Care for a Patient Undergoing Chemotherapy - Case Study Example

Ms. B: A Case Study and Critical Analysis of Care for a Patient undergoing Chemotherapy Introduction No one person and no one profession can meet allthe needs of the client with cancer and the family. To effectively manage outcomes requires teamwork involving the client, the family, the nurse, and other health professionals. (Meier, 2001) The author of this paper works as a nurse in an Oncology Unit. As such, the focus of this paper would encompass the assessment of a breast cancer patient, nursing care plans, medication/drug study, and the medical and nursing management, which were implemented to the client with the purpose of gearing towards positive outcomes. Furthermore, this paper aims to provide a critical analysis of all aspects of care, including the medical management and the nursing interventions that are purposefully rendered to the patient. Hence, the bases for the discussion and analysis in due course of this paper were gathered from relevant literatures and reputable references, thereby exemplifying its intent. Important Note: The data presented therein are with strict and utmost confidentiality to protect the client's rights. In this regard, the identity and other markers of the client and the hospital are intentionally obscured to ensure observance of confidentiality. As such, the Nursing and Midwifery Council (NMC, 2002) stated that, as nurses (and midwifes), we must protect the confidentiality of all information pertaining to the patients and all aspects of their care, thereby warranting us to guard against any breaches of confidentiality. Furthermore, the so-called "Confidentiality Advise Sheet", which was updated by NMC (2008), explicated the following valuable reminder, which is quoted below: To trust another person with private and personal information is a significant matter. The person who is in the care of a nurse or midwife has a right to believe that information given to them in confidence is only used for the purposes for which it was given and will not be disclosed to others without permission. (NMC, 2008) The Patient This is the case of Ms. B, a 44-year old, single lady, who was diagnosed to have a Grade 3 breast cancer last year and just recently was re-diagnosed to have cancer metastasis into liver and bones. Currently, she is staying with her parents while receiving chemotherapy at home, as it was her choice. Chemotherapeutic agents include Docetaxel, Trastuzumab and Zoledronic Acid. Additionally, Zomorph was also given for pain management. Most recently, Ms. B was also recommended to start wearing a wig and/or a set of headscarves Key words: confidentiality, respect for client's choice, choice for home chemotherapy treatment, advanced breast cancer, docetaxel, trastuzumab, zoledronic acid, zomorph, consent. Discussion and Analysis Ms. B's choice to be at home After several hospitalizations, the patient (Ms. B) opted to have the continuation of her chemotherapy at home. This is because she does not want to cause distress to her elderly parents, which could be brought about by the hospital environment. In this regard, the health professionals, who were responsible for Ms. B's care, gave utmost respect to her decision, thereby freely giving the client to decide for herself as a sane and rational individual. Moreover, though the client is in the advanced stage of breast cancer, she is still deemed as capable of making decisions for her treatment. We can correlate this concept to the Mental Capacity Act 2005 (Department of Health [DH], 2007), where the following significant idea is stated: A presumption of capacity - every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise (DH, 2007) In addition, the Mental Capacity Act 2005 "makes it clear as to who can take decisions in which situations and how they should go about it It enables people to plan ahead for a time when they may lack capacity" (DH, 2007). In this manner, the client, though having some depression but undergoing weekly psychiatric counseling, still has an optimal mental ability to support her choice to stay at home to continue her treatment regimen. Background of the Disease Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer in American women (Black, Hawks, and Keene, 2001; MedicineNet, Inc., 2009), as well as affecting women in England and Wales, where about 40,500 new cases diagnosed and 10,900 deaths recorded each year, (NICE, 2009; Office for National Statistics, 2008; Welsh Cancer Intelligence and Surveillance Unit, 2008). The following are said to be the risk factors for breast cancer, as listed by Black, Hawks, and Keene, 2001: 1. Early menarche 2. Late menopause 3. Being nulliparous 4. More than 30 years at the birth of her first child Accordingly, hormonal changes and genetic factors are figured to predispose women to breast cancer. Nevertheless, many women who were diagnosed with breast cancer have no known risk factors (Black, Hawks, and Keene, 2001). Additionally, "there are a significant number of women who have been previously treated with curative intent who subsequently develop either a local recurrence or metastases" (NICE clinical guideline 81 - Advanced breast cancer, 2009). With this, heightened awareness and vigilant breast examinations are recommended to enable early detection of the disease, thereby facilitating prompt treatment and improvement in survival rates (MedicineNet, Inc., 2009). Care for Advanced Breast Cancer Patients The National Institute for Health and Clinical Excellence (NICE, 2009) exemplified the following guideline in regard to the support and care for advanced breast cancer patients: Healthcare professionals involved in the care of patients with advanced breast cancer should ensure that the organisation and provision of supportive care services comply with the recommendations made in 'Improving outcomes in breast cancer: manual update' (NICE cancer service guidance [2002]) and 'Improving supportive and palliative care for adults with cancer' (NICE cancer service guidance [2004]), in particular the following two recommendations: 1. 'Assessment and discussion of patients' needs for physical, psychological, social, spiritual and financial support should be undertaken at key points (such as diagnosis; at commencement, during, and at the end of treatment; at relapse; and when death is approaching).' 2. 'Mechanisms should be developed to promote continuity of care, which might include the nomination of a person to take on the role of "key worker" for individual patients.' (NICE clinical guideline 81 - Advanced breast cancer, 2009, p. 6) A Detailed Health Assessment for Ms. B Case management for clients with cancer involves the clients emotional, physical, and psychological state; component clinical care; education about treatment and further options; and helping the client to use preventive measures as possible. (Noetscher, 2001) In order to render purposeful nursing interventions that match to the needs of the clients, a careful assessment must be done to identify the actual and potential nursing concerns (Berman et al., 2008; Potter and Perry, 2001). This is because assessment involves gathering of information from and about a patient, thereby determining the specific healthcare problem and needs that relate to a particular problem or condition (Freshwater and Maslin-Prothero, 2005). With this, the following details were gathered (and modified for the purpose of this paper to maintain confidentiality) to underpin the nursing management for Ms. B. Further, the assessment guideline is taken and adapted from An Exhaustive Health History Format by Black, Hawks, and Keene (2001, pp. 131-135). Additionally, the involvement of the client's family and related information in this assessment guideline exemplifies a holistic approach in the care of the client/patient. Current Health According to her recent medical examination, Ms. B's breast cancer has metastasized to her liver and bones. Evidently, she appears cachectic, which is characterized by emaciation, dry skin, and extreme malnutrition. With this, Ms. B undeniably feels devastated and is frequently feeling depressed with her condition. She now attends psychiatric counseling once a week with her psychiatrist visiting at home. Further, Ms. B verbalized a feeling of disturbed body image, which is related to the hair loss or alopecia, secondary to chemotherapeutic treatment. Past Health History Past Illnesses Ms. B. did not have any serious illness all her life, except for the diagnosis of her breast cancer last year. Thereafter, she had experienced pneumonia twice during a 12-month period, which can be said as an adverse effect of the chemotherapy. Hospitalizations After the diagnosis of breast cancer last year, Ms. B. had frequent hospital admissions, which from 7 to 9 hospitalizations in a 12-month period. Her admissions were due to her chemotherapy sessions and pneumonia. Just recently, she requested to return to her parents' home and there she will be continuing her chemotherapy. Surgeries Ms. B. underwent total mastectomy of her left breast last year in order to rid of the tumor cells. Serious injuries or accidents Ms. B. has never had any serious injuries and accidents. Obstetric history Ms. B. is single and has never had a child. Last visit to health care provider About a month ago, Ms. B. had her last confinement due to mild case of pneumonia and thereafter, she requested to continue her chemotherapy at home. Allergies Ms. B. has no known allergies to any food and/or medications. Medications As regarded earlier, Ms. B. is under chemotherapy and also receives Zomorph for pain management. Family Health History Ms. B's parents are free from any serious illness but are constantly monitoring their blood pressure and take their maintenance anti-hypertension medications. On the other hand, breast cancer is found to run in Ms. B's genes. Two of her first-degree cousins, in her maternal side, were diagnosed to have breast cancer in their early 40s. Psychosocial History (and Support System) Ms. B has never had any psychiatric ailment. However, due to her disease condition, especially upon knowing the metastasis of cancer to her vital organs, Ms. B feels so much hopeless and devastated. She frequently chooses to spend time alone. Although Ms. B is not observed for any suicidal ideations, she is still