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Case Management

Discuss about the Clinical Case Conference Report.

This is a clinical case conference report of a patient who is 51 years of age who has been admitted to the hospital with the chief complaints of severe headache, blurred vision and vomiting and a diagnosis of Astrocytoma. Prior to admission, the patient had a very supportive family as he lived with his wife and two children and his relatives visited him often. At the time of admission, he needed a little bit of assistance with his daily life activities but presently, he is no more independent. He needs nursing care with sling lifter, suffering from a stage 4 sacral ulcer and has got VRE. Apart from this, he has the past medical history of lung fungal infection, high cholesterol, UTI, high blood pressure, chronic back pain, B-cell lymphoma and diabetes type 2. This report will explore the medical condition of the patient and consider the assessment of his pathophysiology, nursing interventions, medications, problem evaluation and nurse to patient-specific education.

Presently, the patient has been diagnosed with the pathophysiological condition of astrocytoma along with severe headache, blurred vision and vomiting. Astrocytoma is a type of brain cancer that originates in the cerebrum in star-shaped brain cells called astrocytes. This tumor does not tend to spread out of the spinal cord and brain and does not affect other organs. It is the commonly occurring form of glial tumor and can appear on several parts of the nervous system and the brain that includes cerebrum, cerebellum and other central parts of the brain, spinal cord and the brainstem. The exact pathogenesis of the tumor is unknown like many other types of tumors (Wick et al. 2012). As symptoms of the diagnosis, severe headache with vomiting and blurred vision occurred. Along with this, he needs the management of some of his chronic problems like subdural hemorrhage, VRE, high cholesterol, high blood pressure, diabetes and chronic back pain. Since the patient is suffering from astrocytoma, it aggravated his other chronic problems.

Clinical assessment using a system based approach like ISBAR can be used to explain the relationship of nursing management with medical management. Since the patient is suffering from astrocytoma, he is having severe headache as a symptom for which analgesic medication like paracetamol has been prescribed. Apart from this, nursing intervention like setting the administration of narcotics can be done with the rationale of providing sedative effect and elimination of anxiety and discomfort. The involvement of interdisciplinary teams of healthcare professionals like social worker, psychologist, palliative team, nurses and dietician is essential as each team member contributes their unique expertise. It is also required to overlap their professional skills and practice areas for providing seamless care coordination in a complex situation of astrocytoma to minimize morbidity, optimize survival and maximize the quality of life. Primary healthcare strategies for astrocytoma include operative intervention by the application of radiation therapy and chemotherapy (Jones et al. 2013). The primary strategies are decided by the team of professionals involved in the care process and include input from the concerned neurologist and oncologists. For the nursing management of his chronic back pain, the lumbar flexion can be improved by changing the sleeping position and encouraging him for bed rest. Assessment of his standing and moving posture by the nurse can also help in the management of his chronic back pain. For the nursing management of his diabetes type 2, encouragement of physical activity and enteral nutrition support are provided for improving his functionality and dependence and for providing diet that is low in carbohydrate and high in monounsaturated fat for improving his quality of life.

Medical Management and Treatments

Medical management and treatments described for the patient include pharmacological and non-pharmacological treatments with pain management for his pathophysiological condition. Considering his present diagnostic condition of astrocytoma and other problems like subdural hemorrhage, diabetes, chronic back pain, UTI and other problems, he has been prescribed medications like Enoxaparin, Dexamethasone, Enoxaparin, Novorapid, Paracetamol, Fentanyl, Vancomycin and other medications respectively for management of the problem and the side effects emerging out of the medications. This is evident from the prescribing of the medications Movicol and Coloxyl Senna as they are the laxatives and has been prescribed for the management of constipation occurring out of the medication side effects like antibiotics. This is the pharmacological management provided for pain and discomfort. For the non-pharmacological management of astrocytoma, mechanical thromboprophylaxis is an effective tool to reduce bleeding as the patient is also suffering from subdural hemorrhage. Foot pump devices, intermittent pneumatic compression and graded elastic stockings are other non-pharmacological measures for the management of astrocytoma (Fontebasso et al. 2014). For cancer-related pain, muscle relaxation, diaphragmatic breathing and guided imagery are the preferred non-pharmacological treatment and for the management of his chronic back pain, behavioral therapy can be effective for short-term pain management and as an adjunctive therapy, hypnosis can be used. For his diabetes 2, stress management, physical activity and diet are the preferred non-pharmacological treatment (Jó?wiak, Nabbout and Curatolo 2013).

