Section Introduction (patient and problem)

Information to Include

Explain who the patient is (Age, gender, etc.) Explain what the problem is (What was he/she diagnosed with, or what happened?) Introduce your main argument (What should you as a nurse focus on or do?)

Pathophysiology

Explain the disease (What are the symptoms? What causes it?)

History

Explain what health problems the patient has (Has she/he been diagnosed with other diseases?) Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

Nursing Physical Assessment

List all the patients health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

Related Treatments

Explain what treatments the patient is receiving because of his/her disease

Nursing Care Plan Nursing Diagnosis & Patient Goal

Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?) Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

Nursing Interventions

Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

Evaluation

Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

Recommendations

Explain what the patient or nurse should do in the future to continue recovery/improvement

Nursing Management of Patient with Ovarian Cancer H.S., a 57 year old female with a medical history of hypertension and chronic kidney disease, was diagnosed with a Stage IIIB clear cell carcinoma of the ovary and had surgery in April of 2007. When the patient began to have physical discomfort, an exploratory lapartomy was performed. A pelvic mass had developed post peritoneal chemotherapy. The patient had surgery to remove the intraperitoneal port, pelvic mass fluid drainage and pelvic biopsy. Often patients with cancer develop cachexia and should be assessed for adequate nutritional intake. Martin (2006) states that one of the greatest challenges for a woman with ovarian cancer is malnutrition: she may have little appetite as a result of treatment of advancing disease, causing her to lose weight. Pathophysiology The symptoms of ovarian cancer are vague and the causes may be related to several factors. As Bohnenkamp (2007) has explained, one or more risk factors may increase the likelihood of developing ovarian cancer, but their presence does not guarantee the cancer will occur. Martin (2006) claimed that the most significant risk is a positive family history of the disease; it is present in about 10% of women with the disease. Although it is not known if H.S. had a history of ovarian cancer in her family, Ignatavicius (2006) noted that other risk factors include being over the age of 40, family history, diabetes mellitus, null parity, being under 30 years of age at first pregnancy, breast cancer, colorectal cancer, infertility, and BRCA1 or BRCA2 gene mutations. Martin (2006) found that 70% of women with ovarian cancer had symptoms for 3 months or longer before diagnosis; H.S. states her symptoms were present for two years, which is why her ovarian cancer had advanced.

History H.S., a 57 year old female, has a medical history of hypertension and chronic kidney disease. She was diagnosed with Stage IIIB clear cell carcinoma of the ovary and had surgery in April of 2007. The patient had 18 cycles of peritoneal and intravenous chemotherapy and had an excellent response with C-125 that reached a low of 10. After completion of chemotherapy, the patient was readmitted 11/15/2007 for removal of a pelvic mass status post peritoneal chemotherapy. The pelvic mass was simple cyst structure with displayed the bladder bilaterally. The patient elected for removal of the peritoneal port and a lapartomy with biopsies to ascertain the nature of the abdominal cyst, which was benign. Nursing Physical Assessment H.S. was alert and oriented to person, place and time. The patients temperature was 98.0 F, pulse rate was 74, respirations were 18, blood pressure was 126/66, oxygen saturation on room air was 98%, apical pulse was 74, lungs were clear, and the patient stated her pain level was 5. The patient has an IV heplock in her right jugular. The patients skin was warm and dry with a moderate bilateral hand grip. The patients surgical incision was from the umbilicus to suprapubic with staples and was intact with no erythema. The patients bowel sounds were hypoactive and stated no bowel movement today but had passed flatus. The urine output from 0600-0800 was 200ml. The patient was on a liquid diet starting 11/06/2007 and changed to a regular diet on 11/08/2007. The patient ate 70% of her breakfast and stated she did not have much of an appetite. H.S. appeared frail and thin with some general weakness. The patients height was 57 (1.70m) and her weight was 105 lbs (47.7 kg). The patient was ambulatory and was able to perform independent activities of daily living. The patient used the incentive spirometer ten times an hour as instructed by physician. Nursing Management 4

