Assessment Two Case Study Information – Interactive Book: Consider the Patient Situation
\nConsider the Patient Situation
\nFortunato (Frank) Rossi, is a 60 year old male who was born in Italy and Migrated to Australia with his wife in 1952, both he and his 58 year old wife Sofia have dual citizenship in Italy and Australia. Frank and his wife practice a strong catholic faith. Frank has worked as a Secondary School Science and Mathematics teacher at a local Catholic Secondary School for over 20 years and loves his job. He is well respected by his colleagues and students with his very -quick wit and sharp mind with problem solving- that he prides himself on
\nSofia has been a stay at home mother and carer for their 2 daughters:
\n\u2022 Eldest Daughter: Anna married Phillip have 2 daughters Bella (6) and Emily (3 months)
\n\u2022 Youngest Daughter: Gabriella married Michael have 1 son (18 months old)
\nTogether they have had a wonderful life, with supportive family visiting from Italy and the Rossi family themselves being able to go over to Italy for many family holidays. Both Frank and Sofia are very excited and enjoying being grandparents, they are looking forward to Frank\u2019s decision for an early \u2019self funded retirement’ to enjoy more time with the family. Frank has arranged with his school to be able to undertake a small amount of casual teaching if he and his family require some small income once he has retired, although he is very keen to work in his garden and spend time helping to raise the grandchildren and enjoy the many years of hard work that he and Sofia put in to support their family and the -good life- they have created in Australia.
\nThree months ago
\nFrank experienced some confusion at work and a seizure -of unknown origin- that was witnessed by his wife and grandchildren. Sofia immediately called 000 and Frank was transported urgently under the care of paramedics to the emergency department (ED) of a major metropolitan hospital as they lived close to the city.
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\nAssessment Two Case Study Information – Interactive Book: Collect Cues and Information
\nCollect Cues and Information
\nBaSSfS cwr\u00abx (\u00ab.g toxXwvr mporti.
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\nCollect cues,’ information
\n(Levett-Jones 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online)
\nFrank has now spent some time in a general medical ward at the Tertiary Level City Hospital that he was originally transferred to by ambulance 2 weeks ago. During his admission the following cues and information were collected and a diagnosis made. Prior to his transfer and admission to the palliative care unit in an outer city hospital closer to his family home
\nPast Medical Hx
\n\u2022 Tonsillectomy as a child
\n\u2022 Ex smoker (quit smoking 25 years ago was a packet a day smoker)
\n\u2022 Diet Controlled type 2 Diabetes
\nCurrent History
\n\u2022 Seizures of unknown origin
\n\u2022 Confusion
\n\u2022 Headache
\n\u2022 Blurred vision
\n\u2022 Difficulties with problem solving and decision making
\n\u2022 Gradual onset of speech disturbance
\n\u2022 Muscle Weakness
\n\u2022 Behaviour Changes
\n\u2022 Vomiting
\n\u2022 Sleepiness
\n\u2022 sluggish pupil response to light
\nGathering new Information
\nFrank’s vital signs upon admission to medical ward
\nRR : 18
\nHR: 84 bpm
\nBP: 185\/95
\nSaO2: 96% on 3Lmin via N\/P (For Comfort measures)
\nRaised Intracranial Pressure (ICP) – constant headache
\nGCS – 9\/15 (eyes open to painful stimuli 2 I confused and disorientated verbal response 4 \/ Abnormal Flexion from painful stimuli 3)
\nIntermittent Patient Notes
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\n-Patient transferred to medical ward following observed seizure of unknown origin by wife and grandchildren who called 000 for paramedic support. In ED patient’s conscious state was altered with confusion and inability to recognise wife-
\n-Pupil size of both eyes was equal however pupillary light reflex is sluggish, positive babinski sign response bilaterally, renal function normal, patient experiencing double incontinence, normal FBE and U&E-
\n-Initial MR! clearly showed abnormalities in the frontal and temporal regions, with a differential diagnosis of metastatic tumors in the brain from an unknown primary-
\nFrank was experiencing Increased Intracranial Pressure likely from brain lesions and possible Diagnosis of a Glioblastoma Multiforme (GBM)
