JB: My New Fav Patient

Client Report: Background

Admission Story. JB came in with complaints of burning during urination, abnormal urine color, nausea/vomiting, dysarthria (difficulty speaking), dysphagia (difficulty swallowing) and extreme pain in extremities (especially in long bones). The patient, in his fifties, worked as a mechanic his entire life and was medically diagnosed with esophagus cancer, and had a history of depression. It was noted that JB has chronic hypocalemia (low serum calcium) as well. The patient’s vital signs were BP 99/79 mmHg, HR 102 beats/min, R 13 breaths/min, T 99.0 degrees ferinheight, pulse 102. 

Medical Diagnosis, Typical Medical Care, and Nursing Concerns

            Typical medical care. Patient was diagnosed with Metastatic Esophageal Cancer. The typical care involves an endoscopy biopsy that takes cultures from the esophagus and tests the tissue cells for malignancy. PET scan and CT scans are used to see how advanced the cancer is, stage wise (i.e. has is metastasized for not). All the tests are combined to help form the diagnosis and prognosis. Vital signs and infection assessments are usually strict with these patients because of increase risk of infection. Surgery is usually scheduled to remove the tumor, and the patient is placed on antineoplastic (anticancer) medications. Radiology and Chemotherapy are also treatment options for cancer patients, and specified to the individual’s treatment plan.

            Nursing concerns.

            With cancer, pain management is a major concern for these patients because they are in pain because of tumors or metastasis, or even from surgery to remove said tumor. If pain is not managed, blood pressure and respirations increase, possibly causing secondary complications. Since the patient has a poor prognosis and a history of depression, I feared that depression and anxiety would only increase. Nurses should be honest and authentic with this patient in treatment and prognosis, and explore options on how to proactively cope with the news either through patient teaching or spiritual discussion, etc. In a nutshell, “nurses goal revolve around improving the patient’s tolerance of treatments, maintain stability and …help the patient attain an optimal quality of life”  (Logue and Griffin 2011).

MRSA prevention is key to help contain the infection. Nurses must perform good hand hygiene to ensure that they are not the one to pass the infection along to the next patient. Making sure all wounds are covered and areas surrounding the patient are kept clean will aid the nurse in this effort. Appling antiseptic washings and nasal ointment, as well as consistency amongst staff members, is recommended for the treatment and eradication of MRSA (Hansen et al 2007). Also, nurses should communicate to the staff of this infection so that others will take the same precautions and maintain treatment of the infection (i.e. dressing changes, noting infection, etc) (McAuther 2008).

Past Medical History and Influence on Current Problem

            Patient has a history of depression, which will only add to the psychological disturbances cancer may cause. “After cancer diagnosis and its treatment, about 30% of cancer survivors express a need to professional support in managing …psychological…problems (Korstjen et al 2011). Logue and Griffin (2011) agree and further explain, “anxiety levels often remain high as patients have little time to absorb information and develop realistic expectations. This anxiety is often intensified by the fact that a reliable prognosis can be given only after surgical resection and pathology results are available.”

            Because this patient has suppressed immune system, the body cannot fight off infection as well. Therefore, he is more susceptible to infections such as MRSA, and it is difficult to treat infections because of the weakened immune system. The patient has flaky skin, which will only aid in the transference of the infection to other areas of the body and possibly other patients as well because the infection is on the skin cells. Infections with cancer patients are a serious matter.

Pathophysiology of Admitting Medical Diagnosis and Contributing Conditions

            People dealing with diesel pollutants, like JB was, as well as those consuming pickled products chew tobacco, and have a history of GERD are at a higher risk for developing this tumor disease (Kollarova 2007). With the patient’s form of esophageal cancer, the cells of the esophagus began to shed and new malignant cells replaced the older healthy cells (Lewis et al 2011). There is no specific answer to why malignant cells form, but the risk facts that the patient experiences did help mutate the cells into cancerous cells. Those cancerous cells continue to grow upon each other and form a hard mass, or tumor. That tumor begins to infringe on the body’s ability to function. For instance, with JB, since the tumor was in his throat, it was harder for him to swallow, speak and even breathe. If the tumor was not removed, then the tumor could spread to other areas of body, effecting different systems, and eventually even grow large enough to block of the entire esophagus, allowing no air or nutrients to pass.

            Depression can be shown with a lack of activity in the brain on a PET scan, and includes the neurotransmitters norepinephrine and serotonin imbalance (Varcarolis & Halter 2010). It is a chronic disease that affects the individual’s mood, may cause suicidal ideations, fatigue, withdrawing from friends or other social interactions and just leaving the person in an altered state of mind. The only way to help this disease is to treat the imbalance between the neurotransmitters. Different medications may need to be prescribed, and treatment should be costumed to the individual’s needs.