Related treatments The patient has no allergies to latex, iodine, or adhesives and is using an abdominal binder for support. The patient has an IV heplock in her right jugular vein due to chemotherapy. As Ignatavicius (2006) has noted, insertion sites must be chosen carefully after consideration of skin integrity, vein condition, and activities of daily living. Ignatavicius (2006) also has stated that IV therapy involves the entire vascular system or multiple systems. Access to other sites for IV insertion was not available due to damage occurring from chemotherapy. The patient was ambulatory and used the incentive spirometer ten times every hour as ordered by physician. The patient stated her pain level is a 5. According to Ignatavicius (2006), the Numeric Pain Distress Scale of 0-10 has zero to 4 being no pain, 5 to 9 being distressing pain, and 10 being unbearable pain. The patient was taking pain medication of Motrin 600mg as needed. The physicians discharge orders were to stay on a low cholesterol, low fat diet and no lifting over 15 pounds. Carpenito (2000) has explained that even though some people can ingest food, they may eat an inadequate or imbalanced quality or quantity. For instance, the diet may be insufficient protein or excessive fat content. Ignatavicius (2006) stated that recent testing and management guidelines from the National Cholesterol Education Program (NCEP) have a major preventive focus for individuals with multiple risk factors. The patients medications were Ducosate Sodium 100mg tab to promote bowel movements; VICODIN 5-500mg every 4 hours for pain as needed.; Metroclopramide 10mg every 6 hours for nausea and vomiting; and Enoxaparin injection 40mg an anticoagulant as a prophylactic to prevent deep vein thrombosis after surgery. Since the patient stated that she was no longer nauseated and her pain level was a five, she chose to not take metroclopramide for nausea or vicodin for pain. Because the patient was up and out of bed Nursing Management 5

and walked up and down the halls at least three times per shift, there was a decreased chance of deep vein thrombosis. Nursing Care Plan H.S.s nursing diagnosis is nutrition, altered: less than body requirements related to increased caloric requirements and difficulty in ingesting sufficient calories secondary to cancer (Carpenito, 2000). According to Martin (2007), malnutrition is one of the greatest concerns for a patient with ovarian cancer. Fitch (2006) also noted that fatigue and anorexia are not uncommon side effects of both chemotherapy and surgery. Patients appearance was frail, with dry skin, and she was underweight for her height. Her height and weight were obtained and compared to the BMI. Patients height was 57 (1.70m) and her weight was 105lbs (47.7kg). Her BMI was 16.50 and needs to be at least 19 (Christensen & Kockrow, 1999). The short term goal is to assess appetite, dietary patterns, activity levels, and knowledge of nutrition (Carpenito, 2000). Nursing interventions for the patient include explaining the need for adequate consumption of carbohydrates, fats, protein, vitamins, minerals, and fluids. Determine the patients food preferences and arrange to have these foods provided, as appropriate. Give the patient printed materials outlining a nutritious diet that includes a high intake of complex carbohydrates and fiber with a decreased intake of sugar, salt, cholesterol, total fat, and saturated fats (Carpenito, 2000). The patient needs proper caloric intake to reach ideal weight, which is at least 121 lbs. The rationale behind this is that food nutrients provide an energy source, build tissue, and regulate metabolic processes (Carpenito, 2000). Even though the patient stated that she was no longer nauseous, she complained of decreased appetite and was unable to finish her meals. Carpenito (2000) has claimed that an even distribution of the total daily caloric intake throughout the day helps prevent gastric distention, possibly increasing appetite. If unable to Nursing Management 6

responsive to education regarding nutrition and requested a consultation with a nutritionist on discharge. tolerate increased food intake, she should be offered frequent small meals throughout the day, as well as liquid nutritional supplements (Christensen & Kockrow, 1999). The patient was Recommendations The patient should follow up with her physician regarding surgery and post-cancer treatment, as scheduled. The patient should also follow up with a nutritionist regarding her diet to gain weight. Christensen (1999) has claimed that dietary treatment should create both a positive energy and a nitrogen balance in the underweight patient, and advised that high-kilocalorie and high-protein diets can provide this in frequent small-volume meals. Martin (2007) suggested that medications such as oxandrolone or megestrol be given to improve appetite. She also advised supplying small, frequent meals served at room temperature, as well the use of nutritional supplements. Fitch (2006) has pointed out that nurses can teach patients how to advocate for themselves with their healthcare providers by helping them formulate and write down questions about their treatment to bring to appointments and by encouraging them to bring a supportive person with them to their medical appointments.