The relevant diagnostic tests for astrocytoma include physical examination and along with that several other methods can be employed like biopsy, magnetic resonance imaging (MRI) and computed tomography (CT) scan. Biopsy can definite the diagnoses of tumor while the other two types can suggest the presence of a tumor. The diagnosis of chronic back pain will include physical exam that will be followed by CT scan, X-rays and MRI. MRI can be the most effective way to determine the damage of the pinched nerve and disk compared to X-rays and CT scan (Center et al. 2012). For his diabetes type 2, glycated hemoglobin (A1C) test, oral glucose tolerance test, fasting blood sugar test and random blood sugar test will be included (Inzucchi et al. 2012). Screening tests can be included for the patient that will include initial glucose challenge test and follow-up glucose tolerance test. Apart from these diagnostic tests, other tests will be carried out for determining his other medical complications that include rectal swabs or urine and stool samples for VRE, lipid profile tests for high cholesterol and a pressure measuring gauge for measuring the blood pressure.

Psychosocial, environmental and economic aspects can be discussed concerning the patient condition since he is suffering from a number of complications apart from astrocytoma. With such a burden of diseases, the patient will undergo a number of medical procedures during his stay in hospital. Therefore, psychosocial support has to be provided to the patient to avoid the stress of the treatment and diagnostic procedures and make him realize the meaning of the results of the tests. This will lessen the psychological pressure on the aged patient and aid him with emotional support  (Johnson and Galanis 2014). Environmental aspects can be the root cause of the burden of disease for the patient and therefore, it is advised that a healthy environment has to be provided to the patient for his quick recovery. The key areas of risk have to be identified and eliminated since the patient is suffering from VRE, he should be provided with a protective environment to control the further growth of the disease. Since the treatment of such a large number of diseases can be another economical burden on the patient and his family, it can be reduced by avoiding the developing of the diseases like sacral ulcer by effective nursing management by constant changing of his sleeping posture and maintaining a moist environment  (Strowd et al. 2016).

Diagnostic Tests


Ethical aspects included, in this case, will be to make the treatment cost-effective and maximize the health benefits with the provision of limited resources. The patient should be discussed with his prognosis and diagnosis, his quality of life should be monitored during and after the procedure of treatment and there should be respect for non-maleficence, beneficence, justice and autonomy (Frederickson and Ghere 2013). The legal aspects can be stated as according to the common and statute law of Australia, the confidentiality and privacy of the medical information of a patient should be well maintained. This is particularly important in this case as the patient is suffering from many diseases and a multidisciplinary team of professionals is involved in the care management of the patient. The ‘Health Services Act 1988’ states that disclosing of the patient information is strictly prohibited that leads to his identification unless he has committed an offense under the law (Legislation.vic.gov.au 2016).

Education needs of the patient and the family will include a detailed description of his complications by the nurse including astrocytoma along with any relevant grouping or classification, associated symptoms, diagnostic tests and the treatment guidelines. The family will be provided with the education materials and education regarding care providing at home after discharge. Nurse to patient-specific education will also include the guidance on his activities of daily living where he needs assistance as he has lost his independence post his admission to the hospital (Bastable 2016).

Discharge planning will include considering him to get admitted in a nursing home or hospice as the patient is in need of active treatment like transfusion. Since he requires the support of three persons with his sling lifter, it would not be safe for him to return to his home. Therefore, the factors like available assistance, architectural barriers, quality of life and availability of home therapy has to be considered while planning his discharge. As the patient is not safe physically or cognitively and there is no assistance available at his home, facility with assisted living has to be planned on discharge (Altfeld  et al. 2013). Hospice can be preferable for the patient as his prognosis is poor and it can provide him with tremendous support for the patient and his family for improving his quality of life.

The patient presented with the diagnosis of astrocytoma along with several other complications like subdural hemorrhage, chronic back pain, diabetes type 2, high blood pressure, high cholesterol and VRE. Apart from this, he was having sacral ulcer – stage 4 and complaints of severe headache and vomiting with blurred vision. For these complaints, he has been provided with the necessary pharmacological and non-pharmacological interventions and discharge plans have been prepared. However, there are several research findings that are relevant to the case management. Few of the critical complications like astrocytoma, chronic back pain and diabetes type 2 will be selected and associated with the research findings for critiquing the provided management and suggesting alternative management.


