The Cowboy: Hospice Care and the Terminal Esophageal Cancer Patient

Kay M. Sackett, EdD, RNDecember 16, 2010

Selected Pertinent Patient InformationJS 56 year old Male  Born 08/29/1945  Unmarried, long term

girlfriend  Two living siblings  Retired Navy Enlisted  Retired Barber  Cowboy  Artist  

History of PTSD  Alcohol abuse  Chronic Smoker 3-4

packs/day  Diagnosed Esophageal

Cancer Stage 4B June 2009  

Home hospice provided by long-term girlfriend

Moravian

Current HistoryChronic nonproductive cough

 History of hypertension

currently on no medications  

Dyspnea on exertion and shortness of breath when resting required O2 @ 2-3 L prn via nasal prongs  

Chronic anemia with Hgb 5 si units (Normal male 8.7-11.2) Hematocrit .32 (Normal 0.42 - 0.52) equals low RBCs volume and hypoxemia  

Chronic fatigue  

PTSD with periods of confusion  Generalized weakness  Chemotherapy and radiation

treatments begun but aborted per patient request after week 6 due to radiation burns of the throat, esophageal strictures

Current pain medications include:Oxycotin 30 mg po q 8 hours; Fentanyl Patch 75mg. changed

q 2 days; Tylenol 650mg po x 2 q 4hours

prn; Dulcolax Suppository 1 daily

prn,Imodium 5 ml. po prn

Today’s Foci

JS C/O chronic intractable pain in the neck, esophagus and shoulders

JS desire to use nonpharmacological pain relief in the form of Healing Touch

PathophysiologyStage IV esophageal cancer is divided into

stage IVA and stage IVB, depending on where the cancer has spread.

Stage IVA: Cancer has spread to nearby or distant lymph nodes.

Stage IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body.

http://www.cancer.gov/cancertopics/pdq/treatment/esophageal/Patient/page2 - Keypoint13

Nursing Physical AssessmentPupil equal and responsive to

light (PERLA)Respirations 16-18B/P 126/78Pulse 80 at rest 96 on exertionPositive bowel sounds X4 prn

incontinenceGU has a foley draining cloudy

increasingly yellow urineSkin dry and intactAlert and oriented X3 with some

periods of confusionAlternating black tarry stools

and constipationRequires assistance with

ambulation due to positive risk of fall

Peripheral pulses wrist +2 ankles +1Pain assessment = check for quality,

duration, severity, location, aggravating and/or alleviating factor Intense, constant 0-10 scale is

always between a 9-10 in the neck and shoulders

Chemotherapy and radiation therapy discontinued by patient.

Hospice care with palliative measures related to pain control and nutrition

Pharmacological Pain Management includes:

Oxycotin 30 mg po q 8 hours; Fentanyl Patch 75mg. changed q 2

days; Tylenol 650mg po x 2 q 4hours prn; Dulcolax Suppository 1 daily prn,

Imodium 5 ml. po prnO2 @ 2-3 L prn via nasal prongs

Nursing Diagnoses http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

Chronic pain arising from actual or potential tissue damage or defined in terms of such damage  

 NANDA Definition:

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.  

Energy Field Disturbance………….  NANDA Definition: A disturbance of the flow of energy

surrounding a person’s being which results in disharmony of the body, mind and/or spirit

Care Giver Role Strain…………..  

NANDA Definition The focus of this care plan is on the supportive care rendered by family, significant others, or caregivers responsible for meeting the physical and/or emotional needs of the patient  

 

Sample Patient Goal and Nursing Outcomes Classification Patient Goal Nursing Outcomes

Classifications (NOC) Patient verbalizes

acceptable level of pain relief and ability to engage in desired activities

Pain control  

Quality of life  

Family coping

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=41

Nursing InterventionsNursing Interventions Classifications (NIC)http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index

Pain managementHeat and coldSimple MassageHealing Touch (Not NIC) closest relevant are Therapeutic Touch

and Energy Management

http://www.rncasemanager.com/articles/NursingInterventionsClassificationLabelsDefinitions.pdf

Nursing Care Plan Chronic Painhttp://www1.us.elsevierhealth.com/Evolve/?site=/MERLIN/Gulanick/

Ongoing AssessmentAssess pain characteristics:

- Quality (e.g., sharp, burning)- Assess the patient’s perception of the

effectiveness of methods used for pain relief in the past.--Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain.

