Background

Write a structured essay that reports on a comprehensive patient health history and physical assessment that you conduct on a chosen consenting patient*.  You will need to critically analyse your findings and recommend health and clinical decision making priorities for the patient.

The current assignment focuses upon the aspect of comprehensive nursing care. It is based on conducting a clinical assessment test for recording of the vital patient signs and symptoms. Based on the symptoms the diagnosis of the patient is done.  However, in providing appropriate care and support to the patient the nursing profession should take into consideration the confidentiality factors. These have been further supported by the guidelines as highlighted in the Nursing and Midwifery Board of Australia (NMBA). As per the NMBA standards; at no stage of the clinical assessment and support care the confidentiality standards should be breached by the nursing professional (Birks, Davis, Smithson & Cant, 2016). Additionally informed decision making should be supported in designing of care plan for the patient. This helps in providing sufficient autonomy to the patient and their respective family members as they can have a say in choosing the appropriate care plan. It has been seen that most of the times a chronic or end of life care patient is unwilling to undergo an aggressive treatment. Therefore, the nursing professional catering to the health requirements of the end of the life care patient needs to be sensitive in their approach to dealing with the patient. They need to ensure that sufficient and services are delivered for monitoring the health conditions in the patient effectively.  Comprehensive Nursing Care For A Patient With Ewing’s Sarcoma Discussion Paper

However, as per the NMBA standards the healthcare professionals cannot force the patient to the patient or their respective families to undergo certain treatment or procedures.  Therefore, the nurse should abide by the standards and guidelines as enlisted in the NMBA.  As stated in the Standard 1 of NMBA the nursing practices should be guided by experience, knowledge, beliefs of the past encountered by one in a past acute clinical setup.  Some of the past experiences help the nursing profession in the development of effective clinical judgment skills. The current assignment focuses upon the different steps undertaken by a nursing professional in meeting with the support and care requirement of a patient admitted in a chronic care ward.

The current scenario focuses on the case study of Mary who is a five-year-old girl suffering from Ewing’s sarcoma. The Ewing’s sarcoma is a rare cancer of the bone or soft tissues and mostly affects white people within the age group of 10-20. It is a malignant, small, round, blue cell tumour. As mentioned by Clappand and Rowlands (2014), the disease has high survivability rates depending upon the stage of diagnosis and kind of treatment and support received by the patient. It starts from the pelvis and is followed by thigh bone affecting the cartilage and the nerves. As suggested by Sadak, Neglia, Freyer and  Harwood (2013), 87% of the Ewing’s sarcoma appears in the bone and rarely found in the soft tissues. A common genetic locus is responsible for large percentage of Ewing’s Sarcoma and has the characteristics of both mesodermal as well as ectodermal origin.

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Comprehensive Nursing Care For Mary

The current highlights the condition of Ewing’s Sarcoma as suffered by Mary who is a five-year-old girl. She lives with her single mother and is the only child. She was suffering from fever and chest pain and had lost 2 kilos weight in the last month. The deteriorating condition of the patient led to several clinical visits and hospitalizations. The patient had been prescribed with antibiotics and steroids. The patient here was prescribed with a number of assessments and clinical tests such as CT scan of the chest, comprehensive blood assessment, bone marrow biopsy.

In order to proceed with the treatment and care it is very important to gain consent from the patient and their respective families (Stolic, 2014).  In this context, an approval had already been taken from the patient and her mother before commencing her upon the treatment process. Additionally, anonymity had been guaranteed while sharing of the confidential details of the patient during the future study or research processes. This  is further supported by the Privacy  Act, 1988, which  states that, “ information or opinion about an identified individual or an individual is who is reasonably identifiable, whether opinion is true or not or recorded or expressed in  a material form or not should be preserved” (Cappelletti, Engel and Prentice, 2014). Hence, confidentiality serves as a very important criterion for delivery of an effective nursing and support care services. A full blood count (FBC) test was conducted for the patient in order to check the normal blood cells count along with the measurement of lactate dehydrogenase in the blood. As mentioned by Parker and Magnusson (2016), high or low LDH indicated the presence of organs or tissues.

The CT scan of the chest conducted on the patient could have been particularly n beneficial over here. Some of the results as noted through performing the CT scan have been highlighted such as large sternum mass and associated pleural effusion. Since the patient was suffering from Ewing’s sarcoma it resulted in a malignant growth in sternum bone resulting in a huge mass. The patient was also diagnosed with pleural perfusion which is characterised by deposition of fluid inside the cavity of the lungs. As mentioned by Garcia, Whitehead and Winter (2015), the patient had been provided with Peripherally inserted central catherers (PPICC) for drainage of the pleural fluid. The patient Mary had been commenced on chemotherapy as a side effect of which the patient had been losing weight.  Additionally, coming from a single parent household the patient lacked the proper economic and health resources which further deteriorated the health standards within the patient.