Ouyang et al. (2014) carried out a research work that discussed the present and future of the management of astrocytoma. The research work is relevant to the case management of the patient as it focused on medication and surgery and for the patient, medications were prescribed for management of the disease. The article also expressed the various parameters of the disease that were in alignment with the clinical condition of the patient and its subsequent management. Kahn, Cooper & Del Prato (2014) carried out a similar study to explore the treatment and pathophysiology of diabetes type 2 and this has resemblance with the present case of the patient as it discussed the treatment procedure which was similar to that of the patient. Novorapid is the insulin analog that has been prescribed to the patient and the article also discussed about the potential benefits for the using insulin as the frontline treatment of diabetes type 2. Gatchel et al. (2014) carried out a similar research work for discussing the aspects of chronic pain management and it had relevance to the case of the patient as it suggested interdisciplinary therapy for pain management and the patient was also provided with a multidisciplinary team for managing his pain and discomfort due to the burden of a number of diseases.

Psychosocial, Environmental, and Economic Aspects

The management and care provided to the patient can be compared and critiqued with the research finding and best practice that has been included in the literature. For astrocytoma, the research finding by Ouyang et al. (2014) stated that surgical management is the standard treatment procedure for the disease whereas, the patient has been prescribed with medications like Enoxaparin, Filgrastim and Dexamethasone. Pharmacological management of astrocytoma has been proposed by mTOR inhibitors like everolimus and sirolimus in the research finding for maximum therapeutic benefits but the patient has not been prescribed these medications for his management of the disease. Since the mTOR inhibitors have been proved to be potentially beneficial for the treatment of astrocytoma, prescribing them could have been considerably reduced the burden of the diseases that the patient is suffering from. So, it can be stated that there have been deviations in the management of astrocytoma of the patient when compared to the best practice provided in the literature. A similar finding has been derived from the research literature by Kahn, Cooper & Del Prato (2014) for the management of diabetes 2 of the patient where the researchers have found that the second generation sulfonylurea antidiabetics like Gliclazide, Glibenclamide and Glipizide can be equally effective as insulin. Although the researchers have proposed insulin as the first line of therapy for diabetes 2, it has several side effects like hypoglycemia, neuropsychological impairment, ocular disturbance and lipohypertrophy. These can be avoided with the use of the proposed medications of the researchers that can act to reduce the disease burden effectively, without adding up the side effects of insulin with the administration of Novorapid. Keeping in tune with the research findings, Gatchel et al. (2014) has described chronic pain as a costly and significant problem and considering the economic aspects of the patient, it can be stated that he is a huge burden of expenditure due to the treatment of the large number of diseases that he is suffering from. For providing cost effective treatment of his chronic back pain, the authors have proposed interdisciplinary programs of pain management considering the social, psychological and physiological factors including family, cognitions and medications. However, in the present case, although there has been an involvement of the multidisciplinary team for his treatment and medications has been provided, incorporation of the psychological parameters like attention, behavior, emotions and cognitions can improve his pain without adding up to the extra cost. The nurse will be required to play an integral role in the process by monitoring and evaluating the treatment outcomes and maintaining effective communication with the treatment team. There have been these deviations when the best practice was compared and critiqued with the nursing care and management of the patient.

Apart from the treatment procedures adopted in the research literature, several other options can be suggested for the alternative management or nursing care of the patient. Corticosteroid therapy can be effective in the management of astrocytoma and medical therapies can be complimented with the application of biobehavioral nursing interventions (Seyfried et al. 2012). Alternative approaches of taking Chromium, Alpha-Lipoic Acid, Aloe Vera and Cinnamon can significantly control the diabetes type 2 of the patient and the nurse educators are expected to provide appropriate guidance to the patient regarding these alternative therapies (Ley et al. 2014). Chiropractic manipulation can be an effective alternative for the management of chronic back pain and the nurses providing physical and psycho-social support to the patient can add up to the procedure (Chaparro et al. 2014).

Ethical Aspects

Conclusion

From the case, it is evident that the patient is under a huge burden of several diseases that requires effective management and nursing care. An effective clinical case conference report will aid to understand the case of the patient better and find out the gap in the present treatment regime. Filling up of the gap by the management strategy from the research findings can help to support the multidisciplinary team with the easy management of the diseases and provide psychosocial and economic support to the patient. The ethical and legal aspects have to be considered to provide effective treatment and support to the patient and his family within the permitted regulations by the Australian authority of healthcare. This report identified several crucial aspects that can effectively modify the treatment procedure and efficiency of the patient.

