NR 601 Week 7 Soap -Chemo Alternatives

NR 601 Week 7 Soap -Chemo Alternatives

NR 601 Week 7 Soap -Chemo Alternatives

C.G, 69 M, what race?

Subjective

CC:  tired from chemo and radiation; choosing not to pursue any more treatment

O: diagnosed with cancer 2 years ago, received 6 weeks of chemo and radiation. When did you begin feeling the effects? And what effects are you feeling?

L: Do you have any pain anywhere? Radiation to head and left lingual tonsil region; METS to liver and lungs.

D:  6 weeks of chemo and radiation.  Now, METS present.

C:  Do you have any pain? Feeling tired of effects.  Nausea? Vomiting? Weight loss? Hair loss? Skin changes? Fatigue? Bleeding disorders? Lack of senses?

A: Does anything make symptoms worse?

R: Does anything make the symptoms better?

T: Have you tried any treatment to alleviate side effects? Has it helped?

Background:

Right head and neck cancer with metastasis to liver and lungs; patient is refusing further treatment.

PMH:

Hypertension

Hyperlipidemia

Stomatitis

Anemia

Neutropenia

Current medications:

Carvedilol 12.5 mg po 1 daily

Furosemide 40 mg po daily

Surgeries:      

2012: right radical neck dissection

Allergies:

None

NR 601 Week 7 Soap -Chemo Alternatives

Vaccination History:

Influenza vaccine last received 1 year ago

Received pneumovax at age 65

Received Tdap 5 years ago

Has not had the herpes zoster vaccine

Social history and Risk Factors:

Former smoker-stopped smoking at the time his cancer was diagnosed-2 years ago

Negative for alcohol intake or drug use

Patient does not have an advanced directive or living will. He is refusing further treatment for his cancer and his wife and children are in disagreement with him. The patient wants to know what his options are for the remainder of his life.

Family history:

Negative

ROS

Constitutional: fatigue? Have you had any fever or chills? Weight loss? Lack of appetite? Mood changes? Night sweats?

HEENT:  Any vision changes? Hearing changes? Headaches? Dizziness? Sore throat? Cough?

Cardio: Any chest pain, palpitations, dizziness, edema?

pulmonary:  Any SOB, wheezing, dyspnea?

GI: Any nausea, vomiting, diarrhea, constipation? Are you experiencing dysphagia? Abdominal pain? Bloody or black tarry stools? Vomiting blood?

GU: do you have any urinary frequency, any pain on urination? Emptying bladder? Blood in urine?

Skin: Any skin changes? Blisters? Lesions? Ulcers? Dry skin? Lumps?

Psychiatric: (+) tired of effects of chemo, (+) refusing to continue treatment (-) living will, do you have any periods of sadness? Anxiousness? Depression? Do you feel like crying? Feel like you have a short fuse at home? Do you wish to continue living? Do you have any thoughts of hurting yourself? Would you consider other options to control side effects?

NR 601 Week 7 Soap -Chemo Alternatives

Objective

Vital Signs: Height:  6’0   Weight: 140 pounds; BMI: 19.0   BP: 156/84  P: 84 regular R: 20

HEENT: normocephalic, symmetric PERRLA, EOMI; poor dentition

NECK: left neck supple; non-palpable lymph nodes; no carotid bruits. Limited ROM

LUNGS: rhonchi in anterior chest bilaterally.

HEART: S1 and S2 audible; regular rate and rhythm

ABDOMEN: active bowel sounds all 4 quadrants; Normal contour; RUQ tenderness; liver palpable

NEUROLOGIC: negative

GENITOURINARY: negative

MUSCULOSKELETAL: negative

PSYCH: PHQ-9 is 15

SKIN: oral mucosa irritated-stomatitis

 

NR 601 Week 7 Soap -Chemo Alternatives 

Assessment

Primary Diagnosis

1. Procedure and treatment not carried out because of patient’s decision for unspecified reasons (Z53.20) – Patients have the right to choose whether or not they wish to receive treatment as long as they are competent.  Frenkel (2013) reported that a study proved that those who refused to continue treatment of cancer carried out the same quality of life as those who continued with therapy.

Secondary Diagnoses

2. Major Depressive Disorder (F32.3) – Individuals who receive chemo and radiation experience a wide variety of side effects. Depression can occur as a result of individuals feeling fatigued of symptoms, as well as finding out that even though they received treatment, the cancer has spread.  This is the case for this patient.  Furthermore, this patient states he does not wish to continue with treatment despite what his family wants.  Brothers et al (2011) reported that quality of life regarding mental health can significantly be reduced in individuals diagnosed with cancer.  This patient had a PHQ-9 score of 15 which classifies him as depressed.
3. Hypertension (I10) – The CDC (2016) defined hypertension as a patient who has had 3 separate instances of a systolic greater than 140 mmHg. This patient has already been diagnosed with HTN and is currently taking anti-hypertensives.  His BP reading during this visit was still elevated.

Differential Diagnosis

4. Other fatigue (R53.83) – fatigue related to cancer treatment. This patient states he is “tired” of the effects of the treatment he has been receiving.  Cancer related fatigue can occur in patients who have experienced at least 2 weeks of fatigue in one month.  This is often deemed the worst symptoms of cancer therapy and can greatly affect one’s quality of life (Yeh et al, 2011). This patient finds the effects of chemo and radiation so unbearable he wishes to stop treatment altogether.

Regarding this patient’s decision to discontinue treatment, I would make sure the patient understand the risks of stopping treatment which include death.   Providers take an oath act in the best interest of his or her patient to both do no harm and respect the patient’s autonomous decisions if deemed competent (Peppercorn, 2012).  The provider is required to explain both the risks and benefits of different interventions, and from there, the patient should have the right to choose his or her best option, even if that means discontinuing treatment.  However, we cannot allow for the patient to make an uninformed decision without all the facts.

