ADVANCED PALLIATIVE CARECASE PRESENTATION

Prepared by: Amani AbdullahSupervised by: Dr. Ruqayya Al Zeilani

CHIEF COMPLAIN

Mr. Kh.O is a 77-year-old male patient, a case of metastatic colorectal carcinoma, Mets to liver, lymph nodes and peritoneum

on 10/10/2013 admitted via ER due to increasing abdominal pain (NRS=8/10), vomiting and constipation of two days duration prior to admission.

BIOGRAPHIC DATA

Name of patient: Mr. Kh.O Age: 77 years old Gender: male Place of birth: Palestine Address: Al- Zarqa District Religion: Muslim Nationality: Jordanian Civil status: Married Occupation: A Carpenter. Educational attainment: Intermediate Level

2011 started to complain of severe abdominal pain,7days of constipation associated with nausea and vomiting.

Attended the general hospital emergency department; but had difficulty to get early appointment to follow up with his investigations CT scan and colonoscopy was postponed many times

PATIENT’S STORY

PATIENT’S STORY

Mr. Kh.O underwent a surgical procedure of

colectomy and colostomy on may/2013

Had used the medication “Irinotecan" on 1st/

Sept/2013 which is a drug used for the treatment

of cancer.

His complain at that time was relieved by using enema and laxatives

Continued to have on/off constipation On Oct / 2012 diagnosed as a colorectal

carcinoma of stage 2

On may/2013 confirmed diagnosis of CRC with METs to liver, lymph nodes and peritoneum

PATIENT’S STORY

PATIENT’S HX

Past Medical and Family Hx: No history of hypertension or diabetes mellitus.

Past Surgical Hx: only the surgical intervention for the resection of the carcinoma in addition to chemotherapy.

Patient was informed by his oncologist that further chemotherapy was unlikely to be effective

Mr. Kh.O is Married with two wives Has one son Had his own shop watched by his nephew but

with low income Mr. Kh.O is an ex-smoker, quit age (40), used

to smoke two packets per/day. Insured Own a house His 2nd wife is the one taking care about him

and the for their child who is cp and blind and caring for the other wife as she is an aged one.

SOCIAL HX:

ASSESSMENT

Lifestyle: Personal habits: Early in the morning, drinks

a cup of coffee and three cigarettes

Diet: before hospitalization: Mr. Kh.O claimed that

he eats one meal a day. He loves to eat meat and salty food. He drinks very little amount of water per day and only after meals then follow it with three pieces of cigarettes.

During hospitalization: Has difficulty in having food related to his

obstructed bowels although no limitations needed

Has poor appetite yet likes to have a piece of (kaak) and a cup of tea with meramia

Sleep and rest Pattern:Before hospitalization The patient normally sleeps at 9:00 pm but

often a hard time to get a good sleep, he usually wakes up at 6:00 am and starts his work cycle

During hospitalization: The patient stated that he usually sleeps at

10:00 pm and wakes up around 6:00 “due to sleeping pills” as he stated. (Xanax)

Elimination Pattern:

Before Hospitalization: Mr. Kh.O voids yellow colored urine 6 times a day,

he also claimed that he had not experienced any difficulties in urination he also claimed that he used to defecate once every 3-5 days with brown, formed or semi-solid stool and used to have laxatives

During hospitalization: Mr. Kh.O urinates using condom catheter, with

yellow colored urine, total output in 24 hrs = 3000cc.

Can’t defecate as of his total bowel obstruction, a phosphate enema trials done but failed to help and was of no use..

Activities of daily living:Before hospitalization: The patient had no difficulties in performing

the basic activities such as grooming, dressing and toileting. 

During hospitalization: The patient can perform few of the basic

activities specifically grooming, dressing and toileting and needed the assistance of his wife.

PSYCHOSOCIAL ASSESSMENT

Social Data:Family Relationship/Friendship Assessment: Mr. Kh.O lives at his own house with his two

wives and his sick son at the same building

His second wife is the only one to care for his family and extremely exhausted for they don’t have money to afford a servant

Mr. Kh.O stated “ I thank my wife because she is taking care of me day and night and she never leaves me, although she get’s tired all the time and she never sleeps well because of the noisy hospital environment but she never complained”.

Occupational Hx: Mr. Kh.O was a carpenter at his own place and after being sick he delegated his nephew for taking care of his shop

Socioeconomic status: securely covered by the health insurance

He stated that his major stressor aside from his condition is the issue of leaving his family alone with no support even the house he owns has a court case and the only son he has is already sick.

He always pray every day and asks for guidance from Allah. He has the ability to verbalize appropriate emotions and uses non verbal communications such as eye movements, gestures and interacts clearly during an interview.

Mr. Kh.O is very attached to his family presence during his disease, he expressed that they were the only supporter for him during his treatments..

SPIRITUAL ASSESSMENT

“ I feel guilty about one thing in my life, that I was putting myself last on everything, I should have taken care of myself much better than that” he stated. Patient looked really sad and he also added “am not afraid of death”.

