Work Book on the Case Scenario of Mr. Thomas Dwight

Answer

NSB334 Assessment Task 1: Work Book on the Case Scenario of Mr. Thomas Dwight

Question 1a.

Two strategies for facilitating early detection of bowel cancer are faecal occult blood test (FOBT) and colonoscopy test. FOBT is an immunochemical test in which individuals can complete at the comfort of their homes and mail it to the National Bowel Cancer Screening Program’s (NBCSP) pathology laboratory for analysis. Laboratory findings are then sent to the individual/participant, his/her General Practitioner, and those with positive FOBT test are referred to a General Practitioner (NBCSP, 2015, p. 4). Colonoscopy is an endoscopic examination of the entire colon with a sensitivity of >95% for colorectal cancers. It is indicated for visualisation of the entire colon and for detection of proximal and distal lesions. Besides, colonoscopy can be used for removal of lesions at the time of their detection (Simon, 2016, p. 971).     

Question 1b.                                                                          

Barriers for patients accessing FOBT test include General Practitioner’s (GP) preferences for colonoscopy over FOBT and poor population awareness about the test. Australian GPs tend to prefer colonoscopy since they can immediately diagnoses and begin management of polyps or colorectal cancers. On the other hand, the population’s lack of awareness about FOBT and its effectiveness is another key barrier of access (NBCSP, 2015, p. 9). Barriers for patient access to colonoscopy test include associated costs and the risks posed by the test such as bleeding and bowel perforations (Simon, 2016, p. 971).

Question 2a.

1. Educating the patient about bowel cancer pathophysiology and the need of to carry-out Hartmann’s procedure with intend of getting informed consent (Hallam, Mothe, & Tirumulaju, 2018, pp. 305-6).
2. Educating the patient about the risks associated with permanent stoma following the Hartmann’s resection (Hallam, Mothe, & Tirumulaju, 2018, p. 305).

• Educating the patient about stoma and stoma bag management approaches and how to reduce risk of complications such as surgical site infections, leakage, and parastomal hernia (Wasserman & McGee, 2018, pp. 157,160).

1. Educating the patient about the importance of cessation of oral hypoglycemics and not anything orally 24 hours before the scheduled time of the procedure (Hochberg et al., 2019, pp. 737-8).

My Response to Question 2b.

            Patient education should be offered by a multidisciplinary team. The first education strategy to be used is the direct patient engagement in a face-to-face education sessions while responding to patients’ and their concerns (Wasserman & McGee, 2018, p. 160). Members of a multidisciplinary should use plain language when delivering oral education to the patient (Parnell, 2015. P. 115). The other strategy is to provide the patients with self-directed learning materials such as audio-visual aids and printed education materials with pictorials (Wasserman & McGee, 2018, p. 160).

Question 2c.

            The effectiveness of the education sessions can be evaluated by letting the patient ask question during and/or at the end of each sessions and by asking the patients critical questions to confirm that he has understood all concepts that have thought previously (Maclachlan et al., 2016, p. 625).

Question 3a.

            Four observations that should be made around the skin surrounding the stoma post-operatively include peristomal abscess, prolapse, leakage, and retraction (Steinhagen, Colwell, & Cannon, 2017, p. 186).

Question 3b.

            Complications such as prolapse and retraction may require surgical revision (Steinhagen, Colwell, & Cannon, 2017, p. 186).  Peristomal abscess is treated with oral antibiotics and if there is severe tissue infection, then the patient should be administered parenteral antibiotics (Steinhagen, Colwell, & Cannon, 2017, p. 190). Leakage can be corrected by proper stoma bag adjustment. If the leakage becomes chronic, then the patient should be given a properly fitting pouching system (Steinhagen, Colwell, & Cannon, 2017, p. 187).

Question 4a.

            Bowel obstruction may occur as a terminal complication of peritoneal carcinomatosis. It can present as a malignant bowel obstruction distal to the ligament of Treitz and secondary to either the extra-abdominal malignancy (breast cancer and melanoma) (rarely) or the primary intra-abdominal malignancy in most cases (metastatic gastric cancer and colorectal cancer) (Franke et al., 2017, p. 427).

Question 4b.

            Pathophysiology of malignant bowel obstruction include bowel distension due to building of gastric contents and voluminous digestive secretions. A patient may also experience obstipation or defecation inabilities as a result of complete obstruction. The symptom is paradoxical diarrhoea, which may suggest partial obstruction (Franke et al., 2017, p. 427).

Question 5a.

