Sara Abaza is a 69-year-old woman who was presented to the Oncology ward three days ago following deterioration over the last week. The patient has stage-4 cancer and is in severe pain.
Her family is uncomfortable attending to end-of-life requirements at home. The patient's husband and two sisters have accompanied the patient to the hospital for end-of-life care. The husband informs the nurse that Sara has not been sleeping well for the past week due to experiencing severe pain.
Sara is becoming less conscious and is no longer verbalizing but opens her eyes to pain. Vital signs have remained stable for the past three days. The patient is receiving regular subcutaneous morphine and hyoscine via an abdominal subcutaneous butterfly. The patient is NBM. Mouth care has been attended to, and the colostomy has minimal output.
Sara has a three-year history of Colorectal Cancer and had a Colostomy in situ following bowel resection surgery three years ago. Sara developed terminal metastases in her lungs and brain three months ago. The patient's medical notes contain the required documentation for an Advanced Care Directive (ACD), including a do-not-resuscitate order and no other acute.
Analysis of the Case Study
Sarah Abaza is a 69-year-old female patient who was presented to the Oncology ward three days ago due to the deterioration of her health in the past week. As a result of being in the terminal stage of cancer, the patient experiences severe pain characterised by a lack of good sleep. Nurses must always identify the pertinent patient health issues in their daily practices to help patients in care and recovery. For instance, Sarah presents various problems, such as having colorectal cancer at the terminal stage, being underweight, and having a Colostomy in situ. Nurses play an integral role in care provision; thus, they are encouraged to study and analyse a patient's health issues to provide appropriate intervention. In the case of Sarah, the three main health patient issues presented include severe pain management, nutritional and support problems, and an ineffective respiratory system. The nursing fraternity can address these issues based on their prioritisation in all Australian healthcare organisations.
Nutrition and Comfort Support
Patients require adequate and recommended dietary intake to help their recovery and well-being. Sara's 16.6kg/m2 BMI indicates she is underweight (Silva et al., 2020). Alongside dietary requirements, nurses also promote comfort considerations for patients facing end-of-life illnesses, such as cancer. As a result, nurses can promote Sara's dietary well-being by designing an individualised diet and desires to assist her in becoming healthier while facing a terminal illness. Nurses often acknowledge that patients in Sara's condition might not require much food and fluids and, therefore, administer them appropriately. As one ages, there is a decrease in thirst and hunger, with digestive systems becoming complicated, thus manifesting in weight loss, as in Sara's case. Therefore, Sara's disease progression has impacted her nutritional ability, leading to her underweight issue. Nurses can determine Sara's preferred diet to maximise her comfort and food satisfaction while considering her NBM status (Wuyts et al., 2022). Nurses can also provide small amounts of favourite foods and beverages while altering the textures of some foods to assist Sara in overcoming her swallowing problem if present. Supplements and other oral care should be provided according to the available information on the patient. Finally, her family can be incorporated in suggesting her preferred diets and comfort. Nurses can improve Sara's comfort at the facility by bathing her, conducting skin care services, dressing, and changing her regularly to make her feel comfortable. Sara's nutritional conditions raise concerns regarding her well-being and safety during the terminal stage of care in the ward; thus, nurses should work on rectifying the situation.
Ineffective Hearing System
Given Sara's medical report, it is safe to say that her respiratory system is impaired, thus presenting another health issue in this scenario. The report indicates that the patient is becoming less conscious and is no longer verbalising, although she opens her eyes in response to pain. Importantly, this issue has remained constant for the last three days, presenting an important issue that nurses can address through their professional scope. The signs illustrated in this case study show that Sara suffers from an impaired respiratory system. According to Bhargava et al. (2023), an SP02 of less than 95% in adult patients is associated with chronic illnesses, as in Sara's case. Therefore, nurses should administer ABG to Sara for her lower SPO2. On the other hand, the respiration rate (RR) is the number of breaths an individual takes per minute. Currently, Sara's low RR increases her susceptibility to adverse conditions.
Additionally, fine crackles in bilateral lower lung sections exacerbate Sara's respiratory impairment. Thus, these conditions might arise due to the present lung metastases or other issues linked to her current situation. Nurses can play a significant role in assisting end-of-life patients, such as Sarah, in improving their respiratory functions. For instance, the nurses initially identify the patients at risk of developing respiratory failure and then observe closely for deconditioning (Millar, 2020). In the ward, the nurse can take care of Sara's respiratory challenges by maintaining the required amount of fresh oxygen by opening the windows and providing mechanical ventilation in cases where Sara fails to breathe correctly. Other practices within the nursing practice for patients such as Sara include moving her in bed and maintaining her tracheostomy.
Pain Management
As indicated in the case study, Sara is constantly experiencing pain due to her terminal cancer illness. The patient records an extreme pain score of 8/10, indicating the discomfort and reduced quality of life she is experiencing due to terminal cancer. Given this information, nurses must design strategies to ease her pain and improve her quality of life and comfort during end-of-life care (Skorpen et al., 2020). Therefore, nurses must manage and control her pain, reducing stress, blood pressure, and heart conditions. In turn, this practice leads to positive healing and recovery since pain often entails cognitive, physical, and behavioural components. Therefore, nurses have a crucial role in handling the three patient health issues affecting Sara. However, there is a need to classify the three issues in terms of priority in a healthcare facility.
