The Role-Played of Nursing in Caring for the Patient - Case Study Example

COMPLETE Transition to Practice Introduction While nursing is recognized as a unique discipline, nurses play a very important role in care giving and improving the patient’s condition (Bastable, 2008, p.5). Aside from knowledge of the nursing process, nurses understand the health problems faced by their patients and become positive role models that sacrifice their own health practices because of so much demand from families, patients, and work (Rankin et al, 2004, p.21). New nurses are not volunteers but health care professionals seeking a real-world learning experience in providing care to those who need it (Schwab & Gelfman, 2005, p.156). Most nurses find their clinical experiences challenging that provides opportunity for personal and professional growth (Shives, 2007 p.2). This essay discusses my recent experiences while caring and managing a patient with acute leukaemia and reflection of the role-played while caring for the patient. In order, the following contains a summary of the patient’s health condition, a presenting situation, and brief outline of the aetiology of the disorder. A discussion about the ongoing management and latest treatment modalities will be presented including relevant nursing assessments and care for this condition. Finally, this essay will reflect the role-played in caring for the patient mentioned earlier such as the level of performance while providing care compared to ANMC Competency Standards for Registered Nurses and recommendations for future practice. My first placement in a public hospital near _______________put me in a very challenging situation doing supportive therapy in a medical day unit along with IV therapy delivery team trained in venepuncture and cannulation skills. On the second week of my placement, I was assigned to Mr. Willy, a 62 years old male suffering from acute leukaemia. The haematologist recommended chemotherapy and supportive therapy using different methods to keep Mr. Willy’s body and mind healthy during the treatment. The goal of treatment is remission of signs of cancer in the blood or bone marrow and brings blood cell counts to normal. The nursing care requirements of Mr. Willy or other patients in this oncology unit are greater compared to medical-surgical units. Nursing care hours may take up to 6.16 for oncology patients while only 4.88 hours for medical-surgical unites. Overview of Patient Condition Mr. Willy’s condition is a disorder caused by the malignant transformation of a bone marrow hematopietic stem cell or Acute Myelogenous Leukemia (AML). It is an aggressive and fatal hematologic malignancy (Fathi & Chen, 2011, p.176) but no genetic abnormalities like APL (Hassan et al, 2005, p.71). The stem cell in AML has an increased rate of self-renewal and is inevitably associated with aberrant or absent differentiation leading to an accumulation of cells in the marrow. The usurpation of normal bone marrow by leukemic cells suppresses normal haematopoiesis and produces clinical signs and symptoms of bone marrow failure (Handin et al, 2006, p.483). Mr. Willy was showing the clinical symptoms of people with AML such as swelling of the lymph nodes, hepatomegaly, and splenomegaly (Siegenthaler, 2007, p. 242). These include physical signs of leukaemia such as paleness, fatigue, shortness of breath, weight loss, repeated infections, excessive sweating, fever, easy bruising, slow-healing cuts, bone and joint pain, nosebleeds, swollen lymph nodes, and enlarge liver (Balch, 2006, p.288). Mr. Willy has vague history of chronic progressive lethargy and acutely ill because of significant infection. For this reason, Mr. Willy’s diagnosis shows presence of Granulocytopenia, universal in patients with AML with serious risk of infection. His platelet counts are also less than 20,000 cells/ while 75% of the marrow-nucleated elements are leukaemia cells which is common to patients with AML (Humes 2011, p.416). Older patients with AML tend to have lower or poor performance status or PS and unfavourable response to therapy. In the study of five oncology trials, result shows that a patient as Mr. Willy has the worse PS thus selecting the best treatment was often difficult. However, therapeutic options for elderly AML patients have been developed recently that include palliative treatment, attenuated chemotherapy, and standard intensive chemotherapy. The therapeutic choice of certain patient however must be based on objective criteria rather than chronological age and physician’s attitude. This is because patients with AML generally prefer induction therapy so they can retain their quality of life and functionality with both intensive and non-intensive therapy (Hurria et al, 2010, p.249). Care and Management of Patient