Importance Of Confidentiality And Informed Decision Making In Nursing

A number of comprehensive methods and approaches could be undertaking an effective clinical assessment. Two such approaches could be used over here which are the HEADSS approach and the   ABCDE approach. The HEADSS approach could be broken down into subfactors which are – Home, education/employment, activities, drugs, sexuality and the occurrence of suicidal or depressional thoughts. Therefore, alignment of the factors with the patient condition helps in the development of sufficient knowledge regarding the patient which helps in the treatment process (Araki et al., 2016).  However, a number of factors had been eliminated over here as the patient was a 5-year-old child.  Therefore, the nursing professional looking after the support care of the patient need to be careful while conducting the assessment tests. The patient taken into consideration over here is a 5-year-old child and therefore cannot effectively provide responses to all the questions presented through the HEADSS assessment. Therefore, consent from the parent of the child should be taken before conducting the assessment test. Additionally, the involvement of the parent is a pre-requisite every time the assessment tests are done or performed (Freemyer et al., 2016).

The home environment of the patient determines to a great extent the overall health pattern in the patient.  Mary had been living with a single parent that is she had been living with her mother only and lacked the presence of a father.  Since she had only a single parent to support her, it resulted in economic dwindling. Hence, the patient lacked the appropriate economic and health resources. Additionally, there was lack of relatives who could actually care for the patient, which further worsened the situation.

The patient here was suffering from Ewing’s sarcoma which is rare form of cancer. Therefore, the deteriorating health condition of the patient resulted in suspension of the study plans of the patient. Therefore, as a nursing professional one need to be sympathetic to the patient and their respective families. As mentioned by Sardi-Brown, Kupst, Brown and Wiener (2017), extension of the community healthcare structures can provide additional layer of support to the patients. Therefore, in this case, the nursing professional could start the interview by asking the child simple random questions such as, “how do you feel?,“ Who stays with you at home”
,  “do you miss school”. The answers to some of these questions would help the nurse in evaluation of the psychoanalytic stage of the child.   As a child Mary should also feel inclined to move and play around freely. However, when the child was asked questions such as, “what do you do for fun?” .The child had simply listed indoor and sedentary activities. On prolonged interrogation, the child replied that she often felt fatigued on a little exhaustion. This could be attributed to the development of pleural sac infection in the child. This further resulted in difficulty in breathing in the child.

Clinical Assessment Test And Diagnosis

In this context, support and participation from the mother of the child could help in collection of the required amount of results. In order to begin with the chemotherapy of Mary, full past details of the patient needs to be taken into consideration which includes the medication details of the patient.  Therefore, questioning about the medication pattern can help in designing an effective care plan. For the provision of complete and effective treatment of the child, the details of past for any forms of abuse needs to be taken. As mentioned by Sadak, Neglia, Freyer and Harwood (2017), a thorough knowledge about the patient and their past life can help in designing a compressive care plan which takes into consideration the emotional requirements of the child.

The child could also be accessed for the development of any forms of depressive or suicidal thoughts. As suggested by Tyser, Holt and Randall (2017), prolonged sickness or chronic ailment is often associated with development of symptoms of depression within the patient.  hence,  getting  answers on  some of the questions  from the mother of  child such as, ” how  long do you child sleep?” ,  ” does  she often get up in the middle of the night?” , “have  you  recently  noticed  withdrawal  or impulsive  behaviour  within  your child?”,  “ has  your  child  recently depicted   changes in eating patterns such as eating too little  or eating too more?”.

As mentioned by Ohara et al. (2016), sleep is very important to maintain the normal homeostasis within the body of a patient. The lack of sufficient sleep can affect the recovery rate of the patient.

Some of the other assessment tests or methods which could be employed by the patient are the ABCDE approach. Here, ABCDE refers to Airway patent, breathing, circulation, disability and exposure etc.

The attending nurse could access the condition of the patient using gradual steps and procedure. When asking a question the child could answer briefly and easily without many gags, which ruled out the presence of any breathing difficulty in the child. The patient reported oxygen saturation at 97% on 1 litres of O₂ via nasal cannula. In the context of any further breathing difficulties in the patient head tilt and chin lifting methods could be applied to relieve the condition. The metastasis of the malignant tissues can risk airway. As mentioned by Lewin et al. (2015), uncontrolled tissue growth can result in Retrotracheal Ewing’s sarcoma in the child. The laryngeal edema can prevent tracheotomy decannulation, which may hinder the process of treatment.