References

Altfeld, S.J., Shier, G.E., Rooney, M., Johnson, T.J., Golden, R.L., Karavolos, K., Avery, E., Nandi, V. and Perry, A.J., 2013. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. The Gerontologist, 53(3), pp.430-440.

Bastable, S.B., 2016. Essentials of patient education. Jones & Bartlett Publishers.

Center, C., Relief, P., Covington, L.A. and Parr, A.T., 2012. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician, 15, pp.E159-E198.

Chaparro, L.E., Furlan, A.D., Deshpande, A., Mailis-Gagnon, A., Atlas, S. and Turk, D.C., 2014. Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine, 39(7), pp.556-563.

Fontebasso, A.M., Papillon-Cavanagh, S., Schwartzentruber, J., Nikbakht, H., Gerges, N., Fiset, P.O., Bechet, D., Faury, D., De Jay, N., Ramkissoon, L.A. and Corcoran, A., 2014. Recurrent somatic mutations in ACVR1 in pediatric midline high-grade astrocytoma. Nature genetics, 46(5), pp.462-466.

Frederickson, H.G. and Ghere, R.K., 2013. Ethics in public management. ME Sharpe.

Gatchel, R.J., McGeary, D.D., McGeary, C.A. & Lippe, B. 2014, "Interdisciplinary chronic pain management: past, present, and future", The American psychologist, vol. 69, no. 2, pp. 119-130.

Inzucchi, S.E., Bergenstal, R.M., Buse, J.B., Diamant, M., Ferrannini, E., Nauck, M., Peters, A.L., Tsapas, A., Wender, R. and Matthews, D.R., 2012. Management of hyperglycemia in type 2 diabetes: a patient-centered approach position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care, 35(6), pp.1364-1379.

Johnson, D.R. and Galanis, E., 2014, August. Medical management of high-grade astrocytoma: current and emerging therapies. In Seminars in oncology(Vol. 41, No. 4, pp. 511-522). WB Saunders.

Jones, D.T., Hutter, B., Jäger, N., Korshunov, A., Kool, M., Warnatz, H.J., Zichner, T., Lambert, S.R., Ryzhova, M., Quang, D.A.K. and Fontebasso, A.M., 2013. Recurrent somatic alterations of FGFR1 and NTRK2 in pilocytic astrocytoma. Nature genetics, 45(8), pp.927-932.

Jó?wiak, S., Nabbout, R. and Curatolo, P., 2013. Management of subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis complex (TSC): clinical recommendations. european journal of paediatric neurology, 17(4), pp.348-352.

Kahn, S.E., Cooper, M.E. & Del Prato, S. 2014, "Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future", Lancet (London, England), vol. 383, no. 9922, pp. 1068-1083.

Ley, S.H., Hamdy, O., Mohan, V. and Hu, F.B., 2014. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. The Lancet, 383(9933), pp.1999-2007.

Ouyang, T., Zhang, N., Benjamin, T., Wang, L., Jiao, J., Zhao, Y. & Chen, J. 2014, "Subependymal giant cell astrocytoma: current concepts, management, and future directions", Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, vol. 30, no. 4, pp. 561.

Seyfried, T.N., Marsh, J., Shelton, L.M., Huysentruyt, L.C. and Mukherjee, P., 2012. Is the restricted ketogenic diet a viable alternative to the standard of care for managing malignant brain cancer?. Epilepsy research, 100(3), pp.310-326.

Strowd, R.E., Abuali, I., Ye, X., Lu, Y. and Grossman, S.A., 2016. The role of temozolomide in the management of patients with newly diagnosed anaplastic astrocytoma: a comparison of survival in the era prior to and following the availability of temozolomide. Journal of neuro-oncology, 127(1), pp.165-171.

Victorian Legislation and Parliamentary Documents. (2016). Legislation.vic.gov.au. Retrieved 8 November 2016, from https://www.legislation.vic.gov.au/

Wick, W., Platten, M., Meisner, C., Felsberg, J., Tabatabai, G., Simon, M., Nikkhah, G., Papsdorf, K., Steinbach, J.P., Sabel, M. and Combs, S.E., 2012. Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in the elderly: the NOA-08 randomised, phase 3 trial. The lancet oncology, 13(7), pp.707-715.

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