Therapeutic Nurse-Client Relationship in Nursing - Assignment Example

Running Head: CLINICAL CASE SCENARIO Clinical Case Scenario Name Institution Clinical Case Scenario Question 1 The spread of lung cancer (metastasis) depends, to some extent, on the form of lung cancer that is present in an individual. According to Stewart & Kleihues (2003), one can either have small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC), with NSCLC being the most common, as approximately 80 percent of all lung cancer cases are NSCLC. SCLC occurs when small cells with the lung become cancerous (have excessive, abnormal growth) before some cancerous cells break off and metastasize, most commonly through the bloodstream. On the other hand, NSCLC takes place when cancerous cells begin growing in the lung and form a tumour which progressively grows larger within the lung, but metastasizes at a later stage than SCLC. According to Boyle and Ferlay (2005), SCLC responds better to chemotherapy than NSCLC, which is why NSCLC is usually treated by surgery, while SCLC is usually treated by chemotherapy. Radiotherapy is used in conjunction with the other two treatments as necessary. The primary method of the spread of NSCLC is angiogenesis, which refers to the growth of blood vessels inside and surrounding a tumour, which enhances blood supply to the tumour, thus contributing oxygen and nutrients which contribute to the continued development of the tumour. The spread of SCLC is primarily through metastasis. As mentioned above, this happens when cancerous cells from the original tumour detach themselves from the parent tumour and are transported to other locations, primarily through blood circulation and the lymphatic system. The cancer cells then begin to grow and multiply in their new sites. Although lung cancer can metastasize to any part of the body, there are certain sites where metastasis is more common. For example, when lung cancer metastasizes to bone, cancerous cells most often affect bones with the greatest blood supply, such as the ends of the arms and legs nearest the torso (the shoulders and hips), the pelvis, the ribs, and the spine. Apart from bone, other sites to which lung cancer may metastasize include the brain, the liver, the adrenal glands, and the skin (British Thoracic Society, 2001). A NSCLC tumour may grow out of the lungs and invade the pleural membranes, causing pain. As these membranes are closely connected to lymph nodes, lung cancer may also spread to the rest of the body through the lymphatic system. However, bone metastasis is the most rapid method by which lung cancer cells spread. Once the cells have broken off their parent tumour and have become established in a bone, they trigger certain processes that hasten their development. The cancer cells secrete parathyroid hormone-related protein (PTHrP) a hormone that increases the number and activity of osteoclasts (cells which break down bone tissue). In turn, this process releases growth factors which accelerate the growth of cancer cells, creating a vicious cycle of tumour growth and bone destruction (British Thoracic Society, 2001). Furthermore, the growth factors support angiogenesis (growth of blood vessels inside and outside a tumour). The main one of these symptoms is severe pain. Question 2 According to Wood and Haber (2006), nursing decisions should not be one sided and only relying on the knowledge of the nurses. It should go to the extent of looking at the nurses’ experience, the patient preferences along with evidence from conducted researches. Therefore nurses should not just be functionaries who take orders from doctors, but they should apply their own professional knowledge and experience towards caring for patients. Although Mrs. Parker is exhibiting a wide spectrum of signs/symptoms, three of the most significant are pain, depression, and constipation. Pain caused by cancer is usually acute and persistent. However, there are a number of evidence-based strategies that nurses can use to manage it. According to the American Geriatrics Society (2002), the patient’s own report is the best way of assessing pain. Nevertheless, nurses should know the patient’s medical background to understand the causes of pain. Nurses should also know which pain relief methods are effective for the patient. The American Geriatrics Society (2002) also recommends that nurses should assess pain at least once every four hours, and should monitor pain intensity after administering drugs to test their effectiveness. This can be done by observing nonverbal signs of pain, such as grimacing, rubbing, limping, shifting of position, agitation, crying, and changes in behaviour. Evidence-based nursing management of depression requires psychosocial as well as pharmacological responses to patients. Alexopoulos, Schultz, and Lebowitz (2005) state that preferred psychotherapies for geriatric patients include cognitive-behavioral therapy, problem-solving therapy, and interpersonal therapy. Nurses can help in administering such therapy, under the direction of psychiatrists, in addition to administering drugs. The authors also mention cancer as a specific comorbid condition that accompanies depression. Nurses can help diagnose depression by looking out for characteristics such as an irritable mood, frequent crying, weight loss or gain (especially loss), sleep disturbance, fatigue, diminished concentration, feelings of worthlessness, suicidal thoughts or attempts, recent losses or crises (examples being death of spouse, friend, pet; retirement; move to another residence, nursing home); and changes in physical health status. Nurses can manage such