being monitored by her caregivers and significant others. In fact, a psychiatrist is visiting her once a week for psychiatric evaluation and counseling. Additionally, she seeks spiritual advice from a pastor who also visits her every Sunday afternoon. On the other hand, her parents are there to support her all the time through constant encouragements and expression of love for their daughter. Moreover, the presence of two (2) Oncology Certified Nurses (OCNs), who work alternately on a weekly basis to administer intravenous chemotherapeutic agents, also serve as an augmentation to Ms. B's support system. Thus, it can be said that Ms. B has an evidently involved support system, as well as a responsive social environment, necessary for her individual coping. Critical Analysis Point: The fact that she does not have a child predisposed her to hormonal causation for breast cancer. Further, the existence of the disease in her close relatives strengthened the risk for her disease condition. Hence, the health assessment for Ms. B revealed and typified the genetic and hormonal risks of Ms. B for contracting the disease. On the other hand, the presence of her significant others (SOs) throughout the treatment process seemingly eases the burden of having the disease. As a result, the client's support system, which includes her parents, relatives, caregivers and the health care team, fairly enables her to cope with the challenges of her underlying disease process. Drug Study The chemotherapeutic agents that Ms. B is taking were duly prescribed by her physician, at the same time, a specialist. This in line with the Guidelines for the Safe Use of Cytotoxic Chemotherapy in the Clinical Environment (2000, by Parsons, et al. [eds.] [Endorsed by the Royal Pharmaceutical Society of Great Britain (Scottish Branch)]), which says: 1.1.1 The initial decision to prescribe cytotoxic chemotherapy must be made by a consultant or a senior specialist with appropriate experience (as defined by local policy). This person should record their decision and the proposed plan of treatment in writing. 1.1.3 Cytotoxic chemotherapy should be prescribed by an appropriately qualified, competent practitioner (as defined by local policy). Prescribing should be in accordance with written local treatment protocols that are readily available in the ward, clinic and pharmacy department. (p. 2) Furthermore, as mentioned earlier, there are two Oncology Certified Nurses (OCNs) who work alternately on a weekly basis to administer chemotherapeutic agents to Ms. B at home. According to the literature, only adequately prepared registered professional nurses, who are skilled in the administration of chemotherapeutic agents, should assume the responsibility of performing the task of administering chemotherapeutic agents (Powel, 1996, as cited in Meier, 2001, p. 381). In this manner, the specialized knowledge and skills that only these trained nurses can execute fairly help in ensuring the appropriateness and safety in handling the chemotherapeutic medications (Meier, 2001). Furthermore, in order for us to critically analyze the appropriateness of the chemotherapeutic agents, it is necessary to provide an in-depth approach in this medication/drug study section. The following tables illustrate all the relevant information on the chemotherapeutic drugs that were given to Ms. B, including the generic and brand names, actions, uses, route and dosages, special nursing considerations, common and life-threatening adverse effects, and critical analysis of care, respectively. In addition to the chemotherapeutic agents, Zomorph is also explained within this medication study, as it was given to Ms. B for her cancer pain experience. Table 1. DOCETAXEL Generic Name Docetaxel Brand Name Taxotere Classifications Antineoplastic Agent; Taxane Agent Actions It binds to the microtubule networks to inhibit mitotic activity or cell division. Accordingly, it has greater anti-tumor activity with lesser toxicity potential (Wilson, Shannon, and Stang, 2004). Uses Metastatic breast cancer Route and Dosage Intravenous; 60-100 mg/m2 once every 3 weeks Special Nursing Considerations Premedicate patients with Dexamethasone 8 mg b.i.d. x 5 d, starting 1 day prior to starting docetaxel. Rationale: Premedication with corticosteroids like dexamethasone prior to docetaxel is essential to prevent hypersensitivity (Wilson, Shannon, and Stang, 2004). Common Adverse Effects Cardiovascular: fluid retention as evidenced by peripheral edema and weight gain. Gastrointestinal: nausea, vomiting, diarrhea, stomatitis Skin: alopecia General: hypersensitivity reactions Life-threatening Adverse Reactions Hematologic: neutropenia, leucopenia, thrombocytopenia, anemia Critical Analysis of Care For patients with advanced breast cancer who are not suitable for anthracyclines (because they are contraindicated or because of prior anthracycline treatment either in the adjuvant or metastatic setting), systemic chemotherapy should be offered, where single-agent docetaxel is the first line drug. (NICE, 2008, p.10) ___ Table 2. TRASTUZUMAB Generic Name Trastuzumab Brand Name Herceptin Classifications Immunosuppressant; Monoclonal Antibody; Anit-HER