            MRSA, or a methicillin-resistant Staphylococcus aureus, infection is very difficult to eradicate but easy to obtain. “Healthcare-associated MRSA is when infection occurs during or after a period of hospital care” and surgical or immunosuppressd patients “have a higher risk of acquiring MRSA” (McArthur 2008). According to McArther, MRSA can spread either by the patient or healthcare provider. The patient may touch the infection, i.e. scratch the infected area, and then touch another part of their body; and now, the infection has spread to different parts of the patient’s body. The healthcare provider may touch the area, to change dressing for example, but not effectively wear gloves or perform good hand hygiene, go into the next patient’s room and infect that patient. Because the infection is contact basis, and a resistant strand of S.aureus, the wound may stay infected for a long period of time. This patient has had this MRSA infection for months.  Prevention is key.

Complications since Admission

Patient’s sister recently informed the healthcare team about a methicillin-resistant Staphylococcus aureus (MRSA) infection that was obtained during the patient’s esophectomy to remove the tumor a few months ago. Since the healthcare team was not informed, the wet-to-dry dressing became harden over the several days where it was not attended to and was causing the patient excessive pain in this right shoulder (where the incision was made and the infection is now). The healthcare team added this medical issue into the treatment plan of the patient, and educated the family on the importance of MRSA eradication and how wet-to-dry dressings need to be changed twice daily, which helps pull the infect out from the wound instead of allowing the infection to remain there.

Assessment of Basic Conditioning Factors

Factors related to the Individual

            Age/gender. 57 yrs old. Male.

            Developmental state. Patient is at the end stages of life, as he sees it. He is fully aware of the situation he is in and has full capability to know his disease process and understand any prognosis. He’s level of thought process and maturity is appropriate for his age.

Factors related to Family and Culture

            Family system factors. Patient was previously married at least once. He divorced his wife once she became a drug addict and sold his belongs to gain extra money for her addiction. There was denial of any other significant other, and no mention of children. At the current moment, JB’s sisters and brother-in-laws visit frequently and are extremely supportive of him while he goes through treatment. Even with his family around, the patient feels more of a burden and shows shame when asking for help with a task. Still, he also shows gratitude and appreciates when they visit, even when just sitting quietly while he sleeps.

            Sociocultural orientation. JB is occasion, raised in Northwest Ohio. There were no cultural influences on his beliefs towards treatment. His sister, and power of attorney, KB, worked in hospitals before as a respiratory therapist and new most of the tests and treatments JB received, and he usually based his actions on what KB reported to him. Patient did have a prayer book, but he was never seen reading it since he sleep most of the day. Family was never seen or heard reading the prayers to him either.

Factors related to the Individual in the World

            Health state. The patient’s current health state is diminished. He faces a poor prognosis with esophageal cancer, “even when tumor is surgically removed at its early and operable stage. Five-year survival is leas than 5%” (Kollarova 2007). As shown in PET scans and CT scans, JB has metastasis in his long bones, which is causing his pain in his legs and low serum calcium levels. He sleeps most of the day, interacting minimally with those around him. He refuses bathing because it causes him too much pain. My goal is to help manage the pain so it is tolerable, and the patient then could partake in some activities of daily living such as hygiene. I would also like to address his grey outlook on life along with his depression and possible anxiety levels, in the hopes that an intervention may help the patient have a more positive attitude that is still realistic to his situation.

            Health care system factors. Patient believes that invasive surgeries are acceptable, especially if they can help with his prognosis. He did recently have an esophagectomy, where a tumor was removed. MRSA infection is now where that wound is, but the patient and family members did not inform the current healthcare team of this infection for several days.

            Pattern of living. JB was a mechanic, before becoming ill. He enjoys painting cars; that was what he did primarily at work. He enjoys little things, conversation with family members and reading. He does not have very many hobbies.

            Environmental factors. Most of the pollutants he is exposed to come from work, and they do create an increase in risk for developing disease such as his esophageal cancer (Kollarova 2007). He came from a clean nursing home, according to a family member, but is looking to return home soon. His sister keeps a clean and organized home, which might be an alternative to a hospice home when that time comes.

            Resource availability and adequacy. The family as a whole does have enough income to provide this care, especially when combined with the patient’s insurance. This disease impacts the family more emotionally than it does financially. JB’s sister and power of attorney is retired and is able to care for him on a regular, around the clock, schedule. Again, this may be a good alternative to a nursing home or hospice house.

