Answer:
Introduction:

P.B is a 68 years old male. E was brought to the East Jefferson General Hospital o 4th April 2017. His wife stated that he is suffering from abdominal pain and could not move die to the pain. His admitting diagnosis is ileus and dehydration. He is married and non Hispanic Roman Catholic. He lives with his wife. His highest level of education is college graduate. Is past medical history includes many problems. He had some allergic problems. However, he has sigmoid colon cancer, which metastized to the liver and the bone. He has colonic stent place that provide relief of obstruction. He has practice of smoking and taking alcohol. He consumes wine 3 to 5 times in a week. His wife provided oxtocin to reduce is abdomen pain. However, with the time, the pain did not reduce and he was admitted to the hospital at 2 am.

The patient has the history of intractable abdominal pain, hypophosphatemia, hypokalemia, metabolic acidosis, pressure ulcer left heel, type 2 diabetes mellitus, colorectal cancer, HTN and hypomagnesima. Moreover, the patient is suffering from the pancytopenia due to the chemotherapy. Bennouna et al., (2013) mentioned that the metastatic cancer refers to the cancer that is spreading to the other body parts. When the cancer reaches to the colon, there is a chance of spreading of cancer to the liver. Moreover, it can spread to the lungs and other organs of the body. Since last 3 days, he is suffering from the constipation and very hard stool was coming out of his ostomy. He was denying the fevers, sick contacts, cough, chills, chest pain and dyspnea. Moreover, the patient was denying changes in the oral intake that is dysuria. He had the appointment with his oncologist DR Gertler for the next chemotherapy.

Patient has the sigmoid colon cancer, which is matastized to the liver and the bones. From the demographic data, it is seen that the patient had colonic stent, which is placed to relieve the obstruction. Moreover, from the demographic data the history of Mr. P.B. is found as well as the review system states the progress of him, which can help in the study.

In past days, the patient had different problems like asthma, degenerative disk disease. Moreover, he had hypertension, diabetes mellitus, irritable bowel syndrome, perineal pain, osteoarthritis and prostate cancer. However, in the present days, some new symptoms are seen in the patient. The patient is suffering from hypertension, diabetes mellitus, GI bleed, abdominal pain, prophylactic anticoagulation, abdominal pain, bilateral DVTs, metastatic colon cancer. The patient is suffering from severe abdominal pain since last Friday. With the time, the condition of the patient became worse. At 2 am, he awoke with the intense pain in the morning in left lower quadrant at ostomy site. The pain spread to the left back and became worse with the movement.

The family members provided oxytocin for the pain management, but the medicine did not provide relief to him. He was unable to sit or stand. The pain was none remitting and recently he is receiving the IV narcotics 6 out of 10. Currently he has the chronic problem of diarrhea that alters with the constipation. Since last 3 days, he is suffering from the constipation and very hard stool was coming out of his ostomy. He was denying the fevers, sick contacts, cough, chills, chest pain and dyspnea. Moreover, the patient was denying changes in the oral intake that is dysuria. He had the appointment with his oncologist DR Gertler for the next chemotherapy.

Hypertension refers to the problem that occurs due to the high blood pressure. The main cause of the sigmoid colon cancer in the patient is the bad practice of smoking and alcohol consumption. Moreover, He has the family history of diabetes mellitus. His father and grandfather also had the same health problem of diabetes mellitus. Moreover, the cancer is also the genetic disease. His father, grandfather and brother had died due the prostate cancer. Therefore, it is clear that the major health issues of Mr. P.B. were genetically and his social history influenced the other health issues.

P.B. has the past medical history of diabetes mellitus. This may cause of the dehydration, ileus, and pressure ulcer on the left heel. Another reason of diabetes mellitus can be the overweight. Therefore, he needs to be careful about the weight gaining and quit the bad habit of alcohol consumption. He takes alcohol 3 to 5 times in a week that is highly risky for health. He needs to modify his diet and habits. However, his past medical history has improved and he overcame many of his health problems over the time.

From the past and present symptoms, it is found that the patient is achieving new symptoms. The main cause of this can be the metastatic colon cancer. As the cancer is spreading, it affects the other body parts as well like the lung and bones. The patient has the bad habit of tobacco smoking that needs to be reduced. The doctor suggested him to avoid the narcotic use but he was unable to avoid the bad habit. This can be another reason for which the patient is suffering from such symptoms. There was no chest pain previously but present days he is achieving the chest pains that can be harmful for him.

