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Oncology Unit Case Study

PB, a 58-year-old Caucasian female, presented to her primary care provider with complaints of weakness and fatigue. She has continued to work as she is the primary wage earner. She experienced recent weight loss of 15 lbs over the past 6 months not attributable to diet or exercise. She complains of severe fatigue. Her physician suspects colon cancer.

1. The patient is found to have severe anemia and is admitted to receive a blood transfusion of 2 units of PRBCs.

Explain specific patient teaching, assessments, interventions, and evaluation of the patient receiving 2 units of PRBCs.page 892
? Pre-transfusion

1. Confirm type and crossmatch
2. Obtain informed consent per institution or agency policy
3. Obtain baseline vital signs
4. Explain to patient s/s of transfusion reaction and instruct to report these s/s
5. Pre-medicate w/diphenhydramine (Benadryl), hydrocortisone (Solu-Cortef), acetaminophen (Tylenol)
6. Establish access w/large bore IV (20 or greater); Use special tubing that contains a blood filter to screen out fibrin clots and other particulate matter.
7. Double-check ABO and Rh compatibility w/another nurse
Explain specific patient teaching, assessments, interventions, and evaluation of the patient receiving 2 units of PRBCs.
? During the transfusion
1. Run no faster than 5 mL/min for first 15 minutes. Observe patient carefully for adverse reactions.
2. If no adverse reactions, increase flow rate.
3. Continue to monitor for adverse reactions, circulatory overload. Continue to take vitals at regular intervals per institutional protocol.
4. Change tubing after every 2 units to decrease risk of contamination. Be careful to keep administration time no greater than 4 hours to decrease risk of bacterial proliferation
Explain specific patient teaching, assessments, interventions, and evaluation of the patient receiving 2 units of PRBCs.
? Post-transfusion
1. Obtain vitals, compare w/baseline.
2. Dispose of used materials in proper receptacles.
3. Document procedure, noting assessment findings and tolerance to procedure.
4. Monitor patient for response to and effectiveness of procedure. (Pg. 892)
colon cancer is confirmed. The patient is admitted for removal of the tumor and resection of the bowel. Discuss preop teaching appropriate for this patient.
1.Antibiotic requirements
2.Diet before and after surgery
3.Bowel preparation that needs to be taken before surgery; normally cleansing laxatives
4.Post-op management such as monitoring for S/S of infection or paralytic ileus
5. Verbal information about the procedure and what it consists of
6.Make sure patient and family takes active role in care
colon cancer is confirmed. The patient is admitted for removal of the tumor and resection of the bowel. Discuss anticipated postoperative care.
1.Assesses Patient’s responses to the surgery and monitors the patient for complications (infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, organ dysfunction.
2.Provides for patient’s comfort.
3.Teach about wound care, activity, nutrition, and medications.
4.Initiate plans for discharge, follow-up, home care, and treatment as soon as possible.
5.Encourage patient and family to use community resources such as American Cancer Society for support and information.
6.Encourage mobility; turn frequently to prevent abdominal distension and paralytic ileus; also, stimulates peristalsis
3. After 1 round of chemotherapy the patient experiences severe thrombocytopenia and is hospitalized.
? What nursing diagnosis takes priority?
Risk for bleeding
? List at least 10 nursing interventions appropriate for this condition with rationale.
severe thrombocytopenia
1. Assess for potential bleeding: monitor platelet counts. Mild risk: 50,000—100,000; Moderate risk: 20,000—50,000; Severe risk: < 20,000 2. Assess for bleeding: petechiae or ecchymosis [indicates injury to microcirculation and larger vessels]; decrease in hemoglobin and hematocrit [indicates blood loss]; prolonged bleeding from invasive procedures, venipunctures, minor cuts or scratches [indicates blood loss] 3. Instruct patient and family about ways to minimize bleeding: use soft toothbrush or toothette for mouth care [prevents trauma to oral tissues]; avoid commercial mouthwashes [contains high alcohol content that will dry oral tissues]; use electric razor for shaving [prevents trauma to skin]; use emery board for nail care [reduces risk of trauma to nail beds]; avoid foods that are difficult to chew [prevents oral tissue trauma]. 4. Initiate measures to minimize bleeding: draw all blood for lab work with one daily venipuncture [minimizes trauma & blood loss]; avoid taking temperature rectally. apply direct pressure to injection and venipuncture sites for at least 5 minutes [minimizes blood loss]; lubricate lips with water-based lubricant [prevents skin from drying]; avoid bladder catheterizations and use smallest catheter if catheterization is necessary [prevents trauma to urethra]; use stool softeners or increase bulk in diet [prevents constipation and straining that may injure rectal tissue]; avoid medications that will interfere with clotting (e.g. aspirin) 5. When platelet count is < 20,000, institute the following: bed rest with padded side rails [reduces risk of injury]; avoidance of strenuous activity [increases ICP and risk of cerebral hemorrhage]; platelet transfusions as prescribed, administer prescribed diphenhydramine hydrochloride (Benadryl) or hydrocortisone sodium succinate (Solu-Cortef) to prevent reaction to platelet transfusion [allergic reactions to blood products are associated with antigen-antibody reactions that cause platelet destruction]; supervise activity when out of bed [reduces risk of falls]
? What laboratory value/s should be monitored?
severe thrombocytopenia