“Its just that I will miss my family, but that’s what Allah wants, Thank Allah for everything”.

SPIRITUAL ASSESSMENT

He prays 5 times a day although sometimes it seems very hard for him to move, he prays while he’s sitting on her bed because he can’t stand for praying and that makes him feel sad because he used to perform it well when he was healthy but now all he could do is doing” the minimal things” as he expressed.

He reads Qur’an whenever he’s able to; also he stated that he likes the spiritual advisor to visit him frequently and pray for him as that comforts him a lot as he said, because he can ventilate what he feels to him and makes him think that he is getting closer to Allah.

PHYSICAL EXAMINATION

General Survey: Assessed/received patient lying on bed

comfortably, awake, conscious, responsive, and coherent with ongoing IVF NS 0.9 at 60 ml/hr with the following VS

Temperature: 37.3 C Heart Rate: 90 bpm Respiratory Rate: 18 rpm Blood Pressure 100/70 mmHg Oxygen Saturation: 95% (room air)

Skin, Hair and Nails Presence of bruises noted on the upper limbs

at site of (clexane) injections, no pallor is noted, cool and clammy to touch, fair skin turgor in both upper and lower extremities.

Bed sore at the sacral region stage2 pen skin Hair is white and not evenly distributed. Nails are trimmed convex shaped, smooth in

texture, intact epidermal lining around the nails, capillary refill test less than 3 seconds.

Skull and Face Rounded (normocephalic and symmetrical with

frontal parietal and occipital prominences), no nodules or masses upon palpation.

Eyes and vision: Eyelids are intact, sclera appears white, pale

conjunctiva and no discharges.

Ears and Hearing Ears are symmetrical in size, able to hear.

Nose and Sinuses Symmetric, has a good sense of smelling (can

smell orange fruit) no tenderness or pain noted.

Oropharynx (Mouth and Throat) Dry and cracked tongue and lips, able to

move freely has difficulty to swallow foods, needs good oral hygiene.

Neck Lymph nodes are noted and palpable at RT

side of the neck. Cardiovascular, Peripheral Systems and

Respiratory System No abnormalities found or observed.

Breast and Axillae With Rt lymph nodes enlarged.

Abdomen Presence of colostomy intact ,no infection

bruises, distended abdomen no audible bowel sound upon auscultation, had X-ray with fluid collection into abdominal cavity, had a trial of enemas for supportive measures no effect.

Musculoskeletal Unable to stand straight, difficulty to stand

can’t walk alone.

Neurologic Patient is oriented to time, person and place.

He was able to state where he lives. Patient was able to answer well when asked

of his complete name, birth and age, GCS = 15/15.

Reproductive System: Not done.

LABORATORY TESTS COMPLETE BLOOD COUNT (CBC):Test Name Result Normal

ValueSignificanc

e

HB 9.9 12-16 g/dl Indicates Anemia

RBC 3.16 4-5.5 X10^6/ul

PCV 30.0% 37-46%

WBC 5.9 4-11X 10^3/ul

Within N

PLT 152 150-400 X10^3/ul

At border

KIDNEY FUNCTION TEST (KFT)

Test Value Result Significance

NA 140 Within N

K 4.7 Within N

Ca 9.9 Within N

Cr 2.6 Dehydration /Renal

Impairment

Uric Acid 11.8 Hyperuricemia

Urea 29 Uremia

DRUG REGIMEN

Drug Name Dose/Route/Frequency

Indication

Morphine 40 mg 1x2 po Relief Pain

Dexamethasone

4mg inj 1x1 iv Decrease Edema

Xanax 0.75 mg po ABT

Promote sleep

Ranitidine 4mg 1x3 Stomach Prophylaxis

Clexane 40 IU/ SQ 1x1 DVT Prophylaxis

NURSING CARE PLAN PHYSICAL DIMENSION

Nursing DiagnosisPain related to total bowel obstruction secondary to

metastatic liver, lymphnodes and peritoneum evidenced by patient verbalization by NRS (8/10) , facial grimace and restlessness.

Goal Within 35 mints of giving appropriate nursing

interventions, patient will be able to verbalize reduction of pain from 8/10 to (1-3)/10

Nursing interventionsProvided non-pharmacologic comfort measures and

diversional activities.Evaluate pain relief/ control at regular intervals. Adjust

medication regimen as necessary. Noted and investigated changes from previous reports. Provided comfort measures and quiet environment Instructed and encouraged used of relaxation technique such

as focus breathing. Administered analgesic as indicated by the physician Evaluation After 35 mints of giving appropriate nursing interventions and

pain medications goal partially met, Patient verbalized reduction of pain from 8/10 to 4/10

Nursing interventionsFluid volume deficient related to decreased oral intake

evidenced by physical examination (dry skin) v/s and laboratory tests ( CBC + KFT ).

GoalWithin 3 days of giving appropriate nursing interventions, patient

will be able to maintain fluid volume at a functional level .