Assessment of the Universal Self-Care Requisites

Air. Patient has little endurance to walk around due to weakness and slight shortness of breath. He was a mechanic, breathing in fumes majority of the time, which may explain why he developed esophageal cancer.

Food. He is currently ordered NPO, but typically he eats little because of the pain caused when he swallows. He enjoys popsicles and crushed iced, however. He has experience extreme weight loss related to his diagnosis of cancer and lack of nutritional intake. He did have an NG and J tube placed at one point during his hospitalization, but not at the current moment.

Water. He does not drink alcohol. He mostly drinks iced water. He also has an IV running normal saline at a rate of 100 mL/hr.

Elimination. He has bowel movements on a daily basis. There are some reports of diarrhea and occult blood in stool samples.

Activity and Rest. Patient cannot perform ADLs because of muscle weakness, but mostly because of pain (according to the patient himself). Patient often likes to sleep most of the day, and often finds himself very fatigued.

Solitude and Social Interaction. JB’s primary interaction is with his family, sisters and brother-in-laws. He divorced his wife previously, and has no children. Even when family is there, he often does not contribute to conversations, and falls asleep easily during visitations. There are moments when he will make jokes with others, and converse with family members when addressed. Family states this is normal for him.

Normalcy. Patient has a poor self-concept and thinks of himself unable to do anything. He believes to be on his deathbed, before any information was given to confirm or deny that. He appears to have little spirituality, or belief in a purpose to his suffering. He uses inappropriate jokes as a way to cope with the situation.

Hazards. Patient has a MRSA infection on the right shoulder blade from previous surgery. However, current healthcare team was not informed of this until several days after his admission. He is a fall risk because of his inability to stand or walk without two people helping him.

Information about Patient’s Medications

            The patient’s medications are as follows:

·      Citalopram (10mg orally once a day). This drug is an antidepressant, which inhibits serotonin uptake. Side effects that are common are suicidal ideation, headache, nervousness, constipation, insomnia, fatigue, dry mouth, anorexia, sweating and fever. This patient is on citalopram because of his chronic depression.

·      Docusate Sodium (110mg orally once a day). This medication is a stool softener, which increases water and fat penetration in the intestine, allowing for easier passage of stool.  Patients are typically put on stool softeners because other medications can cause constipation, and it is essential for the patient to be able to have bowel movements, since it does eliminate waste. Also, it ensures that elimination will happen after surgery, which surgery itself may cause issues with ability to void or pass stool.

·      Fentanyl (1 patch, every 72 hours). This is a pain medication, where ascending pain to the CNS is inhibited, increasing the patient’s pain threshold. Common side effects are bradycardia and respiratory depression. It is important for nurses to take vital signs, and note if these side effects are present and are worsening or not.

·      Ferrous Sulfate (325 mg, once a day, with breakfast). This is iron, used mostly for those who are anemic or have nutritional concerns and this survives as a supplement. JB uses this as a supplement that helps 02 exchange and red blood cell development. Iron can cause constipation, so nurses should be assessing for bowel movements.

·      Gabapentin (900 mg daily). According to Mosby’s Nursing Drug Reference book, the mechanism is unknown for this drug, and this drug has many uses. For our patient, it is a good pain reliever. Side effects include, but are not limited to, suicidal ideation, seizures, leukopneia and Stevens-Johnson syndrome. Patients should avoid alcohol, antacid and antihistamines while on this drug. Nurses should double check other medication orders for these and call pharmacy with any questions.

·      Mirtazapine (7.5 mg daily at bedtime). This medication is also an antidepressant that inhibits the reuptake of serentonin and norephrine, which allows for more of those neurons to be available. This is good for JB, because is helps with his depression. A few side effects include seizures, hypertension and low blood counts. Nurses would need to continue to take accurate vitals and assess blood counts if a patient is on this medication.

·      Pantoprazole (40 mg daily). This drug is an antineoplastic, which decreases growth and survival of cancer cells. This medication is treatment for the patient’s esophageal cancer. This does cause some angioedema (swelling of the face), fatigue, ocular toxicity and fatal infusion reactions. Nurses should stay in room when the drug begins to infuse, and assess for any signs of reaction (i.e. fever, chills, hypotension) and note any eye irritation. 

·      Tamsulosin (.4 mg given orally 30 minutes after supper). This drug is typically given from enlarged prostates. Healthcare team should note any changes in urination, edema and watch input and output records carefully before and after this medication is administered.

