Nursing Care Plan A Client with Cancer James Casey, age 72, is of Northern European heritage. He has moved in with him to provide care and sup been receiving medical care for the chronic obstructive pulmonary port during his final months. The daughter has the ac- disease, chronic bronchitis, status postmyocardial infarction, and accepts, saying she is glad to be able to spend this time with her fa- type I diabetes mellitus for over 15 years. He reports that he lost her; she has been informed of the physical and emotional stress of his wife from lung cancer 5 years ago and still" misses her terribly." this will entail. He describes his bad habits as smoking two packs of cigarettes a day for 52 years (104 packs/year), one to two six-packs of beer an ASSESSMENT week, one " bourbon and water" a night, and "a lot of sugar-free Glynis Jackson, RN, the hospice nurse assigned as case manager junk food, like french fries." He assures the nurse that he quit for James Casey, completes a health history and physical exami- smoking 2 years ago, when he could no longer walk a block with- nation during her first two visits in his home, 1 day apart. She out considerable shortness of breath, and just quit drinking alco- gathers this information over 2 days to conserve his strength hol a few weeks ago at his physician’s insistence. About a year and allow more time for James and his daughter to talk about ago, he had a basal-cell carcinoma removed from his right ear. Six their concerns. months ago, cancerous tumors were discovered in his bladder, During the physical assessment, Glynis notes that James is pale and he underwent two 6-week chemotherapy courses of bladder with pink mucous membranes, thin with a wasted appearance instillations of BCG. His latest report indicates that the tumors and a strained, worried facial expression. He complains of severe have grown back and no further chemotherapy would be useful. back pain no longer adequately relieved by Percodan and Vicodin The urologist had considered surgery but believed that James’s alternating every 2 to 4 hours. His blood pressure is 90/50, right other medical problems would compromise his chances of sur- arm in the reclining position with no significant orthostatic vival. James decides to let the disease run its course and to be change; his apical pulse is 102, regular and strong; respiratory rate managed at home through hospice care. Because he lives alone 24 and unlabored; breath sounds are clear but diminshed in the in a modest home, he asks his daughter, Mary, and her family to bases; oral temperature is 96.8.F. (continued) Nursing Care Plan A Client with Cancer (continued) A tunnelled Groshong catheter as a VAD PLANNING AND IMPLEMENTATION is present in the right anterior chest. There is no . Ask about favorite foods, and ask Mary to offer a small portion drainage, redness, or swelling at the site. The catheter was placed of one of these foods each day. last week when the client was being evaluated at the anesthesiol- Encourage drinking up to four cans of liquid nutritional supple- ogist’s office for pain management, but no medication is running ment with fiber a day, sipping them throughout the day. via the VAD. Mary reports that his urinary output is adequate. Talk with the physician about prescribing a medication to help Approximately 200 mL of yellow, cloudy, nonmalodorous urine is stimulate the appetite. present in the urinal at the bedside from his last voiding. Plan to have a home health aide come to the home, give him a James states that he spends most of his time either in bed or shower or bed bath daily, and assist his daughter with some of sitting up in a chair in his room. He reports that he has no energy the household chores. any more and is unable to walk to the bathroom unassisted, dress Talk with Mary about having her adult son and daughter relieve himself, or take care of his own personal hygiene. Glynis rates her of the housework and stay with James so that she can get James’s functional level at ECOG level 4: capable of only limited out of the house occasionally. Offer to talk with them if she is self-care, confined to bed or chair 50% or more of waking hours uncomfortable doing so. (Karnofsky 10 to 20). He tells the nurse that his daughter "is work- Request a volunteer to spend up to 4 hours a day, twice a week ing day and night to help me and is looking awfully tired." with James so that Mary can attend to outside activities and Many reports that James is eating very poorly: He usually eats a chores. small bowl of oatmeal with milk for breakfast and vegetable soup Talk with the anesthesiologist, and work out a pain control pro- and crackers for lunch, but he tells her that he is too tired for dinner gram, using the VAD and a CADD-PCA infusion pump with a and wants only fruit juice. James tells the nurse that he has no ap- continuous morphine infusion.