\nDifferential Diagnoses had not yet been ruled out
\n-Patient was administered mannitol every 12\/24 over 16 days to reduce Intra Cranial Pressure (ICR) Lyrica 150mg BD for seizure activity, and Diazepam 10mg PRN….. 5 days post initial seizure pt woke with normal cognitive responses and recognition of family members once ICP had begun to reduce. Progressively pt’s ability to walk without deficit returned. Pt was fully continent, had good long term memory recollection, however short term memory was impacted-
\n-Pt’s oral mucosa had multiple abrasions and thrush evident from possible injury during seizure, patient complained of mouth and throat pain, often refusing to eat and drink-
\n-Differential Diagnoses of ?Infection, ?metastaic cerebral tumors were discussed however following lumbar puncture for collection of cerebrospinal fluid (CSF) specimen, and further MRI results showing rapid tumor growth particularly in Frank’s frontal lobe just 18 days after his initial ED presentation, the diagnosis was highly indicative of a GBM-
\n-Patient and wife agreed to surgical tumor resection as a palliative measure with the knowledge that this was not a cure. Histopathology post surgical resection clearly identified a rapidly growing GBM with temporal lobe metastases as the definitive diagnosis. A family meeting was arranged with the neurosurgeon, oncologist, palliative consultant, social worker, nurse unit manager, Frank and his family to discuss options-
\nConfirmed Diagnosis, medical imaging and histopathology results
\nFollowing CT Brain and MRI it was concluded that Frank had a Glioblastoma Multiforme (GBM) in his frontal lobe which had likely metastasized in both temporal lobes, thus his prognosis was devastatingly a Stage IV GBM with a likely survival of 2 – 3 months without surgical resection and\/or palliative radiation therapy.
\n-Family advised to discuss and complete an Advanced Care Directive whilst Frank was competent with the knowledge that his ICP was likely to increase again, and a decision on how to proceed with interventions was needed. Palliative radiotherapy was offered to Frank, he and his wife refused and decided to be transferred to an inpatient palliative care unit closer to their family where he could go home on day visits and also spend more time with his family at the palliative care unit, rather than in a busy medical ward-
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\nAssessment Two Case Study Information – Interactive Book: Processing Information
\nProcessing Information
\nProcess infor motkwi
\nIfSUMPf\u2019M mvMysetWa 10Comoro an understand\/^ of atyu ex symptoms. Compare nwmat Vs abnormal
\nDaSCflftWte Ctyztgmsn rcto.act from \/rexTrtKtf NMomvu-iOn focogpis* ncons*stonaos nano* down me mfprms\u2019Km to what\u00ab most \u00bbmpo tant aixl recognise (yip* in ct\/*R coMected
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\nconsoquetKOs.
\nb\/iV; ctMtont equation to past
\n6.v.htlx ft& or cumwt: patient to past pationh. (utuaSy an vxptwt thought ptocew}.
\nPj8C \u00ab1 an outcome (mwaliy an ?xpert Ihoughl procew)
\nArrival and Admission to the Palliative Care Unit
\nFrank expressed some personal family history and wishes for his disease progression
\n-Frank informed medical and nursing staff that his father had died from a GBM, restless, undignified crawling on the floor from terminal restlessness and his only desire was to not die like his father had-
\n-Nil Advanced Care Directive had been completed with Frank and Sofia as they thought they still had plenty of time when informed about an ACD on the Medical Ward. However, with Frank’s fluctuating ICP and disorientation he is now deemed incompetent for any legal decisions or changes to his Will-
\n-Sofia was Frank’s medical Power of Attorney, presenting paperwork to support this to the admitting palliative Care Team-
\n-Sofia stayed with Frank during his admission and together they communicated that they wanted him to be comfortable and dignified-
\nMedications Commenced once reviewed by Palliative Care Team
\n\u2022 Dexamethasone: 8mg BD oral or S\/C (0800 and 1400) – To aid in reduction of ICP and Pain Relief from headache (Consider side effects and behavioural changes from dexamethasone – How can these be managed?)
\n\u2022 Lyrica : 75mg BD Oral (0800 and 2000) – To manage seizure activity (consider side effects ofLyrica, are there other options that could be considered for Frank?)
