Doña María is a 72-year-old woman, who was followed up since February 2012 by the Primary Care Team (EAP) of the health area for symptom control and observation of her disease.
Since his hospital discharge in February 2012, the primary care team went to assessment and control once a week, until he felt at 2 months, Maria noticed an increase in pain and not with the scheduled analgesia doses.
Maria calls her reference nurse in the EAP because she cannot tolerate this situation, and needs to improve her current health condition, which causes her current suffering.
This process was reported to the EAP, who attended a new multidisciplinary assessment and review of treatment.
With the following work, we intend to describe the case of a patient from our team, through the model of Dorothea Orem, valuing, diagnosing NANDA, planning, executing and evaluating the NIC taxonomy forgotten to follow.
We will focus mainly on pain management and control, insisting on the importance that this data represents as a value in a fifth vital constant, since the deterioration of health for which the patient suffers from neoplasic pain is due to the pain.
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Valuation
Next, the nursing assessment performed after the arrival to Primary Care from the hospital is exposed.
Initial evaluation.
Dorothea Orem model 2012
Basic conditioning factors
• Descriptives of the person: Living with her husband on a third floor without elevator and a child.
It usually takes care of a niece several afternoons a week.
For 10 months, Maria has not worked in her garden (only work outside the home) and dedicates her time to domestic work.
• Pattern of life: Maria's life is serious since the beginning of her disease; she refers to getting up every day at 8:00 to prepare her husband's standard routine for the asylum.
Play solid foods. A glass of coffee with milk. In mid-morning, another coffee with milk is taken, and an attempt is made to drink a glass of fruits, because it better tolerates crushed foods than
In general, they try to follow a Mediterranean diet, controlling salt intake even though they have to crush a lot of meals or eat more blurring foods because they have difficulty changing due to pain. or
Eat at the same time every day, except for weekends, which you eat later.
He mentions that in diet, as a rule, there is no initial, a second and poster; they usually do a first and unique thing and, in dessert, a piece of fruit or a yogur.
Try to ingest a 2-dose bottle in water apart from other foods and other beverages.
sleeping and rest well (7-8 hours a day).
With the indication of suffering difficulty sleeping, in those situations of anxiety or states of pain.
This means that for approximately two months, their sleep pattern is increasing at intervals since pain is increasing and reports no improvement with analgesic treatment.
General health status and health care system factors
The patient is diagnosed with recurrent gastric cancer.
As a personal history, Maria has arterial hypertension, type II diabetes mellitus and has undergone different surgical interventions, such as inguinal vascular disease due to an ischemic right herniography and an infracondylar amputation of the left lower limb a year ago.
Accredited by the nurse: the treatment of pain, control of nutritional status by odynophagia, as well as the difficulty presented for sleep should be assessed.
Physical restraint: The patient does not have any known drug allergies; he is an ex-smoker to daily medication.
His vital signs are within normal limits: blood pressure 140 mm Hg, respiratory rate 18 breaths/minute, frequency of 64 pulses per minute and without arrhythmias, weight 165 centimeters, weight 69 kilograms.
He has good hydration and nutritional status, well hydrated skin and mucous membranes; he has no risk of pressure ulcers (Bradem-Bergstrom 20 points).
General assessment of the person's capabilities
• Cognitive capacity: The patient has the ability to learn the care required, has the cognitive ability to perform self-care actions, as she is conscious, oriented, with good verbal compression and shows interest in learning.
• Cognitive limitations: Maria has gone through several operations (affective apexotomy, right inguinal herniography and left lower limb amputation), in which she did not know how to act, how to perform the care, etc.
• Ability to perform actions: You have the ability to move and skills to perform your self-care.
You have a Karnofsky index (7) of 60%.
• Limitations to perform actions: The pathology suffered by the patient limits moderate activity and effort, especially in periods of pain.
On the other hand, little has been said about the patient's daily life with the help of household chores and prostheses placed on the left lower limb, which sometimes requires the help of her husband to perform some of the activities.
Universal self-care requirements
• Maintaining sufficient air supply: permeable airways.
It has good coloration of skin and mucous membranes.
Sometimes there are bronchial secretions, which are capable of exploding cough with an effective appearance and normal coloration.
Maria comes every year to the influenza vaccination campaign and is vaccinated against pneumococcus.
Therefore, this requirement does not identify self-care deficit.