 It is seen that there are several problems from which he is suffering. There are various reasons of deteriorate of the patient. He was a former smoker but stopped smoking at the age of 57 years. However, he always tries to avoid the substance abuse but had the practice of alcohol intake. He takes wine 3-5 time in every week. Hunt et al., (2014) suggested that people need to avoid the intake of alcohol. He has the family history of diabetes mellitus. His father and grandfather also had the same health problem of diabetes mellitus. Moreover, the cancer is also the genetic disease. His father, grandfather and brother had died due the prostate cancer. Therefore, it is clear that the major health issues of Mr. P.B. were genetically and his social history influenced the other health issues.

The reason of the asthma may be the allergic and the tobacco smoking can influence the disease more. He has the problem of constipation due to the upper bowel movement. As a result, the stool was not clear and the patient was suffering from the constipation. The cause of the pressure ulcer on left heel can be the reduced blood supply and infection in the blood cells. The bacteria affected the left heel and the heel became hard. The cause of the pressure ulcer on heel may be either the pressure from the hard surface, pressure via the involuntary muscle movement or the moisture (break down of the epidermis) (Martinez & Mattu, 2014).

A. Correlation Of The Client’s Signs And Symptoms And Abnormal Diagnostics With Pathophysiology

With the other signs and symptoms, the side effects of the chemotherapy are seen. The patient was suffering from the hyperplasia. Viral infection can occur in between the cancer cells and normal cells. In such condition, the body organs may increase in size and therefore, the cancer can spread to the other body parts. The patient has severe abdominal pain. The reason of this can be the metastatic colon cancer. The patient has to take various types of medication. At home, he had to take the cardura via the oral route 4 mg per day with the dinner. The doctor prescribed to take the dilaudid orally 4 mg at the interval of 4 hours and lomotil oral tablet in the interval of 6 hours.

The physical exam report shows that he has the primary pain intensity. He has problems in movement. However, he has no signs of the head trauma, no signs of adenopathy and no JVD. The psychiatric condition of the patient is normal. The pupils of the patient are equal and extraocular motion intact happened.  He had hearing intact grossly. The oropharynx is normal. In case of the chest, there is no wheeze, rhonchi or rales and the breath sounds bilaterally. The abdomen is soft and the stool is hard.  

With the diabetes mellitus, hypertension and metastatic colon cancer, the patient has achieved other symptoms of disease also that is risky for the patient. He is suffering from the dehydration, which is the result of the diarrhea. The patient needs to follow the orders of the doctor and avoid the habit of tobacco smoking. The main cause of the dehydration is the negative fluid balance. The intake of the fluid is less than the output of the fluid. Therefore, the doctor is providing the adrucil continuous IV with the 340 ml of normal saline of 0.9%. Moreover, the adrucil injection of 1000 ml and 20 mL IV is pushed once in a day. Dexamethasone injection of 1 mL, 1 mg and dilaudid injection of 1 mL, 1 mg are injected to the patient. Zofran injection of 8 mg, 4 mL and ondansetron injection of 16 mg and 8 mL are given.   In the hospital he was given the eloxatin IVPB with the dextrose 5 % in the 500 mL water and the leucovorin IVPB with the dextrose 5% 100 ml of water. With the normal saline 145 mL 5% the emend IVPB was given. It can be expected the patient would response to the treatment and would follow the instruction of the doctor. For the immunization, the doctor prescribed various vaccines that would help him to be protected from the virus and bacteria (Price et al., 2014)

The medical course was different at home and the hospital. In the hospital most of the medicine were liquid and injection, whereas the medication at the home was oral. The patient was admitted for several days in the hospital. At home, he had to take the cardura via the oral route 4 mg per day with the dinner. The doctor prescribed to take the dilaudid orally 4 mg at the interval of 4 hours and lomotil oral tablet in the interval of 6 hours. It is necessary to mention that the medication can help the patient to get well soon if the patient follows the guidelines of the doctor. The patient needs to complete the medication course that is provided by the doctor. Moreover, the doctor suggested to avoid the alcohol intake so that it cannot damage the liver and led him to death. The doctor is providing the adrucil continuous IV with the 340 ml of normal saline of 0.9%. Moreover, the adrucil injection of 1000 ml and 20 mL IV is given once per day. Dexamethasone injection of 1 mL, 1 mg and dilaudid injection of 1 mL, 1 mg are injected to the patient. Zofran injection of 8 mg, 4 mL and ondansetron injection of 16 mg and 8 mL are given.   In the hospital he was given the eloxatin IVPB with the dextrose 5 % in the 500 mL water and the leucovorin IVPB with the dextrose 5% 100 ml of water. With the normal saline 145 mL 5% the emend IVPB was given.