Since Mr. Willy deserves palliative therapy and the best supportive care, he was receiving one or two courses of daunorubicin, vincristince, and cytarabine for remission reduction. He was also receiving additional cycle for consolidation and supportive care including mild cytoreductive chemotherapy to relieve his progressive AML-related symptoms (ibid, 250). As mentioned earlier, Mr. Willy will receive curative or palliative treatment as most elderly patient wants to retain quality of life. For this reason, treatment was divided into two phases- induction and consolidation. The object of curative treatment is rapid elimination of cancer cells with induction chemotherapy or remission. However, since Mr. Willy is already 62 years old, the duration of remission may be shorter because it is related to several factors such as the ability to tolerate intensive treatment and age (Schwab, 2008 p.31). Complications observed during the treatment include several infections and bleeding and during this time, supportive care provided includes isolation to prevent infection, antibiotics to treat infections, and transfusion of blood products. After achieving remission, consolidation was conducted to achieve a permanent cure (ibid, 32). In the case of Mr. Willy, these include bone marrow or stem cell transplantation rather than further chemotherapy. Some of the new treatment available for those patients unable to tolerate intensive chemotherapy includes monoclonal antibodies, demethylating agents, and experimental drugs. However, decisions to treat patients with these new approaches must be based on the sum of patient factors such as age, previous history of MDS, comorbidity, frailty, and patient’s preferences (ibid 33). A monoclonal antibody is a specialized form of antibody that binds to a particular molecule on the surface of a certain type of leukaemia or other cancer (Ball & Kagan 2012, p.40). Histone deacetylase inhibitors or HDI improve different anticancer mechanisms thus can be antileukemia agents. The use of HDI in combination with DNA demethylating agents has been found to be a promising alternative treatment for leukaemia (Acton, 2011, p.6). ABT-737 is one example of experimental drug that has the potential to AML blast, progenitor, and stem cells. According to Doherty (2005), ABT-737 potentiates the effects of chemotherapy and radiation in tumour cells lines in vitro and significantly improve survival in a murine tumour model of disseminated disease using DoHH-2 lymphoma cell line and induced regression of established tumours in xenograft models of SCLAC (p.255). There was also an observation that Vitamin D can induce AML blast cells in vitro but it needs more clinical test (Harrison & Bershadskiy, 2012, Abstract). Specific to older patients, new treatments options are also available such as farnesyl transferase inhibitor of FTI that can induce a response with minimal myelotoxicity, mylotarg for remission reduction, and cyclosporine, a drug that has the potential to reverse the resistance to chemotherapy (Pathy et al, 2006, p.467). Nursing Assessment and Nursing Care for AML One of the most critical parts of nursing is health assessment. Nursing observation and reporting, and technical data collect skills is essential to treatment health outcomes. According to McSherry (2010), there has been a general agreement that nursing assessment involves systematic collection and analysis of data in order to make appropriate judgement about health and life processes of patients, their families, and the community (p.140). This systematic collection often involves validation and documentation to confirm and verify the subjective and objective data’s reliability and accuracy. This may include deciding which data require validation, determining ways to validate the data, and identification of missing data (Weber & Kelley, 2009, p.206). Nursing assessment for AML patient include exploring the health history for common signs and symptoms such as recurrent infections, fever, or fatigue. Examination of medical history for risk factors such as race, previous chemotherapy, and genetic abnormalities. Physical examination including observation of skin palor and salmon-colored or blue-gray popular lesions. Record occurrence of headache, visual disturbances, and signs of intracranial pressure such a vomiting (Ricci & Kyle p.1649). These may include bleeding precautions by examining several symptoms such a malignant invasion in bone marrow, suppression of the bone marrow caused by chemotherapy, hypersplenism, disseminated intravascular coagulation, and altered coagulation. For this reason, the patient may be assess for onset of petechiae in trunk or legs, hypotension, tachycardia, dizziness, epistaxis, respiratory distress, abdominal distention, rectal and urethral