Epidemiology / pathophysiology of disease processes
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Epidemiology / pathophysiology of disease processes The National Health Priority Area of Cancer Control was established with the aim of improving health outcomes in this area. The most common diagnoses for cancer in men are prostate (1 in 5 males), colorectal (1 in 11 males), melanoma of the skin (1 in 13 males) and lung (1 in 13 males). For women, the most common diagnoses are breast (1 in 8 females), colorectal (1 in 16 females), melanoma of the skin (1 in 23 females) and lung (1 in 22 females). Cancer screening programs have been large public health initiatives in this area aimed at reducing illness and death resulting from cancer through an organised approach to screening. It would be of benefit for you to research the three cancer screening programs of BreastScreen Australia, National Cervical Screening Program and the National Bowel Cancer Screening Program to understand the importance of these programs and the benefits obtained. The World Health Organisation defines palliative care as: ‘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. Your own values and beliefs about death and dying may impact on your interactions with a dying person, reflect on your own self-awareness as an important strategy in palliative care nursing. |
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Gain an initial impression of your patient |
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Question 1. ReviewMr Dwight’s background and history. Mr Dwight has a history of bowel cancer. What two (2) signs and symptoms might Mr Dwight have had prior to his diagnosis? Why would these signs and symptoms have occurred? |
Answer:
The two signs that might have occurred prior to the diagnosis of bowel cancer are constipation and weight loss, accompanied with weakness and fatigue. Changes in the bowel habit result in bowel obstruction, which contributes to constipation. This commonly occurs due to physical blockage of the proximal colon, which in turn prevents passage of solid, liquid or gases through the colon. Thus, formation of tumor in the far end of the colon or in the rectum creates difficulties in the passage of the excretory wastes.This further leads to bloating and abdominal cramps. Weight loss is another symptom that is associated with fatigue caused by the cancer cells that use up the body’s energy. Energy is also consumed by the immune cells that protects the physiological system by fighting against the disease. Change in bowel habit also results in blockage of the colon that contributes to thie unexplained weight loss and fatigue.
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Question 2: Mr Dwight has had a hemicolectomy with the formation of a colostomy. Discuss the anatomy and physiology of this condition and the surgical procedure? |
Answer:
Bowel or colorectal cancer represent a complex disorder caused due to certain genetic alterations, which are associated with progression of the cancer from a pre-malignant lesion to an invasive adenocarcinoma. An abnormal growth of cells is observed in the rectum or the colon, that is a part of the large intestine. Colostomy refers to the surgical procedure of forming a stoma or an opening by drawing healthy end of the colon through the incision that is made in the anterior wall of the abdomen. It is further sutured into place. This stoma in combination with an ostomy pouching system helps in providing an alternative route for passage of fecal matter outside the body. The process of right hemicolectomy involves an removal of the right side of the colon, the cecum, hepatic flexure, and terminal ileum, along with the lymph nodes and fat. through laparoscopy (Waters et al., 2012). The operation does not encompass removal of the stoma. This helps in removal of malignant neoplasm from the right colon. On the other hand, the procedure of ileostomy involves making a surgery in the abdominal wall by bringing together the loop or ends of the small intestine on the surface of the skin. It helps in collecting intestinal wastes in the artificial pouching system (Nagle et al., 2012).
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Question 3: What two risk factors can lead to bowel cancer? |
Answer:
- Sedentary lifestyle leading to excess deposition of body fat
- Significant family history of polyps or bowel cancer
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Question 4: MrDwights BGL on admission to the ED is 22 mmol. What level should a normal BGL be? Explain MrDwights BGL reading and the interventions in place to address his diabetes. |
Answer:
Normal values of BGL ranges from 4-6.1 mmol/L during fasting. The mean normal BGL is about 5.5 mmol/L. A BGL of 22mmol represents hyperglycemia, that suggests presence of high blood sugar levels. The underlying factors that might have contributed to his condition are related to increased consumption of carbohydrates, mental and emotional distress, physical inactivity, obesity and infection. On arrival of the ambulance, Mr. Dwight reported that he is diabetic. Thus, this increased BGL is due to the less insulin secretion in his body.
