Assessment Task 2 Details
Students are to provide an 1800-word critique of the provided case study using only ONE CPG.
To complete this task, you will need to discuss and critique relevant elements of the CPG and case study whilst upholding:
• NSQHS and/or
• NMBA standards and/or
• National Palliative Care standards
Do we need to use all these standards to do well?
• As the rubric states if you provide -Outstanding knowledge of themes and principles associated with palliative care- this will demonstrate an outstanding application of your knowledge to practice therefore using standards from more than one of the above and relating them together to uphold your critique of the patient care and support the clinical practice guideline selected will demonstrate excellent knowledge and understanding. Using one standard from one of the above will not provide strong application of knowledge. However, a comparison of multiple standards that as registered nurses we are required to uphold will absolutely demonstrate very strong knowledge and understanding, if you link them together well with evidence-based practice (EBP)
Where do I find all these standards?
You should be aware of all the standards above as they have been discussed in many units throughout your degree, so now it is time to demonstrate your knowledge and bring them together. to assist you We have provided links below to each of the standards we would like you to utilise in your critique.
Eight National safety and Quality Health Service Standards to provide a nationally consistent level of care that can be expected by all consumers from all health organisations
Seven Standards that all Registered nurses must uphold to ensure that they maintain their registration and provide person centred and evidence based preventative, curative, supportive, formative and palliative elements to their practice
National Palliative Care Standards
Nine National palliative Care standards that you know well as they have formed the framework of NRSG374 and were fundamental for assessment task 1
How do I relate these standards to Frank's experiences as a patient?
This is where your critical thinking and application of theory to practice is required, we cannot tell you how to do this, as a final year nursing unit is essential that you are aware of how all of these standards, uphold and maintain, patient centred care, dignity, patient assessment and safety to name a few. Spend some time reviewing these and map out the ones that you believe are important for your critique.
Due date: 16/10/2020 1600 hours
Length and/or format: 1800 words +/- 10%
Purpose: Students are required to demonstrate an understanding of how theory translates into practical nursing care and how evidence underpins best practice. Each student will review and critique the care given in the Case Study provided according to their choice of ONLY ONE of the provided Clinical Practice Guidelines (CPG’s) best suited to the highlighted discussion.
Where will I find the CPG's that you want me to use?
You are provided with CPG's for this task, you need to choose one of these only to demonstrate the area of care that you are providing a critique of. You do NOT have to look for other CPG's to support your work, however evidence-based practice of peer reviewed journal publications are expected to further reinforce your critique.
Assessment criteria: The assessment will be marked using the criteria-based rubric. Please note that in-text citations are included in the word count whilst the reference list is not included in the word count. Words that are more than 10% over the word count will not be considered
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.
Collect Cues and Information
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 following another seizure. 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
• Seizures of unknown origin
• Blurred vision
• Difficulties with problem solving and decision making
• Gradual onset of speech disturbance
• Muscle Weakness
• Behaviour Changes
• sluggish pupil response to light
Gathering new Information
Frank's vital signs upon admission to medical ward
HR: 84 bpm
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 / confused and disorientated verbal response 4 / Abnormal Flexion from painful stimuli 3)
Intermittent Patient Notes
-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 MRI 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 (ICP,) 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 cerebro-spinal 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-
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 of Lyrica, are there other options that could be considered for Frank?)
• MS Contin 10mg BD Oral (0800 and 2000hrs) - Analgesia
• Morphine 5-10mg 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
• Catholic Priest visits and wish to be anointed ASAP
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- ADL 10+
• 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?
• 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?
Establishing Goals and Taking Action
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 mls 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.
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 commenced 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.
Evaluating and Identifying new problems
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 18
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 glycopyrrolate S/C as an anticholinergic agent to aid in excessive secretions and try to ease his work of breathing.
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.
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.
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 another 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