bleeding, and mental status changes. In order to very these suspected onset, a laboratory test may be needed. For instance, it is necessary to monitor complete blood count and platelets on a daily basis and notify physician if the count is < 10,000/mm3 or changed significantly from last test. Urine and stool tests are also necessary for presence occult blood (Smetlzer et al, 2009, p.938). More importantly, the patient should be test against other complication such as lung injury following chemotherapy (Christie & Wesselius, 2012, p.88). Supportive care plays an important role in the management of Mr. Willy’s AML particularly when a new bone marrow is regenerating. These include pre-emptive use of broad-spectrum antibiotics and hematopietic growth factors to improve induction outcomes (Carroll & Finlay, 2010, p. 198). Supportive care with oxygen, intravenous fluids, and monitoring of electrobytes and renal function were also conducted. Critical Reflection Reflecting using Gibbs Reflective Cycle, I will start my reflection with a description of the event, followed by exploration of my feelings, evaluation of the event, analysis, conclusion, and my action plan. Description It all happened on my first week on clinical placement when Mr. Willy was asking for somebody he could trust with his supportive care. I was not assigned to him but when I heard that he needs special attention; I volunteered and asked my immediate supervisor to recommend me. I made some inquiry about him and found out that Mr. Willy is suffering from anxiety; a reaction to stress that is common in oncology patients. It is sometimes called an adjustment disorder with anxious mood alone or in combination with depressed mood caused by uncontrolled symptoms, treatment side effects, conflictual relationship with others, phobias activated by some aspect of medical care, panic, and others (KlaStersky & Schimpff, 2009, p.307). Consequently, Mr. Willy is sometimes refusing some medical intervention which I personally witnessed a couple of times, and need to undergo some behavioural intervention to overcome his difficulties. Honestly, I never had a problem convincing Mr. Willy that I am a responsible person worthy of his trust particularly when his physician assured him that we all after his recovery. In fact, he asked me and my fellow nurses that are also assigned to the unit to discuss once in a while how he will going to cope with his illness. An opportunity, I asked him what he thinks of the situation and there I found that he is panicking whenever he is experiencing intense discomfort such as shortness of breath and palpitations. Upon discovering the sources of his anxiety, I remember Hughes et al. (2009) suggestions that supportive care should address behavioural symptoms in the most diplomatic approach (p.192). First, I extended my patience and tried to be consistent and deliver what I believed was an individualized treatment. In return, Mr. Willy seems gradually being trustful of me and becoming more positive about his condition. For instance, he no longer question or refuse the medical intervention, and wanted to participate more actively in decisions about his care which he did not mention earlier. This reaction seems close to published reflection of a patient who underwent a bone marrow transplant in 2010. After ten months of chemotherapy, this patient experienced anxiety because he thinks his physician, friends, and family’s insights of his own therapy are isolating his decision (Rosenbaum & Rosenbaum, 2012, p.78). Mr. Willy therefore additionally wanted to be involved but never given an opportunity before so I decided to talk to the team and relay the information to his family and friends. Feelings At first, I felt confused if I do really like to be assigned to a patient with an already acute myelogenous leukaemia but thinking that proper supportive care can really make a difference in Mr. Willy’s quality of life and chances for recovery, I made up my mind and decided positively. However, a supportive care nurse with insufficient knowledge of Mr. Willy’s condition will not help him recover so I decided to conduct an inquiry about his anxiety and research on the most appropriate approach to this type of patient. At that time, I was thinking that knowing Mr. Willy very well is the key to successful supportive care because understanding the unique attributes of a particular patient enable individualized treatment (Yarbro et al, 2010, p.1396). For instance, if I know the sources of his anxiety then I can eliminate them by developing a new care plan that does not include these sources. In addition, if can make Mr. Willy trust me with all his heart then I will be very easy for me to extract the information I need and use it in developing an individualized care. However, although I