Assessment Task 2 Case Study — Community Nurse
CASE STUDY 9
Patient Care Plan Based on the Clinical Reasoning Cycle
Ellie Jones is a 73 years old female. She has been diagnosed with inoperative liver carcinoma and undergone one round of chemotherapy aimed at reducing the size of the tumour. The chemo treatment has seen her experience a significant level of fatigue, compelling her to delay her second round of chemotherapy. She prefers to be at home with her husband Mark.
Ellie Jones has reported, she is fatigued and rates her pain level between 5 and 6 on the pain scale of 0 to 10. She is currently taking several medications as part of her treatment including Oxycodone 5mg six hourly, Movicol 1 sachet BD, and Metoclopramide 10mg 4 hourly prn. With the reported fatigue and increased falls risk, she requires assistance with Activities of Daily Living (ADL).
The patient’s information shows that patient had begun her chemotherapy, but was compelled to initiate the second round of treatment due to experiences of fatigue. Treatment of cancer results in fatigue, which manifests as emotional, physical, or cognitive exhaustion that cannot be attributed to the patient’s current activity. In this case, caring of such patients require the nurses to assess the fatigue level using the 0-to-10 numeric rating scale recommended by the National Comprehensive Cancer Network (NCCN) (Gholz & Engstrom, 2010). If the patient’s fatigue level is 7 or greater, it should be treated as severe and appropriate measures taken to reduce it to comfortable level. Although the patient’s fatigue may be attribute the chemotherapy, it is important identify the contributing factors because fatigue may arise from distress, medication, nutrition or the pain (American Cancer Society, 2015). This would allow for effective control of such factors in the process of helping the patient to reduce the fatigue level. It would be important to review the medication the patient is currently using to determine if any of them is contributing to the fatigue and provide an alternative. On the other hand, the request for assistance in ADLs can be interpreted to mean that the reported fatigue has resulted into reduced physical activity in the patient. As such, management of the fatigue and encouragement of the patient to engage in progressive physical activity would be an important part of her nursing management (Bolt, 2014).
Ellie has reported experiences of fatigue as the reason she has posted her second round of the chemotherapy treatment recommended as necessary to reduce the size of the tumor. In this case, the issue of fatigue needs to be addressed to allow her to continue with her treatment. Therefore, the nursing management should concentrate on identify the cause of the fatigue and initiate interventions to reduce the levels of fatigue. Cancer-related fatigue has been attributed to several factors including pain, medication, or distress. Evaluation of her medicine to determine of either of the drugs are contributing the fatigue level would be a critical step in managing the fatigue levels.
The other nursing issue that needs to be prioritized in the nursing care is pain management, which Ellie has reported to be at the scale of 5-6 on the 0-10 pain scale. Nurses should consider a combination of both non-pharmacological interventions and pharmacological interventions as a way of ensuring effective management of her pain.
The last nursing issue that needs attention revolves around the ADL’s. The need to be helped with ADLs expressed by Ellie could be attributed to the reported high levels of fatigue and perhaps pain that limit her physical activity. There is need to ensure that as help is provide for her ADLs, her physical activity does not deteriorate to levels that compromise her health and overall quality of life.
Goals for Priority of Nursing Care
Identifying or establishing the actual levels of fatigue and pain using standard scales.
identifying factors contributing to the fatigue
Enhancing the Ellie’s physical activity as part of the strategies for addressing the request for ADL’s activities
Strategy for ensuring that Ellie receives continued care including frequent monitoring of her health
Ellie’s Nursing Care
Ellie’s nursing care revolves around pain management and efforts to reduce her fatigue levels to improve her quality of life. With research evidence showing a strong association between and cancer related fatigue, the first step in her care would management of the pain to the best level possible. This may include both pharmacological and non-pharmacological nursing techniques (Thomas & Weiss, 2000). In addition to the prescribed medication for management of pain, nurses will also consider the use of patient education about the pain and its management, relaxation, cognitive behavioural therapy, and music therapy to support the analgesics prescribed for the patient (Blahd, 2015). The relaxation technique involving breathing techniques and gentle movements would particularly play a critical role in reducing not only the pain but also alleviating anxiety in the patient. The combination of the non-pharmacological techniques and the analgesics has the potential to minimize the level of fatigue associated with the medication with consequent improved quality of life. Research has shown that pain levels in cancer patients may be predicted or contribute by emotional distress including anxiety, depression and beliefs about pain (Blahd, 2015). In this case, pain education would play a critical role in reducing the level of pain.
