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Care Study of Client with Gestational Trophoblstaic Diseaes

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UNIVERSITY OF CAPE COAST
SCHOOL OF NURSING

MSC. ADVANCED NURSING PRACTICE

COURSE: ADVANCED CLINICAL PRACTICUM I AND II IN SPECIALTY AREA

COURSE CODE: NUR 822S and NUR 829S

PATIENT / FAMILY CASE STUDY
(A NURSING PROCESS APPROACH)
ON
A CLIENT WITH GESTATIONAL TROPHOBLASTIC NEOPLASM

BY: CHARLOTTE LAMPTEY
SN/ADN/15/0030

AUGUST, 2016

CONTENTS * PREFACE

* ACKNOWLEDGEMENT

* INTRODUCTION

CHAPTER ONE:
OVERVIEW OF CLIENT SITUATION
I. Literature review of gestational trophoblastic neoplasm

CHAPTER TWO: COMPREHENSIVE HOLISTIC ASSESSMENT OF PATIENT/FAMILY
I. Patient’s medical and personal history including review of the systems
II.Physical examination
III.Diagnostic evaluation
IV.Nutritional assessment V. Psychosocial history
VI. Patient developmental assessment
VII.Spiritual assessment
VIII.Quality of life assessment
IX.Admission of patient

CHAPTER THREE: ANALYSIS OF DATA

CHAPTER FOUR: COLLABORATIVE PLAN OF CARE
I. Presumptive medical diagnosis
II.Nursing diagnosis
III.Evidence-based interventions
IV.Additional diagnostic procedures warranted but not done
Medication to be ordered

CHAPTER FIVE: DISCHARGE PLAN
I. Community service and resource needed
II.Client education plan
III.Plans for follow-up of care

CHAPTER SIX: EVALUATION PLAN Termination of care

* SUMMARY

* CONCLUSION

* REFERENCE PREFACE
The patient / family care study is an essential and relevant study undertaken on the patient and the family by a final year nursing student as part of the required curriculum to complete the Master of science in Advance Nursing Practice program
Advanced Practice Nurses (APN) play a pivotal role in assisting patients through the disease process. From the time of diagnosis through the rehabilitative phase of care, the skills and knowledge of the APN is essential to clients receiving high-quality comprehensive care. In particular, expert clinical judgement and leadership often have been cited as the two most important components in the delivery of expert patient care by APN (bishop, 2009).The APN scope of practice includes performing comprehensive health assessment and physical examinations, making a differential diagnosis, ordering and interpreting diagnostic tests and providing appropriate follow-up.
An important aspect of developing a patient’s treatment plan is using evidenced based guidlines.Evidenced based health care provides the APN with the scientific data necessary to provide high-quality care to patients. The information available assists in making complex clinical decisions regarding the best recommended practice This study gives a detailed report about the total nursing care given to the patient as an individual and the family as a whole aimed at their physical, social, psychological and spiritual needs. It also gives the APN, the opportunity to practice the knowledge and skills acquired through her training in order to give a holistic care to the patient using the nursing process approach.
In order to ensure privacy and to protect identities of client and her family they will be represented with initials instead of their full names.

ACKNOWLEGDEMENT

INTRODUCTION
This patient case study is written as part of the academic requirement to assess the final year student nurse for the award of Master of Science in Advanced Nursing Practice.
When a woman gets pregnant everyone is very excited towards the baby especially the father. But what if the baby in the uterus is not actually a real one; but a cluster of Mole. The fetus or developing baby and the placenta normally develop together, in parallel, the end result being a healthy baby and a placenta which is no longer needed, so the latter is expelled just after the baby is born. The placenta is made of millions of cells called trophoblasts. In trophoblastic disease there is an abnormal overgrowth of all or part of the placenta, causing what is called a molar pregnancy or hydatidiform mole.
The purpose of this case study is to be familiar with Gestational Trophoblastic Neoplasm (GTN); pathophysiology, signs and symptoms, medical and comprehensive oncological nursing management. I chose this case study because Gestational Trophoblastic Neoplasm is a rare gynecological oncology condition which is treatable yet silently, many women die from it annually.(GTN mortality data is not readily available at the Gynecology Department of the Korle-bu Teaching Hospital, but five to seven deaths are recorded each year)
This case study is about Miss.R.B, A 28years old student nurse with Gestational Trophoblastic
Neoplasm who was seen at the National Center for Radiotherapy and Nuclear Medicine Department of the Korle-bu teaching Hospital in Accra, Ghana on 12th January 2016 with a histopathological diagnosis of Gestational Trophoblastic Neoplasm (Choriocarcinoma type). She was managed on out-patient basis with chemotherapy of which she had good response and went into remission.
The management of Miss. R.B at the National Center for Radiotherapy Department of the Korle-bu Teaching Hospital has been outlined in this case study in six chapters. These include:

