Symptom Management Case Study
Week 3 Case Studies
Case Study One
Patient History:
Diana at first reports no problems, but later admits that she developed very minor low back pain. She attributes this to increased activity as she has been remodeling her home. When the pain does not abate with over the counter medications (e.g., ibuprofen, acetaminophen) and non-pharmacological techniques (e.g., massage, heat), she will occasionally take a Vicoden® (5 mg hydrocodone/500 mg acetaminophen). When questioned why she does not take more, she states “I don’t like taking narcotics” and “My husband doesn’t like when I take the pills.”
Diana describes her pain as 2 or 3/0-10, located in her low back. The pain is aching and throbbing. When pressed to report other pain sites, she admits she has some shoulder pain, but rates it as a 1 currently. She also describes tingling in the feet bilaterally, extending to the ankles. “It is not pain really, just burning”.
Other history: Diana is married, lives with her husband and 2 teenage sons in a suburban home. She works as a receptionist in a dentist’s office.
Physical Assessment:
During the history, Diana’s posture indicated that she was not comfortable. When Diana gets up from her chair to get onto the exam table, the nurse notes that she does so with difficulty. Palpation of the lower lumbar spine (L3-4) produces pain. Diana denies pain when the clavicle is palpated. Straight leg raises of less than 30 degrees increase the low back pain significantly. Neurological examination reveals weakness in lower extremities, with R > L. Sensory loss is noted bilaterally in the toes and feet to the ankles. Reflexes are intact.
Discussion Questions:
- What are the barriers to pain relief in this case?
- What types of pain is Diana experiencing and what might be the underlying etiologies? What other questions should the nurse ask this patient?
- Devise a plan of care for this patient.
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Case Study Two
Ms. Smith is an 85-year-old woman with end-stage cardiac disease in a home hospice program. She has been very comfortable, not experiencing any other symptoms, and has been quite functional until the last two weeks. Her family contacts the home hospice nurse concerning her lack of appetite, “continual sadness,” and anxiety which they feel is affecting her ability to function.
During a routine home visit by the hospice nurse, the patient relates she has no appetite and is quite comfortable just having occasional “snacks” when she pleases. However, her family remains adamant that she requires better nutrition and they request an IV be inserted. In addition, the family believes Ms. Smith is depressed and “too antsy,” and these contribute to her lack of appetite. Mrs. Smith states that she has had trouble with depression for many years, but has always tried to find “the brighter side” to fight off the sadness. She also acknowledges that she becomes anxious when her children come to visit, as they “don’t want to admit I am dying,” she says. She reports that she does not always sleep well at night, because she is afraid to die and leave her family behind. She says, “I wish I had raised my children better. If I had, there might not be all of this fighting going on about my care. I wish they would leave me alone so I can die the way I want to.”
Discussion Questions:
- How might the hospice nurse incorporate interdisciplinary care for this patient?
- What additional assessments would be needed?
- What interventions might be considered?
Case Study Three
Mr. Hayes is a 53-year-old with widely metastatic colon cancer, which has spread throughout his abdomen. He arrives on your palliative care unit with a chief complaint of intractable nausea and vomiting for 24 hours and diarrhea (1000 cc emesis and 400 cc diarrhea in the past 24 hours). He describes that he is barely capable of managing any activities of daily living. Mr. Hayes has been found to have a non-resectable partial small bowel obstruction. The patient asks, “How much longer do I have?” and “Can we speed this up?” “I don’t want my children (ages 11 & 13) to see me like this.” The patient admits to feeling down but denies any suicidal ideation. He is clearly anxious about becoming a burden to his family and wonders how his children see him. His 13 year-old daughter confides in you that she is “afraid” her daddy is going to die. He is a devout Catholic and mentions to the night shift nurse that he is certain his symptoms and suffering are a punishment for his having a divorce ten years ago. He says to the nurse that he just wants to be left alone and does not want anyone to bother him tonight.
Discussion Questions:
- What additional assessment should be done?
- Is additional suicide assessment indicated?
