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Question:

Discuss about the Presentation and Management of Chronic Pain.

The current assignment focuses upon pharmacological management of a patient in end of life care.  The assignment discusses regarding the various aspects of pharmacological management. Here, emphasis have been placed upon the overall  health condition of the patient, as the pharmacological management becomes considerably difficult when the patient is suffering from a  number  of co-morbid conditions. For instance, in case of acute gastroenterology pain, the medicines may not be of the patient condition (Weinberg, Smalley, Heidelbaugh & Sultan, 2014, p.1147). The assignment focuses upon the removal of strong medicines, which could initiate side effects in the patient when continued for longer period of time and provision of alternate medication strategies. However, a number of hindrances are faced over here such as lack of cooperation from the patient as well as loss of hope of recovery. Some of these may act as discouraging aspects in the delivery of care.

The current study focuses upon the aspect of pharmacological management for an end of life patient suffering from bowel cancer. Here, JR is an 80 years old female patient diagnosed with bowel cancer and has been affected with abdominal pain and constipation.

The bowel cancer of JR is at an advanced stage and has been accompanied by a number of co-morbid conditions such as – urinary tract infection, incontinence of urine and faecal, constipation, abdominal pain, hypertension and increased anxiety. The rejection to take chemotherapy can further alleviate the problem. However, she wants to discontinue with the use of the same and lead a comfortable and pain free life. 

Though, the patient has been on chemotherapy along with radiation therapy for a while.

The abdominal pain and situation of constipation required the patient to use excess PRN medications. However, it had little therapeutic effect on the patient. Some of the medicine doses which were administered to the patient over here were endone 5 mg bd; panadole 500 mg X 2 bds; Movicol one X BD; Oxazepam; atorvastatin. The patient also reported allergy for keflex, which caused nausea in the patient.

The patient is supported through the crisis by her husband and two children. The patient also had a past history of smoking which  could contributed significantly in the development of colon cancer in the patient.

Therefore, in order to relieve the patient from the present health situation it was required that an effective pain control mechanism be designed for the patient. Hence, the assessment will be mainly upon the control of pain owing to bowel cancer and constipation in the patient.

Goals and specific outcome criteria

Identified  problems

Goals and specific  outcome criteria

Patient and nurse practitioner actions

Time for follow up

Constipation

·       Relieve the symptoms  of  constipation in the patient

Outcome :

·       Patient  should show less dependence upon laxatives

The  nursing professional  should  put the patient under an effective care process where  medicine administration  will be balance  with  physiotherapy sessions to  normalise the bowel movements pattern of the patient JR.

The follow up should be done on weekly basis.

Abdominal pain

·       The  pain in the patient to be  controlled  with the  help of effective medication management

·       The pain to be measured with the  help of a Braden scale

Outcome:

·       The patient should be able to report less pain

The  patient to be provided  with  cognitive behavioural  and therapeutic  approaches  which will  help the patient develop  a  less critical response to  pain.

The entire process to be followed up on a weekly basis.

(Source: Author)

In order to administer effective constipation management and pain control treatment to the patient it was required to access the clinical condition of the patient.  For the purpose of which the clinical reasoning cycle could have been used over here. The clinical reasoning cycle could be divided into a number of steps a few of them have been discussed over the following sections.

The patient here had been suffering from bowel cancer and was previously subjected to chemotherapy and radiation therapy. Additionally, excess use of PRN medications has been seen to result in additional abdominal discomfort in the patient (Mayer et al., 2015, p.1915).

The patient was put on some of the regular medications such as endone 5 mg which was provided to the patient for effective pain control. The Panadole was also administered to the patient for effective pain management as the paracetamol helped in the controlling of pain. The movicol was administered for the management of constipation in the patient. The patient was also put on anti-anxiety drugs such as oxazepam for the management of anxiety in the patient. However, as argued by Beaugerien and Itzkowitz (2015, p.1452), excessive intake of anti-anxiety drugs could have strong impact upon the digestive system by a altering the HCL secretion capacity of the stomach and produce further negative symptoms in colorectal cancer. Additionally, higher doses of analgesics could also lead to intestinal cramping or intestinal contractions.