\n\u2022 MS Contin 10mg BD Oral (0800 and 2000hrs) – Analgesia
\nPRN Medications
\n\u2022 Morphine 5-1 Omg S\/C
\n\u2022 Midazolam 2.5-5mg s\/c
\n\u2022 Ondansetron 8mg wafer (maximum dose of 16mg in 24 hours ) for nausea and vomiting
\nUpon arrival and admission to the palliative care unit the following referrals were made
\n\u2022 Physiotherapist review for assessment of walking aid due to increasing parasethsia and weakness in Frank’s legs
\n\u2022 OT home assessment and equipment for home visits
\n\u2022 Dietician to review loss of appetite, cachexia and anorexia
\n\u2022 Pastoral care
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\nAssessment Two Case Study Information – Interactive
\n\u2022 Catholic Priest visits and wish to be anointed ASAP
\nBook: Processing Information
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\nAssessment Two Case Study Information – Interactive Book: Identifying problems\/issues
\nIdentifying problems\/issues
\nProcess
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\nEOiS-ct an outcome (usually an eipen mougru process).
\nConsiderations for the Palliative Care Setting
\nFrank arrived on the Palliative Care unit late on a Sunday afternoon at 2pm, he was welcomed by his RN who undertook the following assessments and discussions between him, his wife and two daughters:
\n\u2022 Welcome and orientation to the ward
\n\u2022 Falls Risk Assessment
\n\u2022 Braden Pressure Risk Assessment
\n\u2022 Pain Assessment
\n\u2022 Allied Health Referrals made
\n\u2022 NOK contact details
\n\u2022 Modified Karnofsky Score of 40-50
\n\u2022 RUG-ADL10+
\n\u2022 SAS Tool Partially Completed 5 of the 7 symptoms only (planned to discuss fatigue and bowel issues tomorrow as patient was sleepy and Sofia had gone home to get clothes and come back to sleep the night at the palliative care unit
\n\u2022 Palliative Care Phase – -Deteriorating-
\nWhat might be some things I need to consider as an RN caring for Frank and his family ?
\n\u2022 National Palliative Care Standards ?
\n\u2022 NSQHS Standards?
\n\u2022 NMBA Standards?
\n\u2022 What do I know about GBM illness Trajectory?
\n\u2022 How will I recall information on GBM?
\n\u2022 Where are some of the best locations to access EBP on GBM and current standards of care?
\n\u2022 What is my role in supporting Frank’s wife and family?
\n\u2022 What is a SAS Tool?
\n\u2022 What is the Problems Severity Score\/ (PSS)
\n\u2022 What is a Modified karnofsky Score?
\n\u2022 What is a RUG-ADL Score?
\n\u2022 How do I determine the Palliative Care Phase that the patient is in?
\n\u2022 Do I need to start having some difficult conversations and ask Frank and his wife what they understand about his prognosis?
\n\u2022 What some of the complications that Frank may face?
\n\u2022 Are there any specific symptoms that I should be looking for when developing Frank’s care plan?
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\n\u2022 What is the pathophysiological response when someone dies from a GBM?
\n\u2022 What should I expect?
\n\u2022 Am I ready to deal with this?
\n\u2022 Where do I get support as an RN if i feel overwhelmed?
\n\u2022 Have I thought enough about my own well being and resilience for this professional soeciality?
\n\u2022 How do I care for a deceased person?
\n\u2022 How will I know what to say?
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\nAssessment Two Case Study Information – Interactive Book: Establishing Goals and Taking Action
\nEstablishing Goals and Taking Action
\nDKCntie \u00bb nut you wan! to tuppon. a desired outcome, a time frame.
\n(Levett-Jones, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online)
\nMonday Morning
\nDuring handover the day after Frank was admitted to the Palliative Care Unit we are told that he had a fall overnight trying to get to the toilet and became confused as he was unable to void, telling the nursing staff that his -feet felt numb-.
\nFrank was reviewed by the Night General Medical Registrar who in consultation with the Urology Registrar decided to insert an IDC into Frank as on the bladder scan it showed that he had 800 mis in his bladder, and was in obvious discomfort from urinary retention. During this procedure the medical and nursing staff gave Frank a breakthrough of s\/c morphine 5mg to assist with his discomfort. He had a full neurological assessment with lower limb weakness evident, however nil skin tears, breaks or lacerations to the body or head. Frank appeared slightly confused, although was orientated to place and person.