Actions Selectively binds to the human epidermal growth factor receptor-2 protein (HER2), thereby inhibiting human tumor cell growth (Wilson, Shannon, and Stang, 2004). Uses Metastatic breast cancer Route and Dosage Intravenous; Loading Dose 4mg/kg; IV Maintaining Dose 2mg/kg every week Special Nursing Considerations (1) Monitor for blood test results; (2) monitor for chills and fever with initial infusion; and (3) monitor for cardiovascular status of the patient. Rationale: This drug can be cardiotoxic, so cautious use and constant monitoring must be implemented for patients with pre-existing cardiovascular dysfunctions/conditions (Wilson, Shannon, and Stang, 2004). Common Adverse Effects CNS: headache, insomnia, dizziness, paresthesias Gastrointestinal: diarrhea, abdominal pain, nausea, vomiting, anorexia Hematologic: anemia, leucopenia Respiratory: cough, dyspnea Skin: rash General: pain, asthenia, chills, fever Life-threatening Adverse Reactions General: hypersensitivity (anaphylaxis, urticaria, bronchospasm, angioedema, or hypotension) (Wilson, Shannon, and Stang, 2004) Critical Analysis of Care Consideration must be taken when administered with Paclitaxel. It is because Paclitaxel may increase Trastuzumab levels and toxicity (Wilson, Shannon, and Stang, 2004). Moreover, the NICE (2009) explicated the following quoted guidelines: The use of continued trastuzumab in patients with progressive metastatic disease should be investigated as part of a randomised controlled trial. Trial design should incorporate collection of data required for prospective cost-effectiveness analysis. This is because of the fact that there is currently no high-quality published evidence about whether continuing trastuzumab is effective in prolonging survival in patients with HER2-positive advanced breast cancer who develop progressive disease (outside the central nervous system) during or after first-line treatment with trastuzumab and cytotoxic chemotherapy. Any studies should be carefully planned to permit a high-quality cost-effectiveness analysis. (NICE clinical guideline 81 - Advanced breast cancer, 2009, p. 17) ___ Table 3. ZOLEDRONIC ACID Generic Name Zoledronic Acid Brand Name Zometa Classifications Regulator, Bone Metabolism; Biphosphonate Actions It inhibits various stimulatory factors due to osteoclastic activity by bone tumors (Wilson, Shannon, and Stang, 2004). Uses It is used for the treatment of bony metastases from solid tumors (Wilson, Shannon, and Stang, 2004). Route and Dosage for Mutiple Myeloma and Bony Metastases from Solid Tumors Intravenous; 4 mg over a minimum of 15 minutes every 3-4 weeks. Special Nursing Considerations Baseline renal function tests must be obtained prior to each dose; notify physician for deteriorating renal function; encourage the client to maintain adequate daily fluid intake (Wilson, Shannon, and Stang, 2004). Common Adverse Effects General: fever CNS: insomnia, anxiety, confusion, agitation Cardiovascular: hypotension Gastrointestinal: nausea, vomiting, constipation, abdominal pain, anorexia Hematologic: anemia Metabolic: hypophosphatemia, hypokalemia, hypomagnesemia Respiratory: dyspnea, cough Urogenital: renal deterioration Life-threatening Adverse Reactions Hematologic: pancytopenia Critical Analysis of Care Careful consideration must be implemented when administering with other nephrotoxic drugs as they may increase Zalidronic Acid likelihood of renal toxicity (Wilson, Shannon, and Stang, 2004). ___ Table 4. ZOMORPH Generic Name Morphine Brand Name Zomorph Classifications Central Nervous System Agent; Analgesic; Narcotic (Opiate) Agonist Actions It controls severe pain through spinal activity. Uses Symptomatic relief of severe acute and chronic pain, including pain of MI and cancer pain (Wilson, Shannon, and Stang, 2004). Route and Dosage Intravenous; 2.5 to 15 mg every 4 hours or 0.8 to 10mg per hour by continuous infusion. Special Nursing Considerations Obtain baseline respiratory rate and function prior to administration of morphine (Wilson, Shannon, and Stang, 2004). Common Adverse Effects General: pruritus due to hypersensitivity Gastrointestinal: constipation, nausea Life-threatening Adverse Reactions General: anaphylactic reaction Cardiovascular: cardiac arrest Respiratory: severe respiratory depression or arrest Critical Analysis of Care According to the American Pain Society (1999, as cited in Keck and Baker, 2001), 40% to 70% cancer patients experience pain. However, cancer pain treatment may be difficult due to variety of causes. Nevertheless, pain management is possible with effective pain management, including the administration of NSAIDs and opioid analgesics just like morphine (zomorph) (Keck and Baker, 2001). Nursing Diagnoses Based on the above drug study, the following are the actual and potential nursing diagnoses relevant to Ms. B. In the same manner, Meier (2001) and Doenges, Moorhouse, and Geissler-Murr (2004) enlisted these diagnoses as applicable cancer patients like Ms. B. 1. Disturbed Body Image related to side effects of illness treatment (chemotherapy) 2. Risk for Injury related to side effects secondary to chemotherapy. 3. Risk for Infection related to leukopenia secondary to chemotherapy. 