I would first screen for depression and give this patient several options, including alternative medications to alleviate some of the symptoms he is tired of experiencing, as well as offering a counselor and support group therapy recommendations.  If the patient still wishes to discontinue treatment, I would discuss the option of palliative care to help alleviate some of the symptoms such as pain from the cancer.  It is important to discuss further details with the family and refer the patient to a palliative care facility.

Plan of Care

Diagnostics: Diagnostic tests are not required for a patient to transition to palliative care (Gorroll & Mulley, 2014).

Medications:

New-

Zoloft.  This medication helps the patient’s brain keep serotonin longer which would alleviate this patient’s depression symptoms (NIH, 2016).

Zoloft 25 mg tablet

One table daily

Dispense 30, refill: 2

Oxycodone.  Oxycodone is needed for patients who have moderate to severe pain as a symptom of his or her cancer.  Long acting opioids are suggested, so this patient should be taking the controlled-release oxycodone (Groninger, & Vijayan, 2014).

Oxycodone CR 20 mg tablet

One tablet daily as needed for moderate to severe pain 7/10 or greater

Dispense 14, refill: 0

Zofran.  This is an anti-emetic that can relieve the patient’s nausea and vomiting symptoms.  Often times, patients who take opioids become nauseas as a side effect (Gorroll & Mulley, 2014).

Zofran 4 mg ODT

Let 1 tablet disintegrate on tongue every 8 hours as needed for nausea or vomiting.
Dispense 30, refill 1

Continued-

Lasix 40 mg PO daily– this medication can help with dyspnea in the palliative care patient (Kamal et al, 2012).

Carvedilol 12.5 mg po 1 daily – this medication will manage the patient’s blood pressure.

 

NR 601 Week 7 Soap -Chemo Alternatives

Patient Education:

Refusal of Treatment – ­­­­­­

• Since the patient and family do not agree with the patient’s decision to stop treatment, it is important for the patient to create an advanced directive outlining what he or she would want or not want moving forward. This should include life-sustaining treatments such as being intubated, CPR, life-sustaining medications, or therapies (Sedig, 2016).
  • Each state has forms that can be downloaded and filled out. Once signed, these forms should be witnessed according to state regulations.
• The patient should also choose a proxy or point of attorney in case the time comes the patient cannot make decisions or speak on his own behalf. This individual should have a copy of the advanced directive as well as understanding of the patient’s desires.
• It is important to understand that a person can seek palliative care or hospice care and reverse his decision later on. The decision does not have to be indefinite (Gorroll & Mulley, 2014).
• Patient should understand the risks and benefits of refusing treatment before making educated and informed decision.
• Benefits of continuing treatment include possibility of improving the presence of cancer, potentially longer life expectancy
• Benefits of stopping treatment include possible better quality of life, no more side effects of treatment, medication to manage symptoms

Medications –

• Side effects of oxycodone include constipation as well as opioid dependence. Some individuals find they need to take higher dosages to alleviate symptoms.  This can lead to substance abuse.  Call your provider immediately if your medication does not seem to be effective and only take prescription as directed.
• Zoloft can cause you to feel drowsy the first week due to increase in serotonin. This is a normal side effect of the medication. To reduce the effects, take ½ pill the first 4 days to allow body to adjust to medication.

Neutropenia –

• Since you have been diagnosed with Neutropenia, it is important to keep yourself as healthy as possible. This can be done by wearing a mask around patients, and keeping the door closed when in a facility.
• Ensure than family and friends wash their hands prior to making contact (Lustberg, 2012).

Referrals/Consults: Patient should follow up with Palliative Care within one week (Gorroll & Mulley, 2014).

Follow-up: Patient should return to office in 1-2 weeks to evaluate if medication regimen is working, or sooner to have Provider sign legal documents.

NR 601 Week 7 Soap -Chemo Alternatives

KINDLY ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER

References

Brothers, B.M., Yang, H.C., Strunk, D.R., & Anderson, B.L. (2011). Cancer patients with major depressive disorder: testing biobehavioral/ cognitive behavior intervention. Journal of Consulting and Clinical Psychology, 79(2): 253-260. Doi: 10.1037/a0022566

Frenkel, M. (2013). Refusing Treatment. The Oncologist, 18(5), 634–636. http://doi.org/10.1634/theoncologist.2012-0436

Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer

Groninger, H., & Vijayan, J. (2014). Pharmacologic management of pain at end of life. American Family Physician, 90(1): 26-32. http://www.aafp.org/afp/2014/0701/p26.html

Kamal, A. H., Maguire, J. M., Wheeler, J. L., Currow, D. C., & Abernethy, A. P. (2012). Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options. Journal of Palliative Medicine, 15(1), 106–114. http://doi.org/10.1089/jpm.2011.0110

Lustberg, M. B. (2012). Management of Neutropenia in Cancer Patients. Clinical Advances in Hematology & Oncology?: H&O, 10(12), 825–826.

Peppercorn, J. (2012). Ethics of ongoing cancer care for patients making risky decisions. Journal of Oncology Practice, 8(5): e111-e113. http://ascopubs.org/doi/full/10.1200/jop.2012.000622

Sedig, L. (2016). What’s the role of autonomy in patient-and-family-centered care when patients and family members don’t agree? AMA Journal of Ethics, 18(1), 12-17. doi:10.1001/journalofethics.2016.18.ecas2-1601

Yeh, E., Lau, S., Su, W., Tsai, D., Tu, Y., & Lai, Y. (2011). An examination of cancer-related fatigue through proposed diagnostic criteria in a sample of cancer patients in Taiwan. BMC Cancer, 11: 387. Doi: 10.1186/1471-2407-11-387