Nursing Cancer Patient Case - Assignment Example

A. Discuss the factors that must be considered before initiating therapy for your chosen case study. The following are the factors which must be considered before initiating therapy for Burt. History of fall Burt lives in an old age hostel and had a fall. Falls are very common in elderly people like Burt. This is because of decreased speed, poor balance and decreased muscle strength in this age group (Lord, 2003). Falls in elderly people are a cause of worry because of risk of development of fractures like fracture of hip, spinal vertebra, fore arm and proximal femur. The main problem with osteoporosis related fractures is that the fractures can end up in long term disability and the quality of life may be decreased. These fractures are mainly osteoporosis-related. Osteoporosis is a chronic progressive metabolic disease of the bone characterized by low bone mass and micro-architectural deterioration of the tissue of the bones (Serota and Lane, 2006). It affects 16% of women and 7% of men above 50 years of age (Tenenhouse et al, qtd. in Targownik, Lix and Metge, 2008). The most dreaded complication of fall in this age group of people is hip fracture. Aging Burt is 68 years old. Aging is a natural physiological process and there are many changes which occur in the various organs of the body. The common health problems frequently encountered in the elderly are altered response to medication, altered nutritional status, urinary incontinence, urine retention, fecal incontinence, pressure ulcers, mood disorders, dizziness, dementia and functional impairment, immobility and impaired gait (Nettina, 2006). Elderly people are more prone to falls and fractures, cognitive dysfunction, postural hypotension, electrolyte disorders, cardiac failure and polypharmacy. Altered pharmacokinetics due to age Burt needs to be given several medications because of his health condition. Pharmacokinetics of the aged is different and hence the effects of the drugs are more. The factors which contribute to altered pharmacokinetics are decrease in lean body mass and total body weight, increased percentage of body fat, decreased protein binding of drugs, increase in volume of distribution for lipophilic drugs that penetrate the central nervous system, decline in the metabolic capacity of the liver, decreased liver mass and hepatic blood flow, decreased renal blood flow and glomerular filtration rate. There may also be changes in the receptor numbers, affinity, and post receptor cellular effects. Along with these, there are also changes in the homeostatic mechanisms (Tregaskis and Stevenson, 1990). Dementia Dementia is a haunting problem amongst elderly who frequently get admitted to acute care settings for other health problems. Due to dementia, proper treatment is difficult to institute. Dementia seldom goes identified and physicians and nurses dealing with elderly population must keep this in mind. Abuse and neglect of elderly residents in hostels Burt lives in an oldage hostel. Abuse and neglect of residents in nursing homes and long-term care settings has been a widespread problem in all societies. Elderly persons, who are residents of nursing homes, can be deprived of basic needs leading to various physical and mental consequences. The consequences can cause various degrees of discomfort and even death. Elderly people are frequently subjected to abuse because of their physical and mental vulnerability and dependence on others even for basic needs and activities. They are also not in a position to communicate the abuse and thus suffer in silence (IQ Nursing Homes.com, 2008). According to the reports from the U.S. General Accounting Office, 43% of elderly population will live in a nursing home during a lifetime and of these atleast 3 million will be subjected to abuse and atleast 300,000 will die following abuse and neglect at nursing homes (cited in Roberts, 2004). Abuse in the elderly can be physical, sexual, emotional or even wrongful death. Financial exploitation and abuse can also occur. Most of the times, abuse occurs by the staff of the nursing home. However, abuse can occur from other residents of the nursing home too. Alcoholism Burt is a chronic alcoholic. Harm due to alcohol comes in 3 main ways: binge drinking, addiction and chronic disease. Initially, alcohol produces mild euphoria, stimulation of behavior and minor disturbances in performance. As the levels of alcohol in the blood increase, more severe effects, and changes in behavior are seen. Excessive alcohol consumption over a period of time leads to various health problems and can involve any organ in the body. The side effects include damage to the heart and blood vessels, liver disease, increased blood pressure, stroke, cancers of the digestive system and breast, sexual impotence, reduced infertility, sleeping difficulties, behavioral and psychological problems like personality changes and mood changes, difficulty in concentration, poor memory, sleeping difficulties, neurological problems such as epilepsy and certain types of vitamin deficiency (DASSA, 2008). Other than these, chronic alcohol consumption also causes to develop tolerance and dependence. Excessive