Nursing interventionsEstablished rapport to the patient. Assessed V/S Encouraged fluid intake to 3000 ml a day, unless contraindicated. Evaluated CFAC (Color, Frequency, Amount, and Consistency) of

urine.Regulated IVF level (NS 0.9%) accurately EvaluationAfter 3 days of giving appropriate nursing interventions, goal

partially met Patient was able to slightly maintained fluid volume balance

Nursing interventions Constipation related to total bowel obstruction evidenced by

Distended abdomen even with colostomy. GoalWithin 6 hrs. of giving appropriate nursing interventions, patient

will be partially relieved of fullness. Nursing interventionsIdentified areas of stressPalpated abdomen and noting bowel sounds .Provided adequate fluid intake as toleratedAdmisnter laxatives and stool softeners as physician ordered. If

not possible encourage activity and exercise within limits of individual ability

EvaluationAfter 6 hrs. of giving appropriate nursing interventions, goal not

met and Patient was not able to defecate.

Psychosocial dimension

Nursing interventionsAnticipatory grieving related to loss and altered role function

evidenced by patient’s verbalization and expression of guilty feeling as he forms a burden on his family.

Goal: Within 6 hrs. of giving appropriate nursing interventions, patient

will be able to identify and express feelings freely and effectively.

Nursing Interventions: Determined circumstances of current situation Encourage the Chaplin presence to clear out stressors Evaluated patient‘s perception of anticipated situation

Provided open environment and trusting relationship

Nursing Interventions: Be honest when answering questions, providing information Reviewed past life experiences and previous loss, noting

strengths and successes Given information that feelings are accepted and are to be

expressed appropriately Evaluation: After 6 hrs. of giving appropriate nursing interventions, goal

met. Patient was able to accept his situation and express feelings freely.

Spiritual dimension

Nursing interventionsFear and ineffective coping related to patient’s disease

progression and poor prognosis evidenced by patients verbalization of guilt feeling, regrets and helplessness.

Goal:Within 6 hrs. of giving appropriate nursing interventions, patient

will be able to perceive available support system (family support) to assist in coping up from fear .

Interventions: Presented information at patient‘s level of understanding or

acceptance Conveyed acceptance of the patient‘s perception of fear Used calm and reassuring approach. Spent time with patient in each shift

Interventions: Oriented family to patient‘s specific needs, allowing

family members to participate in giving care. Arranged for family member to stay with the patient Used relaxation technique to reduce attention of fear .

Evaluation : After 6 hrs. of giving appropriate nursing interventions,

goal met. Patient was able to perceive available support system (family support) to cope up form fear .

FAMILY CARE PLAN (WIFE) PHYSICAL Nursing interventionsSleep pattern disturbance related to interruptions by health

care professionals on V/S monitoring and care providing evidenced by his wife verbalization of inability to sleep well at night, feeling tired and restless during the day.

Goal: Within 2 days of giving appropriate nursing interventions, the

wife will be able to report good sleep pattern in absence of disturbance.

Interventions: Identified presence of related sleep disturbance factors Recommended restriction of caffeine

Interventions: Assessed her usual sleep pattern Determined her sleep expectations. Provided quiet environment

Evaluation: After 2 days of giving appropriate nursing interventions,

goal met, she was able to sleep within 4-5 hrs. in absence of disturbance

Psychosocial dimension

Nursing interventionsIneffective role performance related to changes in family dynamics

secondary to her husband’s illness evidenced by verbalization of not being able to perform her duty and responsibilities toward her sick son and feeling helpless toward her husband’s condition.

Goal: within 48 hours of nursing interventions the wife will verbalize

increased confidence in ability to deal with her current situation and adjust to possible role limitations.

Interventions: Discuss her perception of how she perceives limitations. Acknowledge and accept feelings of grief, hostility, and

dependency.

Interventions: Discuss meaning of loss or change to her . Ascertain how she views self in usual lifestyle functioning. Set limits on maladaptive behavior. Assist her to identify positive behaviors that will aid in coping.Involve her in planning care and scheduling activities.Evaluation: Goal was met as she could verbalize increased the confidence in ability to deal with her husband’s illness and current health condition.

Spiritual Dimension

Nursing interventionsRisk for spiritual distress related to challenged beliefs and

value systems evidenced by inability to express her personal response toward her dying husband.

Goal: within 48 hours of nursing interventions the wife will be

able to express her acceptance toward her husband’s health status and her personal response toward the dying process.

Interventions: Assess her for signs of depression. Assess her for signs of spiritual pain. Respect her beliefs. Promote the visitation of family and friends.

Be physically present and actively listen to her. Assist her in identifying meaningful experiences. Hold her hand or place hand gently on her arm if she is

comfortable with touch Assist the her in exploring reasons for living and

promote hope Assist her in any religious rites/rituals that she request. Allow her a privacy and a quiet place for prayer. Evaluation: Goal was met with the assistant of the spiritual advisor .

Thank you