HEADSS Approach For Clinical Assessment

The patient recorded respiratory rate of 44 breaths per minute whereas the normal rate should be somewhere between 20-25 breaths per minute.   Therefore, such high respiratory rate signifies the presence of breathing difficulty in the patient.  Hence, it pointed towards the presence of a number of conditions such as pulmonary oedema, pleural inflammation. The abnormal patterns noticed over here could be further confirmed with the help of chest X-ray and CT scan. The inflammation present further requires the implementation of additional investigation strategies such as testing the fluid through the peripherally inserted central catheter. Though the patient had oxygen saturation at 97 %, the mild tracheal tug pointed towards extra effort done by the patient in undertaking normal respiration. The sharp pulling of the intercostal muscles was a sign that the patient had slight airway blockage (Palmerini et al., 2018).

The increased sternum mass could lead to a situation known as costochondritis where the cartilages in the breast bone become inflamed. The inflammation suggests that there is an ineffective clearance of airway.

The patient recorded a blood pressure of 114/70 mm HG using blood pressure cuffs. The patient also had a peripheral heart rate of 158 bpm, which signalled abnormal circulation. This is because in children below the age of 10 years the heart rate varies between 60 to 100 bpm. Though the blood pressure of the patient seemed normal the patient recorded high heart beat rate. Therefore, it was necessary to monitor the vital signs in the patient as the patient had a history of Ewing’s sarcoma which was characterised by malignancy of soft tissues and cartilages mainly affecting bones (Brunetto et al., 2015). The malignant growth found in the tissue could affect the normal blood circulating capacity of the patient.  The tumerous tissues have oxygen scavenging properties, which results in oxygen deconcentration where the RBCs are not able to carry sufficient oxygen. Therefore, a high respiratory rate in the child signifies the need for a comprehensive blood profiling to find out the abnormalities present.

Hence, further assessment could be conducted for checking the condition of sepsis present within the patient. The nurse could follow the process of six sepsis measurements such as taking blood culture using PPICC, administration of antibiotics and fluids, monitoring the blood lactate dehydrogenase count. As mentioned by Lewin et al. (2017), monitoring anomaly in the LDH levels can also help in cheeking for the presence of serious disorders.

Patient’s Home Environment

The patient was conscious and could effectively answer the questions asked of her. Hence, there was no need to use additional tools such as the Glasgow Common Scale to measure the amount of awareness present within the patient. It was necessary to analyse some of the current days to day issues faced by the patient such as abdominal pain and constipation.  Comprehensive Nursing Care For A Patient With Ewing’s Sarcoma Discussion Paper The patient could be suggested mild analgesics over here for controlling the abdominal pain. Additionally, suggesting laxatives to the patient can also help in controlling the occurrence of constipation. However as argued by Palmerini et al. (2018), the before prescribing of any medication the patient should be tested for the presence of any form of allergies. The pain assessment could be in the patient using a Wong baker scale. The scale measures feeling of hurt or pain felt by a patient on a scale of 0 to 10 where 0 is generally depicted mainly in the form of a happy face by the child and resembles no pain; whereas  10 is represented in the form of crying by the child which represents acute pain. Therefore, the emotions projected by the child can be used by the physician for asserting the presence of pain in the patient.

The patient had been running mild temperature around 38.9-degree centigrade. This further pointed towards the presence of infection within the patient.

Therefore, based on the presence of fever and pleural inflammation present within the child the focus should be shifted to the assessment of the respiratory system. It could be further divided into four essential parameters which are – inspection, auscultation, palpation and percussion. The inspection could be carried out using normal clinical guidelines such as monitoring the vital signs for the presence of serious ailment. These could include recording of the respiratory rate of the patient along with recording of the body temperature, monitoring of the dilation of the pupils etc. The skin colour could be accessed for the presence of cyanosis. The blue colour of the skin could point towards the presence of oxygen asphyxiation.

The air movement of the patient could be followed with the help of using a simple stethoscope. It helps in monitoring the normal inspiration and expiration a rate in the patient.  As mentioned by Sender and Zabokrtsky (2015), using a stopwatch for monitoring the falling and rise of the crest could help in accessing the normal respiration rates.

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Psychoanalytic Stage Of The Child

Here, Mary has been provided with a Peripheral intercostal catheter to drain the fluid from the intrapleural space. In case the air does not drain well into the PICC chamber used for the purpose it enters into the sub-cutaneous chamber resulting in bubble wrap.

