A Nursing Care Case Study and Assessment

This case study will review the condition of a recent patient, explain how I came to the conclusions in my assessment of her condition, and provide my diagnosis and recommended course of treatment for her pain when it became apparent this was a key priority. My analysis will focus on a forty one year old woman who was on the surgical ward during my clinical rotation as a student nurse. She had just undergone a modified radical mastectomy. Two months prior to the operation, a biopsy had revealed a ductile carcinoma of the right breast. In addition, a review of her medical history uncovered the fact that she had had a previous bout with cancer at 13 when doctors discovered Hodgkin’s lymphoma that was subsequently treated with chemotherapy and radiotherapy. From that point on she remained relatively healthy and stated there was no family history of breast cancer.

As part of a multi-disciplinary team (Improving Outcomes in Breast Cancer Manual Update, National Institute for Clinical Excellence), my first priority was to conduct a thorough examination to assess her current condition and then provide the appropriate care as indicated from my holistic assessment of her needs. “Assessment is the first step of the nursing process. It involves the orderly collection of objective information about the client’s health. Objective data are observable, measurable and verifiable by more than one person.” (pp. 7; Altman, Gaylene; Physical Assessment Skills; Delmar Learning; c. 2004). This information aligns with training received in nursing classes by my instructors and reinforces the important point that organization and thoroughness are of the utmost importance. It has been my goal to develop the nursing assessment skills that mirror this philosophy, and believe the reader will find that my personal nursing assessment routine, detailed in the body of this essay, honors the same recommendations presented by my professors and the latest research. Finally, the results of my evaluation will be presented, and as required by this assignment, I will share the nursing interventions determined by me to be the most effective way to combat her physical discomfort.

The first stage of the nursing process is to conduct a thorough holistic nursing assessment (of the patient’s needs beginning with a physical assessment. “An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient may have from being physically exposed and vulnerable. The patient will be much more relaxed and cooperative if you explain what will be done and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a nursing assessment is on the patient’s responses to actual or potential problems.” (pp. 22; Cox, Carol; Physical Assessment for Nurses; Blackwell Publishing Ltd.; 2004).

Understanding the importance of any type of knowledge (pgs. 496-7; Walker, Jennie-April, Philosophy, knowledge and theory in the assessment of pain; British Journal of Nursing, 2003, Vol 12, No 8) and keeping in mind the NMC Code of Standards of Conduct required of me, that includes providing a high standard of care, and remembering that this woman trusted me with her health and well-being; I greeted the patient as I entered the room, inquiring as to how she was feeling that day. She indicated that she was feeling a lot of pain. I then requested she rate it on a scale of one to ten with one being little and ten being excruciating pain. She replied that her pain was a ‘7’ and relieving it became one of my top priorities as I began the exam. For the next several moments I worked to subtly assess the current condition of my patient while carrying on a light, distracting conversation (Page 542, Haber, Judith; Comprehensive Psychiatric Nursing‎, 1992), searching for obvious signs or symptoms that correlated to the patient’s complaints. Even without extensive formal training in examination and assessment of pain, pertinent and useful information (signs) can be derived from careful observation(pg. 2295; Price, Christopher IM, Seong W Han, Iain A Rutherford; Advanced nursing practice: an introduction to physical assessment; British Journal of Nursing, 2000, Vol 9, No 22); thus, I inspected her wound area both visually and by touch, carefully searching for signs of infection from the post op drains in situ; and found she had begun the early healing process appropriately. I then used my stethoscope to find there was no variance in the movement of blood through the cardiovascular system; and proceeded to take her vital signs. These included blood pressure, pulse, temperature, respiratory assessment and palpation (pg 485; Simpson, Heidi; Respiratory assessment; British Journal of Nursing, 2006, Vol 15, No 9), and a further examination of the musculoskeletal system.

The patient manifested a slight fever as her temperature was 100.2 degrees Fahrenheit. This symptom compounded with the statement of pain implied there was an underlying and continuing health issue, although nothing was immediately apparent. Her blood pressure was a normal 120/80; her pulse rate was 75 BPM; her respiratory rate was near 14 breaths per minute. I then took a moment to review her chart as we continued quiet conversation. The patient’s complete nursing history was organized from her earliest health problems to her current hospital stay. A detailed psychological and social exam indicated that the patient was battling minor depression due to the seriousness of her illness. She had adequate insurance to cover her medical expenses and a very supportive family. The final two aforementioned factors would help to

assure a speedier recovery (Gregg, Davis Weinert; pg. 29; Life and Health Insurance Handbook‎; 1964 and Pg. 293 Crisp, Jackie, Patricia Ann Potter, Anne Griffin Perry, Catherine Taylor; Potter and Perry’s Fundamentals of Nursing; Elsevier Australia, 2005). Her doctor had advised there was no need to do the musculoskeletal assessment so I moved on to quickly look over her scalp, fingernails, and toenails. Nothing seemed out of the ordinary. I quickly examined her nose ears, mouth and throat, looking for signs of an infection that may have taken root in one of these body parts, and found nothing. I followed this with a quick gastrointestinal exam which also reaped negative results. The patient had not had a bowel movement for two days, but had little appetite since the surgery.

