A multi-faceted approach

to cancer, TTP, and the

snowball effectPresented by Rose Wituka BSN,RN,OCN

02/23/2019

Conflict of Interest Disclosure

There’s no an actual, potential or perceived conflict of interest for myself as

a speaker

There’s not a potential for conflicts of interest as pertains to the content of

this educational activity. There’s no financial relationship with a commercial

interest, * the products or services of which are pertinent to the content of

the educational activity.

There are no payments or solicitation for payments being accepted for the

content in this learning activity.

Objective

1. Discuss the treatment regimens for Colon cancer and TTP

2. Understand medical issues associated with the diagnosis and

treatment of cancer.

3. Discuss challenges involved in taking care of Cancer patient

4. Describe Resources available for cancer patients

Patient care concerns

Colon Cancer with metastasis to the liver

TTP- Thrombotic Thrombocytopenic Purpura

GI Bleed

Multiple Deep Vein Thrombosis, CVAs

Cardiac Concerns

Sepsis

Abdominal wound

Psychosocial issues

Background

E.G. 56 year old African American Male

Family Dynamics

Pertinent Medical History

Allergy to Vancomycin

Recent Hospitalizations

Arrival to Piedmont 3/28/2015 Wife brought patient to ED, admitted to cardiac

floor for Non Q wave MI and elevated troponin levels

Labs

WBC 18.5

H/H 10.4/33.2

Troponin .26

Bilirubin 2.3

AST 116

ALT 77

Plan of Care

IMS with telemetry

Heparin drip –Contraindicated-due to TTP

Doppler to BLE-Negative

Continue IV Cefepime & Fluconazole

Consult to ID

Serial Lactic Acids-1.4, 1.2

Fall precautions

Full Code

On 4/2/15 RN called MD @ 2125 patient reports right

sided weakness

MRI of brain shows multifocal bilateral infarcts

NIHSS 5 –moderate stroke

Neuro checks q 4 hours

4/5 RLE more swollen than left, Doppler done 4/7 –

negative

4/8 Transfer to 2 North to start Chemotherapy

4/13 Pt’s mother is admitted to 2 North

4/17 Pt is upset about mother’s diagnosis, refusing his own treatments

4/20 Pt and family encouraged to use Cancer Wellness Center

Mom d/c home to hospice

4/24 Pt discharged

Platelets 129 WBC 4.6H/H 8.7/26.7

AST 65 ALT 47 Bilirubin 1.1

Back to Piedmont 04/27 Arrived to ED with weakness and diarrhea

Labs

WBC 6.9 H/H 9.8/31.0 Platelets 116

Bili 6.0 AST 123 ALT 94

K 3.3

Plan of care- SCDs, stool studies, replace K+, IVF,

recheck labs, WOC

4/29 Refuses chemotherapy

Chaplain services requested

5/1 started plasma pheresis and daily 80 mg prednisone, still

refusing chemo

5/4 agrees to start chemotherapy again

5/7 positive for Clostridium Difficile-

5/8 Rituximab is given for TTP management

WBC is 5.5, H/H 7.0/21.9, Platelets 63

RN notified MD- 2 Units RBCs ordered

Pt received notification of mother’s death

during his first unit of blood

GI Consult ordered for liver impairment

Patient develops gross anasarca, scrotal

swelling-started Bumetanide drip

5/13 Blood cultures results Negative

5/14 Missed mother’s funeral, very tearful

5/17 Altered Mental Status- metabolic encephalopathy

CT head

Neuro checks

CBC

5/22 MRI of abdomen-worsening hepatomegaly and increased

intrahepatic biliary duct dilation- No more chemo, supportive

care only

5/23 Clostridium Difficile still positive

5/24 restart plasma pheresis

Start PO Vancomycin-monitor closely

5/26 STAT Team called

Lactic acid 6.0 Platelets 76

WBC 27.8H/H 9.8/31.1

Afebrile

Lactic acid ranges 5.3-9.9

Complications

5/28 Bleeding from Abdominal Wound after PT

5/29 Doppler positive for multiple BLE DVTS

IVC Filter placed 5/30

Red Sepsis @ 1435 Lactic Acid 7.7 WBC 25.2,

Acute DVTs, H/H 7.7/24.4

2 Units transfused

MEWS 5

Complications continued

6/2 Abdominal wound bleeding

Dressing saturated, notified CN, STAT, and MD

H/H 10.5/33.3

6/4 Rectal bleeding

H/H 9.1/29.5

GI Consult ordered-Sigmoidoscopy

6/5 Altered Mental Status, 2 bloody stools, H/H 7.3/23.9, Lactic Acid 9.9

2 Units RBCs and 2 Units FFP

Severe Sepsis Bundle ordered- Unasyn & Diflucan

Consult to Intensivist

Vitals 104/61, RR 12, HR 108, 97.6, 100% on 2L

6/6 Blood cultures Gram Positive cocci in clusters-Candida

Pt diagnosed with CLABSI

1st CLABSI on 2 North in nearly 8 years

Contributing Factors

6/7 profound jaundice, hematochezia, minimally

responsive

6/8 rectal bleeding resolved, wife asks to take

him home

6/9 Unarousable

6/10 Family meeting

6/11 Pt was unresponsive and code changed to

AND

Passed away same day

Nursing Challenges

Co-morbidities

Multiple Psychosocial issues

Preventing and treating Infection given the High risk

Treatment in presences of Allergies to medications and contraindications

Patient compliance

Multiple complicated treatments

Emotional toll on Staff

Nursing Diagnosis

Risk for bleeding related to TTP as evidenced by

low platelet count

Ineffective Coping related to situational crisis as

evidenced by the death of his mother and the

patients refusal to participate in his plan of care

Risk for infection related to compromised immune

system as evidenced by elevated WBCs and lactic

acid

Care Teams

Hematology/Oncology

Cardiology

Neurology

Rehabilitation (PT, OT, Speech)

Nephrology

ID

Chaplin services

GI

Surgical services

WOC Services

Dietary

Intensivist

Resources

Chaplin Services

Palliative care services

Hospice services

Cancer Nurse Navigator

Piedmont Cancer Wellness center (currently 4 centers)

Free counselling services for patient and family

Financial Assistance

Nutrition support

Support groups

Genetic counselling

References

https://www.uptodate.com/contents/search

Polovich, M., Olsen, M., LeFebvre, K.B., (2014) Chemotherapy and Biotherapy Guidelines and Recommendations for Practise, 4th ed., ONS

Patient Chart Review

www. Chemocare.org

www. Cancer.org

Ralph, S. & Taylor, C. (2014). Nursing Diagnosis Reference Manual (9th ed). Philadelphia, PA: Lippincott Williams & Wilkins.

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical-Surgical Nursing. China: Wolters Kluwer

Health/Lippincott Williams & Wilkins

https://www.uptodate.com/contents/search