Pathophysiology of Lateral Epicondylitis The tendinous origin of extensor carpi radialis brevis (ECRB) is the area of most pathologic changes. Changes can also be found at musculotendinous structures of the extensor carpi radialis longus, extensor carpi ulnaris and extensor digitorum communis. Overuse and repetitive trauma in this area causes fibrosis and micro tears in the involved tissues. Nirschl referred to the micro tears and the vascular in growth of the involved tissues as angiofibroblastic hyperplasia. A tear occurs at the teno-muscular junction, in the tendon, or at the tenoperiosteal junction. The resulting inflammation produces exudate in which fibrin forms to heal the torn tissue.Repeated activity causes microtrauma, with subsequent granulation tissue formation on the underside of the tendon unit and at the teno-periosteal junction. The granulation tissue formed appears to contain large number of free nerve endings, hence the pain of the condition. The major problem is that the granulation tissue does not progress quickly to a mature form, and so healing fails to take place, almost a type of tendinous 'nonunion'. Lateral epicondylitis is a result of inflammation, or enthesitis, at the muscular origin of the extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon, with subsequent fibrosis and, ultimately, tissue failure. Less commonly, the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved.[4, 5, 6] Etiology of Lateral Epicondylitis The most common cause of Lateral Epicondylitis in tennis players is a 'late' mechanically poor backhand, that places excess force across the extensor wad, that is, the elbow leads the arm. Other contributing factors include incorrect grip size,string tension, poor racket dampening, and underlying weak muscles of the shoulder,elbow and arm.Tennis grips that are too small often exacerbate or cause tennis elbow. Often a history of repetitive flexion-extension or pronation-supination activity and overuse is obtained (eg.,twisting a screw driver, lifting heavy luggage with the palm down). Tightly gripping a heavy briefcase is a very common cause.Raking leaves, baseball, golfing, gardening, and bowling can also cause Lateral Epicondylitis. Less commonly,tendonitis is simply a result of single acute injury.

Clinical Presentation At first, the athlete may be aware of only fatigue and spasm of dorsal forearm muscles related to unaccustomed activity. Then they may note the onset of aching lateral elbow pain after playing. Eventually the pain may become so constant and severe so as to stop the athlete from further playing and to interfere with activities of daily living, such as carrying a briefcase, wringing wet clothes or even holding a cup of tea. Grip becomes weak.Morning stiffness may be felt.

Physical Examination -Point tenderness over or just distal to the lateral humeral epicondyle (the bony attachment of the common extensor tendon) which gives rise to burning sensation when pressure is applied. -Tenderness over muscles of dorsal forearm. -Pain with resisted wrist extension, finger extension and resisted radial deviation. -Pain with passive stretching of wrist extensors. -With long standing symptoms, there is likely to be considerable atrophy and weakness of extensor muscles and limitation of passive wrist flexion. Accessory movements of the elbow and superior radio-ulnar joint may be reduced in along term problem. Special tests for Lateral Epicondylitis 1)Cozen's test- The patient's elbow is stabilized by the examiner's thumb, which rests on the patient's lateral epicondyle. The patient is then asked to make a fist, pronate the forearm and radially deviate and extend the wrist while the examiner resists the motion. A positive sign is indicated by sudden severe pain in the area of lateral epicondyle of the humerus. 2)Mill's test-While palpating the lateral epicondyle, the examiner pronates the patient's forearm, and flexes the wrist fully and extends the elbow. A positive test is indicated by pain over the lateral epicondyle of humerus.