Chapter one; Overview of patient situation
Chapter two; Comprehensive assessment of patient and family
Chapter three; Analysis of data
Chapter four; Collaborative plan of care
Chapter five; Discharge plan
Chapter six; Evaluation plan

CHAPTER ONE

OVERVIEW OF CLIENT SITUATION
Miss R.B. is a 28year old young woman who was referred to the National Center for Radiotherapy and Nuclear Medicine Department of the Korle-bu teaching hospital on the 12th January 2016 from the Gynecology department of the same hospital with a histopathological diagnosis of Gestational Trophoblastic Neoplasm (Choriocarcinoma type) for further specialist oncological management. Client and mother were anxious. They were all made comfortable and reassured of restoring Miss R.B’s health to her normal functioning. Nursing care was given using the nursing process to provide individualized care. Vital signs such as blood pressure, temperature, pulse, respiratory rate, weight, height, body surface area and performance status (ECOG) were assessed. Blood samples were taken for laboratory investigations such as full blood count, blood urea and creatinine, liver function tests and beta HCG. Medical images such as Chest x-rays, abdominal and pelvic ultrasonography were also done to rule out differential diagnosis. Routine nursing care such as chemotherapy administration, monitoring of vital signs, health education, counselling on chemotherapy, consenting and other procedures were carried out successfully during the period of admission. Much time was invested into educating patient about condition, treatment regimen and relieving her anxiety. Nursing diagnosis were made and interventions implemented to ensure client’s recovery. Prescribed drugs included cytotoxic drugs, analgesics, anti-emetics and intravenous infusions. These were administered successfully without adverse reactions. Nursing problems were managed throughout by the use of nursing care plan. Goals set for the various objectives were fully met. One home visit was conducted to familiarize with client’s home environment to identify health risks and resources that she could benefit from as well as for continuity of care. This home visit was made two weeks after admission. The care was finally terminated on 11th March 2016 when she came for her 9th cycle of her chemotherapy regime. This was to enable me round up my practicum period

LITERATURE REVIEW OF GESTATIONAL TROPHOBLATIC NEOPLASM
Gestational trophoblastic neoplasms (GTN) comprises of a group of interrelated conditions that arise from an abnormal fertilization, and they consist of five distinct clinicopathologic entities: -
-Complete hydatidiform mole (CHM)
-Partial hydatidiform mole (PHM)
-Invasive mole (IM) -Choriocarcinoma (CCA) and
-Placental site trophoblastic tumors (PSTT).

EPIDEMIOLOGY

GTN arises most commonly after a molar pregnancy, but can also occur after normal or ectopic pregnancies and spontaneous or induced abortions. These tumors represent less than 1% of gynecologic malignancies. Approximately 20% of women with CHM develop either IM or metastatic disease. There appears to be a greater risk of developing GTN in patients with a history of molar pregnancy. The incidence of GTN after spontaneous miscarriage is estimated at 1:15,000, while the incidence after a term pregnancy is 1:150,000. The overall incidence of GTN following all types of pregnancies is estimated at 1:40,000.
They are more frequent in the extremes of reproductive age, the lowest rate occurring between the ages of 25 and 29 years
Data on GTN is not readily available at the National Center for Radiotherapy Department of the Korle-bu teaching hospital as it’s added onto the total gynecological cancers and forms the least seen, two to three cases are seen in a year at the department.