As I mulled over the facts of this patient’s holistic assessment I took the time to freshen her linen(Page 77; Narrow, Barbara W., Kay Brown Buschle; Fundamentals of Nursing Practice‎; Wiley; 1987, help her wash up and get her fresh water. She perked up a bit as she had the chance to move around and take control of her appearance, but noted that her pain was nearly the same.

“If pain is a symptom determine the following: site; radiation; character, eg. Pressure, ache, stabbing, dull; severity, eg, Did it interfere with what you were doing? Does it keep you awake? Have you ever had this type of pain before? Does the pain make you sweat or feel sick to your stomach?”(pp. 34; Carperito-Moyer, L; Nursing Care Plans and Documentation; Lippincott, Williams & Wilkins; 1999). These questions were posed to the patient and she responded that the pain was dull and it had kept her awake the previous night. However, it did not make her sweat or feel sick to her stomach. Having completed my holistic assessment it was evident my focus should be to determine the source of her pain and attempt to relieve it. I redoubled my efforts to determine the source of the pain by asking questions that would help her narrow down the location from which the pain was emanating. We began with the head and worked our way down the body until we discovered that, indeed, she was feeling residual post-op pain from the location of the surgery.

“To make a valid diagnosis, and for assessment to be purposeful, the nurse has to know the following: What is the range of normal? What is the range of abnormal? What are the health risks?” (pp. 10; McFarland, Gertrude & McFarlane, Elizabeth; Planning for Patient Care; Mosby Pub.; c1999). One of the most difficult aspects of making accurate diagnoses is to determine whether the data confirms the actual nursing diagnosis. In fact, I needed:1). to be knowledgeable of what the normal range of pain is for a post-op breast cancer patient who had just days before undergone a modified radical mastectomy; and 2). a multi-disciplinary assessment (pg. 863, Catriona McMillan Breakthrough pain: assessment and management in cancer patients; British Journal of Nursing; 2001, Vol 10, No 13). Research shows that up to fifty-seven percent of women who undergo a mastectomy will experience acute pain post-op. These statistics support the use of a stronger pain medication to be given to the patient.

Personally, I am very sensitive to a patient’s cry for help from relief of pain, particularly so soon after major surgery. In other words, when a patient in this position says they are in pain, I believe them and intend to correct the problem as quickly as possible. We are not inside their bodies and are not experiencing their distress. The best we can hope to do is provide a modicum of relief. The following quote reinforces my opinion. Indeed, pain is a subjective phenomenon (pg. 81, Locker , Sarah; Holistic assessment of cancer patients’ pain: reflections on current practice; International Journal of Palliative Nursing, 2008, Vol 14 No 2).

“It is argued that pain is experienced by people and families, not by nerve endings (Watson et al, 2005). Otis-Green et al (2002) define cancer pain as a multidimensional and complex experience and Watson et al (2005) support the notion that pain management is complex due to the dynamic and fluctuating interaction between external stimuli and the individual’s capacity to cope at a particular time in their life. Therefore, methods utilized to manage pain need to be multidimensional and reflect this complexity.”(Locker, Sarah; International Journal of Palliative Nursing; 2008, Vol.14.No.2).

The patient indicated that although she would like to have something stronger for her pain, she was fearful she would become addicted to the medicine or develop a tolerance and it would stop working. I assured her that research shows it is rare for a cancer patient to become addicted to the pain medicine, and although she might develop a tolerance for the medicine, long term, the most important thing was to control the pain. Dosages can be altered to address the issue of tolerance. I reviewed her chart to see what pain medication had been prescribed up to now. I found that, to this point in her treatment, my patient had been on a patient controlled analgesia (PCA) (morphine sulfate) for the first twenty four hours post op; which meant she had an electronic device that allowed her to self-administer opiates according to her own pain relief needs. The dose per bolus (referring to the rate at which the medicine is administered) was 0.5mg., and the maximum dose was set for four hours with ten minute lock out intervals.

It would appear that the anesthesiologist had spent some time with the patient pre-surgery because he would have had to order an initial dose for her IV in post-op recovery. She was a perfect candidate because she was bright and quickly learned how to use the equipment, and once she had awoken and showed no signs of delirium she was adept at manipulating the equipment.

There are several advantages to this approach to pain management. First, it has been proven to have less post-op delirium than other analgesic techniques; it has the lowest incidence of pulmonary complications and the highest patient satisfaction (Pg. 116; K. W. M. Fulford, Steven Ersser, R. A. Hope, Tony Hope; Essential Practice in Patient-centred Care‎; 1996). The side effects were constipation and nausea.