\nFrank was sent for further scans in the morning showing spinal metastases and a rapidly advancing spinal cord compression, that are considered rare but seen in cases of GBM. Spinal cord compression in these cases are known as drop metastasis whereby cellular spread within the sub-arachnoid space travels within the cerebrospinal fluid (CSF) onto the actual spine as an effect of gravity usually settling and growing in the lower thoracic and upper lumbar spine regions (Shripad, et al, 2015 – Research Paper Writing Help Service).
\nTalking with Frank and his wife
\nFrank and his family are devastated by the news of the rapid progression and the knowledge that he is losing more independence with an inability to walk, and control his urinary and faecal continence. Frank becomes very withdrawn and refuses to take his medication and eat.
\n(Levett-Jones, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online)
\nWednesday Afternoon
\nhttps:\/\/leo.acu.edu.au\/mod\/book\/view.php?id=3272423&chapterid=300551
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\nThe afternoon shift nurse walked in to introduce herself and found Frank alone as his wife had left only half an hour ago, his breathing is short, shallow and laboured, with a respiratory rate of 6, Frank is aggitated and trying to crawl out of bed, removing his clothes and pulling out is S\/C breakthrough Intima’s (s\/c butterfly).
\nThe Palliative Care Team review Frank and recognise signs and symptoms of terminal restlessness likely from an inreased ICP and ongoing disease growth. Frank’s wife is called and informed of his sudden alteration in behaviour and advised that a syringe driver was required to be commenced as his refusal to take his oral medication particularly his dexamethasone may have contributed to this cerebral oedema. Sofia agrees to subcutaneous medication being commences as she promised him when his father was dying that she would do whatever she could to make sure he died with dignity and respect. Sofia began making her way back to the Palliative Care Unit with her family.
\nhttps:\/\/leo.acu.edu.au\/mod\/book\/view.php?id=3272423&chapterid=300551
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\nAssessment Two Case Study Information – Interactive Book: Evaluating and Identifying new problems
\nEvaluating and Identifying new problems
\nD\u2019.\u2019SCr hi! what you w, tit to happen, a des red OblcooHi. a time frame.
\n(Levett-Jones, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online)
\nWednesday Evening
\nFrank has been unresponsive, and experiencing periods of apnoea since earlier this afternoon. He has been commenced on a syringe driver containing dexamethasone, morphine and midazolam. Frank has not spoken to his family since they arrived nor has he held or squeezed Sofia’s hand.
\nFrank is now fully bed bound thus his Modified Karnofsky Score is 10, with him now in the -Terminal- Palliaitve Care Phase.
\nFrank is on a pressure mattress, and is being turned every 2-4 hours or when exhibiting sounds or signs of moaning or restlessness to maintain comfort and skin integrity, this takes x2 nursing staff to perform this care, along with full mouth care as he is now longer eating or drinking.Frank’s RUG-ADL total is now 8
\nSyuli?2xsr facts and
\n\u00a6 rfer&ncos to make a
\ntbo patient’s psobtom.
\nWednesday Night \/ Early Thursday Morning
\nThroughout the night Frank’s family remains by his side listening to his -rattly breathing-, nursing staff position Frank from side to side regularly rather than on his back to ensure that terminal secretions drain from his mouth, he is administered PRN doses of glycopyrroalate S\/C as an anticholinergic agent to aid in excessive secretions and try to ease his work of breathing.
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\nAt 0215 hours Frank’s periods of apnoea began to change to Cheyne-Stoking upon examination Frank\u2019s pupils had become fixed and dilated, he was cyanosed around his mouth, on his fingers, toes and knees. Frank’s family was with him in the room when within a few short minutes he ceased breathing and died. His death was much faster than his family had anticipated leaving staff to support them and explain the results of raised ICP and brain herniation into the brain stem, that can occur with a GBM diagnosis.