alcohol (ethanol) consumption induces pathological changes in the liver which include alcoholic fatty liver, alcoholic hepatitis, and alcohol-related cirrhosis (Ismail, 2006). Alcohol magnifies the effects of diazepam, cannabis, some antipsychotics, antidepressants and some pain killers (DASSA, 2008). Smoking Burt is a smoker. Smoking is associated with many health-related problems and hence is a major health-related issue. A smoker is at risk of developing cancers of the throat, mouth, lungs, bladder and esophagus and also heart attack. Research has shown that smoking increases the risk of lung, throat and mouth cancers by 14 times, cancer of the esophagus by 4 times, chances of death through heart attack by two times and chances of bladder cancer by 2 times (Bernstein, 2006). Other health-related problems occurring due to cigarette smoking are emphysema, chronic bronchitis, peptic ulcer disease, pneumonia, cancer of the lip, cancers of the larynx and pharynx, malignancies of the abdomino-pelvic organs like pancreas, bladder and kidneys and also cancer of the cervix. Cigarette smoking can also increase the risk of burns (Bernstein, 2006). Esophageal cancer Burt is diagnosed to have non-metastatic esophageal cancer. Carcinoma that arises from the mucosa of the esophagus is known as esophageal carcinoma. Most of the times, the cancer is squamous-cell carcinoma. It has a tendency to invade the submucosa and metastatise. Some of the commonly known etiological factors are smoking and alcohol. The cancer mainly occurs after the 6th decade of life. The most common presenting symptoms is dysphagia. Other symptoms include weight loss, pain on swallowing, hoarseness of voice and aspiration of food (Fisichella and Patti, 2009). Malnutrition While the development of dysphagia in esophageal cancer leads to malnutrition, nutritional and vitamin deficiencies also lead to esophageal cancer. The extent of malnutrition depends on the age, sex, stage of cancer and the degree of dysphagia (Saito et al, 1991). Infection Infectious outbreaks are common in oldage hostels. The outbreaks can occur through kitchen workers, contaminated water or drink and poor handling of food. In case of viral diseases like human calcivirus, the spread occurs through feco-oral route and airborne route and is often difficult to control (Milazzo et al, 2002). These viruses are hard and can survive on contaminated clothes and beddings and can even re-aerosolise. In a study by Mylotte et al (2002) in which the evaluated the epidemiology of infections in a nursing home, it was found that the most commonly isolated blood stream infection was E.Coli (in 27 percent cases) followed by staphylococcus aureus and proteus mirabilis. In the study is was found that the most common source of infection was urinary tract, followed by lungs. B. Explore the goal and rationale for the choice of treatment prescribed for your chosen case study. The aim of any antineoplastic therapy, either surgical, radiotherapeutic or pharmacological is complete elimination of all neoplastic cells, and, if this is not possible, atleast to reduce the number of neoplastic cells so that there is improvement in the symptoms, thus prolonging survival and maintaining an adequate quality of life. Surgical resection is the best treatment for carcinoma of the esophagus. However, since Burt is an elderly person with many associated problems like residing in hostel, history of alcohol and smoking, malnutrition, increased risk of infection and increased risk of poor care, non-surgical therapy is suitable for him. Non-surgical therapy involves two aspects, chemotherapy and radiation therapy. Both must be in combination to be effective in esophageal cancer. Research has shown that radiation therapy relieves dysphagia in 50 percent of the patients (Fisichella and Patti, 2009). The chemotherapy combination which works for esophageal cancer is cisplatin or its analogue carboplatin and 5-Fuorouracil. The chemotherapy should be given twice during the treatment and the doses will be based on weight, height and lab values. Thus in case of Burt, a combination of radiotherapy and chemotherapy was provided and for this a central catheter was inserted peripherally (PICC). Chemotherapy is associated with certain side effects like vomiting, nausea, diarrhoea, decreased electrolytes, decreased cell count and hiccups. 5-Fluorouracil causes soreness of mouth and hearing deficits (Fisichella and Patti, 2009). Carboplatin is considered as one of the well-tolerated cytotoxic agents available currently. It is frequently used both as initial therapy and also second line therapy (Markman, Kennedy & Webster et al, 1999). Carboplatin by itself has low tendency to develop nephrotoxicity and neurotoxicity (Markman, Kennedy & Webster et al, 1999). Hypersensititivity reaction to carboplatin is rare. Carboplatin is an excellent drug for out patient management. Aggressive rehydration is not necessary with this drug. Since the major route of clearance is renal, it is possible to predict drug exposure based on glomerular filtration rate (Bookman, McGuire, Kilpatrick, et al, 1996). C. In planning the management for your chosen case study, identify one important nursing consideration throughout or after the active treatment phase. Justify the selection of this nursing consideration. Detection of oral mucositis Butt is on a combination of chemotherapy and radiation therapy. Once of the common complications of such a cancer therapy is mucositis. Mucositis occurs because of the damage to mucosa that occurs as a result of interference of normal epithelial cell turn over subsequent to cancer therapy. 