- Evaluate gender, cultural, societal, and religious factors that may influence the patient’s pain

Nursing Care Plan Chronic PainTherapeutic Interventions

Acknowledge and convey acceptance of the patient’s pain experience. The patient may have had negative experiences in the past with attitudes

of health care providers toward the patient’s pain experience. Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship.

Provide the patient and family with information about chronic pain and options available for pain management.

Lack of knowledge about the characteristics of chronic pain and pain management strategies can add to the burden of pain in the patient’s life.

Assist the patient in making decisions about selecting a particular pain management strategy.

Guidance and support from the nurse can increase the patient’s willingness to choose new interventions to promote pain relief. The patient may begin to feel confident about the effectiveness of these interventions.

Nursing Care Plan Chronic PainEducation/Continuity of Care Teach the patient and family about using

nonpharmacological pain management strategies:Cold and/or heat applications

Massage of the painful area Healing Touch

Knowledge about how to implement nonpharmacological pain management strategies can help the patient and family gain maximum benefit from these interventions.

Determining the Level of Evidence Based Practice

Search Strategy

Evidence-Based Hierarchy

Meta-analysis

Randomized-controlled trials

Clinical trials without randomization

Systematic ReviewsNon-experimental studies

Uncontrolled studiesConsensus reports, clinical guidelines

Qualitative studies, expert opinionClinical expertise, intuition, anecdote

(Sackett & Jones, 2005)

Articles for EBP AssignmentCassileth, B.R. & Vickers, A.J. (2005). High Prevalence of Complimentary and

Alternative Medicine Use Among Cancer Patients: Implications for Research and Clinical Care. Journal of Clinical Oncology, Vol 23, No 12, pp 2590-2592.

Freese, J. (2003). Healing Touch in the Hospice Environment. Healing Touch Newsletter. Volume 03, Number 4, p. 6-7.

Langford, R.M. (2006). Pain management today-what have we learned? Clinical Rheumatology 25 (Suppl 1): S2-S8.

O’Mathuna, D.P. (2000). Evidence-Based Practice and Reviews of Therapeutic Touch. Journal of Nursing Scholarship, 32:3, 279-285.

Post-White, J., Kinney, M.E., Savik, K., Gau Berntsen,J., Wilcox, C. & Lerner, I. (2003). Therapeutic Massage and Healing Touch Improve Symptoms in Cancer. Integrative Cancer Therapies 2(4), pp. 332-344.

Van den Beuken-van Everdingen, M.H.J., de Rijke, J.M., Kessels, A.G., Schouten, H.C., van Kleef, M & Patijn, J. (2007). Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology. Advance Access published March 12 2007.

Wardell, D.W. & Weymouth, K.F. (2004). Review of Studies of Healing Touch. Journal of Nursing Scholarship. 36:2, 147-154.

EBP AssignmentReview articles provided about chronic pain

in cancer patients and use of selected complimentary and alternative therapies including Healing Touch for nonpharmacological treatment

In which tier of the evidence based hierarchy do you place the article?

In which tier of the search strategy hierarchy do you place the article?

Evaluation NEEDS WORK!!!!!Patient moved from home hospice care

provided by girlfriend to hospice facility  Nursing staff and physician assessed need for

change in pain/medication management (NIC categories) due to increased intractable and unreliaved pain, change in mentation, and  

Change in pain/medication protocol to provide better pain control

Continuation of Healing Touch per patient request

Recommendations

Continue chronic pain medication management to keep patient as comfortable as possible

Continue non pharmacologic Healing Touch at the hospice facility per patient, girlfriend and family request

The Cowboy: A Self Portrait

DebriefingAim of the presentation

The aim of this presentation was toAssessment of whether this was

accomplished

Thank you for the opportunity to interview for a faculty position at Virginia Commonwealth University.

Questions and Answers