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\nAssessment Two Case Study Information – Interactive Book: Reflection
\nReflection
\n(Levett-Jones, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online)
\nQuality of Life Considerations
\nConsider some of the following as you select one of the clinical practice guidelines supplied in the assessments folder to assist you with working through Frank’s diagnosis, surgical preparation and move to the palliative care setting all in a matter of weeks from the time he was diagnosed with a terminal illness from being at a stage in his life that he had worked for to retire and enjoy his family.
\n\u2022 Headaches are multifactorial for patient’s with a GBM causing not only physical pain but social, psychological and emotional issues as they find their social lives being limited related to the reminder that they have a life limiting illness that is a painful psychological reminder of the poor prognosis of a GBM (Bennett, et al, 2016: 2024 – Do my homework – Help write my assignment online)
\n\u2022 Rapid diagnosis and disease progression leaves little time to consolidate and prepare for death – spiritual needs must be considered
\n\u2022 Was an adequate pain scale used?
\n\u2022 A rapid decline like Frank’s does not give the patient nor the family time to prepare, are there any other interventions that could have been considered to assist Frank’s family after his death ?
\n\u2022 How can Frank\u2019s family be provided support and continuing bereavement follow-up ?
\n\u2022 Consider the adequate and detailed use of the SAS tool
\n\u2022 Is there anything that could have been done to ensure that Frank had his dexamethasone to assist with his raised ICP?
\n\u2022 Does Frank have a right to refuse treatment ? Was he competent to make this decision?
\n\u2022 What can nursing staff provide families and the deceased patient to aid them in their grief, loss and need to say goodbye?
\n\u2022 Are the National palliative Care standards considered in the CPG?
\n\u2022 Were the NMBA and NQHS standards considered in the CPG?
\n\u2022 Can the CPG be improved in any way to assist its affiliation with care planning, assessment tools and care provided in the palliative setting?
\n\u2022 What is your responsibility as an RN to understand the disease trajectory of your patient’s, plan their care and the care of their loved one’s through the knowledge of nursing standards?
\nConsider these points and the many others that you may have also thought of as you reflected on Frank’s short and aggressive journey with a GBM diagnosis.
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\nAssessment Two Case Study Information – Interactive Book: Clinical Practice Guidelines
\nClinical Practice Guidelines
\nCPG’s
\nWhat are they?
\nWhy are they important?
\nHow do they help us to maintain high levels of care?
\nDo we improve our care by reflection and updating CPG’s through evidence Based research?
\nFrank\u2019s Case Study
\nAs described in the Unit Outline you are now required to:
\n\u2022 Three CPG’s are on the LEO tile select ONE of the Clinical Practice Guidelines provided on the Assessment LEO tile
\n\u2022 Two of these CPG’s are correct for this case study whilst one is NOT (Selecting the correct CPG as per criteria 3 of the Paper Writing Service – Topic Examples – Rubric) is essential within the workplace.
\n\u2022 The CPG’s to select from are:
\no Care of the Dying patient
\no Organ and Tissue Donation
\no Managing Psychological Issues inclusive of Terminal Restlessness
\n\u2022 Review and critique the care given to Frank against the CPG you have selected and providing evidence to support your critique through other additional research that you will undertake
\n\u2022 Highlight the importance of the many standards and how they influence our practice
\no NSQHSS and\/or
\no NMBA standards and\/or
\no Palliative Care standards
\n\u2022 Demonstrate knowledge on the illness trajectory of a Glioblastoma Multiforme (GBM) in line with palliative Care principles
\n\u2022 Provide links between the case study and your chosen CPG to identify highlights or limitations in care
\n\u2022 Where any areas of the CPG omitted in the care?
\n\u2022 Do you believe that the CPG requires updating? If so support with contemporary literature
\n\u2022 Ensure that your sources are all contemporary (within the last five years) and from evidence based sources)
\n\u2022 Read all instructions and the rubric very carefully
\n\u2022 PLEASE NOTE, YOU DO NOT NEED TO INCLUDE ALL OF THE POINTS ABOVE IN YOUR ESSAY. THESE ARE GIVEN TO YOU TO ENVOKE THOUGHT PROCESS.
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\nSystematic review, metaanalysis, qualitative metasummary
\nRandomised & non-randomised trials
\nCohort study
\n(Borbasi, Jackson, East, 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers)
\nPrevious: Reflection
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