Students are to provide critique of the provided case study using CPG. (Clinical Practice Guideline).
Title: Managing Psychological Issues Inclusive of Terminal Restlessness.
To complete this task you will need to discuss and critique relevant elements of the CPG and case study whilst upholding:
- NSQHS and/or
- NMBA standards and/or
- National Palliative Care standards
Purpose: Students are required to demonstrate an understanding of how theory translates into practical nursing care and how evidence underpins best practice. Each student will review and critique the care given in the Case Study provided according to their choice of the provided Clinical Practice Guidelines (CPG’s) best suited to the highlighted discussion.
Fortunato (Frank) Rossi, is a 60 year old male who was born in Italy and Migrated to Australia with his wife in 1952, both he and his 58 year old wife Sofia have dual citizenship in Italy and Australia. Frank and his wife practice a strong catholic faith. Frank has worked as a Secondary School Science and Mathematics teacher at a local Catholic Secondary School for over 20 years and loves his job. He is well respected by his colleagues and students with his very "quick wit and sharp mind with problem solving" that he prides himself on
Sofia has been a stay at home mother and carer for their 2 daughters:
- Eldest Daughter: Annamarried Phillip have 2 daughters Bella (6) and Emily (3 months)
- Youngest Daughter: Gabriellamarried Michael have 1 son (18 months old)
Together they have had a wonderful life, with supportive family visiting from Italy and the Rossi family themselves being able to go over to Italy for many family holidays. Both Frank and Sofia are very excited and enjoying being grandparents, they are looking forward to Frank's decision for an early 'self funded retirement' to enjoy more time with the family. Frank has arranged with his school to be able to undertake a small amount of casual teaching if he and his family require some small income once he has retired, although he is very keen to work in his garden and spend time helping to raise the grandchildren and enjoy the many years of hard work that he and Sofia put in to support their family and the "good life" they have created in Australia.
Three months ago
Frank experienced some confusion at work and a seizure "of unknown origin" that was witnessed by his wife and grandchildren. Sofia immediately called 000 and Frank was transported urgently under the care of paramedics to the emergency department (ED) of a major metropolitan hospital as they lived close to the city.
Frank has now spent some time in a general medical ward at the Tertiary Level City Hospital that he was originally transferred to by ambulance 2 weeks ago following another seizure. During his admission the following cues and information were collected and a diagnosis made. Prior to his transfer and admission to the palliative care unit in an outer city hospital closer to his family home
Past Medical Hx
- Tonsillectomy as a child
- Ex smoker (quit smoking 25 years ago was a packet a day smoker)
- Diet Controlled type 2 Diabetes
- Seizures of unknown origin
- Blurred vision
- Difficulties with problem solving and decision making
- Gradual onset of speech disturbance
- Muscle Weakness
- Behaviour Changes
- sluggish pupil response to light
Gathering new Information
Frank's vital signs upon admission to medical ward
RR : 18
HR: 84 bpm
SaO2: 96% on 3Lmin via N/P (For Comfort measures)
Raised Intracranial Pressure (ICP) - constant headache
GCS - 9/15 (eyes open to painful stimuli 2 / confused and disorientated verbal response 4 / Abnormal Flexion from painful stimuli 3)
Intermittent Patient Notes
"Patient transferred to medical ward following observed seizure of unknown origin by wife and grandchildren who called 000 for paramedic support. In ED patient's conscious state was altered with confusion and inability to recognise wife"
"Pupil size of both eyes was equal however pupillary light reflex is sluggish, positive babinski sign response bilaterally, renal function normal, patient experiencing double incontinence, normal FBE and U&E"
"Initial MRI clearly showed abnormalities in the frontal and temporal regions, with a differential diagnosis of metastatic tumors in the brain from an unknown primary"
Frank was experiencing Increased Intracranial Pressure likely from brain lesions and possible Diagnosis of a Glioblastoma Multiforme (GBM)
Differential Diagnoses had not yet been ruled out
"Patient was administered mannitol every 12/24 over 16 days to reduce Intra Cranial Pressure (ICP,) Lyrica 150mg BD for seizure activity, and Diazepam 10mg PRN..... 5 days post initial seizure pt woke with normal cognitive responses and recognition of family members once ICP had begun to reduce. Progressively pt's ability to walk without deficit returned. Pt was fully continent, had good long term memory recollection, however short term memory was impacted"
"Pt's oral mucosa had multiple abrasions and thrush evident from possible injury during seizure, patient complained of mouth and throat pain, often refusing to eat and drink"
"Differential Diagnoses of ?Infection, ?metastaic cerebral tumors were discussed however following lumbar puncture for collection of cerebro-spinal fluid (CSF) specimen, and further MRI results showing rapid tumor growth particularly in Frank's frontal lobe just 18 days after his initial ED presentation, the diagnosis was highly indicative of a GBM"
"Patient and wife agreed to surgical tumor resection as a palliative measure with the knowledge that this was not a cure. Histopathology post surgical resection clearly identified a rapidly growing GBM with temporal lobe metastases as the definitive diagnosis. A family meeting was arranged with the neurosurgeon, oncologist, palliative consultant, social worker, nurse unit manager, Frank and his family to discuss options"
Confirmed Diagnosis, medical imaging and histopathology results
Following CT Brain and MRI it was concluded that Frank had a Glioblastoma Multiforme (GBM) in his frontal lobe which had likely metastasized in both temporal lobes, thus his prognosis was devastatingly a Stage IV GBM with a likely survival of 2 - 3 months without surgical resection and/or palliative radiation therapy.
"Family advised to discuss and complete an Advanced Care Directive whilst Frank was competent with the knowledge that his ICP was likely to increase again, and a decision on how to proceed with interventions was needed. Palliative radiotherapy was offered to Frank, he and his wife refused and decided to be transferred to an inpatient palliative care unit closer to their family where he could go home on day visits and also spend more time with his family at the palliative care unit, rather than in a busy medical ward"