From case study C, Harold is a widowed farmer, he 75 years old, and has been diagnosed with advanced non-small-cell lung cancer with metastasis of the spinal bone (stage IV). He lives with his son on a farm in the countryside. Harold initially had an x-ray on his chest followed by an ultrasound-guided bronchoscopy before being diagnosed. A scan of the bone also reveals multiple metastasis sites. He also has tested negative for the EGFR mutation. Moreover, he also has other comorbidities, of congestive cardiac failure and chronic obstructive airways disease. His performance score was 2 in The Eastern Cooperative Oncology Group (ECOG). He was to start a treatment regimen of gemcitabine days 1, 8, and 15 repeated every 4 weeks and vinorelbine days 1 and 8 repeated every 3 weeks for his treatment.
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The goals and rationale of the choice of treatment prescribed for Harold.
Lung cancer according to Lung Cancer (2018) is the uncontrolled growth of abnormal cells in both or one of the lungs. As they grow, they can form tumors in the lungs and interfere with the lung’s function in the provision of oxygen into the body. Lung cancer is the leading cause of Cancer-related adult mortality in many countries particularly smokers (Stinchcombe & Socinski, 2009; Younes, Schutz, & Gross, 2010).In western countries, the second most common malignancy in Non-small cell lung cancer (NSCLC), and this signifies about 85% of all lung cancer cases among the elderly (Owonikoko et al., 2007). The majority of the NSCLC occurs in individuals aged 65 years and above (Noone & Garshell, 2010), and there’s an increasing incidence rate among the elderly because of the rise in life expectancy. Cancer diagnosis and treatment have implications on the physical, psychological, and social functioning of a patient during the treatment phase and in the longer term. Cancer as well as its treatment can result in a wide range of psychological and physical problems that do not disappear with time. Some of these problems come up after or during cancer treatment and continue to manifest in a long-term, chronic manner. Regardless of what is presented late effects and long-term effects of cancer can have negative effects on the quality of life of the survivors of cancer. Some of the long-term effects include numbness, fatigue, pain, no parties with related weakness, sexual or cognitive difficulties cover, and elevated depression or anxiety (Stein, Syrjala & Andrykowski, 2008).
Even though it is acknowledged that the patients that are older when placed under cytotoxic chemotherapy, may experience more toxicity compared to the younger patients (Azzoli, Baker & Temin, 2009), research should address pediatric infections and resistant organisms in Aseptic Technique for peripheral IV insertion. There are much evidence suggests that chemotherapy is superior even to this particular setting of the patients (Meoni, Cecere, Lucherini, 2013). A growing number of published trials over the past few years which assessed the effectiveness of gemcitabine and platinum-based doublet in elderly patients with NSCLC (Comella et al., 2004; Lim, Lee, & Song, 2013; Pereira et al, 2013) and the findings from recent meta-analysis indicates that doublets are more tolerable and effective compared to single-agent chemotherapy for treating of the elderly patients with NSCLC with a good status of performance (Xu, Chang, Wang, & Qi, 2013). In patients with metastatic/ advanced disease or elderly patients with advanced NSCLC, improving their life quality is important. therefore, the main treatment goal in the case study is to improve the quality of life and also to extend life expectancy for Harold.
The therapy options, that is; targeted therapy, irradiation, chemotherapy, and surgery, are normally applied by the molecular signature and TMN staging (Adjei, 2008). A combination of first-line chemotherapy is usually applied to get maximum effectiveness. For the first-line therapy, chemotherapy based on cisplatinum combined with radiotherapy is superior to chemotherapy or radiotherapy alone (Gewanter et al., 2010; Mantovani et al., 2006). Several agents have been used besides cisplatinum, for instance, gemcitabine, vinorelbine, docetaxel, paclitaxel, and irinotecan. According to (Gewanter et al., 2010; Mantovani et al., 2006)), in squamous cell carcinomas gemcitabine is usually considered as the first choice and that may explain the rationale behind the prescription of gemcitabine for patient Harold. The distinct mechanism of action and the generous single-agent activity could be one of the bases underlying the rationale for adding vinorelbine to gemcitabine when providing treatment to patients with relapsed NSCLC. In their study, which compared single-agent Vinorelbine therapy with vinorelbine plus gemcitabine, Frasci et al (2000) Observed vinorelbine plus gemcitabine therapy demonstrated improvements in both median lengths of survival and quality of life.