PATHOPHYSIOLOGY

Complete Hydatidiform Mole (CHM) is characterized by clusters of hydropic villi and trophoblastic hyperplasia and atypia. CHM are diploid and have a chromosomal pattern of either 46XX or 46XY. All XX chromosomes are androgenetic, that is, from paternal origin and arise from fertilization of an empty ovum by a haploid sperm that then undergoes duplication. Occasionally, CHM arise from fertilization of an empty ovum by two sperm. Maternally transcribed nuclear genome is lost, although one can identify maternal mitochondrial DNA.
Signs and symptoms
Vaginal bleeding
Anemia
Abdominal swelling
Ovarian cysts
Vomiting
Pre-eclampsia
Hyperthyroidism

Partial Hydatidiform Mole (PHM) shows a variable amount of abnormal villous development and focal trophoblastic hyperplasia in association with identifiable fetal or embryonic tissue. PHM contain both maternal and paternal chromosomes and are triploid, typically XXY, which occurs by fertilization of a normal ovum by two sperm.
Signs and symptoms
Vaginal bleeding
Anemia
Swelling of abdomen
Ovarian cysts
Pre-eclampsia

Invasive Mole (IM) occurs when molar tissue invades the myometrial wall. Deep myometrial invasion can lead to uterine rupture and severe intraperitoneal hemorrhage. IM develops in approximately 15% of patients with CHM and about 5% of patients with PHM.Most IM remain localized to the uterus, but metastases to distant sites have been reported.
Signs and symptoms
Vaginal bleeding
Infection
Abdominal swelling
Vaginal mass
Severe abdominal pain
Vaginal discharge
Pelvic cramps
Fever
Signs and symptoms of distance metastasis
Brain: Headache, vomiting, dizziness, seizures, paralysis
Liver: Abdominal pain, jaundice
Lung: Dry cough, chest pain, and dyspnea

Choriocarcinoma (CCA) consists of invasive, highly vascular, and anaplastic trophoblastic tissue made up of cytotrophoblasts and syncytiotrophoblasts without villi. CCA metastasizes hematogenously and can follow any type of pregnancy, but most commonly develops after CHM. Approximately 50% of cases follow a molar pregnancy, 25% follow a spontaneous or ectopic pregnancy, and 25% follow a term delivery. The most common metastatic site is the lungs, which are involved in over 80% of patients. Vaginal metastases are noted in 30% of patients. Distant sites such as the liver, brain, kidney, gastrointestinal tract, and spleen occur in about 10% of patients and constitute the highest risk of death. Metastatic disease is most commonly encountered in postpartum patients where early diagnosis is frequently delayed.
Signs and symptoms
Vaginal bleeding
Vaginal Infection
Abdominal swelling
Vaginal mass
Positive urine pregnancy test but no fetus on ultrasound
Severe abdominal pain
Vaginal discharge
Pelvic cramps
Fever
Signs and symptoms of distance metastasis
Brain: Headache, vomiting, dizziness, seizures, paralysis
Liver: Abdominal pain, jaundice
Lung: Dry cough, chest pain, and dyspnea

Placental Site Trophoblastic Tumor (PSTT) are derived from intermediate trophoblastic cells. Microscopically these tumors show no chorionic villi and are characterized by a proliferation of cells with oval nuclei and abundant eosinophilic cytoplasm. They are seen more commonly after a nonmolar abortion or term pregnancy, but can occur after a mole. They are slow growing and tend to locally infiltrate the myometrium, at which point they metastasize both via the hematogenous and lymphatic systems. Endocrinologically they differ from CCA in that they secrete placental lactogen in greater amounts than human chorionic gonadotropin (hCG). PSTT are also characterized by high levels of free β-hCG.Therefore, a large tumor burden may be present before the disease is diagnosed. These tumors tend to remain localized in the uterus for long periods before metastasizing to regional lymph nodes or metastatic sites.
Signs and symptoms
Vaginal bleeding
Abdominal swelling

DIAGNOSIS
History/physical, including pelvic examination
Histopathology
Ultrasonography
Urine test for beta hCG
Blood for betaHCG
Chest x-ray
Liver function tests
Ct brain, abdomen
Full blood count
Blood urea electrolytes and creatinine
PET scan

