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AT5: Written analysis of case-based scenario

Introduction

The case study that follows concerns Brett Patterson, a 55-year-old man who was diagnosed with Stage III colorectal adenocarcinoma two days after receiving his second FOLFOX chemotherapy dosage. He has chills, slight diarrhea, vomiting, and nausea. In Brett's medical past, an anastomosis and recent successful colon resection are documented. Blood tests reveal a slightly decreased neutrophil count and an elevated hemoglobin. An examination of the body indicates weariness, tongue ulcers, and sporadic nausea. A modest temperature and a mildly low potassium level are vital signs. The Clinical Reasoning Cycle will be used to conduct additional research in light of these findings (Levett-Jones et al., 2017).

Patient Situation

Five months ago, Brett Patterson, a 55-year-old man, was diagnosed with Stage III colorectal adenocarcinoma. He had a successful intestinal resection and is presently on his second cycle of the chemotherapy drug FOLFOX. Real estate agent Brett shares a home with his partner Kim as well as their young adult daughter. He arrived at the ONC unit with chills, nausea, vomiting, and diarrhea brought on by chemotherapy. His medical history reveals a little hypokalemia, a slightly increased hemoglobin, and a reduced neutrophil count. Tongue ulcers, dry mucous membranes, and weariness are discovered during physical examination. Given his latest chemotherapy and the context of Brett's general health, these symptoms necessitate more assessment and treatment.

Collect cues

The negative consequences of Brett Patterson's FOLFOX chemotherapy regimen, a common treatment for colon cancer, are most likely to blame for his current clinical presentation, which causes serious concerns. His signs and symptoms, which include nausea, vomiting, diarrhea, cold, exhaustion, dry mouth mucous membranes, and a tongue ulcer, are in line with the well-known adverse effects of FOLFOX treatment (Pulito et al., 2020). 5-Fluorouracil (5-FU), Oxaliplatin, and Leucovorin are all components of the chemotherapy regimen known as FOLFOX (Webster‐Clark et al., 2021). According to a study by Röhrl (2020), common negative side effects of 5-FU usage include nausea and vomiting. Patients receiving chemotherapy based on this particular experience have such upsetting side effects. Due to Brett's concentrated urine and dry oral mucous membranes, his clinical appearance also raises the possibility of dehydration. His ongoing nausea and vomiting are probably to blame for this dehydration because they have made it difficult for him to maintain a sufficient fluid intake. According to a study by Berardi et al. (2019), dehydration in chemotherapy patients is extremely important to monitor and treat since it might result in electrolyte abnormalities like Brett's mildly low potassium levels (hypokalemia).

Brett's reported sensations of fatigue are consistent with the possibility that electrolyte abnormalities contribute to muscle weakness and exhaustion (Lavdaniti, 2019). Brett's tongue has a tiny ulcer, which is a typical symptom of mucositis, a well-known side effect of chemotherapy (Pulito et al., 2020). The way mucositis can dramatically affect a patient's quality of life and dietary intake after cancer therapy is highlighted in the paper by Lalla & Bowen (2018). This fits with Brett's symptoms and emphasizes the significance of a thorough evaluation and management of the health of his oral mucosa. Brett's somewhat reduced neutrophil count is particularly concerning. Chemotherapy, especially drugs like 5-FU and Oxaliplatin, can lead to myelosuppression, increasing the patient's susceptibility to infections (Chu & Sartorelli, 2018). This study emphasizes the critical role of monitoring neutrophil counts in patients undergoing chemotherapy to mitigate the risk of potentially severe infections.

Process

Brett Patterson's clinical presentation strongly suggests that his current health issues are related to the adverse effects of the FOLFOX chemotherapy regimen, which is the standard treatment for colorectal cancer (Pulito et al., 2020). His aberrant vital signs, which include a little fever, an elevated heart rate, hypotension, and decreased oxygen saturation, are consistent with the treatment's well-known negative effects. According to a study by Kalasabail et al. (2019), chemotherapy-induced cytokine release is frequently to blame for a mild fever in the absence of a clear infection. According to the research conducted by Herrstedt et al. (2022), anxiety-induced tachycardia, a typical emotional reaction to chemotherapy-induced nausea, is likely the cause of Brett's increased heart rate. His hypotension is probably a result of this worry as well as ongoing vomiting and diarrhea. Hypotension can result from the loss of fluids and electrolytes brought on by gastrointestinal symptoms, which is consistent with the research mentioned in the 2017 WSES guidelines (Pisano et al., 2017).