patients by enhancing physical function; developing a daily activity schedule, enhancing social support (i.e., through confidants, friends, hospital resources, support groups); and contacting appropriate clergy. Nurses can also include patients in making daily schedules and setting short-term goals as well as encouraging daily participation in pleasant activities and relaxation therapy. They should provide emotional support by empathic, supportive listening and encourage pleasant reminiscences. Another symptom experienced by Mrs. Parker is constipation. In cancer patients, constipation may be caused by hypercalcaemia (excessive blood calcium levels) caused by the breakdown of bone (British Thoracic Society, 2001). The definition of constipation is still the subject of debate. Some authors define it as obstruction to the passing of stools, and irregular bowel movements during a long period of time (Ramkumar and Rao, 2005). On the other hand, Kalish and Loven (2007) define constipation as a frequency of less than 3 instances of defecation over a period of seven days. Regardless of the definition, evidence-based nursing management of constipation can be achieved by increasing fluid intake to between 1500-2000 ml per day, while minimizing caffeinated and alcoholic beverages, due to their diuretic properties, as recommended by the Registered Nurses’ Association of Ontario (2005). In addition, nurses should ensure that daily dietary fibre intake is between 25 to 30 grams. Initially, nurses should aim for the patient to maintain a fluid intake of at least 1.5 litres in every 24 hours. Once this has been attained, the patient should increase his/her consumption of fibre in slow, measured stages. Constipated patients with limited mobility should undergo the foregoing programme in addition to exercises such as pelvic tilt, low trunk rotation and single leg lifts, which will improve their bowel function (Registered Nurses’ Association of Ontario, 2005). Once the physical discomfort of pain and constipation is dealt with, the nurses will be able to begin addressing the patient’s psychological wellbeing. Question 3 According to the Registered Nurses’ Association of Ontario (2006), a therapeutic relationship between a nurse and a patient is a professional relationship that involves predetermined interventions in terms of drug therapy, psychological therapy, and interpersonal engagement with the intention of positively influencing the patient’s behaviour and emotions. It includes the components of trust, respect, professional intimacy, empathy and power (College of Nurses of Ontario, 2009). For the purpose of establishing a therapeutic association with the specific patient, the nurse should initially earn the trust of the patient, Mrs. Parker. This can be done by responding promptly to the patients’ calls, answering the patient’s questions frankly and honestly, and remaining cheerful even in the face of incessant complaints. Because trust in any relationship is fragile, it is especially important that the nurse should keep promises made to Mrs. Parker. A therapeutic relationship cannot be maintained in the absence of trust. Once trust has been established between the nurse and Mrs. Parker, it will be possible for the therapeutic relationship to move on to the component of respect, which is the recognition of the inherent dignity, worth and uniqueness of every individual. Once Mrs. Parker realizes that the nurse respects her, then she is likely to reciprocate, as respect is mutual. This will facilitate the nurse’s fulfillment of Mrs. Parker’s medical needs. The first two components of the therapeutic relationship lay the foundation for the implementation of the third component, which is professional intimacy. Professional intimacy will be developed through the type of care and services that the nurse will provide to Mrs. Parker in terms of the physical activities that the nurse will perform for and with her. This will create closeness. Professional intimacy also involves psychological, spiritual and social elements. After professional intimacy has been developed between the nurse and the patient, the nurse and Mrs. Parker will be able to develop the fourth component of a therapeutic relationship, which is empathy. Empathy includes understanding, validating and resonating with the significance of the health care experience to the client. The meaning of empathy in nursing differs from the everyday understanding. In the nursing profession, empathy also requires the nurse to keep an emotional distance from the patient in order to maintain professional service to the patient (Registered Nurses’ Association of Ontario, 2006). Thus the nurse must avoid involving herself too deeply in Mrs. Parker’s personal affairs. A patient should never feel under pressure to confide in a nurse, or to disclose personal information. Nevertheless, the nurse should provide the patient with every opportunity to discuss how she feels, and the nurse should be a willing listener, as this will contribute towards managing the patient’s depression, as well as further cementing the therapeutic relationship. The final component of a therapeutic relationship is that of power. In this particular case, the management of power lies with the nurse. The nurse has more knowledge and experience in the healthcare system than the patient, and s/he can use this power to promote the welfare of the patient. Since the nurse has more power than Mrs. Parker, she should use it to help her, because the appropriate use of power, in a caring manner, will enable the nurse to partner with Mrs. Parker to meet the patient’s needs. Abuse occurs when the