o Platelet counts should be monitored. A platelet count of < 20,000 is associated with risk of spontaneous bleeding and most patients with platelet counts in this range require platelet transfusion. o Hematocrit and hemoglobin
severe thrombocytopenia
? What medication/s is/are anticipated specific to this nursing diagnosis?
o In limited circumstances, the nurse may administer IL-11 to prevent severe thrombocytopenia and reduce the need for platelet transfusions.
o Platelet transfusions
o Anti-fibrinolytic agents [aminocaproic acid] to prevent significant bleeding
4. The chemotherapy ordered to treat this patient is known to cause alopecia. List appropriate teaching for this patient.
Alopecia [hair loss] can threaten the patient’s body image and self-esteem. A creative and positive approach is essential when caring for patients with altered body image.
1. Discuss potential hair loss and regrowth with the patient and family; advise that hair loss may occur on body parts other than the head [provides information so patient and family can begin to prepare cognitively and emotionally for loss].
2. Explore potential impact of hair loss on self-image, interpersonal relationships, and sexuality [facilitates coping and maintenance of interpersonal relationships]
4. Prevent trauma to scalp: lubricate scalp with vitamin A and D ointment to decrease itching [assists in maintaining skin integrity]; have patient use sunscreen or wear hat when in the sun [prevents ultraviolet light exposure].
5. Suggest ways to assist in coping with hair loss: purchase wig or hairpiece before hair loss [wig that closely resembles hair color style is more easily selected if hair loss has not begun]; if hair loss has occurred, take photograph to wig shop to assist in selection [facilitates adjustment]; begin to wear wig before hair loss [enables patient to be prepared for loss and facilities adjustment]
6. Encourage patient to wear own clothes and retain social contacts [assists in maintaining personal identity]
7. Explain that hair growth usually begins once therapy is completed [reassures patient that hair loss is usually temporary].
5. After 2 rounds of chemotherapy the patient experiences severe neutropenia and is hospitalized.
? What nursing diagnosis takes priority?
Risk for infection
List at least 10 nursing interventions appropriate for this condition with rationale
severe neutropenia
1. Assess patient for evidence of infection: check vital signs every 4 hours, monitor WBC count and differential everyday, inspect all sites that may serve as entry ports for pathogens [IV sites, wounds, skin folds, bony prominences, perineum, and oral cavity
2. Report fever > 101 degrees or
3. > 100.4 degrees for > 1 hour, chills, swelling, heat, pain, erythema, exudate on any body surface
4. Report change in respiratory or mental status, urinary frequency or burning, malaise, myalgias, arthralgias, rash, or diarrhea
5. Obtain cultures and sensitivities as indicated before initiation of antimicrobial treatment [wound exudate, sputum, urine, stool, blood]
6. Initiate measures to minimize infection. Discuss with patient and family: placing patient in private room if absolute WBC count < 1000, importance of patient avoiding contact with people who have known or recent infection or recent vaccination 7. Instruct all personnel in careful hand hygiene before and after entering room 8. Avoid rectal or vaginal procedures (rectal temperatures, examinations, suppositories, vaginal tampons) [incidence of rectal and perianal abscesses and subsequent systemic infection is high; manipulation may cause disruption of membrane integrity and enhance progression of infection] 9. Use stool softeners to prevent constipation and straining [minimizes trauma to tissues] 10. Assist patient in practice of meticulous personal hygiene [prevents skin irritation]
? What laboratory value/s should be monitored?
severe neutropenia
o WBC count with differential
severe neutropenia
? What medication/s is/are anticipated specific to this nursing diagnosis?
o ABX
o filgrastim (Neupogen)
6. Discuss safe practices for administering chemotherapy. Include interventions to ensure the patient’s safety, as well as the nurse’s safety.
1. Teach patient to adhere to premedication regimen before presenting to infusion center.
2. Teach patient about s/s of adverse reactions that may occur at home following discharge from infusion area that may warrant medication administration or immediate transport to ED.
– Hypersensitivity reaction (symptoms range from urticaria, flushing, pruritis to anaphylaxis)
– Extravasation may take several weeks to become apparent. Teach patient to report local pain and inflammation, tissue sloughing and ulceration at administration site. (Pg. 331, 335-336)
3. Select skilled personnel to select peripheral veins (always in the forearm) and initiate venipuncture. NO VESICANT CHEMOTHERAPY IN PERIPHERAL VEINS OF HAND OR WRIST. (Pg. 335, 331)
4. Don appropriate PPE: double-layer of powder-free chemotherapy specific gloves; long sleeve, disposable gowns without seams/closures w/polypro coating.
5. Observe patient for s/s of adverse reaction and/or extravasation. IF EXTRAVASATION SUSPECTED: stop administration immediately. Depending on the drug, attempt to aspirate any remaining drug from the extravasation site.
6. Linens contaminated w/chemotherapy or blood/body fluids of chemotherapy patient plus used supplies should be placed in labeled, closed system, puncture- and leak-proof containers.
7. Emergency spill kits should always be readily available. (Pg. 335-336)
7. After 3 rounds of chemotherapy the patient experiences severe anemia and is hospitalized.
? What nursing diagnosis takes priority?
Impaired Tissue Perfusion
severe anemia
? List at least 10 nursing interventions appropriate for this condition with rationale.
1.Monitor Vital Signs
2.Check for adequate perfusion: capillary refill, skin color, mucous membranes
3.Administer oxygen as needed