• Maintaining an adequate supply of water: The daily intake of liquids performed by the patient is adequate, approximately 2 days.
It has good nutritional and hydration status, as well as the state of the skin and mucous membranes.
No self-care deficit was identified.
• Maintaining an adequate supply of food: The patient eats three meals a day, referring to having to crush or ground many of them because of odynophagia and dysphagia.
Due to high blood pressure, you should have salt restriction at different meals.
Just carry a specific diet for diabetics.
Currently has a body mass index of 25,34.
There is a lack of teeth in their dentures, some of them identifies teeth, one premolar and two upper molars. There is a deficit of canine self-care and two lower molars, which are not good due to prosthesis.
• Provision of care associated with elimination processes and excretions: Maria has a good defecation and voiding pattern; she performs daily two defecations, which, according to the patient, are of normal intestinal characteristics 6-7.
No self-care deficit was identified.
• Maintaining balance between activity/rest: Maria suffered an infracondylar amputation of the left lower limb and when her stump was in the right condition a prosthesis was placed.
Initially, there is no change in every difficulty sleeping, except when there is pain; in this case, Maria uses the prescribed medication and takes 1-gram paracetamol orally, as the fentanyl patch is used 72 hours.
The patient shows a Karnofsky index (7) of 60 % and an activity scale of the Eastern cooperative oncology group (EC) with 2-3 points.
• Maintaining the balance between loneliness and human interaction: The patient maintains cognitive abilities, she maintains pleasant conversations, without problems or barriers in communication.
It has a high intellectual level and is clearly expressed.
In their daily lives, a good relationship with their families, their niece comes several afternoons to visit her and take care of her, as reported by the patient, her sister comes to visit her afternoon and stays at home for friends.
No self-care deficit was identified.
Risks for life, functioning and human well-being: The patient is conscious and oriented.
You are worried about your health condition and physical appearance normally.
Maria requires help from a deficit of affections; likewise, her husband placed a plastic stool on her face in a sitting position so that the patient could bathe without problem and self-care.
• Promotion of human functioning and development within social groups according to human potential, knowledge of limitations and the human desire to be normal: Sometimes, it is shown when it is alone with a weakened attitude.
In the patient, these signs of anxiety are identified by their verbal expressions, when it indicates that there are days when there is oppression in the chest and when there is physical fear of cancer, sometimes there are expressions of headache that try to control when the patient is sad.
• Demand: Recover a positive self-concept about oneself and overcome the fear of death.
Maintain a positive attitude and self-concept.
• Agreeing with the patient to increase self-esteem and provide knowledge to reduce the level of anxiety, as well as to teach them how to face death as a process within the life cycle.
Developmental self-care requirements
• Create and maintain the conditions that support vital processes and promote development processes: The patient, throughout her life, has been able to carry out the necessary actions to maintain and promote her health in each phase.
On the other hand, it has been able to provide the care required in each of the stages of development, as has played in each of them the role that corresponded to it.
No self-care deficit was identified.
• Provision of care associated with the effects of conditions that may adversely affect human development: In this case, we speak of a terminal illness, which involves learning new treatments, lifestyles and help from different health professionals, groups,
Health deviation self-care requirements
• Search and ensure appropriate medical assistance in case of exposure to specific physical or biological agents or environmental conditions associated with pathological human events and states or psychological conditions known to produce or are associated with human pathology.
The patient has a terminal illness, in which is going to suffer probable deterioration of the emotional state, pain, decreased physical activity and appetite, requiring medical and nursing care.
• Demand: not to mention the signs of pain onset, decreased appetite, etc., and to warn the nursing staff.
Also warn about any other complication.
• Agency: Give motivation to a possible discouragement, avoiding the person not requesting help.
The patient is already aware of the intensity of pain and what this entails.
• Be aware and pay attention to the effects and results of pathological conditions, including effects on development.
Maria knows the influence of the disease on her life and development, but she lacks motivation in some aspects that she should correct. She says that the only thing left is to be able to eat like food, she knows she should not eat sweet yet.
It pays attention to the effects of the pathological state and new changes that can occur, being able even to inform the health personnel about these changes.
No self-care deficit was identified.
• Effectively carry out the prescribed diagnostic, therapeutic and rehabilitation measures aimed at preventing specific types of pathology, the pathology itself or the regulation of integrated human functioning, the correction of deformities or anomalies.