Problem: the problems of the patient are that the patient is suffering from the severe abdominal pain and he has metastatic colon cancer. Moreover, the patient has diabetes mellitus type 2, ileus, intractable abdominal pain, hyponatremia, hypomagnesima, dehydration, metabolic acidosis, tachycardia, hypokalemia, metastatic colorectal cancer, pressure ulcer left heel, diabetes mellitus type 2 and hypophosphatamia. He is suffering from the back pain and facing problems in the movement.

Etiology: the main causes of the problems in the patient were the family history and the social practice of him. He did not practice the substance misuse but he had the bad practice of the tobacco smoking. From his family history, it is seen that his father, grandfather and brother had the prostate cancer. Therefore, cancer is the genetic problem in his family, which he cannot avoid. The reason of asthma can be the tobacco smoking, which causes the chest pain.

Symptom: the symptoms of the patient are the abdominal pain, problem in movement, back pain, bowel problem, hard stool and bloody GI excretion. The patient could not sleep before the day of admission. The use of oxytocin also cannot provide relief to the patient. Therefore, he needs the supportive care that can help him to get relief from the pain. The symptoms of the diarrhea are seen as the fluid intake is less than the fluid output. The patient has the problem of constipation and the stool is very hard.

A. Rationale Of The Treatment Regime

Treatment regime

Rationale

Adrucil continuous IV+ normal saline 0.9% 380 mL

This medication is given due to the metastatic colorectal cancer. Moreover, the patient is suffering from the dehydration. Therefore, the usage of saline is necessary for the patient.

Adrucil injection, 1000 mg, 20 mL, IV push

It is one type chemotherapy drug, which help to reduce the growth of the cancer cells. This is injected in the saline bottle so that the drug can reach to the blood directly.

Dexamethasone injection, 12 mg, 3 mL, IV push

This injection helps to reduce the allergic effects, breathing problem and the cancer. It helps to reduce the swelling and allergic symptoms. Therefore, the injection is given via the spinal rote so that it can reach the body very fast.

Dilaudid injection, 1 mg, 1 mL, IV push

The function of the medication is that it helps to reduce the pain. It is one of the narcotic pain reliever. It acts in the brain, which provides relief from the pain.

Eloxatin IVPB+ normal saline 0.9% 145 mL

This medication is used to provide relief to the patient who is suffering from colon cancer. This helps in the advance treatment of colon cancer. The medication is given with 145 mL of the normal saline 0.9%.

Emend IVPB+ dextrose 5% in water 100 mL

Emend IVPB is used in preventing the nausea and vomiting, which is caused by the chemotherapy. It blocks the natural substance of the body.

Granix injection, 480 mcg, 0.8 mL, SUBQ

This medication helps the body to be ready for the chemotherapy. However, this medication decreases the white blood cells and increases the risks of infection.

Leucovorin IVPB+ dextrose 5% in water 100 mL

This medication is used to reduce the effects of the megaloblastic anemia and reduce the toxicity of the body.

NaCl 0.9%, 1000 mL, IV continuous

This is mainly used to replace the body fluids that are replaced. This helps the body to dilute the other medications. Therefore, it is provided continuously.

Ondansetron injection, 16 mg, 8 mL, IV push

Emend IVPB is used in preventing the nausea and vomiting, which is caused by the chemotherapy. It blocks the action of the serotonin.

Zofran injection, 8 mg, 4 mL, IV push

This medication helps to decrease the effects of the diarrhea, constipation and fever.

Table 1: Rationale for treatment regime

(Source: Thomas, Tomeh & Theard, 2015; Albanese et al., 2014 and Heard et al., 2015)

A. Completion Of The Assessment

The registered nurse uses the systemic and dynamic rater than the static way to collect the data as well as to analyze the data about the patient. This is the first step in delivering the nursing care. The nursing assessment includes the physiological data as well as the sociocultural, psychological, economic, spiritual and life style factor. The assessment of nursing of the hospitalized patient in pain can include the physical causes and pain manifestation with the response of the patient (Shogbon et al., 2013). This can happen due to the inability of the patient, as he could not get rid of bed. The patient may refuse to eat and show anger to the staffs of the hospital. As he is suffering from pain, therefore he can ask for more medicine to get relief of the pain. The nursing assessment needs to include the nursing diagnosis, planning, implementation and evaluation. The nurse needs to think critically and implement the plan successfully. The planning can help the patient to get rid of the pain and be well soon (Grothey et al., 2013). The medication needs to be given timely. Therefore, the nurse needs to be careful about the dosage, route and time of the medication. The nurse should make proper planning to help the patient and implement them for the wellbeing of the patient (Yaeger et al.,  2015). It is the duty of the nurse to provide the quality care to the patient.