MANAGEMENT OF GESTATIONAL TROPHOBLASTIC DISEASE

INDICATIONS FOR TREATMENT
Following a Molar Pregnancy
The early diagnosis of molar pregnancy with ultrasound has led to changes in the histologic characteristics of CHM without changing the potential for developing persistent disease. Following evacuation the diagnosis of GTN is based on the following: the International Federation of Gynecologists and Obstetricians (FIGO) guidelines:
A plateau in β-hCG levels over at least 3 weeks,
A 10% or greater rise in β-hCG levels for three or more values over at least 2 weeks,
Persistence of β-hCG levels 6 months after molar evacuation, or
Histologic evidence of choriocarcinoma.

Following a Nonmolar Pregnancy
Patients who develop rising hCG titers following a nonmolar pregnancy have CCA until proven otherwise. Serum hCG levels are not routinely performed after nonmolar pregnancies (except in following ectopics), unless the women has had a previous molar pregnancy when it becomes the standard of care because of the increased risk of developing GTN. However, any woman in the reproductive age group who presents with abnormal bleeding or evidence of metastatic disease should undergo hCG screening to rule out choriocarcinoma. At this point a thorough clinical and
Radiologic evaluation of the patient should be carried out to determine the extent of disease. Rapid growth, widespread dissemination, and a high propensity for hemorrhage makes this tumor a medical emergency. Metastases are found in the lungs (80%), vagina (30%), pelvis (20%), brain (10%), and liver (10%) and other sites (less than 5%).

Human Chorionic Gonadotropin Measurement hCG is synthesized by syncytiotrophoblastic cells of the developing placenta. In contrast, the hyperglycosylated hCG (hCG-h) produced by gestational trophoblastic tumors is thought to be produced by cytotrophoblasts. It is a glycoprotein that consists of an α-subunit common to other glycoproteins, and an β-subunit that is hormone specific. Therefore, the measurement of hCG in patients with GTN should be performed by assays that measure the β-subunit only. The levels and serial changes in β-hCG are essential to diagnose and track the treatment and outcome of GTN. After evacuation of a molar pregnancy, β-hCG levels usually disappear in 8 to 10 weeks. Persistence of hCG levels indicate local or metastatic disease. With monitoring of the serum or urinary hCG levels, persistent disease can be detected early and therapy instituted. During treatment hCG tests should be performed weekly in the same laboratory. The β-hCG response to each course of treatment is used as a guide to determine whether to continue treatment with an agent or switch to another.

Phantom Human Chorionic Gonadotropin
False positive hCG tests can occur due to the presence of heterophile antibodies that interfere with the immunoassay. Although a rare occurrence, false positive hCG tests can be confusing to clinicians when attempting to diagnose disorders of pregnancy such as ectopic and GTN. Misinterpretations of false positive tests have led to inappropriate treatment including surgery and chemotherapy based only on the persistently elevated serum β-hCG levels. A false positive hCG result should be suspected if the clinical picture and the laboratory results are discordant, if there is no identifiable antecedent pregnancy, or if patients under treatment with persistent low levels do not respond appropriately. In rare instances, particularly in women approaching menopause, the source of the hCG is the pituitary gland. When a false positive hCG test is suspected, a urinary assay should be performed since heterophile antibodies do not cross the renal tubules.

Pretreatment Evaluation and Staging
Pretreatment Evaluation
Once it is determined that a patient has an elevated and rising hCG level a thorough evaluation is required to determine the extent of disease including blood tests to assess renal and hepatic function, peripheral blood counts, and baseline serum hCG levels. A speculum examination should be performed to identify the presence of vaginal metastases, which may cause sudden heavy vaginal bleeding. Radiologic evaluation should include a pelvic ultrasound, both to look for evidence of retained trophoblastic tissue and to evaluate the pelvis for local spread. Chest imaging is also required as the lungs are the most common site of metastatic disease. Pulmonary metastases can be detected by chest computed tomography (CT) in up to 40% of patients with a negative chest x-ray. However, chest CT is not mandatory, particularly if detection of overt pulmonary metastases will not alter the treatment plans. In the absence of pulmonary and vaginal involvement, brain and liver metastases are rare, and, therefore, we frequently omit further imaging of the brain. However, magnetic resonance imaging (MRI) of the brain with contrast is mandatory in women with metastatic disease and in all patients with a pathologic diagnosis of choriocarcinoma. It is usually not necessary to obtain histologic confirmation of the diagnosis because of the highly vascular nature of the tumor and the risk of hemorrhage. Positon emission tomography (PET) scanning is sometimes indicated to identify sites of active disease, and confirm sites of active disease found on conventional imaging.