5-Fluorouracil, which affects the synthesis of DNA in S-phase is known to cause this adverse effect commonly. The incidence and severity of mucositis varies from patient to patient and treatment to treatment. The incidence of mucositis is high and can occur upto 40 percent in those on standard chemotherapy. In those with high doses of chemotherapy or combination of radiotherapy and chemotherapy, the chances of procuring mucositis is as high as 76 percent (Naidu et al, 2004). Though mucositis is not a life threatening condition, it is a distressing condition and increases the number of treatment cycles. Certain factors like advanced age, malnutrition, malignancy of head and neck, depression and poor oral care increase the risk of malignancy (Naidu et al, 2004). With reference to the case under study, Butt, the risk of developing mucositis is high because of advanced age, malnutrition, esophageal cancer, combined chemotherapy and radiation therapy including fluorouracil and increased risk of poor oral care because of residence in hostel. Thus nurses have a major role to play to prevent mucositis and detect mucositis in early stages (Eilers and million, 2007) so that appropriate interventions to prevent the progression of the disease can be instituted. There are several interventions to prevent and detect mucositis in early stages. There are several grading systems for mucositis, of which, the WHO grading is the most widely used (Naidu et al, 2004). According to the World Health Organization, mucositis is graded from 0-4. "If the patient has no signs and symptoms, it is graded as 0. If the patient has painless ulcers, edema, or mild soreness, it is graded as 1. If there is painful erythema, edema, or ulcers but able to eat, it is graded as 2. If there is painful erythema, edema, or ulcers but unable eat, it is graded as 3. If there a requirement for parenteral or enteral support, it is graded as 4" (Wilkes, 1998). One of the major impediment in the management of mucositis is the lack of development of a validated scoring system. In a study by Sonis et al (1999), the researchers conducted a multicentre clinical trial to develop a scale to measure indicators of mucositis. The study was conducted in nine centers included 108 chemotherapy patients and 56 radiation therapy patients. The study was conducted to to test the validity and reprocibility of a simple, objective assessment tool. In each center paired investigators evaluated patients receiving chemotherapy and radiotherapy. The patients chosen for study were those with head and neck cancer and receiving chemotherapy and radiation therapy. The objective measures that were included were pseudomembrane formation, ulceration and erythema. The subjective measures were function, ability to swallow and mouth pain. From the results of the study, it was found that this tool had high interobserver reproducibility, measured elements associated with mucositis and was responsive over time. In another study by Etiz et al (2002), the researchers conducted a study on 43 patients with head and neck malignancies on irradiation therapy to evaluate and validate the most useful scoring system among "Five different mucositis scoring systems (World Health Organization, Radiation Therapy Oncology Group, "Hickey", "Van der Schueren" and "Makkonen")" (Etiz et al, 2002). These 5 scoring systems were compared with each other From the results it was evident that daily mucositis scores and objective mucositis had high correlation between the five scoring systems and thus all the five scoring systems are equally valid. Thus in case of Butt, nurses may use the simple WHO scoring system to detect mucositis in early stages. According to Eiler (2004), "Ongoing assessment and monitoring are critical to the effective management of oral mucositis." Thus oral care protocols are very essential for management of oral mucositis. Palliative care The care which Burt needs is palliative care. Palliative care aims to enhance the quality of life and influences the course of the illness in the most positive sense. The care can be initiated in early stages of illness in conjunction with other medical, chemotherapeutic and surgical interventions which aim to prolong life. This form of care adapts the interdisciplinary practice and the philosophy of hospice care and applies it to the severely sick patients irrespective of their prognosis. According to WHO (2009), “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." The aim of palliative care must be to relieve the patient of suffering, promote function of the patient, deliver help to meet the daily living needs of the patient, provide psychosocial support to the patient and also the family of the patient and clarify goals of care and associated treatments. Role of nurses in the care