Kay M. Sackett, EdD, RN
December 16, 2010
Selected Pertinent Patient
Information
JS 56 year old Male
Born 08/29/1945
Unmarried, long term
girlfriend
Two living siblings
Retired Navy Enlisted
Retired Barber
Cowboy
Artist
History of PTSD
Alcohol abuse
Chronic Smoker 3-4
packs/day
Diagnosed Esophageal
Cancer Stage 4B June
2009
Home hospice provided by
long-term girlfriend
Moravian
Current History
Chronic nonproductive cough
History of hypertension currently
on no medications
Dyspnea on exertion and shortness
of breath when resting required
O2 @ 2-3 L prn via nasal prongs
Chronic anemia with Hgb 5 si units
(Normal male 8.7-11.2)
Hematocrit .32 (Normal 0.42 0.52) equals low RBCs volume
and hypoxemia
Chronic fatigue
PTSD with periods of confusion
Generalized weakness
Chemotherapy and radiation
treatments begun but aborted
per patient request after week 6
due to radiation burns of the
throat, esophageal strictures
Current pain medications include:
Oxycotin 30 mg po q 8 hours;
Fentanyl Patch 75mg. changed
q 2 days;
Tylenol 650mg po x 2 q 4hours
prn;
Dulcolax Suppository 1 daily
prn,
Imodium 5 ml. po prn
Today’s Foci
JS C/O chronic intractable pain in the neck,
esophagus and shoulders
JS desire to use nonpharmacological pain relief in the
form of Healing Touch
Pathophysiology
Stage IV esophageal cancer is divided into stage IVA and
stage IVB, depending on where the cancer has spread.
Stage IVA: Cancer has spread to nearby or distant lymph
nodes.
Stage IVB: Cancer has spread to distant lymph nodes
and/or organs in other parts of the body.
http://www.cancer.gov/cancertopics/pdq/treatment/eso
phageal/Patient/page2 - Keypoint13
Nursing Physical Assessment
Pupil equal and responsive to light
(PERLA)
Respirations 16-18
B/P 126/78
Pulse 80 at rest 96 on exertion
Positive bowel sounds X4 prn
incontinence
GU has a foley draining cloudy
increasingly yellow urine
Skin dry and intact
Alert and oriented X3 with some
periods of confusion
Alternating black tarry stools and
constipation
Requires assistance with ambulation
due to positive risk of fall
Peripheral pulses wrist +2 ankles +1
Pain assessment = check for quality,
duration, severity, location, aggravating
and/or alleviating factor
Intense, constant 0-10 scale is always
between a 9-10 in the neck and
shoulders
Chemotherapy and radiation therapy
discontinued by patient.
Hospice care with palliative measures
related to pain control and nutrition
Pharmacological Pain Management
includes:
Oxycotin 30 mg po q 8 hours;
Fentanyl Patch 75mg. changed q 2 days;
Tylenol 650mg po x 2 q 4hours prn;
Dulcolax Suppository 1 daily prn, Imodium 5
ml. po prn
O2 @ 2-3 L prn via nasal prongs
Nursing Diagnoses
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/
Chronic pain arising from actual or
potential tissue damage or defined in
terms of such damage
NANDA Definition:
Unpleasant sensory and emotional
experience arising from actual or
potential tissue damage or described in
terms of such damage (International
Association for the Study of Pain);
sudden or slow onset of intensity from
mild to severe; constant or recurring
without an anticipated or predictable
end and a duration of greater than 6
months.
Energy Field Disturbance………….
NANDA Definition:
A disturbance of the flow of energy
surrounding a person’s being which
results in disharmony of the body, mind
and/or spirit
Care Giver Role Strain…………..
NANDA Definition
The focus of this care plan is on the
supportive care rendered by family,
significant others, or caregivers
responsible for meeting the physical
and/or emotional needs of the patient
Sample Patient Goal and Nursing
Outcomes Classification
Nursing Outcomes Classifications
Patient Goal
Patient verbalizes
acceptable level of
pain relief and ability
to engage in desired
activities
(NOC)
Pain control
Quality of life
Family coping
http://www1.us.elsevierhealth.com/MERLIN
/Gulanick/Constructor/index.cfm?plan=4
1
Nursing Interventions
Nursing Interventions Classifications (NIC)
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Cons
tructor/index
Pain management
Heat and cold
Simple Massage
Healing Touch (Not NIC) closest relevant are Therapeutic Touch and
Energy Management
http://www.rncasemanager.com/articles/NursingInterventions
ClassificationLabelsDefinitions.pdf
Nursing Care Plan Chronic Pain
http://www1.us.elsevierhealth.com/Evolve/?site=/MERLIN/Gulanick/
Ongoing Assessment
Assess pain characteristics:
- Quality (e.g., sharp, burning)
- Assess the patient’s perception of the effectiveness of
methods used for pain relief in the past.--Patients with
chronic pain have a long history of using many
pharmacological and nonpharmacological methods to
control their pain.