Signs and symptoms of bowel cancer
The primary intervention that should be implemented for lowering the blood glucose levels is administration of insulin. The hormone is synthesized by the beta cells of the islets of langerhans, located in the pancreas and effectively manages to convert blood glucose to glycogen (Dall et al., 2014). There are 3 different types of insulin:
- Rapid acting
- Short acting
- Intermediate acting
Another intervention that can be applied is related to making dietary modifications. A holistic nutritionist should be consulted for formulating a healthy-eating plan that has low calories and fats and is rich in nutrients and fibers. This will also help in reducing the amount of blood glucose.Review and recall knowledge on nasogastric tubes.
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Question 5: (a) Why does Mr Dwight have a nasogastric tube? (b) What three routine checks need to occur of the nasogastric tube while situated in a patient. |
Answer:
- A nasogastric intubation is followed in this case scenario for administering and feeding oral agents and drugs to the patient. Mr. Dwight. He suffered from dysphagia that resulted in difficulties in swallowing. The nasogastric tibue acts as a feeding tube that makes it easier to consume the eatables as well as the medications. His inability to eat due to continuous vomiting and lack of adequate food and liquid intake for the past days made it necessary to administer him the nutrients and durgs using the tube.
- The 3 routine checks are as follows:
- The placement of the tube shall be verified by ausculaing air over stomach by using a Toomey syringe (Irving et al., 2014).
- The pH content shall be checked by using a colour-coded pH paper to confirm the presence of acidic contents in the tube.
- The length of the tube shall be marked from the nose to the tube’souter end
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Question 6 Why are these routine checks important? |
Answer:
The routine checks are essential as they help the healthcare professionals identify presence of any abnormalities in the insertion of the tube. Checking the pH testing of the tube helps to verify its placement. Aspirates below 5.5 ensures that the tube has been inserted correctly. Furthermore, the routine check also involves conduction of an x-ray that confirms the placement prior to using the tube for feeding the patient. pH more than 6 indicates presence of small bowel content or presence of some respiratory fluids.
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Question 7: Discuss the importance ofassessing Mr Dwights social circumstances in his palliative care admission. |
Answer:
Palliative care refers to the specialized medical care that is provided to older people suffering from chronic illness. This kind of care focuses on providing relief from the stress that these illnesses create on the person. There is a need to assess the social factors that might have a role to play in delivering holistic care to the patient. This can be attributed to the fact that research studies provide evidence for the presence of psychological distress among one-third of palliative patients such ads, depression, anxiety and adjustment disorder. The social circumstances act as major reflections of the psychological facet, which refers to the physchological state of the concerned person. This helps in determining the factors that might create a significant impact on the social life. Owing to the fact that diagnosis of a chronic or terminal illness often leads to social withdrawal, due to immobility, risk of infection, and recurrent hospitalizations, it is imperative to consider the circumstances that might play a probable role in the patient’s behaviour.
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(a) Review current information (b) Gather new information (c) Recall knowledge (A&P, ethics, law, cultural safety) Review current information: review and think about Mr Dwight’s presentation, the observations that have been carried out and what further assessment you would want to carry out now? |
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Question 8: Discuss in detail two (2) assessment items that should have occurred on Mr Dwight in the Emergency Department. |
Answer:
The 2 assessments that should have been carried out include the following:
- Triage for palliative care- This is the first stage fro determining the severity of the symptoms presented by the patient. This determines the priority and the order of the emergency transport and helps in sorting patients who require critical attention of the healthcare professionals. Upon completion of this assessment, the nurses and the physicians often label each patient and display their assessment findings, theteby identifying the priority demands of the patient and delivering tailormade healthcare services to meet their needs.
- Pain scale: This should also be used for all patients in combination with the complaint that the patient presents. This helps in assigning patients with similar kind of health complaints to a wide range of triage levels. Pain is a subjective sensation. This scale is generally used to detect the alterations in the severity of the pain experienced by the patients. Usually based on self-reports, the scale should have been used as an assessment for formulating an appropriate treatment plan.