Staging
Table1.1 summarizes the staging of GTN, which follows the FIGO guidelines. In addition to anatomic staging, a prognostic scoring system has been developed to help determine the appropriate chemotherapy regimen that affords the patient optimal management by reducing the risk of developing resistance to chemotherapy. Patients with a score of <7 are considered at low risk of developing resistance and generally achieve remission with single-agent therapy. Patients with scores greater than 7 are at risk of developing resistance to single-agent therapy and should be treated primarily with multiple-agent regimens. All patients with stage IV disease are considered high risk.

Treatment
Chemotherapy is highly effective in most patients with GTN. Cure rates of 100% in low-risk disease and 80% to 90% in high-risk cases are reported from a number of treatment centers. Despite the success of chemotherapy, the role of other modalities such as surgery and radiation therapy should not be overlooked. The best results are achieved when patients are treated under the auspices of a multidisciplinary team.

Low-Risk Disease
Methotrexate (MTX) and Actinomycin-D (ACTD), used sequentially, are the most widely used single agents for low-risk GTN. A number of different regimens are currently in use (Table2.2). MTX with leucovorin rescue is the initial choice at our center because it has the least toxicity. After completion of the first course hCG levels should be followed weekly. A second course, which is required in 10% to 30% of patients, should be administered if the serum hCG level does not fall by 1 log (tenfold) within 18 days, or if the hCG test plateaus for more than 2 weeks. ACTD is used when the patient develops resistance to MTX or if there is evidence of abnormal liver function tests, since MTX is hepatotoxic. Remission is achieved when the hCG level becomes undetectable for 3 consecutive weeks. At this point the patient should be followed with monthly hCG levels for 12 months. During this time effective contraception is mandatory. Pregnancy may be undertaken after 1 year of normal hCG titers. Hysterectomy with ovarian preservation should also be considered as primary therapy in stage I patients who have completed their family. Table 1.1 International Federation of Gynecologists and Obstetricians Staging of Gestational Trophoblastic Neoplasia and World Health Organization Scoring System Based on Prognostic Factors | Stage I | Disease confined to the uterus | Stage II | GTN extends outside of the uterus, but is limited to the genital structures | Stage III | GTN extends to the lungs, with or without genital tract involvement | Stage IV | All other metastatic sites | A risk factor score (see below) should be assigned to each patient. | The stage should be followed by the sum of the risk factor score (e.g., II:4) | Prognostic Factors | Score | | 0 | 1 | 2 | 4 | Age in years | <40 | >40 | - | - | Antecedent pregnancy | Mole | Abortion | Term | - | Interval (months)a | <4 | 4-7 | 7-10 | >13 | Pretreatment serum hCG (mIU/mL) | 1,000 | 1,00-10,000 | 10,000-100,000 | >100,000 | Largest tumor, including uterine | - | 3-5 cm | >5 cm | - | Site of Metastases | Lung | Spleen, Kidney | GI Tract | Brain, Liver | Number of metastases | - | 1-4 | 5>8 | >8 | Prior failed chemotherapy | - | - | Single drug | 2 or more drugs | GTN, gestational trophoblastic neoplasms; hCG, human chorionic gonadotropin; GI, gastrointestinal. aInterval time (in months) between end of antecedent pregnancy and start of chemotherapy. | | |

