NURS5056 Cancer & Hematology Nursing Assessment

NURS5056 Cancer & Hematology Nursing

Topic: The case study activity will be made available on the eLearning site. Case study activities test your ability to find and apply information and knowledge. You will undertake the activity at home and may use appropriate resources such as books and journals, and referencing is required. You will be presented with a number of scenarios in the form of case studies and will be required to provide short/long answers to the questions relating to the scenarios. The purpose of this activity is to assist you to consolidate and synthesise your learning throughout this unit of study by applying concepts to complex situations presented in the case studies. Include APA7th referencing.

Case Scenario A (100 marks)

Susan, aged 74, was diagnosed with multiple myeloma (IgG Kappa, R-ISS stage 1) three years ago. Her myeloma remained stable for two and a half years following induction therapy with cyclophosphamide, bortezomid and dexamethasone (CYBORD) and high dose melphalan (HDM) with an autologous stem cell transplant (auSTC). Susan refused to commence bisphophonate therapy at the time, despite recommendation by her haematologist, as she was fearful of osteonecrosis of the jaw, an adverse effect of some bisphosphonate drugs.

Susan achieved a complete response post HDM and auSCT, but four months ago Susan’s paraprotein reappeared and rose. After a few months of careful monitoring, the paraprotein had risen above 5g/L indicating progressive disease. She also had a skeletal CT scan and a bone marrow aspiration/biopsy. Susan saw the specialist last week who recommended reinstating therapy for 1st progression with daratumumab SC bortezomib twice weekly and dexamethasone 40mg weekly in a 21 day cycle. It was also strongly recommended that she start bisphosphonates and she is considering this.

Susan was brought to the emergency department by her friend who had found her at home unable to keep her eyes open for more than ten minutes, and confused to time and place. In your clinical assessment you find that Susan has not had a bowel motion for ten days, has been vomiting 2-4 times a day for the past week, is constantly nauseous and has no appetite. You notice that she has difficulty walking and she tells you that her feet feel numb and reports them as being painful (6/10 where 1 is no pain at all and 10 is unbearable pain).

Susan tells you that she has severe pain in her left ribs and thoracic spine for which her General Practitioner (GP) commenced her on paracetamol (500mg) and codeine phosphate (30mg) (Panadeine Forte) 2 tablets 4-6 hourly. She also has a 6 week history of reflux and gastric pain, which she has treated herself with frequent small glasses of milk and calcium carbonate, bought from the chemist.

Observations:

Blood pressure 95/40 mmHg

HR 120 beats per minute

RR 15 breaths per minute

Temperature 36°C

GCS 13 (E3, M6, V4)

Susan’s laboratory results of note are as follows: (Reference ranges in brackets)

WBC 4.5 x 109/L (4-11 x109/L)

Hb 125 g/L (120-160g/L)

Platelets 150 x 109/L (150-400 x 109/L)

Creatinine – serum 180 ?mol/L (40-90umol/L)

Urea – serum 14.3 mmol/L (3-8mmol/L)

Sodium – serum 150 mmol/L (135-145mmol/L)

Albumin – serum 29 g/L (32-45g/L)

Calcium – serum 3.5 mmol/L (corrected) (2.1-2.6mmol/L)

IgG Paraprotein – 32g/L

Kappa light chains – 82mg/L

Question 1

In the context of a patient with multiple myeloma, provide a physiological rationale for the changes in Susan’s clinical presentation. Also, provide your clinical assessment plan together with rationale. (15 marks)

Question 2a

With reference to current research, describe a care and treatment plan for Susan, including rationale. (10 marks)

Question 2b

Provide a critical analysis of the key adverse effects of treatment that may occur and the most suitable management of them. (15 marks)

Question 2c

What education would you give to Susan and her family? Provide rationale. (10 marks)

Susan attended the haematology unit a few weeks later as she had experienced an acute exacerbation of severe pain in her ribs and in her right upper arm. She reports her pain as 9/10 in both areas. Susan also reports that she is continually exhausted and unable to continue with her usual activities. She sleeps much of the day and is unable to sleep at night. She also reports that she has no strength. She tells you that she is worried that she has early dementia as she is unable to remember anything, nor is she able to concentrate as she used to.

Question 3

Demonstrating your knowledge of pain physiology, suggest an evidence-based pain management plan for Susan. Include a clear rationale for the pharmacological and non-pharmacological choices and an assessment plan for evaluating the interventions. (25 marks)

Question 4

Describe your assessment of Susan’s symptoms and, demonstrating your knowledge of cancer related fatigue, suggest an evidence-based fatigue management plan for this patient. Your answer should include a clear rationale for intervention choices. (25 marks)

Case Scenario B (100 marks)

Deb, a 68 year old female living in a small rural town, has been diagnosed with stage 2B carcinoma of the left breast. Deb lives alone, enjoys horse riding and manages a small agistment business for horses. She has no family history of breast cancer. Having initially considered a mastectomy, Deb decided to have a lumpectomy followed by radiotherapy (50 Gy in 25 fractions over 5 weeks). Deb’s breast cancer was HER2 negative, ER positive, 2/14 positive axillary lymph nodes, clear margins and she has no comorbidities. She was also commenced on endocrine therapy.

Question 1

With reference to the notion of ‘risk-adapted therapy’, discuss both the prognostic and treatment choice implications of Deb’s diagnosis and discuss the factors which may influence treatment decisions. (15 marks)

Question 2a

With reference to current research findings, describe a care and treatment plan for Deb during the radiotherapy, including rationale for the chosen plan. (10 marks)

Question 2b

Provide a critical analysis of the potential key adverse effects of Deb’s treatment (all treatments) and a suitable management plan. (15 marks)

Question 2c

What education would Deb require in relation to her radiotherapy treatment and possible side-effects? Provide a rationale. (10 marks)

Two years later, Deb presents to her General Practitioner (GP) with right hip pain. Investigations reveal bone metastases in her right hip, bilateral sacro-iliac joints and thoracic vertebrae, and moderately impaired renal function (creatinine clearance 40mL/min) secondary to uncontrolled chronic hypertension. Deb was commenced on an oral CDK4/6 inhibitor (palbociolib) combined with letrozole by the medical oncologist.

Nearly 2 weeks after her first course of chemotherapy, Deb calls you and reports the following: vomiting 3 – 4 times per day, a sore mouth (pain at 5/10), temperature 39°C and generally feeling unwell and lightheaded.

Question 3

In the context of a patient with breast cancer receiving chemotherapy, provide a physiological rationale for Deb’s current clinical presentation. Critically discuss your assessment and recommended interventions. (25 marks)

4 weeks after completing chemotherapy she re-presents with excruciating pain in her right hip, right shoulder and complains of a burning, tingling pain in her right arm.

Question 4

Demonstrating your knowledge of pain physiology, discuss an evidence-based pain management plan for Deb. Your answer should include a clear rationale for the pharmacological and non-pharmacological choices and your assessment plan for evaluating the interventions. (25 marks)