According to Pulito et al. (2019), the association of cues reveals substantial patterns of health-related issues such as immunosuppression, mucositis, dehydration, and gastrointestinal disorders. Brett's digestive issues, such as nausea, vomiting, and diarrhea, are in line with the well-researched adverse effects of the chemotherapy drug FOLFOX, which combines the drugs 5-Fluorouracil (5-FU), Oxaliplatin, and Leucovorin (Webster-Clark et al., 2021). These symptoms, along with the presence of a small ulcer on his tongue, strongly suggest chemotherapy-induced mucositis, a well-established complication Al-Qadami et al. (2022). Furthermore, the combination of hypokalemia and concentrated urine highlights the electrolyte imbalances resulting from excessive gastrointestinal losses Castro & Sharma, 2018). Finally, Brett's slightly decreased neutrophil count raises concerns about his susceptibility to infections, emphasizing the importance of immunosuppression monitoring during chemotherapy (Chu & Sartorelli, 2018)

Nursing issues

Dehydration and Electrolyte Imbalance

Brett's persistent vomiting, diarrhea, and concentrated urine indicate a significant risk of dehydration and electrolyte imbalances. Dehydration can lead to serious complications, including hypotension and impaired organ function ((Pisano et al., 2017). Hypokalemia, resulting from fluid and electrolyte losses, can cause muscle weakness and cardiac arrhythmias (Castro & Sharma, 2018). Immediate nursing intervention is required to assess the extent of dehydration, initiate rehydration therapy, and monitor his fluid and electrolyte status closely. Intravenous fluids and electrolyte replacement may be necessary to manage chemotherapy-induced dehydration effectively (Hwa & Kull, 2020).

Chemotherapy-Induced Nausea and Vomiting (CINV)

Brett's ongoing nausea and vomiting are directly attributed to the FOLFOX chemotherapy regimen. CINV not only impacts the patient's comfort and quality of life but can also hinder the effectiveness of chemotherapy if not adequately managed. Immediate nursing actions involve the assessment of the severity and frequency of CINV episodes and the effectiveness of current antiemetic medications, such as Metoclopramide (Gupta et al., 2021). Adjustments to the antiemetic regimen may be necessary, and non-pharmacological interventions like dietary modifications or acupuncture may be considered. Properly managing CINV is crucial to alleviate Brett's distress and ensure he can tolerate and complete his chemotherapy regimen (Collett & Chow, 2019). In order to increase Brett's comfort during his chemotherapy treatment, avoid additional difficulties, and promote his general wellbeing, it is imperative that these pressing nursing problems/issues are resolved.

Establishing goals

The SMART goals for nursing care in Brett Patterson's case are to ensure he achieves and sustains appropriate hydration and electrolyte balance by the end of the shift. This encompasses enhancing fluid intake, rectifying electrolyte imbalances, and closely monitoring urine output to restore his hydration status to normal levels. Additionally, the objective is to alleviate the frequency and severity of chemotherapy-induced nausea and vomiting (CINV) episodes by at least 50% within the same timeframe. This comprehensive approach aims to provide Brett with immediate relief from discomfort while preventing further complications associated with dehydration and electrolyte disturbances, ultimately supporting his well-being during chemotherapy treatment.

Take action

To address Brett's dehydration and electrolyte imbalance, a comprehensive approach is necessary. Initially, continuous assessments of vital signs, including blood pressure, heart rate, and oxygen saturation, will provide a baseline to monitor his response to interventions accurately. Meticulous monitoring is critical in patients undergoing chemotherapy to prevent dehydration and electrolyte imbalances (Rosner et al., 2021). Intravenous (IV) fluid therapy should be initiated with solutions like normal saline or lactated Ringer's based on the severity of dehydration (Hoorn, 2017). Electrolyte replacement therapy, particularly potassium supplementation, should be administered guided by laboratory values to rectify hypokalemia (Kardalas et al., 2018). Encouraging oral hydration with clear fluids such as water or oral rehydration solutions will supplement IV therapy (Hoorn, 2017). Regular monitoring of Brett's hydration status through vital signs, urine output, and laboratory assessments will enable us to make timely adjustments in fluid and electrolyte management, aligning with evidence-based practices.

