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