Metastatic bone tumors particularly occur at higher rates in cancers of the lung, prostate, breast, and kidney and this accounts for about 75% of all cancer patients (Tofe, Francis, & Harvey, 1975). Many lung cancer patients are usually in their advanced stages of the cancer disease during the diagnosis time. Even though it is stated that metastasis of the bone from lung cancer takes place in between 14% to 40% of the patients, its clinical characteristics have not been described clearly (Johnston, 1970). When offering treatment to the skeletal metastasis condition, it is imperative to understand the prognostic factors and prognosis after the skeletal metastasis to determine the treatment plan. Six factors were proposed by Ferrell, Jennifer, Temin (2017) that predicted the survival of spinal metastatic tumors. They include the quantity of bone metastasis of the extra spinal, general condition, quantity of vertebral body metastases, cancer primary site, major internal organs metastasis, and the spinal cord palsy severity. The malignancy grade of the primary tumors, number of bone metastases, and the vital organs visceral metastases are also reported to be important prognostic factors ( Ripamonti, Bandieri & Roila, 2011; Tomita et al., 2001). Sugiura, Yamada, Sugiura, Hida, & Mitsudomi (2008) conducted a study to test various chemotherapy regimens for 267 patients. Among them, the researchers administered vinorelbine ditartrate and gemcitabine hydrochloride to 11 patients. They then studied the survival rate cumulatively after prognostic factors and bone metastases for patients with bone metastases as a result of lung cancer. The survival rate was calculated overall embarrassed on the presence or absence of an EGFR inhibitor. The arrangement combination showed positive results and that might explain their rationale for its dosage in the case study of Harold who also had a bone tumor.
(Part 2 of the question) – In planning the management for your chosen case study, identify one important nursing consideration throughout or after the active treatment phase. Justify the selection of this nursing case study. Explore the available research supporting nursing practice for this consideration.
Nursing Considerations during the active treatment phase by using available research to support nursing practice for this consideration.
In planning the management of cancer, EdCan (2018) outlines factors and variables that should be taken into account in determining the treatment plan. The aim of cancer treatment may be for curing, controlling, palliation of symptoms, or prolongation of life. The factors include tumor, treatment, and individual factors. Other variables include the assessment tools, performance scales, and the psycho-oncology outcomes database.
During the active treatment phase, one important nursing consideration that the paper has identified is an assessment of comorbid and geriatric conditions of the patient in guiding the treatment (Chernecky & Murphy-Ende, 2009). The paper has settled on this important nursing consideration because continuing treatment of comorbid conditions such as heart disease, pulmonary disease, and diabetes may lead to drug interaction when chemotherapy is introduced, for the elderly like Harold. Chronic diseases such as liver or renal diseases may change the pharmacodynamics and pharmacokinetics of chemotherapeutic agents. These changes in addition to modifications in drug metabolism, absorption, distribution, and excretion lead to more toxicities among the elderly cancer patients (Chernecky & Murphy-Ende, 2009; Itano et al, 2016).
As a consequence, older adults have a lesser likelihood of receiving optimal chemotherapy dosages compared to the younger patients due to complications and toxicities (EdCan, 2018). Careful evaluation of the common conditions as well as compromised functions of the organs and how these factors may consequently lead to subsequent sub-optimal doses of treatment among the elderly patients need to be studied further. In some scenarios where there are altered organ functions, it is significant to consider supportive care and palliation as the best source of management for the elderly patients instead of sub-optimal curative treatment levels.
The geriatric oncologist has proposed a comprehensive Geriatric Assessment (CGA) Tool to determine which elderly cancer patients can accrue some benefits from treatment and which patients may get more benefits when placed under palliative care (Itano et al, 2016). This multidimensional tool includes an assessment of instrumental activities of daily living, physical functioning including daily living activities, cognitive performance, common conditions, nutritional status, psychological status, current medications review, social support, and the existence of geriatric syndromes (Itano et al, 2016).
Another nursing consideration is the functional status of the patient. As the age of the patient advances, it results in loss of physical function and this can result in disability. According to Extermann (2017), for those aged, between 65 to 74 years over 60% of that population have some disability, and often report some conditions that are disabling. Because of that, patients with few or no ADL limitations may be able to tolerate full treatment doses but should be having frequent monitoring identifying potential adverse events. However, Maione et al (2005) reported that global performance status, quality of life, and in prognosticators for the elderly patient survival. Among the elderly cancer patients, disability and losses in physical functions are associated with functional reserve losses, which, in the presence of chemotherapy, raises the likelihood of this elderly patient’s toxic side effects (Chernecky & Murphy-Ende, 2009).