4.Monitor Lab Values
5.Administer Prescribed Medications
6.Assess Level of Consciousness
7.Manage fatigue
8.Prioritize activities and establish balance between rest and activity
9.Ensure appropriate nutrition
severe anemia
? What laboratory value/s should be monitored?
RBC/HCT/HGB
severe anemia
? What medication/s is/are anticipated specific to this nursing diagnosis?
Epoetin Alfa (Procrit)
8. The patient’s CBC recovers enough to receive another round of chemotherapy. A new medication is added to the chemo protocol which is known to cause stomatitis.
? What teaching, specific to stomatitis, should the nurse include prior to discharging this patient?
1. Assess oral cavity daily
2.report any oral burning, pain, redness, open lesions, and decreased tolerance to temperature extremes of foods
3.Teach about proper oral hygiene
4.Maintain adequate hydration
5.Soft bristled toothbrush; brush for 90 seconds after meals and at bedtime; allow brush to air dry before storing; floss at least once a day; rinse mouth 4 times a day with bland rinse; use water-based moisturizers to protect lips
6.Avoid irritants such as commercial mouthwashes, alcoholic beverages, and tobacco
The patient develops stomatitis.
? What nursing diagnosis takes priority?
Impaired oral mucous membranes
? List at least 10 nursing interventions appropriate for this condition with rationale.
stomatitis
1.Use bland mouthwash every 1-4 hours to assist in removing debris, thick secretions and bacteria
2.Use soft toothbrush or toothette to minimize trauma
3.Remove dentures except for meals; be certain that dentures fit well to minimize friction and discomfort
4.Apply water-soluble lip lubricant to promote comfort
5.Avoid foods that are spicy, hard to chew, or temperature extremes to prevent local trauma
6.Obtain tissue samples for culture and sensitivity tests of areas of infection to assist in identifying need for antimicrobial therapy.
7.Assess ability to chew and swallow; assess gag reflex. Patient might be in danger of aspiration.
8.Provide liquid or pureed diet to ensure intake of easily digestible foods without chewing
9.Monitor for dehydration because decreased oral intake and ulcerations potentiate fluid deficits
10.Obtain C&S before ABX
? What medication/s is/are anticipated specific to this nursing diagnosis?
stomatitis
dyclonine (Sucrets), diphenhydramine, and lidocaine for localized anesthetic
Systemic analgesics
palifermin (Kepivance) – directly treats oral mucositis
9. The patient is admitted for a trial dose of a new chemotherapy regimen. Severe nausea and vomiting begins 12 hours after infusion of the chemotherapy.
? What nursing diagnosis takes priority?
Imbalanced Nutrition: Less than Body requirements, related to nausea and vomiting
severe nausea and vomiting begins 12 hours after infusion of the chemotherapy
? List at least 10 nursing interventions appropriate for this condition with rationale.
1.Adjust diet before and after drug administration according to patient preference and tolerance.
2.Prevent Unpleasant sights, odors, and sounds in the environment
3.Assess the patient’s previous experiences and expectations of nausea and vomiting, including causes and interventions used
4.Use distraction, music therapy, biofeedback, self-hypnosis, relaxation techniques, and guided imagery before, during, and after chemo
5.Administer prescribed antiemetics, sedatives, and corticosteroids before chemotherapy and afterward as needed.
6.Ensure adequate fluid hydration before, during, and after drug administration, assess intake and output.
7.Encourage frequent oral hygiene.
8.Provide pain relief measures if necessary
9.Consult with dietician if necessary
10.Assess and address any other symptoms such as diarrhea, constipation, fluid and electrolyte imbalance, GI irritations, radiation therapy, medications, or CNS metastases
severe nausea and vomiting begins 12 hours after infusion of the chemotherapy
? What laboratory value/s should be monitored?
Electrolytes-especially Sodium and Potassium
? What measures can be taken to try and prevent the nausea and vomiting prior to receiving this chemo the next time? Give specific medications.
1.Ondansetron
2.Phenergan
3.Guided Imagery, other distraction techniques
4.Adjust diet
5.Relieve Pain
The patient has lost a total of 25 pounds and has no appetite. A diagnosis of anorexia is made. What nursing interventions should be added to the patient’s care plan?
1. Assess and address factors that interfere with oral intake or increased risk of decreased nutritional status
2.Initiate appropriate referrals for interdisciplinary collaboration to manage factors that interfere with oral intake
3. Suggest foods that are preferred and well tolerated by the patient, preferably high-calorie and high-protein
4. Encourage adequate fluid intake, but limit fluids at mealtime
5.Suggest smaller, more frequent meals
6. Promote relaxed, quiet environment during mealtime with increased social interaction as desired
7.Consider cold foods, if desired (less odorous)
8. Encourage nutritional supplements and high protein foods between meals
9. Encourage frequent oral hygiene
10. Address pain and other symptom management needs
11. The patient has completed all of the ordered chemotherapy and now must undergo external radiation therapy. Explain nursing care for the patient receiving external radiation. Begin with the first visit to the radiation oncologist.
1. Volumetric imaging allows the oncologist to plan angles and planes of RT
2. Mark the area to pinpoint treatment and explain the marks to the patient
3. Use evidenced based treatment protocols for toxicities associated with RT
4. Assess the patient’s skin regularly throughout treatments and several weeks after completion
5. Assess nutritional status and general status of well-being
6. Assess lab values
7. Monitor for GI symptoms
8. Explain to patient that they are not radioactive