The health prioritises for the patient needs to be designed in order to plan out an effective care regimen.  The health priorities have to be designed based on the clinical signs and symptoms expressed by the patient. Some of the clinical symptoms expressed by the patient are- fever, constipation and abdominal pain, nutrition management, PICC management,   health and psychological well being.   The fever and respiratory distress in the patient could be attributed to the presence of pleural inflammation. Additionally, the child depicted increase in the sternum mass which affected the normal movement patterns of the diaphragm. The movement of the diaphragm is necessary to allow normal passage of food into the stomach.  As mentioned by Stefan and Harif (2018), in the lack of effective diaphragm movement the free passage of food is restricted, which further affects the digestion pattern. For the management of constipation and abdominal pain in the patient suffering from Ewing’s sarcoma bulk-forming laxatives could be prescribed to the patients such as Psyllium, Polycarbophil etc. However as argued by Wagland et al. (2016), there are contradictions associated with the use of these products in advanced cancer and ones with faecal impaction.

The fever in the patient could be reduced by proper drainage of inflammation fluid from the pleural sac. In case of improper drainage, it could lead to developments of bubble wrap under the skin. Under such conditions, the nursing profession needs to e remove the PICC and fit it again or replace it with a new one. This helps in restoration of the normal drainage capacity of the lungs.

Conclusion

The current assignment focuses upon the aspect of comprehensive nursing care and management. In this case, the patient had a life-threatening disease which required gradual assessment and comprehensive management process.  In the current study, the importance of the nursing standards as highlighted by the NMBA has been highlighted.  One of the most important aspects which had been highlighted over here was maintaining the confidentiality standards while looking after the patient.

Additionally, the study also discusses the importance of the different assessment methods for looking after the patient. Some of the methods which had been discussed over here are HEADSS approach and the ABCDE method. The HEADSS approach help to take into consideration the psychological well being of the patient with more focus on the social and environmental conditions. On the other hand, the ABCDE approach helps in assessment of the patient based on the clinical conditions presented such as breathing, circulation, disability and exposure. Therefore, using the two different kinds of methods helps in analysis of the overall condition of the patient.  The assessment priorities have been further used in designing of the health priorities of the patient. These are further used in the designing of a comprehensive and effective care plan

Medication Pattern And Past Details Of The Patient

References

Andersen, N. B., Boysen, A. K., Rossen, P. B., Lücke, A. O., & Safwat, A. A. (2016). Bilateral avascular necrosis of the femoral head following treatment of Ewing’s sarcoma. Acta Oncologica, 55(6), 792-795. Retrieved at :  https://doi.org/10.3109/0284186X.2015.1110251

Araki, N., Takahashi, S., Sugiura, H., Ueda, T., Yonemoto, T., Takahashi, M., … & Matsumine, A. (2016). Retrospective inter-and intra-patient evaluation of trabectedin after best supportive care for patients with advanced translocation-related sarcoma after failure of standard chemotherapy. European Journal of Cancer, 56, 122-130. DOI: https://doi.org/10.1016/j.ejca.2015.12.014

Birks, M., Davis, J., Smithson, J., & Cant, R. (2016). Registered nurse scope of practice in Australia: an integrative review of the literature. Contemporary nurse, 52(5), 522-543. Retrieved at : https://doi.org/10.1080/10376178.2016.1238773

Brunetto, A. L., Castillo, L. A., Petrilli, A. S., Macedo, C. D., Boldrini, E., Costa, C., … & Watanabe, F. M. (2015). Carboplatin in the treatment of Ewing sarcoma: Results of the first Brazilian Collaborative Study Group for Ewing Sarcoma Family Tumors—EWING1. Pediatric blood & cancer, 62(10), 1747-1753. Retrieved at : https://doi.org/10.1002/pbc.25562

Cappelletti, A., Engel, J. K., & Prentice, D. (2014). Systematic review of clinical judgment and reasoning in nursing. Journal of Nursing Education, 53(8), 453-458. Retrieved at : https://doi.org/10.3928/01484834-20140724-01

Freemyer, B., Hamilton, E., Warneke, C. L., Ali, A. M., Herzog, C., Hayes-Jordan, A., & Austin, M. (2016). Treatment outcomes in pediatric melanoma—Are there benefits to specialized care?. Journal of pediatric surgery, 51(12), 2063-2067.  Comprehensive Nursing Care For A Patient With Ewing’s Sarcoma Discussion Paper