The Holistic Care of a Patient - Essay Example

Critically Analyze The Holistic Care Of A Patient During A Specific Stage Of The Patient's Chemotherapy Journey This study aims to discuss the holistic care of Tom, a 62-year-old gentleman (name changes for confidentiality, NMC, 2004) undergoing chemotherapy for non-Hodgkin's lymphoma (NHL) with associated human immunodeficiency virus disease (HIV). I aim to concentrate on the chemotherapy journey of this patient in relation to chemotherapy- induced nausea. The phase of the patient's chemotherapy journey I have chosen is the pre chemotherapy assessment as this is where Tom divulged his fears of chemotherapy which made me consider his plan of future care. He is a 62-year-old gentleman who has been diagnosed with non-Hodgkin's lymphoma (NHL) for last 8 months. To make things worse, his NHL is superimposed on a HIV positive state that was diagnosed just 2 weeks prior to the diagnosis of NHL. Tom's HIV disease is obviously a complicating factor in his management. Apart from his therapy for NHL, the parallel therapy for HIV would pose problems in assessing his status due to polypharmacy (Toffoli, G. et al., 2004). The drugs of HIV disease have their inherent side effects, and compounded with that, the side effects of chemotherapeutic agents would further worsen his status. I have seen the patients with NHL being treated with R-CHOP protocol, but in Tom's case (see Appendix-1 for full details), the haematology consultation advised CHOP therapy, which comprised doxorubicin, cyclophosphamide, Oncovin or vincristine, and prednisone. The rationale for combination is while different drugs will target cancer cells in different cell cycles, a combination would produce a synergistic effect at a lower dose and thus would reduce the side effects of individual drugs. This usually requires multiple cycles of treatment at an interval of few weeks (Portlock, C. S.et al., 2004). Doxorubicin is an anthracycline that causes DNA fragmentation and cell death. This drug also generates intracellular free hydroxyl radicles that cause destruction of cell. This causes marrow suppression and GI toxicity, mainly nausea, vomiting, and bloating and anorexia. Cyclophosphamide is a broad-spectrum antitumour agent that leads to DNA strand breakage and cell death. This drug produces severe nausea and vomiting and requires extensive premedication to prevent these. Vincristine is a plant alkaloid that binds to tubulin within the cancer cell and causes cell death (Solal-Celigny, P.et al., 1998), and this is also potentially emetogenic. Tom presented with an 18-month history of weight loss, sense of general malaise, decreased appetite, and a lump in the side of the neck and was diagnosed to be having NHL. Tom was diagnosed to be HIV positive. A whole body computerized tomographic (CT) scan revealed presence of disease both above and below the diaphragm. Tom had involvement of lungs with bilateral upper lobe cavitations and centrilobular nodules and involvement of liver indicated by multiple metastatic hypointense lesions in the liver. Tom appeared to be suffering a lot. He had weight loss, anorexia, diarrhoea, and malaise. The initial blood tests indicated his fitness to undergo chemotherapy. I was present as an observer when Tom attended the day unit for his pre chemotherapy assessment; my ward sister went through the details of Tom's intended treatment with him and discussed the possible side effects. It was at this point Tom disclosed his main fear, which was nausea as a result of chemotherapy; he was concerned about the effect of chemotherapy over the baseline anorexia induced by the antiviral drugs for HIV disease. All the drugs that have been prescribed to him, except vincristine can potentially lead to nausea, specially cyclophosphamide can generate nausea from 18 to 24 hours following the administration. Prednisolone also leads to bloating symptoms and nausea. On the baseline, he was having antiviral drugs, such as, truvada and efiavirenz that might produce nausea. He has a social concern and fear of social isolation if this nausea ensues. He stays with his daughter and was concerned about the trouble the family would suffer with his chemotherapy if he was nauseous. He was also concerned about possible admission to the hospital if he were unable to tolerate fluids or diet.. The unit sister explained to Tom the steps that would be taken to prevent nausea. The unit sister explained to him that there are many drugs available to control the nausea, and in our unit, we follow a protocol of prechemo antiemetic medication that successfully controls nausea in almost all patients during chemotherapy. Apart from that, Tom will be given prescriptions to take home for medications that are designed to control any such symptoms at home. The