nurse oversteps the boundaries of the therapeutic relationship. The obvious issues faced by Mrs. Parker are her disease and her recent bereavements. Since her disease is terminal, the nurse should concentrate on alleviating her pain and easing her psychological trauma. The nurse can achieve this by giving Mrs. Parker time, opportunity and ability to explain herself, and listening to her with the intent of understanding her, and without diminishing the client’s feelings or immediately giving advice, as this may make her feel that her concerns are not being taken seriously. The nurse should also listen to, understand and respect Mrs. Parker’s values, opinions, needs and beliefs and should integrate these elements into her care plan. The nurse should recognize that all behaviour has meaning and should seek to understand the cause of Mrs. Parker’s comments, attitude or behaviour. Mrs. Parker’s nurse can help her psychologically by taking into consideration and discussing her feelings and her life experiences. In addition, the nurse should do whatever possible to reduce any stress experienced by the patient. Thus Mrs. Parker’s symptoms can be managed by proper medication and medical care. The British Thoracic Society (2001) recommends the administration of oral morphine to reduce cancer pain. This is a continuation of the treatment she was receiving before her hospitalization. Oral morphine is also useful in managing breathlessness, together with practical measures such as sitting upright, opening windows, and using fans. In addition, Mrs. Parker may benefit from oxygen supplementation, whenever necessary. Mrs. Parker’s less obvious issues include the fact that she is lonely. The sequence of traumatic events in her life, beginning with the death of her husband, followed by her cancer diagnosis six months later, and then her son’s suicide and her transfer to hospital, mean that Mrs. Parker has not had adequate time to cope with her loss. Her anger is a manifestation of bitterness about her life. It is better that she express her feelings. In the absence of anyone to confide in, this is done by complaining to the nurses and refusing to cooperate. The best way a nurse can deal with this underlying issue is to offer Mrs. Parker an alternative, positive outlet for her feelings. By offering her a shoulder to lean on and someone to talk to (even in the face of her anger and complaints) the nurses will give Mrs. Parker a chance to come to terms with what has happened and to make peace with herself and the nurses around her. This will make their jobs easier and will enable them to implement her care plan. Question 4 Telling your friends directly that you want to talk about your Mum is likely to make them even more reluctant to talk. The best way to go about it would be to make it clear, by non-verbal cues, that you are no longer grieving and that your Mum is not a taboo subject. For instance, instead of offering verbal hints (such as the scones) you could tell a funny story about something that your Mum did or said, which will encourage questions from the friend you are talking to. In this way, your friends will feel more comfortable talking about your Mum, and may even bring up the subject without you prompting them to. Another thing you can do is to confide in very close friends, who have known you for a long time, and who knew your Mum as well. A friend who had never met your Mum is less likely to feel comfortable about discussing your Mum with you. It is also possible that people who have no experience of a similar bereavement in their own families simply do not know what to do or say when you bring up the subject of your Mum, and so they focus in consoling you, not knowing that your intention is not to mourn, but to honour the memory of your mother. Therefore, you should confide in someone who can empathize with what you are feeling. Overall, you should remember that emotional intelligence varies between individuals, and so not everyone will understand why you want to talk about your Mum. However, the Facebook blog is a good idea, as it gives your friends an idea of what your emotional needs are. References Alexopoulos G.S., Schultz S.K., & Lebowitz, B.D. (2005). Late-life depression: a model for medical classification. Biological Psychiatry 58 (4), 283-289. American Geriatrics Society (AGS) (2002). The management of chronic pain in older persons. American Journal of the Geriatrics Society, 46, 635-651. Boyle, P. & Ferlay, J. (2005). Cancer incidence and mortality in Europe, 2004. Annual Oncology 16, 481-488. British Thoracic Society. (2001). BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax, 56, 89–108. College of Nurses of Ontario. (2009).Therapeutic Nurse-Client Relationship, Revised 2006. Toronto: CNO. Wood, L. B. & Haber, J. (2006). Nursing Research, Methods and critical appraisal of Evidence-based Practice (sixth edition). St. Louis: Mosby Inc Publishers. Kalish, V.B., & Loven, B. (2007). What is the best treatment for chronic constipation in the elderly? The Journal of Family Practice, 56 (12), 1050-1052. Ramkumar, D., & Rao S.S.C.R. (2005). Efficacy and safety of traditional medical therapies for chronic constipation: Systematic review. American Journal of Gastroenterology, 100 (4), 936-971. Registered Nurses’ Association of Ontario (RNAO). (2006). Establishing therapeutic relationships. Toronto: Registered Nurses’ Association of Ontario. Registered Nurses’ Association of Ontario (RNAO). (2005). Constipation prevention in older adults . Toronto: Registered Nurses’ Association of Ontario. Stewart, B.W., & Kleihues, P. (2003). World cancer report. Lyon: IARC Press. Read More