Caring for the Hospice Client in the Clinical Setting

Caring for the Hospice Client in the Clinical Setting

Brenda R. Ferguson

November, 2005

The University of South Dakota

Department of Nursing

Abstract

The Author has completed a case study on a patient on a Medical Surgical floor as observed during a clinical rotation. A reader will find complete overview of a woman experiencing primary peritoneal cancer with metastasis who is under the care of hospice. Following a referral from hospice for a thoracentesis the patient is hospitalized. The reader will understand priority nursing diagnosis for a person with this condition.

Case Study

This paper briefly discusses some of the aspects of caring for an individual with complex health needs. Included are a health history, an overview of the medical management, nursing management and roles in caring for the person.

Assessment and Plan

This female patient is seventy two years old, Caucasian, divorced, and living alone on a farm in rural South Dakota. She has a high school education and works in a nursing home doing mending and laundry work. This patient is in Erickson’s Ego integrity versus despair. (Craven and Hirnle, 2003) This theory discusses the person’s point of view of one’s place in life. The patient exhibits integrity. She is accepting of her disease process and is thinking about her life in a positive way.

Chief Complaint and History of Present Illness

This patient, referred through hospice has arrived to be treated for a thoracentesis on an outpatient basis. The patient developed a pneumothorax and received a right chest tube placement. The purpose of the thoracentesis was primarily comfort measures for relief of fluid accumulation and the resulting dyspnea. Therapeutic thoracentesis can commonly cause pneumothorax. (emedicine.com)

Pneumothorax is the accumulation of air or gas in the pleural space. (Lewis, Heitkemper, and Dirksen, 2004) This patient’s pneumothorax was treated with a chest tube and monitored with x-rays. Nursing assessment was minimal. Vital signs were assessed every eight hours as well as a head to toe nursing assessment at the same intervals. The patient’s vital signs were consistently within normal limits and all other assessments were not significant. Crackles heard in the right lower lung would be abnormal, however, considering her status it was not unusual.

Past History

She has a history of CVA and hypothyroidism as well as a D&C for some “sort of hemorrhage”, as stated in the patient’s chart. Patient states it was not malignant. She did have some blood transfusions at that time and relates that she had some type of reaction but was unable to expound on any details. More recently in July of 2005 her history on file reveals history of stage III C optimally debulked primary peritoneal cancer. An omenectomy, appendectomy, small bowel resection with side to side anastomosis, and colon resection with end to end anastomosis constituted the debulking for this patient.

Primary peritoneal cancer can also be referred to as extraovarian primary peritoneal carcinoma. It is a cancer closely related to epithelial ovarian cancer. This cancer occurs in the membrane that lines the walls and organs of the pelvis and abdomen. Under a microscope this cancer looks just like epithelial ovarian cancer. (www.cancer.org) This patient’s treatment of debulking, or removing, much of the cancer is a typical treatment.

Current Health Status

Patient health status is remarkably stable, considering other her diagnosis. Patient exhibits excellent tolerance for activity. She requests to have little assistance and completes activities of daily living with little or no assistance. As a provider of care this student nurse offers assistance when needed. For example, when walking the hallways this was generally done with two people for safety due to the chest tube set up. Patient relates that she sees no reason to cut down from full time at work or to move off of the farm where she resides alone. Although, she is under the care of hospice and in turn does have a diagnosis which the doctors states indicate less than six months to live, this student does not feel the patient is in denial. Rather, she seems to have found a level of acceptance for the place she is at in her life.

Family History

A family history is significant with two brothers having died from lung cancer, both smokers. The patient’s father died of colon cancer. No know gynecological cancer or breast cancer in the family. No other information was available via chart or discussion with the patient.

Medical/Surgical Treatment

Actual treatment the patient is receiving is minimal due to the decision to accept hospice involvement. Hospice refers to a program that supports the patient as well as their family throughout the dying process. (Lippincott’s Case Management) Treatment is related to the relief of symptom’s and aimed primarily at the comfort of the person and the family. For example, lab test are not run on a regular basis for the purpose of diagnosis and medications are aimed at comfort and symptom relief rather than treatment of illness. The reader should note the relation between the thorocentesis and relief of dyspnea for the patient as discussed earlier.

As a manager of care, nurses can assist to minimize anxiety and pain associated with chest tube removal by explaining the process and allowing them to understand that there will be some discomfort, but that the pain will typically not linger. (Appl. Nurs.Res.) A nurse could assist to minimize pain in other non pharmacologic ways for on going disease related pain. For example, heat and cold therapy, distraction, music therapy, pet therapy, and others might be helpful. One could suggest the services of a naturopath or herbalist who could consult with the medical staff. (Nursing)

Diagnostics Tests

Diagnostic tests for this patient were minimal. As a hospice client few tests are run, as the goal is for comfort care rather than curative. However, a chest x-ray was obtained by the physician in relation to removing the chest tube. The results were not in the chart at the time