3)Maudsley's test- The examiner resists extension of the 3rd digit of the hand, stressing the extensor digitorum muscle and tendon. A positive test is indicated by pain over the lateral epicondyle of the humerus. Differential Diagnosis -Evaluation should note possible sensory paresthesias in the superficial radial nerve distribution to rule out Radial tunnel syndrome.It is the most common cause of refractory lateral pain and coexists with Lateral Epicondylitis in 10% of the patients. -The cervical nerve roots should be examined to rule out cervical radiculopathy. -Other conditions that should be considered include bursitis of the bursa below the conjoined tendon, chronic irritation of the radiohumeral joint or capsule, radiocapitellar chondromalacia or arthritis, radial neck fracture, panner's disease, little league elbow and osteochondritis dissecans of the elbow. Investigations X-rays are not necessary. Rarely, magnetic resonance imaging (MRI) scans may be used to show changes in the tendon at the site of attachment onto the bone. MRI typically shows fluid in the ECRB origin. There may also be a defect in this tissue. The use of the word "tear" to refer to this defect can be misleading. The word "tear" implies injury and the need for repair--both of which are probably inaccurate and inappropriate for this degenerative enthesopathy. Conservative treatment of Lateral Epicondylitis Activity Modification -In non-athletes, elimination of activities that are painful is key to improvement (eg., repetitive valve opening). -Treatment such as ice and NSAIDs may lessen the inflammation, but continued repetition of the aggravating motion will prolong any recovery. -Often repetitive pronation-supination motions and lifting heavy weights at work can be modified or eliminated. Activity modifications such as avoidance of grasping in pronation and substituting controlled supination lifting instead may relieve symptoms.

-Lifting should be done with the palm up whenever possible, and both upper extremities should be used in a manner that reduces forcible elbow extension, supination and wrist extension. Correction of mechanics -If a late poor backhand causes pain, correction of mechanics of the game is warranted.Avoidance of ball impact that lacks a forward body weight transference is stressed. -If typing with unsupported arms exacerbates the pain, placing the elbows on stalked towels for support will help. -Calculation of grip-The distance from the proximal palmar crease to the tip of the middle finger determine the proper grip size.The figure obtained represents the circumference of the racket handle. Nonsteroidal Anti-inflammatory Drugs -If not contraindicated, we use Cox-2 inhibitors (rofecoxib, celecoxib) for their improved safety profile. Icing 10-15 minutes of icing, four to six times a day. Cortisone Injection Your doctor may suggest an injection of a small dose of steroid to the affected area. This is not the sort of steroid banned for athletes. If used it can last for up to three months, and although it may need to be repeated you seldom need more than two or possibly three injections. Stretching ROM of exercises emphasizing end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation). Forearm extensor stretch may be performed with the athlete facing the wall.The dorsum of the hand is placed on the wall, and the elbow remains locked. By leaning forward the wrist is forced into 90 degree of flexion,stretching the posterior forearm tissues.

Wrist flexion may be combined with a pronation stretch.Keeping the elbow locked, the forearm is maximally pronated and wrist flexed.Overpressure is applied by other hand and static stretch is performed. The scar tissue is more pliable when warm. So stretching exercises can be given after some superficial heating modality. Counterforce Bracing Brace is used only during actual play or aggravating activity. The tension is adjusted to comfort while the muscles are relaxed so that maximal contraction of the finger and wrist extensors is inhibited by the band. The band is placed 2 finger breadths distal to the painful area of the lateral epicondyle. Some authors recommend 6-8 weeks use of a wrist splint positioned at 45 degree of dorsiflexion. Range of Motion Exercises Exercises emphasize end-range and passive stretching (elbow in full extension and wrist in flexion with slight ulnar deviation). -Soft tissue mobilization- Cross fibre friction massage is done with and perpendicular to the tissue involved. TENS for pain relief -LASER -Phonophoresis or iontophoresis may be helpful. A gentle strengthening program should be used for grip strength, wrist extensors, wrist flexors, biceps, triceps, and rotator cuff strengthening. However,the acute inflammatory phase must have resolved first, with two weeks of no pain before initiation of graduated strengthening exercises.Development of symptoms (pain) modifies the exercise progression, with a lower level of intensity and more icing if pain recurs. The exercise program includes-Active motion and submaximal isometrics.