The vital signs in the patient could be related to the clinical conditions as follows:

Abdominal pain – the abdominal pain could arise due to bowel incontinence in the patient

Constipation- the constipation or the inability to pass gas or stool could be referred to the presence of bowel obstruction in the patient.

In this respect, the patient had been suffering from bowel cancer which made daily life difficult for the patient. The patient suffered from incontinence in the passing of bowel and suffered from incontinence. Due to this, the patient suffered from increased amount of abdominal pain and had to depend on huge amount of pain killer for controlling her pain. However, as supported by  Cho  et al. (2015, p.712), increased uptake of paracetamol could lead to intestinal coiling in the patient. Some of the most common causes of constipation are inadequate fluid intake and excessive intake of pain medications (Nalliah et al., 2017, p.139).  However, considering the condition of the patient JR the constipation could be due to improper bowel movement, which could be again attributed to bowel obstruction.

Patient and nurse practitioner actions

In order to deal with the current health situation of the patient a number of goals could be designed. Some of which have been represented as follows:

  • The patient to be provided with effective  counselling sessions in order to alter or change the attitude of the patient towards  pain which could reduce the feeling of anxiety towards  pain in the patient
  • The symptoms as well as the amount of pain faced by the patient to be monitored with the help of Braden scale.
  • The lifestyle and eating patterns of the patient could be closely monitored as the focus should be to increase the quantity of  roughage in the diet of the patient
  • The patient need to be moved around more freely as being bound to the bed can obstruct the faecal movement in the patient further, as the bowel fails to move effectively through the intestine.
  • The entire process to be followed up on a weekly basis.

Here the goals would be reduce the pain symptoms in the patient by effective medication management. Additionally, reducing the dependence on painkiller or increasing the gap between the administrations of two such doses could be relieving the symptoms of constipation in the patient.

At the end of the assessment the patient should report reduction in pain along with better expulsion of waste through the body.

In order to discuss regarding the management of constipation though medication it is necessary to understand the causes and side effects of constipation. Constipation is expressed in several forms and the symptoms vary from individual to individual (Salvatore et al., 2016, p.68). These could be explained on the basis of stool frequency, stool form as well as difficulty with evacuation. Therefore, all these conditions could be described under a common condition known as irritable bowel syndrome. In majority of the cases, some of the conditions expressed by the patient are thought to be simply a part of irritable bowel syndrome. However, as supported by Misale  et al. (2015, p.112), the condition could be much chronic in patient with cancer.  As the bowel obstruction makes evacuation difficult for the patient. Hence, a number of different symptoms are noted in the patient such as abdominal cramping and pain in the tummy. In the current study the patient has been seen to be dependent mainly upon painkillers and analgesics for the controlling of pain. However, excess dosage of the painkillers has been seen to trigger involuntary contractions in the stomach wall which could further alleviate the condition of pain within the patient. On the contrary, bowel obstruction makes normal passage of faeces difficult for the patient. Hence, the patient has to be dependent upon the external medicine sources for facilitating proper bowel movements. In this respect, JR was given a range of medications for controlling the symptoms of constipation and pain. However, none of the medications were found to produce sufficient relief in the patient.  Recently focus has been shifted upon the use of alternate medicines made out of plant extracts for relieving the symptoms of constipation and abdominal pain in the patient (Muldrew et al., 2018, p.515). Some of these pharmacological interventions could be discussed in the present context. The movicol was administered to relieve the symptoms of constipation in the patient.

Time for follow up

However, there are a number of side effects of the administration of movicol such as bloating of the abdomen, abdominal pain accompanied by a feeling of nausea and vomiting. Therefore, the patient had to be put on an effective and alternate medication pattern. As mentioned by Star &Boland (2018, p.13), more  emphasis needs to be put on the  administration of herbal  medication or laxatives made  out of plant extracts as they have been associated with  reduced  side effects. The FDA had recently approved the administration of bulking agents, which are mainly organic polysaccharides and act by encouraging water retention in the stool (Chua & Nieh, 2017, p.62). Some such herbal remedies which could have been suggested to JR over here are- Psyllium, Bran, Methylcellulose, Calcium polycarbophil, stool softeners, ducosate, stimulant laxatives, osmotic laxatives etc.