·      Tears Naturale II (one drop, three times daily). This eye drop is to help with eye irritation, a symptom of Pantoprazole, and another medication this patient is one. It simply helps the eye keep moist.

·      Promethazine (PRN for nausea). This is an antihistamine drug that works on the GI tract and respiratory tract blocking allergic reactions, and helps with nausea. This patient came into the hospital with a complaint of nausea, and this drug was administered. Since then, the patient does not complained of nausea.

Pertinent Laboratory and Diagnostic Testing

            Diagnostic testing for his cancer was done previous to this admission. Endoscopic biopsy is performed to determine if malignant cells are present (Lewis et al 2011). According to Logue & Criffin (2011), radiographic tests, like a timed-barium swallowing, are performed to determine the environment of the esophagus. Once blockage in the esophagus is confirmed, an endoscopy is performed to determine the location and size of the tumor.  PET scans and CT scans were performed to rule out or confirm lymph node involvement and metastasis. They capture imagery of the tumor and cancerous cells while using radioactive dye, which adds contrast to the image. In the case of this patient, they did confirm metastasis to the long bones. Endoscopic ultrasounds may also be utilized to help locate tumor boundaries, and if the tumor is penetrating other areas. “Information gathered from these specialized tests can be combined to determine the clinical disease stage of the cancer and to develop a treatment plan” (Loge & Griffin 2011).

Analysis of Self-Care Agency associated with Primary Medical Diagnosis

Summary of Capabilities and Limitations

            Capabilities. As stated above, JB is able to make informed decisions about his treatment and life in general. He is cognitively aware of his circumstances, and has been educated on his treatment to the point he can explain the disease process and treatment to his family and healthcare provider.

            Limitations. The patient’s limitations come into play when it comes to activities of daily living. Due to his depression and anxiety, as well as extreme level of pain, JB seems to have most trouble with carrying out ADL’s, such as hygiene. He becomes self-pitying and shameful of his current state, especially when having to use a bedpan or needs assistant getting up to use a commode. I believe if the pain could be managed, and his depression addressed, the patient would be more successful in day-to-day activities, and in a sense owning his illness and prognosis.

Self-Care Deficits:

            Self-care deficit #1.: Chronic Pain r/t metastatic cancer AEB patient grimacing and guarding while being repositioned or transported, patient’s complaint of pain at a level of 6 or higher on a numeric scale from 0-10, patient’s use of a PCA, and patient’s inability to perform ADLs due to his chronic pain.

            Self-care deficit #2. Ineffective coping r/t personal vulnerability in situational crisis AEB patient making inappropriate jokes about death, patient exhibiting lack of caring for his own body, patient’s apologizing for his vulnerability/weakness, and patient’s history of depression.

Plan

Desired Outcomes

            Outcome #1.  Patient will better manage pain within a week’s time AEB less grimacing while being repositioned, patient’s pain level will be 5 or less on a numerical scale from 0-10, and patient will be able to tolerate and perform ADLs more effectively.

            Outcome #2. Client will within a week’s time use effective coping strategies and seek help from a healthcare professional when needed AEB less self-pitying and more proactive attitudes towards his treatments.

Implementation – Interventions and Rationale for each Nursing Diagnosis

            Implementation for self-care deficit #1.

·      Assess for pain and administer all medications on schedule to aid in management of physical pain.

·      Ask client is pain mediation is effective to be better able to select appropriate medication strength

·      Teach patient about guided imagery since research has shown it to be effective on pain level and result in increased comfort levels (Ackley & Ladwig 2008).

·      Allow adequate time between activities so that pain level does not continue to build up and the patient could rest/recuperate in the meantime.

            Implementation for self-care deficit #2.

·      Teach patient about effective coping mechanisms with visual presentation and research evidence (http://prezi.com/a8qs8qyle-w3/coping-how-do-you-deal-with-lifes-stressors/) to help the patient see other ways of coping that may differ from current ones and may be more effective.

·      Perform a talking circle with patient and family to allow everyone involved in the situation to feel free to express their feelings and thoughts on the situation in an open, controlled but welcoming environment.

·      Explore spirituality with the patient to help give the patient a better sense of purpose in life, which may help their outlook on their prognosis.

·      Encourage discuss about previous stressors and how the patient handled the situation, pointing out strengths along the way, so the patient thinks of how they are more able to handle the current situation better than they previously thought.

Evaluation

SOAP:

            SOAP #1.

                        Subjective: Pain complains of pain in extremities, and refuses to be reposition or take a bath because of the pain.

                        Objective: Patient is guarded, with a grimacing face. Pulse was slightly high at 110, and heart rate was 106.