9.Explain to patient that weakness and fatigue are generalized symptoms of RT
10.Teach patient not to apply lotion or powder to the marked areas because it increases radiation uptake to those areas

12. The radiation therapy has caused severe swallowing difficulty for the patient and TPN is begun. List nursing interventions specific to the TPN. Begin with the patient returning to the nursing unit with a newly placed port-a-cath.
1. TPN may be commercially prepared and then customized in pharmacy based on client’s most recent blood analysis findings—DO NOT ADD TO SOLUTION after it has been prepared by pharmacy
2. Orders are written daily based on current FE needs and protein status—always check order for correct fluid for the day
3. Solution may be refrigerated for up to 24 hours but removed from refrigeration 30 minutes before infusion—DO NOT HANG for >24 hours & change tubing with every new bag
4. Begin at a slow rate (40-60 mL/hr) and gradually increase—must be admin via pump
5. Monitor serum glucose levels regularly; (Q4-6H) RT risk of hyperglycemia; Monitor I&O and weight as well; Monitor for infection because PN harbors perfect environment for bacteria STERILE TECHNIQUE
6. If TPN is temporarily unavailable, hang D10 or D20 until PN solution is available—infusions are initiated and discontinued gradually to allow the pancreas to compensate for increased glucose intake
Due to infection of the port-a-cath, the patient must have a G-tube inserted and start receiving gravity feeding q 4 hrs. Explain what teaching the patient should receive.
1. Gastrostomy is a procedure in which an opening is created into the stomach to administer food, fluids, meds or decompression and is preferred over nasally inserted tubes if needed >4 wks
2. wash the area with soap and water daily, remove encrustations, rinse with water and pat dry
3. evaluate daily for breakdown, irritation, excoriation, bleeding, or hypertrophic tissue growth (candida)
4. aspirate for gastric contents before instilling anything into the tube (gastric acid is usually pH of 4) hold feeding if residual is >200
5. patient needs to be in high fowlers during feedings (left lateral if that is not tolerated)
13. The patient is admitted to the hospital with uncontrolled pain.
What medication orders does the nurse anticipate?
1. Opioid—morphine for severe and oxycodone for moderate
2. Nonopioid—Tylenol/Ibuprofen
3. Adjuvant—antidepressants (amitriptyline- helpful for nerve related pain); anti-seizure meds (gabapentin—nerve related pain); muscle relaxants (baclofen, diazepam—best for short term periods of worsening pain RT tense muscles)
What nursing interventions should be added to the patient’s plan of care related to pain?
1. use pain scale to assess pain and discomfort characteristics: location, quality, frequency, duration,. Baseline and ongoing
2. assure patient that you know the pain is real and that you will assist him/her in pain reduction–>fear increases anxiety–>increases pain
3. assess other factors contributing to pain: fear, fatigue, other symptoms, psychosocial distress
4. provide education to patient and family about analgesic regimen and importance of analgesics (around the clock, long acting, breakthrough pain, etc)—analgesics tend to be more effective when admin early
5. Address myths or misconceptions about use of opioid analgesics—barriers to pain management involve fear of side effects, fatalism, addiction, etc
6. offer nonpharm methods such as distraction, imagery, relaxation, cutaneous stimulation etc—increases options
14. The patient learns 6 months after completion of radiation therapy the cancer has returned and has metastasized to the liver and lungs. A new chemotherapy is started. After three months of this treatment the oncologist tells the patient the cancer is not responding and is in fact spreading. The patient asks that home hospice be started and the physician agrees.