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Question 9: Discuss the medication prescribed for MrDwights pain in the palliative care unit. Describe the mode of action of this medication and possible complications. Discuss how this or is not the most appropriate medication for MrDwights case. |
Ms Contine- This is an opioid pain narcotic or extended release formulation of morphine. This medication is prescribed for treating pain that ranges from moderate to severe intensity. It contains morphine sulphate that is an opioid agonist, selective for the mu-receptors. It interacts with more than one classess of the receptors that are located all over the body by binding and thereby activating the receptors in the peri-ventricular and peri-aqueductal grey matter. These receptors are also located in the spinal cord and the ventro-medial medulla that produces an analgesic effect and relieves pain (Wang et al., 2012). Themost common side effects of this drug include the following:
- Blurred vision
- Absominal pain
- Discomfort and pain in the chest
- Reduced urination
- Loss of consciousness
- Weight gain
- Hypertension
- Extreme drowsiness
Surgical procedure of bowel cancer and colostomy formation
However, these drugs should not be prescribed to patients suffering from breathing difficulties or blockage in the intestine and the stomach. Mr. Dwight was suffering from colorectal cancer. Thus, the medication should not have been administered.
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§ § Interpret data – what does it all mean? |
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Question 10: Effective and accurate clinical assessment skills are imperative for the nurse working in emergency department. List two (2) highest priority clinical assessment findings in Mr Dwight when he is admitted to the emergency department. |
Answer:
- Respiratory rate- This assessment helps to detect the respiratory efficiency of the geriatric patient. This refers to the number of breaths taken by a person per minute and is usually measured at rest. Counting the number of breaths and the number of times the chest rose helped in determining the presence of respiratory disorder. Mr. Dwight’s RR was 24. This was beyond the range of the normal respiratory rate for an adult (12-20), thereby indicating that he suffered from tachypnea.
- GCS- Determining the conscious state of the patient using the Glasgow Coma Scale was another reliable assessment as it helped to predict the patient’s progression. It helped to evaluate the impairment of consciousness in response to specific stimuli in a patient. Mr.Dwight’s GCS score for motor, verbal and eye response showed higher values, thereby indicating that he was conscious of his state and was not unresponsive.
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Question 11: Effective and accurate clinical assessment skills are imperative for the nurse working in palliative care. List two (2) highest priority clinical assessment findings in Mr Dwight when he is admitted to the palliative care ward. |
- Fall risk assessment- This is a critical priority that should be determined in case of geriatric patients. Falls are considered as the major source of mortality and morbidity among elederly patients. The increae of inpatient falls is influenced by cachexia (loss of weight, fatigue, muscle atrophy and weakness), experienced by elderly patients. Therefore, conducting an assessment of fall risk was of importance for preventing any severe injuries or adverse events in the hospital setting. This risk assessment would help in implementation of strategies that would improve the safety and quality of care provided.
- Cognition assessment- This helps in determining the presence of symptoms related to delirium or confusional test among patients, which in turn causes a decline from the baseline level of mental functioning. This is essential as it helps in identification of disorganized behaviour, attention deficits, and fluctuating course. Therefore, it facilitates accurate diagnosis of disorders that can impair thinking in the patient.
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Synthesise all information that has been collected and processed. |
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Question 12: Select three highest priority relevant nursing diagnoses for Mr Dwight in the palliative care unit. |
Answer:
- Diagnosis of the spread of metastasis by perfoming colonoscopy
- Diagnosis of impaired physical mobility with respect to loss of muscle tone and strength
- Determination of the vital signs
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What should happen to improve problems/issues and by when?? |
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Question 13: Discuss the three most important short-term goals for MrDwights management in the Emergency Department. |
Answer:
- Management of respiratory rate- The patient presented RR>26 that is higher than the normal limits. This indicates that the patient should receive immediate medical review. Thus, the goal is to increase airflow to the lungs by delivering supplementary oxygen, using a cannula.
- Management of low heart rate- The patient presented a heart rate of 55 beats oer minute that is associated with bradychardia or slow heart rate. Therefore, the short term goal is to restore the heat rate by administration of medications such as, epinephrine, atropine and dopamine.
- Management of pain- The basic goal would be to reduce the perceived levels of pain during the stay in the ED. This will help in reducing discomfort of the patient. Administration of accurate analgesics such as acetaminophen will act on the central and the peripheral nervous system and help in providing relief. Nonsteroidal anti-inflammatory drugs can also be administered for reducing pain severity.