believed in the power of individualized care and educated care plan – respecting the patient, keeping the patient safe, encouraging the patient’s health, authentic relation, and interactive teaching (Dossey & Keegan, 2008, p.107) , I cannot avoid having doubts on my capability as a nursing student in clinical placement to make this all possible for Mr. Willy. I was also afraid that management find my approach inappropriate and blame me for Mr. Willy’s future health conditions. More importantly, I find it difficult to suppress my thoughts about the possibility of losing Mr. Willy’s trust if one of us upset him again. Evaluation and Analysis I firmly believed that my performance should be based on competence and reflecting on previous clinical placement experience, my performance appears satisfactory. However, nurse’s competence is not about rating yourself but compliance to standards set for this profession like the ANMC National Competency Standards for the Registered Nurses. In fulfilling duty of care (section 1.2) in the domain of professional practice (ANMC, 2005, p. 2), I did perform in accordance with recognized standards of practice by following the units standard care procedure. I did inquire and clarified my responsibility (as stated in 1.3 of the same domain) to my supervisor and other members of the unit. In fact, they were always with me cooperating, supportive, and providing valuable advice about Mr. Willy’s care. More importantly, I did some research and identified appropriate strategies for Mr. Willy’s intervention and very careful in making any mistakes that can deteriorate Mr. Willy’s recovery. In terms of nursing ethics (as stated in section 2.1 and 2.3), I can openly say that I performed well without any discrimination. I actually volunteered regardless of Mr. Willy’s gender, age, race, and culture. I was also very careful in imposing my views and beliefs and let Mr. Willy, on his own capacity as a person and a patient decide what he wants about his care. It was actually convenient as Mr. Willy gladly share his thoughts with us. Particularly in 4.2 of the Critical Thinking and Analysis domain, the inquiry I made about Mr. Willy’s health and anxiety is an indication that I do seeks additional knowledge when confronted with unfamiliar situations. For instance, I was never aware of anxiety in the oncology setting and the sources of Mr. Willy’s anxiety but learning needs led me to seek information through research that eventually helped me developed an appropriate approach for Mr. Willy (ANMC, 2005, p. 2). However, I must admit that my performance evaluation will be unrealistic without the difficulties I encountered during my clinical placement particularly in keeping with the standards of provision and coordination of care (ANMC, 2005, p.5). I firmly believed that there were insufficiencies in the conduct of comprehensive and systematic nursing assessment (as required in section 5.1) as I actually did consider all possible assessment tools and strategies during the collection of data. Similarly, my analysis and interpretation of data may not be accurate since I only lightly consider the significance of analysing conflicting information and evidence as required in 5.3 of the National Competency Standards for the Registered Nurse. Conclusion This essay discussed the case of Mr. Willy, a 62-year-old male with AML and clinical placement experiences of the author. The essay presented the importance of appropriate supportive care and understanding the needs of the patient. The reflection presented in this essay using the Gibbs Reflective Cycle enable the author to reflect on how trust can build relationship beneficial to the patient and the value of understanding best practices in supportive care. Similarly, the ANMC is very helpful in determining my level of performance during my first clinical placement. It also reminds me of what I need to do to further improve my practice and the level of care I should provide my patient in future. More importantly, reflecting on previous experiences help me realized that duty of care is not just a matter of following procedures but performing your duty without discrimination. Action Plan Working with similar patient in future will be more challenging in the sense that there will be more interaction, better and innovative supportive care strategies, more evidence-based approaches, and better health outcomes for AML patients. Initially, I will build a strong connection with my patient, gather all relevant information in the earliest time possible, and use this information to build an individualized care plan. There will be a much comprehensive assessment using all relevant tools and strategies and accurate analysis based on evidence and facts. 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