sister also explained in detail the measures that the team shall undertake to alleviate other chemotherapy-induced symptoms (Solal-Celigny, P.et al., 1998). When I asked Tom, what were his main concern and cause of such anxiety, he told me that his disease began with loss of weight and first he started to feel extreme anorexia. He was just feeling like not eating. He has heard that chemotherapy would produce so much nausea that he would not be able to eat at all, thus he would lose more weight, and this may worsen his disease. When I asked which disease he was talking about, he said about the HIV disease; he was not that concerned about the NHL, but he is fearsome about the new therapy, the chemotherapy and all he had head about this. It appeared that he thought or believed that nausea/vomiting is essential to the action of the drugs of chemotherapy, and relief is not possible. He sounded afraid of coming to the chemotherapy session due to fear of being sick or feeling sick. Obviously, he anticipated nausea and was really skeptical about the chemotherapy and antiretroviral drugs would invariably produce nausea. I understood that statement like, "don't worry" or "try to forget about chemo" is not going to work here. It was extremely disturbing to him creating a heavy burden of fear and anxiety. I came to understand that Tom has to debilitating and life-compromising disease, and his rational angles of thought are being compromised. His status is having wide repercussion on his activity and in terms of the quality of life that he is in. I understood that it would be useful, since I became aware of his condition of life and status of social isolation, to pay attention to the psychological aspect of Tom while paying attention to the useful ways of reducing discomfort and having a good nursing management of nausea and its prevention. Nausea is troublesome for the patients undergoing most of the chemotherapy regimens, significant in case of Tom since his regimen comprised of drugs, all of which could cause nausea. Over the top of it, he was already having anorexia. Nausea would reduce his appetite resulting in compromised nutrition. The prevention and treatment of chemotherapy-induced nausea is done with antiemetics and appropriate support to the patient's mind. Cerebral influences play a very significant role in causation of nausea (Burish, T.G. et al., 1987). Tom is exposed to chances of nausea before the chemotherapy, anticipatory nausea; during or immediately or 24 hours after chemotherapy, acute; and nausea spanning over one-week period following a cycle of chemotherapy, delayed. Good control of nausea in the acute phase by drugs is the key to control of chemotherapy-induced nausea of both the delayed type and the anticipatory type, and conversely, protection failure of nausea in the first 24 hours can predict occurrence of delayed nausea in the same cycle (Seigel, L. and Longo, D.L.,1981). The distressing symptoms of nausea have considerable impact on all aspects of the patient's quality of life as well as those of the patient's family and caregivers. Poorly controlled, Tom would develop anticipatory nausea related to visual, gustatory, olfactory, or environmental factors (Coates, A., Abraham, S., Kaye, S.B. et al., 1983). Tom's other concern was gradual increase in the number of drugs that he will be subjected to due to his dual diagnoses. The setting in the ward provides great stress on the treatment of the disease by administration of chemotherapy, but I understood that Tom's main origin of all fears are due to the social isolation, and he needed a dialogue to share his fears. His fears and anxieties were talked about. He expressed his concerns about its effect on his already compromised quality of life. He was already thin, he has lost a lot of weight, and he is suspicious that chemotherapy-induced nausea would make him more thin by reducing his appetite. If it occurs at home, he may be so disabled that, he would not be able to care for himself. He would not be able to eat a meal, perform his daily household tasks, and he would not be able to enjoy other daily activities. In this regard, I reexamined the clinical situation of Tom. The therapeutic part of acute control of nausea has been taken care of by one of the best medications available, that is, ondansetron. This is designed to suppress the serotonin released in the intestinal mucosa and thus vagal afferent fibres to suppress nausea. The prescribed dose is 32 mg; in case of Tom the dose was decided to be 8 mg (Ingle, R.J., Burish, T.G., and Wallston, K.A., (1984); however, I thought that the dose should better be tailored at the outset of chemotherapy. If there is an unsuccessful acute control, there would be devastating effects on Tom's psyche. I made a mental note that I could raise