petite and eats just to please Mary. He does drink at least three to four Call the infusion therapist to set up the equipment and supplies glasses of water a day plus juice. His fingerstick blood sugars remain (including the medication) for the morphine infusion. within normal range. Teach how to use the pump and about the side effects of the His current weight is 120 pounds at 67 inches tall, down from morphine infusion, including those that require a call to the 180 pounds a year ago. He has lost about 30 pounds over the last nurse for assistance. Teach which untoward effects should be 2 months. reported. Available laboratory values from his visit with the doctor show Request a physical therapy consultation to evaluate current the following:

level of functioning and determine how to maintain current Total protein: 4.1 g/dL (normal range: 6.0 to 8.0 g/dL) level. Albumin: 2.2 g/dL (normal range:3.5 to 5.0 g/dL) Instruct Mary to allow ample rest periods for James between Hemoglobin: 10.2 g/dL (normal range: 13.5 to 18.0 g/dL) activities. Hematocrit: 30.5% (normal range: 40.0% to 54.0%) Order a hospital bed with electronic controls to be delivered to BUN: 30 mg/dL (normal range: 5 to 25 mg/dL slightly higher in the house. older people Order a special foam pad for bed and chair and a bedside com- Creatinine: 2.2 mg/dL (normal range: 0.5 to 1.5 mg/dL) mode from the medical supply house. Instruct Mary and the home health aide to inspect skin daily, DIAGNOSIS give good skin care with emollient lotion after bathing, and Imbalanced nutrition: Less than body requirements related to report any beginning lesions immediately to the nurse. anorexia and fatigue Risk for caregiver role strain related to severity of her father’s ill- EVALUATION ness and lack of help from other family members James Casey did increase his oral intake a little, sometimes eating Chronic pain related to progression of disease process the special treats his daughter prepared and drinking one or two . Impaired physical mobility related to pain, fatigue, and begin- cans of liquid nutritional supplement a day. However, his weight ning neuromuscular impairment did not increase; it stayed at about 120 pounds until his death Risk for impaired skin integrity related to impaired physical mo- 2 weeks later. His daughter was very grateful for the extra help bility and malnourished state from the home health aide and the volunteer, though she could not bring herself to ask her son and daughter for help and did not EXPECTED OUTCOMES want the nurse to do so. She did become more rested and re- . Increase oral intake and show improvement in serum protein ported that "Dad and I had some wonderful 3:00 A.M. talks when values. he couldn’t sleep." Daughter will be able to maintain supportive caretaking activi- James was started on 20 mg of morphine per hour with bo- ties as long as James needs them. luses of 10 mg 4 times a day, for breakthrough pain. This medica- Minimal pain for the rest of his life. tion relieved his pain quite well; after 2 days he was alert enough Able to continue his current activity level. most of the time to carry on a normal conversation and still walk Maintain intact skin. to the bathroom with help up until 2 days before he died. The hospital bed simplified James’s care and made it much 3. One of the specified interventions was to easier for him to rest comfortably and change position. His skin consult the physician regarding medication remained intact and in good condition. to increase James’s appetite. What medications might fulfill that Mary reported that James died peacefully in his sleep, about function? What side effects might they have that would con- 2 weeks after care was started. She said spending the last weeks of traindicate these medications for him? his life together was a healing experience for both of them. 4. If James had developed signs and symptoms of sepsis, what manifestations would you expect to see? As the nurse making Critical Thinking in the Nursing Process the home visits, what would be your nursing actions, and in 1. What other tests could be done to evaluate James Casey’s what order of priority? nutritional status? See Evaluating Your Response in Appendix C. 2. James had severe back pain. What were the possible patho- physiologic reasons for his pain?