- Evaluate gender, cultural, societal, and religious
factors that may influence the patient’s pain
Nursing Care Plan Chronic Pain
Therapeutic Interventions
Acknowledge and convey acceptance of the patient’s pain experience.
The patient may have had negative experiences in the past with attitudes of
health care providers toward the patient’s pain experience. Conveying acceptance
of the patient’s pain promotes a more cooperative nurse-patient relationship.
Provide the patient and family with information about chronic pain and options available for
pain management.
Lack of knowledge about the characteristics of chronic pain and pain
management strategies can add to the burden of pain in the patient’s life.
Assist the patient in making decisions about selecting a particular pain management
strategy.
Guidance and support from the nurse can increase the patient’s willingness to
choose new interventions to promote pain relief. The patient may begin to feel
confident about the effectiveness of these interventions.
Nursing Care Plan Chronic Pain
Education/Continuity of Care
Teach the patient and family about using
nonpharmacological pain management strategies:
Cold and/or heat applications
Massage of the painful area
Healing Touch
Knowledge about how to implement nonpharmacological pain
management strategies can help the patient and family gain
maximum benefit from these interventions.
Determining the Level of Evidence
Based Practice
Search
Evidence-Based Hierarchy
Strategy
Metaanalysis
Randomizedcontrolled trials
Clinical trials without
randomization
Systematic Reviews
Non-experimental studies
Uncontrolled studies
Consensus reports, clinical guidelines
Qualitative studies, expert opinion
Clinical expertise, intuition, anecdote
(Sackett & Jones, 2005)
Articles for EBP Assignment
Cassileth, B.R. & Vickers, A.J. (2005). High Prevalence of Complimentary and Alternative
Medicine Use Among Cancer Patients: Implications for Research and Clinical Care.
Journal of Clinical Oncology, Vol 23, No 12, pp 2590-2592.
Freese, J. (2003). Healing Touch in the Hospice Environment. Healing Touch Newsletter.
Volume 03, Number 4, p. 6-7.
Langford, R.M. (2006). Pain management today-what have we learned? Clinical
Rheumatology 25 (Suppl 1): S2-S8.
O’Mathuna, D.P. (2000). Evidence-Based Practice and Reviews of Therapeutic Touch.
Journal of Nursing Scholarship, 32:3, 279-285.
Post-White, J., Kinney, M.E., Savik, K., Gau Berntsen,J., Wilcox, C. & Lerner, I. (2003).
Therapeutic Massage and Healing Touch Improve Symptoms in Cancer. Integrative
Cancer Therapies 2(4), pp. 332-344.
Van den Beuken-van Everdingen, M.H.J., de Rijke, J.M., Kessels, A.G., Schouten, H.C., van
Kleef, M & Patijn, J. (2007). Prevalence of pain in patients with cancer: a systematic
review of the past 40 years. Annals of Oncology. Advance Access published March 12
2007.
Wardell, D.W. & Weymouth, K.F. (2004). Review of Studies of Healing Touch. Journal of
Nursing Scholarship. 36:2, 147-154.
EBP Assignment
 Review articles provided about chronic pain in cancer
patients and use of selected complimentary and
alternative therapies including Healing Touch for
nonpharmacological treatment
 In which tier of the evidence based hierarchy do you
place the article?
 In which tier of the search strategy hierarchy do you
place the article?
Evaluation NEEDS WORK!!!!!
Patient moved from home hospice care provided by
girlfriend to hospice facility
Nursing staff and physician assessed need for change in
pain/medication management (NIC categories) due to
increased intractable and unreliaved pain, change in
mentation, and
Change in pain/medication protocol to provide better
pain control
Continuation of Healing Touch per patient request
Recommendations
Continue chronic pain medication management to keep
patient as comfortable as possible
Continue non pharmacologic Healing Touch at the
hospice facility per patient, girlfriend and family
request
The Cowboy: A Self Portrait
Debriefing
 Aim of the presentation
 The aim of this presentation was to
 Assessment of whether this was accomplished
 Thank you for the opportunity to interview for a
faculty position at Virginia Commonwealth University.
Questions and Answers