this issue of inadequate dosage if there is a failure of the initial regimen to completely control his nausea. Apart from the very expert counseling by the ward sister, I explained to Tom that he should report any feeling of warmth or any feeling of dizziness or lightheadedness. I told Tom to report the incidence of even mild queasiness. It is not at all necessary for him to accept nausea while having chemotherapy, and we have many methods and medications to make him feel well in case nausea happens. I encouraged him to talk since it seemed that Tom needs emotional support, and that would help him to cope up with the anxiety that nausea may happen. I also told him to maintain a diary for recording nausea at home, and I promised him that I shall telephone him after he goes home about how he is doing, since if there are any problems, we can suggest him therapy while at home, he just does not need to wait for the next cycle and report any nausea if at all it happens. Since chemotherapy-induced nausea has three determinants, the chemotherapy drugs, the patient variables, and dosage and efficacy of the antiemetic regimen, I decided that I could influence and motivate Tom in order to modify the patient variables. Total prevention of nausea was the goal in Tom's case in order to maximise his quality of life including his ability to sustain normal daily activities after the chemotherapy. A part of this symptom profile is anticipatory, which is a conditioned reflex from prior experiences and patient's own anxieties related to the possibilities. In Tom's case, the most feared event would be occurrence of nausea spontaneously hours or even days before the next cycle of treatment (de Boer-Dennert M., de Wit R., and Schmitz, P.I., et al., 1997). If there is aggressive control in the first cycle and aggressive prophylaxis for the possible delayed nausea at home following the first cycle, that will confer the most acceptable outcome (Martin, M., 1996). The main concern of Tom was "why me". This was a sense of personal failure for him, and he was thinking that he has some kind of personal responsibility in causation of his disease. This is the result of his maladaptive learnings on disease and the ensuing chemotherapy event. I focused on his anticipatory reaction to the outcome of chemotherapy, since the anxiety related to it can be considerably alleviated to produce control of nausea (Fox, B.H., 1983). His concern about food intake was also dealt by me. I suggested that if at all nauseous, he should try other foods then the food he likes most. I made it a point not to underestimate his concerns (Morrow, G.R.1984). I again stressed that he should report any problems as and when it happens so that the staff here can prescribe him some oral medications, which he will self administer at home in case he has any symptoms following discharge from the hospital. These preventive measures will enhance Tom's quality of life, allay his anxieties and discomforts, and will ensure enthusiastic compliance in the successive cycles of chemotherapy. As along as I am here in this ward, I decided to follow and communicate with Tom, since that will serve as a boost to his psyche, and I can have a chance to document the success of the regimen (Montgomery, G.H. and Bovbjerg, D.H., 2003). In summary, Tom has main concerns about the ensuing chemotherapy that he will have nausea as all other people with chemotherapy have. This nausea may happen in both in the hospital and at home. This will reduce his food intake and will make him thin and weak, and the overall effect may be aggravation of the disease. He had also anxieties about his quality of life, the growing polypharmacy, his dual disease, and his social isolation. He was skeptical about my statements initially whether all the measures of support will work for him to allay his symptoms. I took concerns of Tom very seriously, and I took the role of an educator to explain to him about his chemotherapy, how we are planning to treat his nausea even before it begins, and this is a misconception that all chemotherapy patients suffer from nausea. I talked with him and ensured him that with an enthusiastic mind and the therapy that we are going to follow here would produce very encouraging results for him. The drugs for nausea are very effective. For his concerns about nausea while at home, I encouraged him to report any events, and also I promised him that I will have a phone followup every day for first 4 days following chemotherapy. In all on reflection, I find that Tom's journey in chemotherapy in the phase of nausea has taught me the importance of nursing care and its modification with a holistic approach in control of distress. Reference List Burish, T.G. and Carey, M.P., (1986). 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