            Four adverse effects that might be seen when administering blood product to Mr. Dwight include anaphylactic shock, febrile non-haemolytic transfusion reaction, septic shock and transfusion-associated circulatory overload (Suddock & Crookston, 2019, pp. 6-7). Anaphylactic shock may occur as a result of hypersensitivity reaction to foreign proteins in the blood products. Febrile-non-haemolytic transfusion reaction is caused be cytokines, which are released from the leukocytes of the donor blood.  Septic shock is caused by bacterial by-products such as endotoxins or bacterial contamination of the transfusion blood products (Suddock & Crookston, 2019, p. 6). Lastly, transfusion-associated circulatory overload occurs when the volume of the transfused blood leads to hypervolemia (Suddock & Crookston, 2019, p. 7).

Question 5b.

            In case of suspected adverse reactions during blood transfusion, a registered nurse should take the following actions. The first step to take is to stop the blood transfusion process immediately. The intravenous line should be maintained open using 0.9% saline solution. The second step is to perform a clerical check to confirm the patient’s identification and to examine the product bag. The third action is to take the patient’s vital signs and repeat it a 15-minute interval (Suddock & Crookston, 2019, p. 12). The fourth action is to document the adverse reactions in the patient clinical record (Australian Commission on Safety and Quality in Health Care (NSQHS, 2012, p. 22). The fifth step is to take action so as to reduce the risk/impact of adverse events that had occurred following administration of blood products or blood (NSQHS, 23). The last action is to report the incident internally to the relevant governance level and externally to the blood service, pathology service, or product manufacturer/supplier whenever deemed appropriate (NSQHS, 2012, p. 24).

Question 6a.

            Mr. Dwight requires a nasogastric tube for bowel decompression and maintenance of a decompressed state so as to avoid the risk of aspiration during the general anaesthetised state. Besides, it may be needed to relief symptom of bowel obstruction, for administration of medication, and bowel irrigation in case of gastric bleeding (Makama, 2020, p. 38).   

Question 6b.

            Positioning of the nasogastric tube is checked by attaching a syringe to the free end of the tube and aspirating gastric contents. The pH of the gastric content is then checked using a litmus strip. The pH must be lower than 6 (Makama, 2020, p. 39).

Question 12

            Clinical problems that may be observed during admission of Mr. Dwight with regard to fluid and nutrition in palliative care setting include reduced blood pressure due to hypovolemia and reduced muscle mass respectively (Taylor, Dowding, & Johnson, 2017, p. 7). 

Question 13

            Hypovolemia and loss muscle management goal can be set using the SMART (Specific, Measurable, Achievable, Relevant, and Time bound) framework. Management goal for Mr. Dwight’s hypovolemia is controlled and monitored delivery of 1000 ml normal saline delivered intravenously set to run over a span of 6 hours while checking vital signs after every 30 minutes.

            SMART goal for curbing muscle wasting is maintenance of a healthy weight as defined by the body mass index through strategies such as maintenance of a balanced diet on a daily basis and engagement in physical exercises for about 2 hours each and every day.

Question 14

             Two interventions that may help in achievement of a normal blood pressure and volume is through maintenance of healthy dietary habits and physical activity on a matter of daily basis since they help reduce the risk of development of cardiovascular complications such as cardiovascular disease and coronary disease (Rippe, 2019, p. 204).

            Interventions to promote muscle gain include pharmacotherapy and nutritional interventions. Administration of myostatin inhibitors help prevent further muscle wasting, whereas nutritional interventions, which include balanced diet and supplements, may help in rebuilding of the muscle mass (Haelhling, 2017, 2599).

Question to 15

            Two methods for evaluation outcomes of hypotension management due to hypovolemia is monitoring of blood pressure and pulse rate. The rationale for minoring and evaluation of blood pressure is to ensure that the desired pressure has been attained to stop normal saline infusion. On the other hand, the pulse rate is to ensure that correction of blood pressure arise from fluid replacement rather than from the cardiovascular compensatory mechanisms such as increased pulse rate (American College of Cardiology Foundation and the American Heart Association, 2018, pp. e19-e21).

            One method for evaluation of muscle wastage interventions include daily minoring of body weight and body mass index to evaluate progress in weight gain (Francis et al., 2017, p. 1121). The other method is to assess physical functioning of the patient and asking him questions regarding functionality of different movements/muscles of the body. Strategies such as a 6-minute corridor walk test and handgrip strength may be used during the assessment (Haelhling, 2017, p. 2599).

Question 16a.

            Members of a multidisciplinary team that can manage patients like Mr. Dwight include surgeons, radiologists, specialist cancer nurses, and physicians (Soukup et al., 2018, p. 51).

Question 16b.

            Use of a multidisciplinary team in planning and delivery of care to palliative patients leads to beneficial outcomes such as achievement of positive changes to care management, improved efficacy and quality of clinical decisions, and improved survival of patients with inoperable lung cancers (Soukup et al., p. 51). Besides, impacts of multidisciplinary teams in the management of palliative patients include improved adherence to recommended preoperative assessment, planning of therapy, adherence to medications, and pain control (Taplin et al., 2015, p. 231).