Ranking the Three Patient Issues in Order of Priority
Despite the three patient issues being of greater significance, they can be listed in order of priority to create awareness among the nursing staff to handle key ones for the patient's well-being. The top priority must be dealing with Sara's ineffective respiratory ability for various reasons. Dealing with patients facing respiratory failure tends to be challenging for nursing professionals as it might result in other issues, such as insufficient oxygen at the tissue level to maintain homeostasis (Ugarte & Calderon, 2022). Furthermore, a lack of pain management can lead to further health deterioration and discomfort for patients as they attempt to recover or experience quality of life. Experts argue that effective pain management strategies in end-of-life care can significantly lower stress levels.
Pain management is the second priority that nurses dealing with Sara must practice. Pain management is crucial, just like respiratory failure, which has immediate implications for the patient's life (Lowey, 2020). Therefore, pain mitigation and control are integral to the general patient's relaxation, comfort, and welfare. In palliative care, pain management is vital in managing a disease by reducing or eliminating pain and other physical, cognitive, and emotional distress caused by an illness. Therefore, pain control helps palliative patients enjoy a good quality of life. The exercise seeks safer and more effective pain management during hospital and home care.
Finally, the nutritional and support aspect is ranked last among the patient health issues concerning Sara. Although diets and amenities for end-of-life patients are significant to their overall quality of life, Sara's condition indicates that nutrition and diets cannot be prioritised over the other top issues, as stated by Heydari et al. (2019). In the case study, addressing Sara's respiratory impairment function and alleviating pain in the facility takes the highest consideration as they directly affect her life. The two other issues have life-threatening implications for Sara if not addressed, unlike nutrition and support. Furthermore, Sara's classification as an NBM patient affects her dietary requirements. Therefore, nurses should prioritise Sara's needs from the respiratory impairment, pain management, and nutritional and support order.
The Nurse's Role in Addressing the Top Three Priority Patient Health Issues Concerning Patient Assessment, Coordination of Care, and Delivery of Care
Nurses are crucial to the health and welfare of every community as they provide expert care from birth to the end of life. Importantly, nurses engage in direct patient care and case management by following the recommended nursing guidelines and standards. For impaired respiratory problems, Australian nurses must regularly assess Sara's RR, SPO2 levels, and bilateral lower lung limbs, as recommended by The NSQHS Standards (n.d.). Next, the nurses should implement a multidisciplinary approach with other service providers in the facility to design effective interventions, such as using mechanical ventilators to mitigate the symptoms. Lastly, nursing professionals should prescribe drugs and oxygen and integrate family into the care. These initiatives align with NSQHS guidelines regarding safe and quality care provision.
On nutrition and support, the nurses should conduct tests on Sara's nutritional preferences and evaluate discomfort during her hospital stay. To coordinate care, the nurses should work with other professionals, such as physical therapists and dietitians, to improve her condition. Regarding care delivery, the providers should give the patient food and supplements and offer support services, such as adjusting her head and back (NSW Health, 2018). Lastly, to reduce pain, the providers must assess Sara using the recommended pain score scales while coordinating care, including working with physicians to adjust the medical requirements of the patient according to her pain level. Certain strategies, such as tracking the patient's pain experience, giving them medications to ease pain, and training Sara's family members about handling pain, are vital during the care delivery, as highlighted in Australia's RN policies.
References
Bhargava, A., Bhargava, M., Meher, A., Teja, G. S., Velayutham, B., Watson, B., ... & Joshi, R. (2023). Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India. The Lancet Global Health. https://doi.org/10.1016/S2214-109X(23)00324-8
Heydari, H., Hojjat-Assari, S., Almasian, M. et al. Exploring health care providers' perceptions about home-based palliative care in terminally ill cancer patients. BMC Palliat Care 18, 66 (2019). https://doi.org/10.1186/s12904-019-0452-3
Lowey, S. E. (2020). Management of severe pain in terminally ill patients at home: an evidence-based strategy. Home Healthcare Now, 38(1), 8–15. https://doi.org/10.1097/NHH.000000000000082
Millar, R. C. (2020). Nursing a patient with COVID-19 infection. Tasman Medical Journal, 1(1). https://journal-ebnp.com/2020/02/25/nursing-a-patient-with-covid-19-infection/
NSW Health. healthdirect. (2018, October). https://www.healthdirect.gov.au/partners/nsw-health
Silva, M. J., Kilpatrick, N. M., Craig, J. M., Manton, D. J., Leong, P., Ho, H., Saffery, R., Burgner, D. P., & Scurrah, K. J. (2020). A twin study of body mass index and dental caries in childhood. Scientific Reports, 10(1), [568]. https://doi.org/10.1038/s41598-020-57435-7
Skorpen Tarberg, A., Landstad, B. J., Hole, T., Thronæs, M., & Kvangarsnes, M. (2020). Nurses' experiences of compassionate care in the palliative pathway. Journal of Clinical Nursing, 29(23-24), 4818-4826. https://doi.org/10.1111/jocn.15528
The NSQHS standards. The NSQHS Standards | Australian Commission on Safety and Quality in Health Care. (n.d.). https://www.safetyandquality.gov.au/standards/nsqhs-standards
Ugarte, S. V. G., & Calderón, L. E. M. (2022). Anxiety, Depression, and Delirium in Terminally Ill Cancer Patients. In Supportive and Palliative Care and Quality of Life in the Oncology Field. IntechOpen. https://doi.org/10.5772/intechopen.107325
Wuyts, S. C., Scheyltjens, S., Hubloue, I., Dupont, A. G., & Cornu, P. (2022). Interdisciplinary knowledge gaps on intravenous fluid management in adult patients: a survey among physicians and nurses of a university hospital. Journal of Evaluation in Clinical Practice, 28(4), 599-606. https://doi.org/10.1111/jep.13663