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Question 14: Compare your answers in Q11 to what might be the three most important short-term goals in the palliative care unit. |
Answer:
- Reducing fall risks- Prevention of fall related fatal and non-fatal injuries will be one major short term goal in the palliative ward. This can be brought about increasing the lithting in the ward, removing all kinds of clutters from the passages, installing grab bars in the showers, installation of bed rails and alarm bands that will give an alert when the patient tries to get out of the bed.
- Improving cognition in the elderly- Cognitive impairment in older adults often occurs due to side effects of medications, thereby causing delirium.The short term goal would be to engage in an effective and meaningful conversation, asking for their opinions, encouraging them to learn new hobbies, and solving puzzles. This would create significant improvements in the cognitive skills of the person.
- Providing venous access- This would allow sampling of the blood, along with administration of several medications and fluids. This would be achieved by insertion of intravenous cannula.
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What action/interventions will you do? |
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Question 15: When caring for a person with a life-limiting illness, you also need to care for the caregivers. Consider Mr Dwight and his social circumstances – list one strategy to use to ensure that MrDwights family are considered in his care. |
Answer:
It is essential to involve the family members while delivering patient centred care as the family has an accurate perception of the health beliefs, demands and needs of the patient, suffering from a chronic or terminal illness. Research evidences suggest that clinicians and patients often have different views on the health goals (Barry & Edgman-Levitan, 2012). Family members do not just act as passive observers, but adorn the role of important decision makers. Owing to his old age and reluctance to get admitted in the palliative care unit of the hospital, it is of utmost necessity to involve his wife and three sons while deciding for the therapeutic interventions that are intended to be implemented upon him. This will create provisions for the family members to actively participate in monitoring the outcomes of the proposed interventions and an effective conversation with the physicians will help them to modify the action plan accordingly. Thus, it helps in managing chronic illness and avoids complications and flare-up. They will be able to convince him to show compliance to the treatment at the palliative care unit.
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Question 16: Identify three (3) multi-disciplinary clinicians that you may refer Mr Dwight to? Justify one in detail as to why it would be of beneficial to refer Mr Dwight to. |
Answer:
Three multi-disciplinary clinicians who will be consulted for providing Mr. Dwight a holistic healthcare service are a physiotherapist, a nutritionist and oncologist.
Role of the physiotherapist- The physiotherapist will be a highly qualified primary care practitioner eho will be able to manage the physical limitations in the patient. He will be able to assess the effectiveness of particular modalities and interventions for movement dysfunction, and musculoskeletal abnormlities that makes the patient immobile. He will be able to use a wide range of treatment options that will help in restoring function and movement, thereby relieving pain and preventing further problems. The tailor made programs implemented by the physiotherapist will help in strengthening his posture, muscle and improving the overall fitness.
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Assess the effectiveness of actions |
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Question 17: List two signs and symptoms that would indicate that MrDwights goals are being achieved in the Emergency Department. |
Answer:
- An increase in the heart rate that makes the levels reach the normal value between 70-80 beats per minute will indicate an improvement in the physiological conditions. The common signs that will indicate this increase are elevated pulse rate. This will help in assessing that arrhythmia has reversed and the condition is no longer life-threatening. This can be achieved by adherence to proper mediction and dietary changes.
- A reduction in respiratory rate near 20-22 breaths per minute will also indicate that the patient is not putting in much respiratory effort and the is a lowering of the blockage in the airways. Thus, the breathing passages will get opened up, thereby indicating an overall improvement in his condition. This can be brought about by administration of intravenous fluids, gavage feedings and supplemental oxygen through masks or cannulae.
Thus, an improvement in the above two physiological features will indicate that the goals related to Mr. Dwight’s treatment are being achieved.
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What have you learned from this experience? |
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Question 18: Why could the clinical use of blood and blood products be necessary for a patient with cancer? |
Answer:
Most cancers in the digestive system result in internal bleeding due to anemia (low amount of RBCs). Furthermore, cancer cells that spread out in the bone marrow result in low blood count. This thereby affects organs such as the spleen and the kidney. Drugs such as, adriamycin and cytoxan also affect the bone marrow, leading to low blood count. Thereofre, cancer patients may need blood or blood products.
