatic
improvement
Baseline,
periodically
during
chronic
therapy
Prevention of recurrent
DVT and PE
Baseline and
if stable then
q 4 week
Decreased anxiety and
associated symptoms
During
therapy
Reduced redness,
swelling and bleeding of
During
therapy
CBC, liver and kidney
function tests
Enoxaparin
CBC, liver function tests,
blood pressure
Symptoms of bleeding
Lorazepam
CBC, liver function
Symptoms of upper GI
disease; in patients on
long-term therapy
Chlorhexidine
gluconate
Samah El Salem
PharmD Candidate
Skin irritation
Staining of tooth,
Date: Oct 18, 2011
(oral rinse)
Toothache
the gingivae
Taste sense altered
Fluconazole
N/V, headache
dermatologic symptoms
(potential for rash and/or
exfoliative skin disorders)
improvement of
resolution of clinical
signs and symptoms
Baseline and
within
one
week
if
therapy
is
prolonged
Prevention of cardiac
and cerebrovascular
diseases, normalization
of lipid profile (LDL, TG,
TC)
Relief of bone pain and
possible reduction in
metastatic tumor size
q 6 -8 weeks
ECG (especially QT
interval) in patients with
potentially proarrhythmic
conditions
Pravastatin
hepatic function in
patients who developed
abnormal liver function
tests during treatment
Lipid profile, Liver
Function Test (LFT),
muscle weakness,
insomnia and rash
Radiation
Burning of the skin
(similar to sunburn),
diarrhea, Fatigue,
Inflammation of the
bladder (cystitis),
Narrowing of the urethra
(stricture; causing
urination difficulty),
Nausea
Patient/ family Education & Nurse Education
After therapy
and before
the next
radiation
therapy
Pt/ family to be educated about the possible side effects of medications and what to do in case
of overdose or sever adverse event. Also, the benefits of each drug therapy.
The course of treatments the pt is going to receive and the prognosis of the disease
Chlorhexidine gluconate:
•
Patient should not swallow oral solution and should avoid contact of chlorhexidine
gluconate with eyes and ears.
•
Tell patients using the oral solution not to rinse, brush, or eat immediately after use.
Lorazepam:
•
Patient should avoid activities requiring mental alertness or coordination until drug
effects are realized.
•
Advise patient against sudden discontinuation of drug.
•
Patient should not drink alcohol while taking this drug.
•
Patient should avoid concomitant use of phenothiazines, narcotics, barbiturates,
antidepressants, scopolamine, MAO inhibitors, or other CNS depressants.
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011
Enoxaparin:
• If self-administering, advise patient to rotate injection sites.
•
Patient should lie down during injection.
•
Patient should avoid concurrent anticoagulants, including NSAIDS and aspirin, without
healthcare professional approval.
Bisacodyl:
•
Patient should not take bisacodyl tablets within 1 h of antacids, milk, or milk products.
•
Patient should not take bisacodyl for more than 7 days, unless approved by healthcare
professional.
Tramadol and Fentanyl Transdermal:
•
Patient should avoid activities requiring mental alertness or coordination until drug
effects are realized.
•
Warn patient to not expose extended-release patches to external heat sources while
wearing the system, as this may result in potential overdose.
•
Patient should monitor for signs/symptoms of respiratory depression and
hypoventilation, especially during dose initiation or changes.
•
With long-term use, advise patient against sudden discontinuation of drug.
•
Instruct patient to avoid alcohol or other CNS depressants during drug therapy.
Esomeprazole:
•
To be administered at least 30 min before food
References:
1. National Comprehensive Cancer Network. NCCN guidelines: Bladder Cancer. 2011
[cited 2011 Oct 14]; v2.2011. Available from: URL:
http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
2. Drug monographs. In: DrugPoints System. [Online].2011. Available from: Stat!Ref.
[Cited 2011 Oct 16]
3. MICROMEDEX® Healthcare Series. [online]. [Cited 2011 Oct 16]; Available from, URL:
http://www.thomsonhc.com/home/dispatch
4. http://webed.miner.rochester.edu/encyclopedia/content.aspx?ContentTypeID=34&Cont
entID=19706-1
5. http://adclinic.com/Doctors_Specialties_Maps/Urology/urethral%20cancer.htm
6. http://www.medicinenet.com/laxatives_for_constipation/page6.htm
Samah El Salem
PharmD Candidate
Date: Oct 18, 2011