I felt that my patient needed a stronger pain medication if only for the short term to calm her down and relieve her distress. According to one study, “Opioids, also known as opiates and narcotics, remain the mainstay of systemic analgesia for moderate to severe acute pain. There are a variety of drugs including but not limited to morphine, codeine, and methadone. They are involved in inhibiting pain and are most effective for continuous and dull pain rather than sharp, intermittent pain. (Layzell, Mandy; Current Interventions and Approaches to Postoperative Pain Management; British Journal of Nursing; March, 2008; Vol.17 No.7).

Since she was already on an opioid, morphine sulfate, which is fairly inexpensive, has a record of being the easiest for a patient to tolerate, and is simply the easiest of the IV analgesics to use, I felt the first step would be to increase her dosage from 0.5 mg. per bolus to 1.0 mg. per bolus. This was to begin immediately and I immediately arranged for the IV to be altered.

I spent a few moments talking to the patient about my decision to increase the dosage of morphine sulfate to combat the pain. She would still have the patient controlled analgesic device and the time would be the same. I informed her that this should help ease her pain and I would be back around in an hour to see if she felt better. I reminded her that if she needed anything else she should ring for the nurse’s station and someone would be there. I double checked that all her needs were met; marked the visit in the nurse’s chart and left to see my next patient. An hour later I returned to find her sleeping, and when she awoke later, said she was feeling much better, the pain was in control. She was even hungry!

This assignment has proved personally valuable for several reasons. First, while I have been studying nursing for some time, and beginning to practice in the field on real patients, I find that this opportunity to reflect on the level of my skills, on paper, leaves me feeling more confident. I feel I am beginning to perfect my ability to conduct a holistic assessment as well as a physical assessment and recognize the value of a certain ‘rhythm’ to performing either with professionalism and organization.

This assignment also allowed me to share my first foray into prescribing medication to treat my first real diagnosis, both successful. My chosen intervention was decide after reviewing the patient information available as well as drawing on my knowledge of what the appropriate pain medication is to treat the appropriate symptom. As the reader can see from my bibliography, research supports the use of an opioid for sustained pain. Research reinforces the fact that cancer patients experience acute and sustained pain at a fairly high level post-op and opioids, such as morphine or codeine, are the best weapons in the drug arsenal with which to battle this pain. My choice to increase the dosage made perfect sense as a first attempt to control her pain. The fact that it worked reinforced my self-confidence. Had she continued to complain, I would have chosen to supplement this medicine with a nonopioid before increasing the dosage of the opioid.

Bibliography

Altman, G.Physical Assessment SkillsDelmar, 2004

Carperito-Moyer, JHandbook of Nursing DiagnosisLippincott, 1999

Cox, CarolPhysical Assessment for NursesBlackwell P. 2004

Crisp, Jackie, Patricia Ann Potter, Anne Griffin Perry, Catherine Taylor

Potter; Perry’s Fundamentals of Nursing; Elsevier Australia, 2005

Ferrante, F. Michael, Gerard W. Ostheimer, Benjamin G. Covino; Patient-controlled Analgesia‎; 1990

Fulford, K. W. M., Steven Ersser, R. A. Hope, Tony Hope; Essential Practice in Patient-centred Care‎ Blackwell Publishing1996

Gregg , Davis Weinert; Life and Health Insurance Handbook‎ , 1964

Layzell, MandyCurrent Interventions and Approaches to Postoperative Pain Management British Journal of Nursing, 2004

Locker , Sarah; Holistic assessment of cancer patients’ pain: reflections on current practice; International Journal of Palliative Nursing, 2008, Vol 14 No 2).

Locker, SarahJournal of Palliative CareVol. 14. No.2

McFarland, G. Planning for Patient Care Mosby Pub. 2004

Narrow , Barbara W., Kay Brown Buschle; Fundamentals of Nursing Practice‎; Wiley 1987

National Institute for Clinical Excellence; Improving Outcomes in Breast Cancer Manual Update

Price, Christopher IM, Seong W Han, Iain A Rutherford; Advanced nursing practice: an introduction to physical assessment; British Journal of Nursing, 2000, Vol 9, No 22

Simpson, Heidi; Respiratory assessment; British Journal of Nursing, 2006, Vol 15, No 9

Walker, Jennie-April, Philosophy, knowledge and theory in the assessment of pain; British Journal of Nursing, 2003, Vol 12, No 8

SAMPLE CARE PLAN FOR PATIENT

Directions to the nurse:

Review patient medical history and previous assessments

Review overall assessment and current medical condition

Moving and handling risk assessment

Infection risks assessment

Physical assessment (bp, vitals, etc)

Determine current needs of patient: ie. Pain; mobility and comfort; communication; activities; clothing; hygiene; diet; elimination; relaxation; sleep.

Check that all hoses attached to IV are working and clear. Check the level of the medicine left in the IV to determine how soon you will need to change it.

Maintain records of each visit into the room and the reason for it. Keep careful charting of the amount of medicine prescribed.

Make note of any special needs for this patient and make them visible to each nurse who will follow.

Consider the length of time for the current dosage (for ex. The patient in this case study) for opportunities to decrease the dosage without affecting the pain of the patient.

Try to stop through every couple hours – or more often for patients who are very ill.