Psyllium is the husk of the seed of Planatago ovata, which have shown improved results   in controlling some of the events of faecal impaction (Chang et al., 2017, p.1120). As reported by Lacy et al. (2016, p.1402), out of the three placebo controlled trials two have shown improved in evacuation techniques. However as argued by Lacy et al. (2016, p.1402), the psyllium husk has been seen to take considerably   longer amount of time for producing the desired results. On the other hand bran has been found to be less effective in reduction or controlling the rate of bowel obstruction. However as argued by Prommer (2015, p.420), some of these drugs have been found to be ineffective in people with strong faecal impaction.  As mentioned by Drew, Cao & Chan (2016, p.173), methylcellulose laxatives have been found to be more effective in people with chronic obstruction.


In this context, the use of dulcolax drops has been particularly useful in relieving the constipation in the patient. The dulcolax drop helps in stimulates the bowel and helps in the formation of soft tools. The active ingredient sodium picosulphate has been particularly beneficial in relieving the symptoms of constipation in the patient. Research has shown that the drug could be effectively taken by children as well as adult of all age groups on a regular basis and the rate of side effects have been comparatively less.

Since, some of these drugs have been seen to produce relatively lesser or no side effect, they have been prescribed in patients with chronic bowel obstruction. However, in the lack of knowledge regarding the exact medication patterns and doses the pronouncement of the effect in the patient may not be well understood. A  number  of  clinical studies and trials have  placed  importance upon the use of polyethylene  glycol derivatives for  controlling the  severity of constipation and reducing abdominal  pain in the  patient(Oczkowski, Duan, Groen, Warren & Cook,  2017, p.721). As argued by Hofman  et al. (2015, p.1778), in 40% of the cases  the administration of  PEG has resulted in the  occurrence of diarrhoea in bowel cancer patients. 

Pharmacological Management

However, JR had a number of health co-morbidities which made medication management difficult in the patient. She reported urinary tract infection and faecal impaction, which made the administration of herbal drugs and curatives difficult for the patient. As mentioned by Punt, Koopman & Vermeulen (2017, p.235), excessive intake of such dry husks have been worsen the situation of urine incontinence in the patient with bowel cancer.

Additionally, huge amount of restrictions are faced by the healthcare professionals with respect to the medication management in end of life care patients. Some of these barriers are presented due to differential opinions possessed by the patients regarding certain therapies and medications. The patients who are going though the end of life crisis find little hope in the treatment methods and procedures which   are expressed in the form of non-cooperation with the medical fraternities, which makes yielding the end result even more difficult.

Pain management is medicine branch that deals with the improving the quality of life as well pain reduction through the effective pharmacological management. Management of pain is very vital for the patients having cancer because even after undergoing surgery one in three patients are experiencing pain after treatment. The patients that are affected with the advanced cancer are most likely to suffer from severe pain. Other than the radiotherapy and the chemotherapy there are other types of treatment procedures called targeted therapy, immunotherapy, and surgery (Jamison & Edwards, 2012, p.62).

             The targeted therapy for the colorectal cancer is also called the monoclonal antibody therapy. The bioengineered proteins come from the monoclonal antibodies that help in increasing the body’s immune system and helps in the identification, destruction, attack and of the colorectal cancer cells. Monoclonal antibodies therapy can be used alone or in combination with the other types of therapy like chemotherapy. There are several kinds of drugs that that help in the treatment of the metastatic colorectal cancer.

  • Bevacizumab (Avastin)- this medicine prevents the tumour from further growth by blocking the growth of the blood vessels in to the tumour cells. This helps in effectively cutting off the supply of nutrients from reaching the tumour cells.
  • Panitumumab (Vectibix)- this medicine targets the epidermal growth factor receptor and thus effectively preventing the signals from moving inside the colorectal cancer cells. this medicine thus effectively prevents the growth and division (Hagan, Orr & Doyle, 2013, p.3).
  • Cetuximab (Erbitux)- this medicine works by attaching to a protein called the epidermal growth factor receptor, as this cell exits on the surface of the cells. This type of therapy prevents the signals from reaching the colorectal cancer cells, which further prevents the cells growth and division (Farzaei, M. H., Bahramsoltani, R., Abdollahi, M., & Rahimi, 2014, p.558).
  • The other types of the drug used for the targeted therapy are the Zaltrap, Stivarga. These medicines also cut off the blood supply and prevents the signal passage respectively (Hagan, Orr & Doyle, 2013).