The patient refers to be informed in the diagnostic, therapeutic and rehabilitation tests performed to him, as well as the objectives that are pursued with them.
He is aware of the consequences that could happen to him if he did not carry them out, so he says he prefers to do them to the occurrence of something unwanted.
For this, it will need the help of a nurse, for the correct administration of treatment and assessment of pain.
Demand: Following the prescribed pharmacological treatment, preparation of the medication; the type of diet prescribed for the odynophagia presented and checking the subcutaneous tolerance of the odynogia will facilitate therapeutic measures for the patient
• Agency: The patient knows what treatment will be given to you, but has no knowledge about how to do so.
The patient shows a lack of motivation to perform physical activity, as well as to perform a pain diary.
• Being conscious and paying attention or regulating the effects of the care measures prescribed by the doctor that cause discomfort or deterioration, including the effects on development.
The patient knows the influence of the disease on her life and development, but lacks motivation in some aspects such as, for example, the consumption of salt in some foods, which should be corrected.
No self-care deficit was identified.
• To modify self-concept and self-image to accept themselves as a human being with a particular health status and the need for specific forms of health care.
The patient knows her health situation, but does not accept it, manifesting it with many insecurities and some verbal expressions such as: "I see myself wrong with the prosthesis, I don't like to have cancer", "I don't know".
She accepts the help of other people to carry out the care required, from her family, her husband, her son and granddaughter, to help Maria both in housework and in the activities of daily living.
This requirement does not identify self-care deficit.
• Learning to live with the effects of pathological conditions and states and the effects of diagnostic measures and medical treatment, with a lifestyle that encourages continued personal development.
The patient is aware that he will need help from the health staff, since he needs control and management of acute pain that suffers in his pathological process.
You should change your lifestyle, go to mutual help groups to talk about the development of your condition.
• Demand: Follow a series of guidelines during your pathological process.
• Agency: Encourage motivation to carry out prescribed means, as well as to inform health care professionals of the signs and symptoms that they may experience throughout their process.
Second nurse assessment (April 2012)
During these 2 months after hospital discharge, Maria has experienced occasional increases in her pain level, which was controlled with the prescribed analgesia (paracetamol 1 gram orally, fentanyl patch 25 micrograms every 72 hours).
She tells the primary care team this morning, because for three days she has not been able to control pain, which is negatively affecting her quality of life: odynophagia is more severe, and so does she feel retrograde.
She has headache episodes that make Maria feel limited in performing some activities of daily living.
Without health deviations in any other sphere of nursing assessment, it focuses on solving its current problem: uncontrolled pain.
A focused assessment of pain is then performed (Table 1) (8).
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The PCA comes to reassess the patient, corroborating the following interdependent problem: Pain.
The PAE physician prescribed the treatment: oral tramadol 75 milligrams (mg) every 12 hours, fentanyl 50 every 72 hours, subcutaneous chloride 5 mg c/8 hours if pain persisted and paracetamol 1gram later.
The nurse comes to the patient's home to teach and corroborate the correct administration of treatment and 7 days, at 30 days and two months, to assess that the established care plan is effective.
1.
Diagnosis
1.
• NANDA 78: willingness to improve health management manifested by verbalizing difficulties with the prescribed treatment and desire to manage the disease.
1.
Planning and implementation
The expected outcome criteria (NOC) (10) for the resolution of the diagnoses are the following four, to which are added the indicators and scores related to the case (Table 2): level of pain management/treatment regimen and patient satisfaction.
The nursing interventions (NIC) (11) for the previous results and the proposed activities of these interventions, both Maria and her family, can be analyzed in Table 3.
To be able to control the effectiveness of pain treatment by the nursing staff 4), the physicians intensity and location, Mary is explained what the scale works for and the need to perform a pain diary.Table 20 minutes of pain onset
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Evaluation June 2012)
Maria has managed to control her pain to the maximum pain threshold through the management of the new medication and the nursing interventions applied.
Maria is still controlled by Primary Care, continues with pain control and the care plan proposed.
The Primary Care nurse comes twice a week to control that the activities proposed and explained by the nurse were carried out; using this way to assess the effectiveness of interventions and treatment.
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Correspondence address: Miriam Paula Marcos Espino paulitadue@gmail.com