The objectives of the study are as follows:

To manage the patient’s dehydration: The main objective is to manage the dehydration of the patient. The patient is suffering from the diarrhea, which is the main result of the dehydration. The fluid balance of the body is being misbalanced, which can be fetal for the patient. Therefore, it is necessary to maintain the fluid balance of the patient’s body. For this purpose, the saline is given to the patient in the hospital. The problem of the dehydration can be reduced when the patient would be able to overcome the problem of the diarrhea. As a result, the nurse needs to provide the medication of the diarrhea as prescribed by the doctor.

To manage the pain of the patient: the next objective is to manage the abdominal pain of the patient. Before the day of admission, the patient could not sleep due to the abdominal pain and the pain was increasing with the movement of the body. Mr. P.B. was feeling in the back side also. His family members provide the oxytocin for the management of the pain but the medication did not work. As a result, the patient needed to be hospitalized. The doctor prescribed some new medicine to reduce pain like dilaudid injection (Sweeney et al., 2016). However, it can be expected that the pain can be managed via the nursing intervention.

The patient Mr. P.B. is a 68 years old male, who has been admitted with severe diarrhea, dehydration and abdominal pain. He has colon cancer with progressive metastasis. In this current context, two key problems that have been prioritized are, managing his pain and managing his dehydration.

Managing pain- To manage his pain, initially, pain score would be measured with the pain measuring scale, based on which his management plan would be developed. In the current context, the patient is facing significant pain, as he was administered with oxytocin, which did not affect his pain; as a result he was brought to the hospital. As oral medication did not affect his pain, he should be administered with intravenous pain medication. NSAIDs are effective as pain relief medication (Potter et al., 2016). In this context, opoid is a strong medication for reducing his pain; however, as he is not responding even to oxytocin; he would be administered with morphine, which a strong opoid. However, these medications usually have significant side effects, thus patient should be monitored very carefully for any kinds of adverse effects.

Managing dehydration- The patient is experiencing diarrhea, which the key reason for his dehydration, thus immediate management is crucial. ORS through oral route or saline through intravenous route would be administered. In addition, he should begin with BRAT (Bananas, Rice, Apples and white Toast) or ABC (Apples, Bananas and Cereal) diet. If intravenous fluid is recommended, patient would be thoroughly monitored for drinking clear fluid for replacing fluid lost including plenty amount of water, grape or cranberry juice, decaffeinated tea and oral rehydration drinks such as Pedialyte (Potter et al., 2016). In his diet, sodium and potassium level should be increased; as significant amount of mineral is being lost.  Patient should be allocated to low fiber diet with frequent small meals. He can also administer probiotics. For the immunization, the doctor prescribed various vaccines that would help him to be protected from the virus and bacteria. It is necessary to mention that the medication can help the patient to get well soon if the patient follows the guidelines of the doctor. The patient needs to complete the medication course that is provided by the doctor.

The nursing interventions are appropriate for meeting the goals or objectives of Mr. P.B’s care plan. Two nursing problems have been diagnosed for Mr. P.B., based on his initial diagnosis, which are severe diarrhea and unmanageable abdominal pain. Based on his condition, two nursing interventions, i.e. pain management through medication and dehydration management through fluid supplement has been recommended. Pain medications are provided for reducing inconsolable pain; the pain may be resulted as a result or radiation or chemotherapy. It has been revealed from previous research that radiation or chemotherapy can affect and break skin and rectal wall, causing massive pain in abdomen (Giger, 2016). As oxytocin is not working, he has been recommended to administer morphine, which is a stronger pain medication. It would help to reduce his pain. Additionally, it has also been suggested that the patient would be monitored thoroughly for reducing the chance of adverse effects. In addition, the mind-body medicine team would be appointed to him for teaching the patient relaxation tools, for managing pain by reducing anxiety, fatigue related to his current condition and treatment procedures.