4. Altered Nutrition: Less Than Body Requirements related to disease process and treatment 5. Fatigue related to cancer treatment 6. Ineffective Individual Coping related to cancer diagnosis and disease progression Sample Nursing Care Plan In here, we would pick and discuss the diagnosis of Disturbed Body Image related to side effects of illness treatment (chemotherapy). This is because it is one of the most important concerns of Ms. B during these times. Also, since she is currently taking chemotherapy agents into her system, it is most appropriate to address this concern, specifically, the most common side effect of many anti-neoplastic agents, which is alopecia or hair loss (Meier, 2001). Sample Nursing Care Plan for Ms. B Assessment Subjective: The patient verbalized a feeling of discomfort about her body image, specifically the evident loss of hair (alopecia). Objective: Evident hair loss noted; a common adverse reaction of the chemotherapeutic agent she is taking like Docetaxel. The patient was observed to avoid looking at her image in the mirror. Ms. B was also noted with dry facial skin. Nursing Diagnosis Body Image, Disturbed related to adverse/side effects of illness treatment (chemotherapy). Planning Within the duration of care, the client (Ms. B) will: 1. Verbalize acceptance of self in her current situation; 2. Verbalize understanding of body changes; and 3. Verbalize relief of anxiety and adaptation to altered body image. Interventions 1. Encourage the client to verbalize feelings regarding her hair loss and her current situation. Rationale: This allows the client to ventilate emotions and to ease the anxiety that she feels at the moment. 2. Evaluate the client's knowledge and understanding about her treatment regimen, including the common adverse reactions. Rationale: This is to determine the extent to which the client knows that the hair loss (alopecia) is a common side effect of anti-neoplastic medication like Docetaxel. 3. Educate the client and inform her that hair loss is temporary and may re-grow after cessation of intake of chemotherapeutic agents. Usually, new hair growth begins 4 to 6 weeks after the completion of chemotherapy (Meier, 2001, p. 394). Rationale: This gives hope and reassures the client that her hair will have a new growth after the chemotherapy treatment. 4. Encourage the client to look at her image in the mirror. Rationale: This begins to incorporate changes into body image. 5. Encourage the patient to start wearing wig and/or headscarf as well as to wear make-ups, as recommended by the physician/psychiatrist. Rationale: This promotes self-esteem and enhances the client's perception of her body image. 6. Offer positive reinforcement for efforts made in wearing wig, headscarf, and make-up. Rationale: This provides positive feedback to the client, thereby encouraging her to continue this good trait of improving her self-concept. 7. Reinforce the client's interest to continuously attend the counseling sessions. Rationale: This promotes wellness and makes the client feel that she is someone worthwhile. Evaluation At the end of the care, Ms. B will: 1. Verbalize acceptance of self in her current situation; 2. Verbalize understanding of body changes; 3. Verbalize relief of anxiety and adaptation to altered body image; 4. Verbalized an improved sense of wellness; and 5. Demonstrate a positive and "blooming" image. Adapted from Doenges, Moorhouse, and Geissler-Murr (2004) Conclusion Consequently, the aspects of care and management for Ms. B have been thoroughly dealt with as a result of this case study and critical analysis of care. The health assessment provided a baseline for the discussion and analysis of the medical management, which revolved around the administration of medications, and the nursing management, which included the nursing care plan. In this way, the significant points were highlighted and analyzed with reference to scholarly references and reputable literatures. Moreover, some relevant clinical guidelines were also cited in order to typify the interventions that were rendered to Ms. B. In so doing, we can therefore come up with a substantial solution that the management and treatment of Ms. B were administered appropriately and conscientiously in accordance with the existing guidelines and standards of care for cancer patients who truly deserve rightful care. Additionally, the importance of confidentiality was also depicted in this paper, thus valuing the right of the patient for safe keeping of their records and confidential information. Hence, exemplifying the aptness of the care given to Ms. B is in fact the essence of this paper. References Berman, A., Snyder, S. J., Kozier, B., & Erb, G. (2008). Fundamentals of Nursing - Concepts, Process, and Practice. 8th Edition. Upper Saddle River, New Jersey: Pearson Prentice Hall. Black, J. M., Hawks, J. K., & Keene, A. M. (2001). 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Cancer incidence in Wales 19922002. Cardiff: Welsh Cancer Intelligence and Surveillance Unit. Wilson, B. A., Shannon, M. T., & Stang, C. L. (2004). Nurse's Drug Guide 2004. New Jersey: Pearson Prentice Hall. Read More