High-Risk Disease
Multiple-agent chemotherapy should be used primarily in all patients with prognostic FIGO scores of 7 or greater. Table 3.3 summarizes the most widely used regimen including etoposide, MTX, ACTD, cyclophosphamide and vincristine (EMA/CO) with cure rates ranging from 70% to 90%. A similar regimen containing cisplatin (EMA/EP) can be utilized as salvage therapy for patients who develop resistance to EMA/CO. Treatment should be dose-intensive every 2 to 3 weeks, toxicity permitting. The use of recombinant hematopoietic growth factors such as granulocyte colony stimulating factor (G-CSF) and, when absolutely necessary, platelet transfusions, are important to maintain adequate dose-intensity and to prevent unnecessary dose reduction. It is recommended that three courses of the remission regimen be administered after the patient achieves remission. Death occurs in patients who present with widespread disease frequently due to delayed diagnosis, from life-threatening complications such as respiratory failure and central nervous system hemorrhage, from the development of drug resistance, or from inadequate treatment. The use of radiation therapy in patients with GTN is limited to the treatment of brain metastases. The use of whole head or localized radiation therapy in conjunction with chemotherapy can prevent a life-threatening or debilitating hemorrhage and should be initiated promptly. Solitary superficial cerebral lesions are best treated surgically. Surgery should also be considered as an important adjunct in the management of high-risk patients.

Hysterectomy in patients with heavy bleeding, large bulky intrauterine disease, or in the presence of significant pelvic sepsis should be performed regardless of the patient's parity. Removal of tumor masses in the bowel should also be performed because of the risk of hemorrhage. Unresponsive masses in the liver and kidneys should be removed, although embolization has been used with some success in controlling liver metastases. Splenectomy should always be performed when that organ is involved. After completion of chemotherapy patients with high-risk disease should be followed for 24 months before pregnancy is attempted. Table 2.2 Single-Agent Regimens for Low-Risk Gestational Trophoblastic Neoplasms | MTX
MTX 0.5 mg/kg IV or IM daily for 5 days
Pulse MTX weekly 50 mg/M2 IM weekly
MTX/FA
MTX 1 mg/kg IM or IV on days 1, 3, 5, 7
FA 0.1 mg/kg PO on days 2, 4, 6, 8
HIGH DOSE MTX/FA
MTX 100 mg/M2 IV bolus
MTX 200 mg/M2 12 h infusion
FA 15 mg q 12 h in 4 doses IM or PO beginning 24 h after starting MTX
ACTINOMYCIN REGIMENS
ACTD 12 µg/kg IV push daily for 5 days
ACTD 1.25 mg/M2 IV push q 2 weeks | MTX, methotrexate; IV, intravenous; IM, intramuscular; PO, by mouth; FA, folinic acid (calcium leucovorin); ACTD, actinomycin-D. | | Table 3.3 Protocols for EMA/CO and EMA/EP Regimens | PROTOCOL FOR EMA/CO REGIMEN | Day | Drug | Dose | 1 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | MTX | 100 mg/M2 IV push
200 mg/M2 by infusion over 12 h | 2 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | Folinic acid | 15 mg q 12 h — 4 doses IM or PO beginning 24 h after starting MTX | 8 | Cyclophosphamide | 600 mg/M2 by infusion in saline over 30 min | | Vincristine | 1.0 mg/M2 IV push | PROTOCOL FOR EMA/EP REGIMEN | Day | Drug | Dose | 1 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | MTX | 100 mg/M2 IV push
200 mg/M2 by infusion over 12 h | 2 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | Folinic acid | 15 mg q 12 h — 4 doses IM or PO beginning 24 h after starting MTX | 8 | Cisplatin | 60 mg/M2 with prehydration | | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | EMA/CO, etoposide, methotrexate, and dactinomycin alternating with cyclophosphamide and vincristine; EMA/EP, etoposide/methotrexate/actinomycin-D/etoposide/cisplatin; ACTD, actinomycin-D; IV intravenous; IM, intramuscular; PO, by mouth; MTX, methotrexate. | |

Placental Site Trophoblastic Tumors
The primary treatment of patients with PSTT is surgical because of their relative resistance to chemotherapy. Because the disease infiltrates deeply into the myometrium, lymph node sampling is recommended at the time of hysterectomy. Excellent results have been obtained with EMA/EP in patients with lymphatic spread or extrauterine disease.