In regards to the second nursing problem, i.e. diarrhea and dehydration, a significant amount of fluid has been lost from the patient’s body through bowel, making the patient more weak and vulnerable. Thus, to manage the health issue, reconstructing the fluid balance is crucial, which has been focused in his nursing intervention. He has been suggested to provide ORS or intravenous saline to make up the lost amount of fluid. In addition, low fiber and high mineral diet has been suggested to balance his mineral loss during diarrhea. In addition, he has also been suggested to administered with probiotics, it is because, it has been revealed in many cases, that cancer therapies, i.e. radiation or chemotherapy causes harm to the gut microbial population, which make the gut susceptible for the growth of pathogen (Zimmermann et al., 2014). To combat with this issue, probiotic is one of the best options. Therefore, it can be said that the patient’s interventions are justified for meeting his current health needs.

B. Result Of The Intervention

The pain medication administration, i.e. administration of morphine resulted in the reduction of his pain. Although the patient experienced mild nausea, as adverse effects, these symptoms were manageable. On the other hand, the intravenous saline solution along with low fiber and high mineral, i.e. high potassium and sodium diet rebuilt his body fluid content. For further managing his pain, he is recommended with oncology rehabilitation and physical therapy for pain management (Giger, 2016). These natural strategies would stimulate the release of endophrins, which is a natural defense system against pain.

I. Discharge Planning 
A. Discussion of patient outcome

The intervention of P.B. was very effective but he needs to continue to have the reoccurrence of his admitting diagnostic due to the patient history. He will be discharged as his present symptoms are reduced. The problem of dehydration and ileus can be developed as the symptom of colorectal cancer. After the discharge, he will go to his home where he needs to take complete bed rest. He will get the care of home and can take the health care service of a health care center.  He will get proper medication during the discharge time. The doctor will prescribe the diet chart and medication that he needs to follow. Patient and the doctor both should be agreed and there should be the signature of the doctor on the documents of the discharge paper. The patient needs to follow up the care and visit to the doctor according to the appointment schedule. He needs the patient education that the responsible nurse of the health care center can provide. It can be expected after discharge; he will quit his bad practices and follow the instruction of the doctor.

B. Explanation of the discharge plan

After being discharged from the hospital, the patient would prefer to go to home. Howevr, the doctor suggested him to visit the oncology rehabilitation center for the pain management. Therefore, his family members need to take care of him. The registered nurse and the family members can take care of him. The necessary things for the caring are the medication system, which includes the chemotherapy, medicines and injections. The nurse needs to note the down the progress of the patient. The patient needs to follow up the care and visit to the doctor according to the appointment schedule (Hasler et al., 2013). Before discharging the patient, the final check up is necessary. The patient and the doctor both should be agreed and there should be the signature of the doctor on the documents of the discharge paper. The nurse needs to make proper planning of the discharge and share the concern with the doctor. After that, the nurse needs to teach the patient and his family members about the medication so that they do not face any problem at home. Kalantar-Zadeh, Uppot and Lewandrowski (2013) mentioned that the nurse needs to advise the patient to continue the chemotherapy and visit to the doctor if the signs and symptoms of the abdominal pain and dehydration is seen further. After the discharge from the hospital the patient needs to take bed rest and reduced the movement to avoid the back pain. He can appoint a nurse, who would take care of him and would provide the medication on time with the proper dosage.

It can be said that condition of the patient is very serious and he needs to avoid the bad habits of tobacco smoking. He is suffering from various diseases like metastatic colon cancer, dehydration, hyperkalamia, hyperplasia and other diseases like that. The patient was admitted for several days in the hospital. However, the medication at the home and the hospital was not same. Moreover, he needs to be aware about the diet and should intake the proper amount of fluid. In the hospital, most of the medicines were liquid and injection, whereas the medication at the home was oral. It can be expected the patient would response to the treatment and would follow the instruction of the doctor. For the immunization, the doctor prescribed various vaccines that would help him to be protected from the virus and bacteria. It is necessary to mention that the medication can help the patient to get well soon if the patient follows the guidelines of the doctor. The patient needs to complete the medication course that is provided by the doctor. Moreover, the doctor suggested to avoid the alcohol intake so that it cannot damage the liver and led him to death. After the discharge from the hospital the patient needs to take bed rest and reduced the movement to avoid the back pain. He can appoint a nurse, who would take care of him and would provide the medication on time with the proper dosage.

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