                        Assessment: Patient reported a pain level of 9 on a numeric scale from 0-10, zero being none and ten being the worse pain ever felt. Patient’s body was rigid and tense, more so than normal.

                        Plan: I plan to give patient prescribed medications as well as any PRN pain medications the patient may have. Patient will also be encouraged to use his PCA pump whenever he feels like he needs to more medication, and to not be afraid to push the button because of the safety features of this machine. If the patient’s pain level is decrease significantly, patient will perform some ADL’s with assistance.

                        Evaluation: When asked 45 minutes later, the patient reported his pain to be a 4 on a numerical scale of 0-10, zero being no pain and ten being the worst pain he ever felt. He was allowed to rest for a longer period of time because of family visiting, and on the promise to partake in bathing and standing up later in the day.

            SOAP #2.

                        Subjective: Patient states feeling ashamed of his condition, and feeling depressed about circumstances.  Patient does not have spiritual beliefs about himself, or a concept of his purpose.

                        Objective: Patient has a history of chronic depression, makes inappropriate jokes about his condition (as a way to cope with his probably outcome). He does not seem interested in taking care of himself anymore, saying things like “Well, I’m going to die soon anyways. What does it matter?”

                        Assessment: I will ask the patient about what he finds to be the purpose in his suffering, and if he has dealt with similar suffering before and how did he handle that situation so I have a base to expand on. Likewise, I will ask family members about the same topics.

                        Plan: I plan to facilitate a talking circle, in which each member talks about their thoughts and feeling about the patient’s condition and great possibly of dying from his illness. This way everyone has a feeling of being heard, and cared about in their own way. I also plan to teach JB different ways of looking at situations with different coping strategies from journals, to church, to talking about his feelings proactively. I plan to praise him for his strengths to give him a sense of ability to cope effectively.

                        Evaluation: I will see if the patient changes his words to more positive outlook, and discontinues making inappropriate jokes about dying that may upset family members as well as himself at times. If the family and patient enjoy my implications and they find it to be helpful, I would find ways to make it a permanent part of the patient’s treatment plan.

Self as Nurse

Thoughts and Feelings about Clinical

            This patient helped me realize how much I appreciate working with people, and being able to help them through their trials. It was hard to hear of his prognosis and to know the nurses would have to prepare him for hospice, and not be able to mention that to the client and talk to him about it. This client helped me look at myself in many ways. How would I handle the news of having a rare form of cancer where little can be done treatment wise? How do I myself feel about life and death, and where dignity comes into place? How would I want to die? How would I look at my life? Would I have the same difficulties with coping effectively? Would I have that shame my patient felt? JB helped me learn how to be more authentic with patients; I did not want to sugar code my words or cheapen his experience by ignoring the fact that he can die from his disease.  JB also taught me how important it is to look at myself as a nurse, and how these situations may affect me and then how that translates into my care for him. I felt as if this week taught me a lot about nursing from a different point than just nursing skills, where as weeks that followed I learned more than what I thought I could about nursing skills.

Strengths and Weak Spots with Specific Ideas for Own Growth

            My strengths come from my personality. I am easy-going, resilient and out-going. I am not so prone to anxiety as some of my classmates and future co-workers. I am able to speak more freely to patients about their situations, not from medical stand point, but from a holistic stand point including their thoughts or fears, how their disease impact their quality of life. In a way, I feel my biggest strength is the ability to relate to people in that sense. It helps build report, and bring a sense of ease when interacting with patients one on one so my weaknesses are a little bit better hidden. My biggest fear is becoming that burnt out, cranky and cold nurse who lost sight that this patient is a person and needs care in others ways beside they physical. I want to continue to have that in mind when I treat future patients and when I have the power to advocate that to do so.

            My weak spots, there are a few. I become shy in new environments, especially if I do not understand rules or regulations and where my limits are. Ambiguity is always been a struggle for me. I appear less confident, because I am. I become intimidated and second guess everything I say or do, even what I think, because I have never been in the situation before therefore I do not know how to think, what to say or do. I feel less adequate when it comes to nursing skills, because I either do not remember them as well as I would like to or because I never performed them so I am terrified to do them for the first time with live patients instead of manikins in lab. I plan on reviewing skills sheets over breaks, to help me remember better the steps to each skill. I also plan to offer to help perform the skills, instead of simple watching them like I have the tendency to do. My latest experience with a nurse helped show me that I can do the skills, and that I do know the steps better than I believe I do. If I perform them more with live patients, I believe my intimidation of them would ease up.