Immunotherapy, for the treatment of the colorectal cancer is made for the purpose of enhancing the body’s immune system and recognize, attack and finally kill them. Checkpoint inhibitors can be used to for the disruption of the signalling receptors that cleverly disguise the cancer cells from the immune system. There is a drug called the pembrolizumab (Keytruda) and it is used to treat the patients with metastatic colorectal tumour that is in inoperable condition. Such patients also have genetic features called the mismatch repair deficiency or microsatellite instability-high. This defect has been in 90 percent of the patients along with the patients that have lynch syndrome. The immune therapy helps in the treatment of the patients and the responses sometimes vary (Lynch & Murphy, 2016, p.72).

Side-effects of administration of conventional medicines

Surgery for the colorectal cancer treatment is one most common form. The surgery involves the removal of the tumours and also the section of the colon in which the tumour is found (Rajapakse, Liossi & Howard, 2014, p.175). Sometimes it becomes necessary to remove the entire colon along with the healthy intestine and the lymph nodes. The patients that undergo the surgery receive the radiation therapy or chemotherapy before or after the surgery procedures (Peters, Muir & Gibson, 2014, p.1170). These therapies altogether can shrink the tumour and are effectively used to target the tumour cells that are left even after the surgery (Lee et al., 2017, p.206).

A randomized control trial was conducted to using the different types of the drugs available for the treatment of the colorectal cancer. It was found that the treatment procedure of utilizing the drugs is found to be much more effective for the overall survival of the patients and in leading a disease free life (Akhtar et al., 2014, p.177).  In case all other methods of treatment fail Targin 5/2.5 mf tablets could be suggested to the patient.  It is mainly suggested in case of chronic pain when other medication therapies have failed to reduce the pain. The slow release of oxycodone and naloxone has been effective in controlling the acute pain. As mentioned Star & Boland (2018, p.15), the slow release ensures that the patient can combat with the consequence of drug overdose.

A number of alternate procedures and therapies could be suggested for coping with the deteriorating health condition of JR. JR had been bound to bed and at the progressive stage of bowel cancer.  Her physical conditions provided her with little scope to spend time with her family. Additionally, the lack of hope and positivity to recover fully further affected the mental well being of JR. Therefore, apart from the medication and remedies which were provided to her she could have been put into effective counselling sessions.  As mentioned by Chua & Nieh (2016, p.62), the counselling sessions were supposed to restore faith and positivity in the patient.

Additionally, implementing effective physiotherapies in the daily care routine of the patient can facilitate effective movements of bowel (Chang, Lembo & Sultan, 2014, p.1170). However as supported by Afrin  et al. (2012, p.169), in the end of life palliative care it is more important to focus upon reduction of the pain in the patient  with bowel cancer  and provide them with a holistic and positive care regimen. Therefore, apart from pharmacological interventions focussing upon the diet of the patient and including more roughage in the diet of the patient can help in the elimination of waste from the body (Akhtar, Chandel,  Sarotra & Medhi, 2014, p.177).

Alternate medication patterns

Conclusion

The assignment argues regarding the various clinical and pharmacological aspects for the end of life palliative care.  However, the pharmacological intervention and methods have been found to be associated with a number of limitations. Some of these limitations are offered due to lack of resources as well as insufficient cooperation from the participants. In this respect, a number of alternate medication strategies and procedures have also been highlighted over here.  For example, maintaining the diet of the patient in an effective manner by incorporation of more roughage implementing more effective counselling sessions for the patient. This can help in generating the hope of survival in the patient based upon which the patient show better responses to the altered medicines. Additionally, a number of clinical conditions of the patient needs to be taken into consideration before changing of the medication doses as changing the medicines in case of co-morbid health conditions may illicit strong responses.

References

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