The practice of oncology nurses in different settings include acute care hospitals, private oncologist offices, ambulatory care clinics, home healthcare agencies, radiation therapy facilities, and community agencies. They practice with other oncologic disciplines such as radiation oncology, surgical oncology, pediatric oncology, gynecologic oncology, and medical oncology. The roles of the oncology nurses vary from the focus of the intensive in the transplantation of the bone marrow to the focus of the community of cancer screening, prevention, and detection,n. Some of the roles include the following as discussed by (Chernecky & Murphy-Ende, 2009):
- Patient assessment
The nurses are expected to be experts in conducting assessments on the patient’s emotional and physical status, health practices, past health history, and both the patient and its families’ knowledge of the disease and consequent treatment. The oncology nurses review the plan of treatment with the oncologist. moreover, they are aware of the outcomes that are expected and possible complications and assess the patient’s general emotional and physical status independently. An oncology nurse is also expected to be aware of the general complications and results of all relevant pathology, laboratory, and imaging studies. conducting an assessment on the patient’s understanding of the cancer disease and the treatment that is proposed is fundamental in formulating a plan of care and allaying any anxiety. the preparation of the patient improves compliance with the programs of treatment and may also impact the outcomes of the treatment as well (Itano et al, 2016)
- Patient education
The nurses are better placed in developing the report required for effective educational efforts with the passions families as well as the patient. Family and patient education begins before therapy and progresses during and after therapy. Such educations include unstructured and structured educational experiences for helping the patients in coping with the diagnosis, symptoms, and long-term adjustments (Chernecky & Murphy-Ende, 2009; Itano et al, 2016).
- Coordination of care
The oncology nurses also play a critical role in coordinating complex and multiple technologies currently employed in cancer diagnosis and treatment. This coordination entails direct care of the patient, medical record documentation, symptom management, participation in therapy, referrals organization to other health care providers, education of both the patient and the family, cancelling throughout the diagnosis and fill,ow-up therapy (Itano et al, 2016)
- Direct patient care
The majority of the oncology nurse says provide direct care to the patient which involves chemotherapy. the nation Health and Medical Research Council (NHMRC), Cancer Australia, and Cancer Council Australia have developed guidelines to bring together evidence that is best available for underpinning scientifically valid recommendations for the diagnosis and prevention of cancer as well as treatment care for the patients (Australia, 2018). They provide written policies for certification for chemotherapy, antineoplastic drug administration in all routes, safe drug disposal and handling, management of reactions such as allergic reactions, and documentation methods. One of the important responsibility of the nurses that are involved in the chemotherapy delivery is to ensure that the correct health to ensure the safety of prescribed drugs. This paper discuss the recall of tetrazepam drug and dose are administered to the right patient by the correct route. The provided guidelines on how to ensure safer healthcare and to prevent medical errors (Chernecky & Murphy-Ende, 2009). Additionally, EdCan (2018) developed a module in collaboration with Cancer Australia with an object to develop nurse skills and knowledge to support care assessment, screening, and referral.
- Symptom management
Daily, the oncology nurses are challenged to handle numerous symptoms from the patient suffering from cancer as well as their families as a result of the treatment. The nurses help in the symptoms evaluation as well as the initiation of interventions (Chernecky & Murphy-Ende, 2009). Antineoplastic agents are chemotherapy agents and are used in the treatment of metastatic cancers. EdCan (2018) indicated that the antineoplastic agents are classified according to their cycle activity or structure. Traditionally they are divided by their mechanism action or origin. The main groups include antimetabolites, alkylating and alkylating like agents, plant alkaloids, antitumor antibiotics, hormonal agents, and miscellaneous agents.
In summary, the paper explored the rationale and the goal of the treatment choice that was prescribed for patient Harold who is 75 years and was diagnosed with advanced non-small-cell lung cancer with metastasis of the spinal bone (stage IV). The arguments for the goals and rationale was on the prescribed treatment regimen of gemcitabine days 1, 8, and 15 repeated every 4 weeks and vinorelbine day 1 and 8 repeated every 3 weeks. The paper found out the treatment was based on the goal of the treatment, tumor, patient patient-related as well as treatment treatment-related The paper was identified one important nursing consideration throughout the active treatment phase and justified its selection. These included the assessment of the comorbid and geriatric conditions in guiding the treatment as well as the functional status of the patient. Some of the roles of the patient during active treatment the patient in include; Patient assessment, Patient education, coordination of care, directing the patient care, and management of symptoms.
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