Case study: 35-year-old Esther
35-year-old Esther presented to her General Practitioner after experiencing wo-months of spontaneous bruising to her body without any known injuries, bleeding gum persistent fatigue, and sore throat. Esther was a recent first-time mother (9-month-oldl and thought that these changes were considered normal. Her general practitioner arrang d pathology to take a peripheral full blood count (FBC) which showed the following:
Haemoglobin: 75g/L (ref. range 120 - 150g/L) WCC: 20 (x 10/L) (ref. range 3.5 - 11 (x10/L)) Neutrophils: 0.8 (x 10/L) (ref. range 1.7 - 7.0 (x10/L)) Platelets: 32 mcL (ref. range 150 - 450 (x10/L)) Blasts %: 50% (ref. range <5%)
Image of Normal Blood Smear Normal blood smear Image AML blood smear AML blood smear.
On receipt of the results, the general practitioner rang the haematologist on all at the local healthcare facility. Esther was contacted and told to attend the emergency department for further testing. On arrival to department Esther was met by the haematologist who took her straight to the oncology ward. A physical examination was undertaken, and the haematologist told her that her presentation indicated Acute Myeloid Leukaemia (AML). A bone marrow biopsy was arranged for the next day with the blood smear from this showing 80% blasts cells in the bone marrow; her diagnosis of AML was confirmed.
Central Venous Catheter
Esther had a Hickman's line (Central Venous Access Device- refer to image) placed in her chest, was provided with blood cell support (PRBC's and platelets) and was to begin a high dose chemotherapy induction (7-3 : Cytarabine and DAUNOrubicin) two days following her initial presentation to her GP.
Oral Mucositis in Cancer Patients
On day +6 of her treatment her blood results that morning showed:
Haemoglobin: 82g/L (ref. range 120 - 150g/L) WCC: 8 (x 10/L) (ref. range 3.5 - 11 (x10/L)) Neutrophils: 0.01 (x 10L) (ref. range 1.7 - 7.0 (x10/L)) Platelets: 10 mcL (ref. range 150 - 450 (x10/L))
At 0800 hours, Esther rang the call bell complaining of a sore mouth and difficulty swallowing due to pain. On observation her mouth was filled with new ulcers, her gums were bleeding and mouth/lips dry indicating severe oral mucositis (refer to image). She was provided with mouth care and a stat dose of oral morphine (ordine) 2mg was given.
On a routine observation round at 1000 hours Esther was observed to be diaphoretic, she had an increased work of breathing (WOB), was rigoring (shaking) and pallor. Her vital signs were taken and were as follows:
23/02/20: 1005 hours Heart rate 123bpm Blood pressure 100/53mmHg Respiratory rate 24/m Temperature 39.2 Sa02
AT3: Workbook - Task 1a: Case study analysis
| Nursing diagnosis of the case scenario patient and the most probable cause of infection |
| Examine and interpret the blood results from day +6 |
| Describe the nursing assessment of this patient following her vital signs (using and A-E framework and any associated assessment tools as per the eviQ guidelines |
| Assessment Management A B C D E |
| Care of the Hickman’s line (CVAD) |
| Education you may provide to this patient prior to the commencement of her treatment (Consider psychosocial management in your discussion) |
Nursing diagnosis of the case scenario patient and the most probable cause of infection The risk for internal bleeding is related to declining platelets counts. Esther is receiving chemotherapy which impaired the development of the neutrophils and results in neutropenia condition. In her blood test, the neutrophils finding is 0.8x10/L is very low, putting her more susceptible to infection (Maisel, 2017). The risk of developing infection depends upon the recovery stage of the patient (Babady, 2016). | ||
Examine and interpret the blood results from day +6 Haemoglobin 82g/l of Esther indicates a low red cell count level, due to which the oxygen-carrying capacity of the red cell is also reduced. WCC 8 (X10/L) level is in the normal range, but neutrophils level 0.01x 10L is low and increases the risk of infection. Platelets finding reflects the decreased level of 10mcL indicates that she has a greater risk of internal bleeding (Cancer. Net, 2019). | ||
| Describe the nursing assessment of this patient following her vital signs (using and A-E framework and any associated assessment tools as per the eviQ guideline. | ||
| Assessment | Management | |
| Airway |
|
|
| Breathing | - Assess the clinical features of respiratory stress. - Assess the breathing rate of Esther. - Assess oxygen saturation by the use of a pulse oximeter. - Determine arterial blood gas values |
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Circulation |
| Esther blood pressure and heart rate are 100/53mmHg and 123beats/m (tachycardia), respectively. Immediately provides intravenous and emergency drug (as per order) to promote cardiac output. Esther body temperature is high 39.2, and she observed shivering, so cover Esther properly to prevent heat loss from the body. |
| Disability | Assess the level of conscious level of Esther. | Determine conscious level by rapid assessment AVPU scale. Check ABC to exclude hypotension and hypoxia condition. |
| Exposure |
| - Physical examination should be performed with a gentle approach and privacy consideration so that she continues to manage the care plan for Esther (ABCDE assessment, 2020). |
| Care of the Hickman’s line (CVAD) | ||
There are various responses and challenges in taking care of Hickman’s line, which is placed centrally. It is important to keep the external line patent, fix and comfortable to Esther. The maintenance of the line patency, flushing by heparin zed saline by 5ml of 10U/l is recommended ones in a week (Bosch et al., 2019). At the time of the bath or sleep position, the line should be kept change accordingly and safely. Additionally, maintaining line dry other resources like the use of waterproof covers or any solution is found to be effective in maintenance. The selection of clothes should be concealed and appropriate to accommodate and secure CAVD lines under clothing or secure by sterile dressings (Ryan et al., 2019). | ||
| The education you may provide to this patient prior to the commencement of her treatment (Consider psychosocial management in your discussion) | ||
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