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Assessment Two Case Study Information - Interactive Book: Consider the Patient Situation
Consider the Patient Situation
Fortunato (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
Sofia has been a stay at home mother and carer for their 2 daughters:
• Eldest Daughter: Anna married Phillip have 2 daughters Bella (6) and Emily (3 months)
• Youngest Daughter: Gabriella married Michael have 1 son (18 months old)
Together 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’s decision for an early ’self 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.
Three months ago
Frank 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.
Assessment Two Case Study Information - Interactive Book: Collect Cues and Information
Collect Cues and Information
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(Levett-Jones 2018)
Frank 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
Past Medical Hx
• Tonsillectomy as a child
• Ex smoker (quit smoking 25 years ago was a packet a day smoker)
• Diet Controlled type 2 Diabetes
Current History
• Seizures of unknown origin
• Confusion
• Headache
• Blurred vision
• Difficulties with problem solving and decision making
• Gradual onset of speech disturbance
• Muscle Weakness
• Behaviour Changes
• Vomiting
• Sleepiness
• sluggish pupil response to light
Gathering new Information
Frank's vital signs upon admission to medical ward
RR : 18
HR: 84 bpm
BP: 185/95
SaO2: 96% on 3Lmin via N/P (For Comfort measures)
Raised Intracranial Pressure (ICP) - constant headache
GCS - 9/15 (eyes open to painful stimuli 2 I confused and disorientated verbal response 4 / Abnormal Flexion from painful stimuli 3)
Intermittent Patient Notes
03/10/2020 Assessment Two Case Study Information - Interactive Book: Collect Cues and Information
-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-
-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-
-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-
Frank was experiencing Increased Intracranial Pressure likely from brain lesions and possible Diagnosis of a Glioblastoma Multiforme (GBM)
Differential Diagnoses had not yet been ruled out
-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-
-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-
-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-
-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-
Confirmed Diagnosis, medical imaging and histopathology results
Following 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.
-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-
Assessment Two Case Study Information - Interactive Book: Processing Information
Processing Information
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Arrival and Admission to the Palliative Care Unit
Frank expressed some personal family history and wishes for his disease progression
-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-
-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-
-Sofia was Frank's medical Power of Attorney, presenting paperwork to support this to the admitting palliative Care Team-
-Sofia stayed with Frank during his admission and together they communicated that they wanted him to be comfortable and dignified-
Medications Commenced once reviewed by Palliative Care Team
• 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?)
• 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?)
• MS Contin 10mg BD Oral (0800 and 2000hrs) - Analgesia
PRN Medications
• Morphine 5-1 Omg S/C
• Midazolam 2.5-5mg s/c
• Ondansetron 8mg wafer (maximum dose of 16mg in 24 hours ) for nausea and vomiting
Upon arrival and admission to the palliative care unit the following referrals were made
• Physiotherapist review for assessment of walking aid due to increasing parasethsia and weakness in Frank's legs
• OT home assessment and equipment for home visits
• Dietician to review loss of appetite, cachexia and anorexia
• Pastoral care au/mod/book/view.php?id=3272423&chapterid=300560
Assessment Two Case Study Information - Interactive
• Catholic Priest visits and wish to be anointed ASAP
Book: Processing Information
Assessment Two Case Study Information - Interactive Book: Identifying problems/issues
Identifying problems/issues
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Considerations for the Palliative Care Setting
Frank 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:
• Welcome and orientation to the ward
• Falls Risk Assessment
• Braden Pressure Risk Assessment
• Pain Assessment
• Allied Health Referrals made
• NOK contact details
• Modified Karnofsky Score of 40-50
• RUG-ADL10+
• 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
• Palliative Care Phase - -Deteriorating-
What might be some things I need to consider as an RN caring for Frank and his family ?
• National Palliative Care Standards ?
• NSQHS Standards?
• NMBA Standards?
• What do I know about GBM illness Trajectory?
• How will I recall information on GBM?
• Where are some of the best locations to access EBP on GBM and current standards of care?
• What is my role in supporting Frank's wife and family?
• What is a SAS Tool?
• What is the Problems Severity Score/ (PSS)
• What is a Modified karnofsky Score?
• What is a RUG-ADL Score?
• How do I determine the Palliative Care Phase that the patient is in?