Explain what services hospice will provide.

1. comprehensive interdisciplinary program focusing on quality of life used when cure and control of disease are no longer possible
2. palliation of symptoms, provision of physical, psychosocial and spiritual support
3. Medical appliances and supplies including drugs and biologicals
4. Inpatient care (respite care, short term inpatient for procedures RT pain control and acute and chronic symptom management)
5. Hospice aide and homemaker under supervision of RN 24 hours/day
6. Medical, social worker service and physician services
7. Bereavement services for families up to 13 months following death
What should the patient and family be taught about advanced directives?
1. Advanced directives are legal documents that specify a person’s wishes before hospitalization and provide valuable information that may assist HCP in decision making
2. A living will is one type of AD—individual documents treatment preferences—provides instructions for care in the event that the signer is terminally ill and unable to communicate wishes and is often accompanied by durable power of attorney for healthcare
3. Durable power of attorney for healthcare is another kind—legal document in which the patient identifies a person to make healthcare decisions on his/her behalf when the patient has clarified wishes concerning various situations
4. Physician Orders for Life Sustaining Treatment (POLST): for that translates patient preferences expressed in advance directives into medical “orders” that are transferrable across medical settings and readily available to all HCP, including emergency staff. The form is signed by patient or surrogate and the physician, and is subject to state laws and regs.
5. The patient self determination act requires that Healthcare entities receiving medicare/Medicaid reimbursement must ask if patients have advance directives, and incorporate these into the MR, however these should not be considered a substitute for ongoing communication with patient and family as end of life approaches
As death becomes imminent, what symptoms might the patient experience?
1. patient shows less interest in eating and drinking—offer but do not force fluids and medication—give pain meds in solution under tongue or rectally
2. urinary output may decrease in amount and frequency
3. Mental confusion may become apparent—occurring RT less oxygen available to brain; reorient as necessary in a calm manner
4. secretions collect in the back of the throat and rattle or gurgle as the patient breathes through the mouth—clean mouth frequently, support with pillows, offer water in small amounts
5. breathing may become irregular with periods of no breathing—raise the HOB and know that the moaning sound does not mean that the patient is in distress or pain…it is simply the sound of air passing over very relaxed vocal cords
15. The majority of cancer occurs in the elderly. Discuss normal physiologic changes that occur with aging and the implications of these changes when cancer occurs in the elderly.
1. Impaired immune system— monitor for atypical SS of infection (mental status)
2. altered drug absorption, distribution, metabolism, and elimination—Mandates careful calculation of chemotherapy and frequent assessment
3. Increased prevalence of other chronic diseases
4. Diminished renal, respiratory, and cardiac reserve—be proactive in prevention of decreased renal fx., Atelectasis, pneumonia, and cardiac
5. decreased skin and tissue integrity; reduction in body mass; delayed healing— related to radiation or chemotherapy; monitor nutritional status
6. Decreased musculoskeletal strength—prevent falls;
7. decreased neurosensory function: loss of vision, hearing, and distal extremity tactile sensitivity—provide instruction modified for patients hearing and vision changes; provide instruction concerning safety and skin care for distal extremities
8. altered social and economic resources—assess for financial concerns, living conditions, and resources
9. potential changes in cognitive and emotional capacity—provide education and support modified for patients level of functioning and safety

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