of patient Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. As far as taking care of an elderly person is concerned, the role of nurses is further emphasized. Though, traditionally the care of the elderly has been the responsibility of family members; in the present society, care of the senior citizens is provided by the state or charitable institutions and nurses have a major role to play in these situations. The role of nursing is authenticated in helping people move towards independence in all activities of daily living. They take up the role of a family member. Their actions have an impact on the individual and affect their levels of dependence/independence and these include biological, psychological, socio-cultural, environmental and politico-economic variables (Roper et al, 2002). In case of Burt, nurses play a major role in educating the patient about maintaining hygiene in view of his PICC and hostel accommodation. Pain management The corner stone of palliative care in Burt would be pain relief. The pain management in her must be guided by the cancer pain management protocols. The analgesic ladder approach of pain management by the World Health Organization is an useful guide to management pain in Burt. According to this approach pain in Burt must be first tried to be controlled with paracetamol or non-steroidal anti-inflammatory drugs like ibuprofen. These drugs must be given round the clock, every 8 hours. A combination of paracetamol and ibuprofen also can be used. When these drugs cease to be effective, the analgesics of the next step on the ladder must be chosen. These analgesics are mild opioids like codeine. The most powerful analgesic in the third and last step of the analgesic ladder of WHO is the high opioid analgesics like hydromorphone, morphine and fentanyl (World Health Organization, 2009). Pain management in Burt must be guided by pain assessment tools. There are many pain assessment tools available. Since Burt is an elderly person, PACSLAC or Pain Assessment Checklist for Seniors with Limited Ability to Communicate is an useful tool for pain evaluation (Scottish Intercollegiate Guidelines Network, 2008). Other care Other than medical management, nursing care, personal care bathing, dressing and taking to toilet, diet also must be planned and delivered. The plan must also include appropriate fluid intake, diet intake and dietary fibre intake. Burt must be given the type of food he relishes. In case he is not able to eat on her own, she must be fed. In advanced stages when he cannot swallow, he must be fed through nasogastric tube . Other aspects which need to addressed in nursing palliative care plan are oral hygiene like brushing, care of dentures, mouth wash, prevention of oral thrush and preventive dryness and maintaining skin care like bathing, hair care, nail care, pressure sores care, etc (National Cancer Control Programme, 2005). Palliative care team The main caregiver for Burt is the nursing staff because he is in a residential facility. The activities of the team should coordinated by the primary care physician. Other team members include hospice physician, nurses, home health aides, social workers, clergy, trained volunteers, and other therapists like speech, physical and occupational therapists. The ultimate aim of the team is high-quality comfort care (NHPCO, 2008). Hospice staff also provides bereavement care for surviving family members. This care is provided by trained volunteers, clergy members or professional counselors (American Cancer Society, 2008). Nursing plan The nursing plan is mainly based on the physical and mental needs of the patient and this will be developed after discussion with various members of the team, with the main coordinator being physician. The family members also need to be involved in drawing up the nursing care plan. Nurses play an important role in palliative care of Burt. Since they closely work with him, they are in a position to provide constant personal, emotional and spiritual support. They also have an important role in the assessment and monitoring of management of Burts pain and other symptoms. Nurses can be the first persons to evaluate pain and then can advise the treating physician whether the pain remedy advocated was appropriate. Nurses can also evaluate the effects of the medications prescribed after Burt uses the medicines. Nurses must be aware of the WHO ladder for chronic pain management. They must also be aware of drug-drug interactions, drug side effects and drug-diet interactions (Shaw, 2006). When Burt reports side effects, the nurse must record, manage and monitor the symptoms, guide physician about the condition of the patient and can suggest when to change the step in the analgesic ladder. Nurses have an important role in acting as coordinators of different specialities by educating Burt about the dosage of the drugs and the need for good pain control (Delphi Study, 2007). Spiritual care Addressing spirituality is an essential part of treatment of cancer patients (Taylor, 2006). This is because, spirituality is the basic needed of each and every individual through whom the individual looks for meaning of his life. Pain in cancer affects the spiritual aspect of