- How might various disciplines contribute to his care?
- How would you answer the daughter who says she is afraid her “Daddy is going to die?”
- What community resources are available to assist Mr. Hayes and his children?
- What role might his religion play in his illness?
Case Study Four
Mrs. H., a 55-year-old divorced Hispanic woman with stage IV breast cancer, is admitted to the ED suffering from confusion, pain, anxiety, agitation and constipation (states she has not had a bowel movement in 6 days). In obvious distress, she is crying, moaning, and attempting to get out of bed. Her sister reports that she first noticed that Mrs. H. was more anxious than usual approximately 12 hours earlier. Assessment reveals Mrs. H. to be mildly dehydrated, as demonstrated by poor skin turgor and a heart rate of 110. An IV is started, and she receives hydromorphone 1 mg IV push to control her pain and lorazepam 0.5 mg IV to reduce her agitation. Her laboratory values are normal, as is her oxygenation level (O2 sat is 93% on room air). She becomes less agitated and is transferred to the oncology unit. Mrs. H. has had several prior admissions for treatment of bone pain, primarily in several ribs on the lower left thorax and the right femur. During her last stay, Mrs. H. described right upper quadrant pain and was found to have liver metastases. She was placed on an analgesic regimen of long-acting morphine 60 mg every 12 hours, with immediate-release morphine 20 mg for breakthrough pain as needed. Until a few days ago, she required only two or three doses of breakthrough pain medication daily. But her pain recently intensified, and she has needed as many as six to eight doses of immediate-release morphine daily. She contacted her oncologist, and dexamethasone 16 mg PO daily was started two days ago. The nursing staff is surprised to see Mrs. H. so agitated. During past admissions, she appeared sad and somewhat withdrawn, although she consistently denied being depressed. Her sister and two teenage daughters have offered considerable support, visiting often during each of her previous hospitalizations. At the bedside now, they are tearful at witnessing their mother’s confusion about where she is and why she’s in bed.
Discussion Questions:
- How would you assess each of these symptoms (anxiety, depression, delirium, constipation, pain)?
- How would you develop a care plan to address each of these symptoms?
- What patient/family teaching is essential?
- What cultural considerations might be assessed and addressed?
- What long-term planning should be considered?
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Case Study Five
Ms. King is a 32-year old single Caucasian woman who is actively dying of AIDS (has Kaposi sarcoma, as well as central nervous system lymphoma) on the medicine unit. She has lived in a nursing home for the past 18 months and has no immediate family. When her symptoms became more pronounced and her pulse oximeter read 76% on room air, the nursing home sent her to the hospital to be admitted two days ago. She is dyspneic and has reduced breath sounds bilaterally. For the past 3 days she has had a productive cough and becomes extremely dyspneic when coughing (chest x-ray revealed pneumonia) and also begins to vomit. She is anxious and becomes agitated easily. Generally, she is confused and becomes delirious, mostly at night. “If I go to sleep, I know I will never wake-up,” she told the nurse last night. She is not oriented to time, place or person. She has not slept for three days/nights. She also has nausea and vomiting (3-4 times/day—total emesis over the past 24 hours = 650 cc). She denies the presence of pain.
The staff on this unit is young, for the most part, and has an average of one year of nursing experience. Most of the nurses have not cared for people with AIDS. Some are fearful, others are judgmental. Some staff members have significant anticipatory grief reactions and have difficulty caring for Ms. King. A do-not-resuscitate order (DNR) is in place and the orders revolve around “comfort care.”
As the nurse on this medical unit, you decide that some additional education is needed for the staff. You will provide general AIDs education and then help them to develop a palliative care plan around the dyspnea, nausea/vomiting, cough, anxiety, agitation, and delirium.
Discussion Questions:
As the nurse developing this education for your staff:
- What drug treatments would you want to share with the staff in regards to the symptoms listed above?
- What non-drug treatments would you want to review?
- Discuss your plan to address the staff’s discomfort in providing care to Ms. King.
- Detail educational opportunities for the staff to improve the care provided to Ms. King.
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