With Ellie experiencing significant fatigue, she faces a great risk of reduced physical inactivity. This is evident from her request for assistance with ADLs. As such, there is need to develop a physical activity interventions to improve her physical which is evidently declining. The physical activity intervention is not only important in enhancing her physical activity but helps in reducing the fatigue resulting from the chemotherapy treatment (Pujol & Monti, 2007). In addition, the physical activity is particularly important because Ellie faces increasing falls risk, which can be prevented through improved physical activity. Increased physical inactivity among cancer patients has been associated with muscle weakness, reduced range of motion and eventual loss of body function (Hoppe et al., 2013).
Ellie’s physical activity intervention will entail mild physical exercises including walking around the compound and jogging with the frequency and intensity increased based on her body response. The physical activity is expected to improve her balance and lower the risk of falls as highlighted in the patient information. The exercise will also prevent her muscles from wasting due to reduce physical activity as well as improve blood flow in her system thus lowering the risk of blood clots. Other benefits for the physical activity intervention include reduced nausea, lower anxiety, improve her self-esteem and reduce her dependency on others in undertaking her ADL’s (Hoppe et al., 2013). Through exercise, Ellie will realize reduced fatigue and general improvement in her quality of life. However, the nurses should first understand her nature of treatment and her energy levels in order to decide the appropriate type and intensity of exercises for the patient.
Evaluation of the Nursing Strategies Recommended
The main objective of the recommended nursing strategies is to ensure Ellie’s improved quality of life through reduced pain and fatigue. Therefore, upon education of the patient about pain, her beliefs, and the different approaches in managing the pain, her knowledge will be evaluated, and compared with the level pain to determine the effect of the education and counseling. However, it will be important to note that reduction of pain can be attributed to a combination of both the analgesics and non-pharmacological nursing interventions. As such, her pain will be re-evaluated progressively to determine the effect of the implemented strategies.
Physical exercises has been recommended to improve Ellie’s fatigue levels, reduce her falls risks, and reduce her dependency on other people to carry out her daily activities. The impact of the exercises will be evaluated based on her fatigue level changes on a scale of 0-10, falls risk and her ability to carry out her daily activities without need for assistance. Participation in physical exercises is expected to strengthen her muscles and prevent them wasting with consequent reduction of the fall risks that she was facing. Other benefits for the physical activity intervention include reduced nausea, lower anxiety, and improve her self-esteem. A combination of the analgesics and the non-pharmacological nursing strategies is expected to reduce her anxiety and depression with consequent reduction in fatigue associated with distress, fall risks and enhance her quality of life.
Outcomes of the Nursing Strategies
The expected outcomes from the intervention include identification of the factors contributing to Ellie’s fatigue levels and effective management of her pain for improved quality of life. A combination of the analgesic/medications and the recommended non-pharmacological nursing interventions such as pain education and counseling, and physical activity program for the patient is expected to result into reduced pain as measured using the pain scale, decline in fatigue levels, reduced falls risks, and improved ability to carry out her daily activities without dependency on others.
The interventions are expected to enhance Ellie’s quality of life as she continues to receive the chemotherapy treatment to reduce the size of the inoperative carcinoma. The important aspect of this care is that it can be undertaken in her home setting thus granting her the desire to continue with her treatment around her husband.
American Cancer Society. (2015). Physical activity and the cancer patient. Retrieved from http://www.cancer.org/treatment/survivorshipduringandaftertreatment/stayingactive/physical-activity-and-the-cancer-patient
Blahd, W. (2015). Managing Pain: Beyond drugs. Palliative Care Center. Retrieved from from http://www.webmd.com/palliative-care/managing-pain-beyond-drugs
Bolt, K. (2014). Improved survival for inoperative liver cancer through a combined therapy. Oncology Nurse Advisor. Retrieved from http://www.oncologynurseadvisor.com/web-exclusives/improved-survival-for-inoperative-liver-cancer-through-a-combined-therapy/article/374958/
Gholz, R & Engstrom, C. (2010). Managing hepatocellular carcinoma: The nurse’s role. A Supplement to Federal Practitioner, 27(1), 1-6.
Hoppe, S et al., (2013). Functional decline in older patients with cancer receiving first-line chemotherapy. American Society of Clinical Oncology, 31(31), 3877-3882.
Pujol, L & Monti, D. (2007). Managing cancer pain with nonpharmacologic and complementary therapies. The Journal of the American Osteopathic Association, 104, 15-21.
Thomas. E & Weiss, S. (2000). NonPharmacological interventions with chronic cancer pain in Adults. Chronic Pain, 7(2), 157-163.
University of Newcastle, Australia. (2009). Clinical Reasoning: Instructor resources. Retrieved from http://www.utas.edu.au/__data/assets/pdf_file/0003/263487/Clinical-Reasoning-Instructor-Resources.pdf