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Question 19: If Mr Dwight were to commence on chemotherapy why would he have particular safety risks? |
Answer:
He would have particular safety risksdue to the following reasons-
- Chemotheraoy can create infection of the white blood cells.
- It can result in bleeding due to low platelet count
- It can also result in anemia from low hemoglobin
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Question 20: What are the particular issues for patients undergoing chemotherapy that put them at higher risk of Healthcare Associated Infections? |
Answer:
Chemotherapy resuts in a drop in the count of white blood cells or neutropenia, which in turn increases the risks of infection. These low levels of WBCs susally get recovered over time. However, the issues associated with the higher risks of infection are as follows-
- A feeling of cold and shivers
- Running a high temperature around 37.5oC or 38oC, depending on the dose of radiation that a patient is subjected to
- Headaches
- Lethargic feeling
- Muscle ache
- It suppresses the immune system depending on the patient’s age, the chemo drug that is administered, the nutritional status of the person and the stage of cancer (Nesher & Rolston, 2014).
- Old age beyong 65 years
- Unintentional weight loss
- Bed-bound or failure to take self care
- Associated complications of diabetes, high blood pressure, emphysema, bronchitis or renal disorder
Thus, the aforementioned factors along with the strength of the chemotherapy increases the risks of acquiring infection.
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Question 21: Complete the nursing care plan below from the Palliative Care simulation. You will need to include all assessment data but then choose the two highest priority nursing problems to address in planning, implementing and evaluating. |
Answer:
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Assessment (Subjective and objective data) |
Identification (Patient Problem) |
Planning (patient goals) |
Implementation (Nursing/collaborative interventions) |
Evaluation (Evaluation criteria) |
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Subjective- ‘My bowel cancer will worsen if I eat’ as verbalized by the patient Mr. Dwight Objective- Request for medical history, tendency to show non-compliance to treatment, vital signs measured |
Risk for lack of knowledge on the benefits of palliative care services |
After a close assessment of the vital signs, pain scores, and state of consciousness in the emergency department, the patient will be made to verbalise the understanding of his colorectal cancer and the treatment regimen. |
Assisting the patient in modifying his dietary pattern Providing help during movement and carrying out of daily activites Reinforcing the impprtance of showing adherence to treatment regimen |
After 24 hours of nursing ntervention, the patient will be able to understand the importance of following the interventions implemented in the palliatve care ward. |
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Subjective- ‘Why can I not perform daily activities all by myself?’ as verbalized by Mr. Dwight Objective- Measurement of the pain score and the limb strength |
Lack of knowledge on the musculoskeletal disorders |
After a detailed analysis of the limb strength and the pain scale, the patient will be made to interact with a physiotherapist to understand the needs of moderate exercises that will increase muscle strength |
Consulting a physiotherapist for implementing effective excersie strategies |
Capability to perform simple tasks such as dressing, feeding and walking short distances |
References
Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine, 366(9), 780-781.
Dall, T. M., Yang, W., Halder, P., Pang, B., Massoudi, M., Wintfeld, N., … & Hogan, P. F. (2014). The economic burden of elevated blood glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes care, 37(12), 3172-3179.
Irving, S. Y., Lyman, B., Northington, L., Bartlett, J. A., Kemper, C., & NOVEL Project Work Group. (2014). Nasogastric tube placement and verification in children: review of the current literature. Nutrition in Clinical Practice, 29(3), 267-276.
Nagle, D., Pare, T., Keenan, E., Marcet, K., Tizio, S., & Poylin, V. (2012). Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Diseases of the Colon & Rectum, 55(12), 1266-1272.
Nesher, L., & Rolston, K. V. (2014). The current spectrum of infection in cancer patients with chemotherapy related neutropenia. Infection, 42(1), 5-13.
Wang, X., Loram, L. C., Ramos, K., de Jesus, A. J., Thomas, J., Cheng, K., … & Yin, H. (2012). Morphine activates neuroinflammation in a manner parallel to endotoxin. Proceedings of the National Academy of Sciences, 109(16), 6325-6330.
Waters, J. A., Rapp, B. M., Guzman, M. J., Jester, A. L., Selzer, D. J., Robb, B. W., … & George, V. V. (2012). Single-port laparoscopic right hemicolectomy: the first 100 resections. Diseases of the colon & rectum, 55(2), 134-139.
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