Effective management of CINV in Brett's case is essential for his comfort and chemotherapy continuity. We begin with an assessment of the severity and frequency of CINV episodes while evaluating the effectiveness of his current antiemetic regimen. Evidence from the study by Karthaus et al. (2019) underscores the importance of personalized antiemetic protocols. Adjustments to antiemetic medications, such as Metoclopramide, are made based on Brett's response and the specific chemotherapy drugs used. Non-pharmacological interventions like relaxation techniques, aromatherapy, and dietary modifications will be implemented to complement pharmacological management (Maulidawati et al., 2023). Patient and family education about CINV triggers, management strategies, and adherence to antiemetics is crucial (Soefje, 2018) Continuous assessment of Brett's response to interventions will be conducted, to achieve a 50% or greater reduction in the frequency and severity of CINV episodes.

Evaluate

Anticipating Brett's response to the nursing care strategies, it is expected that the prompt initiation of IV fluids, electrolyte replacement, and tailored antiemetic adjustments will result in improved hydration status and effective CINV management. His vital signs are likely to stabilize, with blood pressure and heart rate trending towards normal, and dehydration and hypokalemia should resolve (Elvir-Lazo et al., 2020). Regarding CINV, a reduction in the frequency and severity of nausea and vomiting episodes is anticipated, enhancing his overall comfort during chemotherapy. Continuous monitoring will enable prompt addressing of any fluctuations and tailor interventions accordingly. The nursing care strategies align with evidence-based practices and are expected to positively impact Brett's well-being during his treatment, ensuring a smoother journey through chemotherapy.

Reflect

Completing this case report has been a rich and illuminating learning experience, shedding light on various facets of nursing care and the intricacies of oncology management. It reinforced the pivotal role of thorough assessment, evidence-based practice, and interdisciplinary collaboration in crafting tailored care plans for patients like Brett Patterson. One significant takeaway from this case was the importance of interpreting vital signs, laboratory results, and patient-reported symptoms within the context of chemotherapy-induced complications. This process enabled me to make informed clinical decisions and develop precise interventions to address Brett's dehydration, electrolyte imbalances, and chemotherapy-induced nausea and vomiting. It underscored the significance of not merely treating symptoms but understanding their root causes to optimize patient outcomes.

Furthermore, this case reiterated the dynamic nature of patient conditions during chemotherapy treatment. Continuous monitoring, ongoing assessment, and the ability to make timely adjustments in nursing care were pivotal in ensuring Brett's safety, comfort, and overall well-being (Melnyk & Fineout-Overholt, 2022). To broaden my understanding further, I recognize the need to focus my efforts on staying updated with the latest developments in oncology nursing, particularly regarding chemotherapy regimens, evolving side effect management strategies, and emerging supportive care interventions.

Collaborating closely with interdisciplinary teams, including oncologists, pharmacists, and dietitians, will be pivotal in delivering comprehensive care (Saint-Pierre et al., 2018). Moreover, getting deeper into the intricacies of symptom management and the psychosocial aspects of cancer care will enhance my ability to provide holistic and patient-centred support to individuals facing cancer-related challenges. Continuing education and staying attuned to the evolving landscape of oncology nursing will be central to providing the highest standard of care to patients embarking on their cancer treatment journey (Duffy, 2022).

Conclusion

In the essay presented, the case of Brett Patterson, a 55-year-old male diagnosed with Stage III colorectal adenocarcinoma and undergoing FOLFOX chemotherapy, is thoroughly examined using the Clinical Reasoning Cycle. The focus of the essay revolves around Brett's presenting symptoms, which are primarily attributed to the adverse effects of his chemotherapy treatment. These symptoms include dehydration, electrolyte imbalances, and chemotherapy-induced nausea and vomiting (CINV). Nursing interventions outlined in the essay are tailored to address these specific health issues, with a strong emphasis on optimizing Brett's hydration, correcting electrolyte imbalances, and devising personalized strategies for managing CINV. The anticipated outcomes encompass the restoration of adequate hydration, resolution of electrolyte abnormalities, and an overall improvement in Brett's comfort and well-being throughout his chemotherapy regimen. This case analysis underscores the pivotal role of evidence-based nursing practices, continuous patient monitoring, and effective interdisciplinary collaboration in delivering comprehensive care to cancer patients undergoing chemotherapy.

References

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Castro, D., & Sharma, S. (2018). Hypokalemia. https://europepmc.org/article/NBK/nbk482465

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