the individual and increases fear of death, loneliness and discomfort. The religious aspect of the patient may be taken care of by taking him to church as much as possible or by asking someone to read bible for him or by asking a priest to meet him. Spiritual care is possible by gauging the depth of despair, distress and anger, supporting all her decisions, offering him to discuss him problems without inhibitions and by showing concern to all him interests like ceremony after death and preparing wills (National Cancer Control Programme, 2005). Good quality of life can be maintained by allowing Burt to lead as much normal life as possible, by facilitating him to indulge in enjoyable activities, by making him feel that he is still wanted and by providing him opportunity, space and time to spend time with his dear ones. References American Cancer Society. (2008). What is Hospice Care? Retrieved on 12th Apri 2010 from http://www.cancer.org/docroot/ETO/content/Eto_2_5x_What_Is_Hospice_Care.asp Alliance for Aging Research or AAR. (2003). Ageism: How Healthcare Fails the Elderly. Retrieved on 12th April, 2010 from http://www.agingresearch.org/content/article/detail/694/ Anderson, P., & Baumberg, B., 2006 Alcohol in Europe: A Report for the European Commission. Retrieved on 12th April, 2010 from http://dse.univr.it/addiction/documents/External/alcoholineu.pdf Drug and Alcohol Services of South Australia (DASSA), 2008. Alcohol and its Effects. Retrieved on 12th April, 2010 from http://www.dassa.sa.gov.au/site/page.cfm?u=122 Delphi Study. (2007). WHO Normative Guidelines on Pain Management. Retrieved on 12th April, 2010 from http://72.14.235.132/search?q=cache:XaoHa1yWUgkJ:www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf+Delphi+Study.+(2007).+WHO+Normative+Guidelines+on+Pain+Management&cd=1&hl=en&ct=clnk&gl=in Eilers, J. (2004). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncol Nurs Forum, 31(4 Suppl), 13-23. Eilers, J., and Million, R. (2007). Prevention and management of oral mucositis in patients with cancer. Semin Oncol Nurs., (3), 201-12. Etiz D, Orhan B, Demirüstü C, Ozdamar K, Cakmak A. (2002). Comparison of radiation-induced oral mucositis scoring systems. Tumori., 88(5), 379-84 Lord, S.R., Corcoran, J., Dayhew, J., et al. (2003). The effect of group exercise on physical functioning and falls in frail older people living in retirement viallages: a randomised controlled trial. JAGS, 51, 1685- 1692. Milazzo, A., Tribe, I.G., Ratcliff, R. et al. (2002). A large, prolonged outbreak of human calicivirus infection linked to an aged–care facility. CDI, 26(2), 261- 264. Mylotte JM, Tayara A, Goodnough S. (2002). Epidemiology of bloodstream infection in nursing home residents: evaluation in a large cohort from multiple homes. Clin Infect Dis. 2002 Dec 15;35(12):1484-90 Naidu, M.U.R., Ramana, G.V., Rani, P.U., et al. (2004). Chemotherapy-Induced and/or Radiation Therapy-Induced Oral Mucositis—Complicating the Treatment of Cancer. Neoplasia, 6(5), 423- 431. IQNursing homes.com. (2008). Nursing home abuse. Retrieved on 12th April, 2010 from http://www.iqnursinghomes.com/signs-of-abuse.cfm Ismail, M.K., 2006. Alcoholic Fatty Liver. Emedicine from web MD. Retrieved on 12th April, 2010 from http://www.emedicine.com/med/topic99.htm National Hospice and Palliative Care Organisation (NHPCO). (2008). Caring Connections. Retrieved on 12th April, 2010 from http://www.caringinfo.org. National Cancer Control Programme. (2005). Manual for Palliative Care. Retrieved on 12th April, 2010 from http://www.whoindia.org/LinkFiles/Cancer_resource_Manual_5_Palliative_Care.pdf Nettina, S.M. (2006). Manual of Nursing Practice. (8th ed.). New York: Lippincott Williams & Wilkins. Polypharmacy and the elderly. (2006). Retrieved on 12th April, 2010 from http://www.neurosy.org/medicine/interactions/polypharmacy.shtml. Roper, N., Logan, W. & Tierney, A. (1996). The Elements of Nursing Model for nursing based on a Model for Living. (4th ed.). Edinburgh: Churchill Livingstone. Roberts, M. (2004). Nursing Home Abuse prevention. Retrieved on 12th April, 2010 from http://www.ehow.com/about_5084343_nursing-home-abuse-prevention.html Scottish Intercollegiate Guidelines network (SIGN). (2008). Control of pain in adults with cancer. Retrieved on 12th April, 2010 from http://www.sign.ac.uk/pdf/SIGN106.pdf Shaw, S.M., (2006). Nursing & Supporting patients with chronic pain. Nursing Standard, 20(19), 60-65. Serota, A.C. and Lane, J.M. (2006). Osteoporosis (Secondary). Emedicine from WebMD. Retrieved on 12th April, 2010 from http://emedicine.medscape.com/article/311449-overview Targownik, L.E., Lix, L.M., Metge, C.J. (2008). Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ, 179(4), 319-326. Tregaskis, B.F., and Stevenson, I.H. (1990). Pharmacokinetics in old age. British Medical Bulletin, 46, 9-21. Greenebaum Cancer Center. Esophageal Cancer. Retrieved on 12th April, 2010 from http://www.umgcc.org/thoracic_program/esoph_therapy.htm WHO. (2009). WHOs pain ladder. Retrieved on 12th April, 2010 from http://www.who.int/cancer/palliative/painladder/en/print.html Wilkes, J.D. (1998). Prevention and treatment of oral mucositis following cancer chemotherapy. Semin Oncol., 25(5), 538-51. Read More