-Isotonic eccentric hand exercises with graduated weights not to exceed 5 pounds. -Theraband extension is performed with athlete sitting.One end of the band is placed under the foot and the other end is gripped. -Wrist curls-Sit with the hand over the knee.With palm up, bend the wrist 10 times holding a 1-2 pound weight.Increase to two sets of 10 daily; then increase the weight by 1 pound upto 5-6 pounds. Repeat this with palm down, but progress to only 4 pounds. -Forearm strengthening-Hold the arm out in front of the body, palm down. The patient clenches the fingers, bends the wrist up, and holds it tight for 10 seconds. Next with the other hand, the patient attempts to push the hand down. Hold for 10 seconds, 5 repetitions, slowly increasing to 20 repetitions 2-3 times a day. -Elbow flexion and extension exercises. -Squeeze a sponge ball repetitively for forearm and hand strength. -Mobilization with movement (MWM)- In this a sustained mobilization is applied to a joint. The mobilization is applied at the same time the patient performs a painful action with the affected joint (extension of wrist). -Progress strength, flexibility, and endurance in a graduated fashion with slow-velocity exercises involving application of gradually increasing resistance. Later on upper limb plyometrics, closed chain activities and sport specific activities are done. Surgical treatment of Lateral Epicondylitis Operative treatment is required in less than 2% cases. Extensor tenotomy-Release of ECRB with debridement of chronic inflammatory tissues is the treatment of the choice. Guidelines of Surgery-Persistent pain (more than 1 year), pain at rest, high activity level, failure of quality rehab program.

Ask the patient to describe normal and unusual exercise and activity patterns. Determine if the patient has had localized joint swelling, pain, and restricted movement and which joints have been affected. Ask if the pain has affected sleeping patterns. Establish a history of repetitive joint stress or trauma. Determine if the patient has either a congenital musculoskeletal condition that might have caused the tendinitis or a history of rheumatic disease. Determine if the patient has allergies to specific corticosteroids or local anesthetics, which are sometimes prescribed for tendinitis. The affected joint may be red, warm, and tender to touch. Note to what degree mobility is restricted and the number and location of joints that are involved. Patients may be concerned about permanent long-term immobility or restricted movement and how it will affect their lives. Assess their coping abilities. Nursing care plan primary nursing diagnosis: Pain (acute or chronic) related to inflammation and swelling of the tendon. Nursing care plan intervention and treatment plan First-line therapy is often pharmacologic. Applications of heat, cold, ice, or ultrasound may be indicated to promote relief of pain and inflammation. The physician may also prescribe immobilization using a sling, splint, or cast. Fluid removal by aspiration and physical therapy to prevent frozen joints and preserve motion constitute supplementary treatment. In extremely rare situations, surgery may be necessary to loosen calcification. Focus on symptom relief. Encourage the patient to elevate the affected joint as often as possible to promote venous drainage and decrease the swelling. After the patient has received an intra-articular injection, apply ice for about 4 hours to help control the pain. Teach the patient how to apply ice and heat properly to prevent burning or chilling. Explain to the patient the need to rest and reduce stress on the affected joints by modifying his or her lifestyle or activities until the condition has improved. If a sling is prescribed, teach the patient how to wear it properly. Instruct the patient to wear a splint during sleep to protect an affected shoulder. When the patients joint pain has diminished, assist with range-of-motion and strengthening exercises. To limit the risk of reinjury, encourage the patient to use proper shoes for exercise and to lose weight if needed. Explain the importance of anti-inflammatory medications, and teach the patient to take them with milk to minimize gastrointestinal (GI) distress. Also caution the patient to report distress, GI upset, nausea, and vomiting. Explain the seriousness of vomiting coffee-groundlike material and the need to seek medical help immediately. Encourage the patient to take medications with food to minimize gastric distress. Nursing care plan discharge and home health care guidelines Help the patient find alternatives to repetitive or stressful joint movement. Be sure the patient understands any medications prescribed, including dosage, route, action, and side effects. Caution the patient not to take aspirin with other nonsteroidal antiinflammatory drugs (NSAIDs). Encourage the patient to use heat or cold therapy as prescribed. Teach the patient to use a barrier between the skin and heat or to use cold therapy to prevent burning or frostbite. Remind the patient to keep follow-up appointments with the physician.