• Do I need to start having some difficult conversations and ask Frank and his wife what they understand about his prognosis?
• What some of the complications that Frank may face?
• Are there any specific symptoms that I should be looking for when developing Frank's care plan?
03/10/2020 Assessment Two Case Study Information - Interactive Book: Identifying problems/issues
• What is the pathophysiological response when someone dies from a GBM?
• What should I expect?
• Am I ready to deal with this?
• Where do I get support as an RN if i feel overwhelmed?
• Have I thought enough about my own well being and resilience for this professional soeciality?
• How do I care for a deceased person?
• How will I know what to say?
Assessment Two Case Study Information - Interactive Book: Establishing Goals and Taking Action
Establishing Goals and Taking Action
DKCntie » nut you wan! to tuppon. a desired outcome, a time frame.
(Levett-Jones, 2018)
Monday Morning
During 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-.
Frank 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.
Frank 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).
Talking with Frank and his wife
Frank 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.
(Levett-Jones, 2018)
Wednesday Afternoon
03/10/2020 Assessment Two Case Study Information - Interactive Book: Establishing Goals and Taking Action
The 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).
The 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.
Assessment Two Case Study Information - Interactive Book: Evaluating and Identifying new problems
Evaluating and Identifying new problems
D’.’SCr hi! what you w, tit to happen, a des red OblcooHi. a time frame.
(Levett-Jones, 2018)
Wednesday Evening
Frank 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.
Frank is now fully bed bound thus his Modified Karnofsky Score is 10, with him now in the -Terminal- Palliaitve Care Phase.
Frank 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
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Wednesday Night / Early Thursday Morning
Throughout 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.
03/10/2020 Assessment Two Case Study Information - Interactive Book: Evaluating and Identifying new problems
At 0215 hours Frank's periods of apnoea began to change to Cheyne-Stoking upon examination Frank’s 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.
Assessment Two Case Study Information - Interactive Book: Reflection
(Levett-Jones, 2018)
Quality of Life Considerations
Consider 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.
• 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)
• Rapid diagnosis and disease progression leaves little time to consolidate and prepare for death - spiritual needs must be considered
• Was an adequate pain scale used?
• 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 ?
• How can Frank’s family be provided support and continuing bereavement follow-up ?
• Consider the adequate and detailed use of the SAS tool
• Is there anything that could have been done to ensure that Frank had his dexamethasone to assist with his raised ICP?
• Does Frank have a right to refuse treatment ? Was he competent to make this decision?
• What can nursing staff provide families and the deceased patient to aid them in their grief, loss and need to say goodbye?
• Are the National palliative Care standards considered in the CPG?
• Were the NMBA and NQHS standards considered in the CPG?
• Can the CPG be improved in any way to assist its affiliation with care planning, assessment tools and care provided in the palliative setting?
• 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?
Consider 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.
Assessment Two Case Study Information - Interactive Book: Clinical Practice Guidelines
Clinical Practice Guidelines
What are they?
Why are they important?
How do they help us to maintain high levels of care?
Do we improve our care by reflection and updating CPG's through evidence Based research?
Frank’s Case Study
As described in the Unit Outline you are now required to:
• Three CPG's are on the LEO tile select ONE of the Clinical Practice Guidelines provided on the Assessment LEO tile
• 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 Rubric) is essential within the workplace.
• The CPG's to select from are:
o Care of the Dying patient
o Organ and Tissue Donation
o Managing Psychological Issues inclusive of Terminal Restlessness
• 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
• Highlight the importance of the many standards and how they influence our practice
o NSQHSS and/or
o NMBA standards and/or
o Palliative Care standards
• Demonstrate knowledge on the illness trajectory of a Glioblastoma Multiforme (GBM) in line with palliative Care principles
• Provide links between the case study and your chosen CPG to identify highlights or limitations in care
• Where any areas of the CPG omitted in the care?
• Do you believe that the CPG requires updating? If so support with contemporary literature
• Ensure that your sources are all contemporary (within the last five years) and from evidence based sources)
• Read all instructions and the rubric very carefully
Assessment Two Case Study Information - Interactive Book: Clinical Practice Guidelines
Systematic review, metaanalysis, qualitative metasummary
Randomised & non-randomised trials
Cohort study
(Borbasi, Jackson, East, 2019)
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