NURSING MANAGEMENT
Continuously monitor blood pressure, and quantity of blood loss and to notify the attending physician immediately should there be deviations Teach deep breathing techniques to alleviate the pain. Use diversional activities if possible. Check for abdominal pain, assess the abdominal area for signs of internal bleeding (e.g. Cullen’s sign).
If nausea and vomiting are present, ensure patient do not aspirate it.
After Manual Vaginal Aspiration (MVA), patient is at risk for infection. Ensure the client have good perineal hygiene.
Administer all medications as ordered
This is very hard for the patient to accept, provide emotional support. Explain to the patient that it is not her fault this happened.
Discuss the family planning methods available for her. Reiterate the importance of monitoring the hCG level and follow-ups.
For women on high-risk chemotherapy, the intensity of treatment can be debilitating. Alopecia, fatigue and nausea impact significantly on these women who are young and often have small children to care for. It is vital that nurses who care for these patients have knowledge of the disease. It is important to emphasize that despite the short-term difficulties, the long-term outlook is excellent. At the end of treatment, these women will need encouragement to re-establish their normal lifestyle and relationships with their families.

SUBSEQUENT PREGNANCY
Patients treated successfully with chemotherapy can expect to experience normal reproductive function. A total of 2,657 subsequent pregnancies have been reported, which resulted in 77% full-term deliveries, 5% premature births, 1% stillbirths, and 14% spontaneous miscarriages. Despite the use of potentially teratogenic drugs, no increase in congenital malformations have been reported. Furthermore, Woolas et al. noted that there was no difference in either the conception rate or pregnancy outcome in patients treated with single or multiple agent protocols. And the fertility rate was essentially normal as well.

PSYCHOSOCIAL ISSUES
Women who develop GTN can experience significant mood disturbance, marital and sexual problems, and concerns over future fertility. Because GTN is a consequence of pregnancy, patients and their partners must confront the loss of a pregnancy at the same time they face concerns regarding malignancy. Patients can experience clinically significant levels of anxiety, fatigue, anger, confusion, sexual problems, and concern for future pregnancy that last for protracted periods of time. Patients with metastatic disease, in particular, are at risk of psychological disturbances and need assessments and interventions both during treatment and after remission is attained.

PROGNOSIS
All patients in the low- and middle-risk groups can be expected to be cured of their GTN since the introduction of etoposide (Bagshawe et al., 1986; Newlands et al., 1986).for high risk patients, survival has progressively improved and is currently 86%(Bower et al., 1997).The diagnosis of choriocarcinoma is often not suspected until the disease is often advandced.as a result, some deaths occur before chemotherapy has a chance to be effective. However patients in the high risk group still die from drug resistant disease and there remains a need to develop novel therapeutic approaches.

CHAPTER TWO

COMPREHENSIVE HOLISTIC ASSESSMENT OF PATIENT/FAMILY Assessment is a key component of nursing practice, required for planning and provision of patient and family centered care. The advanced practice nurse assess,plans,implements and evaluates nursing care in collaboration with individuals and the multidisciplinary health care team so as to achieve goals and healthcare outcomes. It involves the gathering of information about patient’s physical, physiological, psychological, sociological and spiritual status. This information is obtained from the patient/family and significant others. Various assessment tools (Gordon’s functional health patterns, Epworth sleepiness scale, perceived stress scale and twenty four hour diet recall) were employed in the gathering of information.
The purpose of this stage is to identify the patient’s problems. These problems are expressed as either actual or potential and based on this, a nursing diagnosis is established.
Both objective and subjective data were used in this study. The assessment of the client involved patient’s medical and personal history including review of systems, physical examination, diagnostic evaluations, nutritional assessment, psychosocial assessment, developmental assessment, spiritual assessment and quality of life and indicators. These have been outlined as follows:

ADMISSION OF CLIENT The Gynecology specialist team of the korle-bu teaching hospital approached the oncology department to discuss the diagnosis of client with the oncology specialist team, the definitive diagnosis of Gestational Trophoblastic Neoplasm, (Choriocarcinoma type) was arrived at and the Oncology specialist team decided to take over the management of client. Client walked in with her mother to the national center for radiotherapy and nuclear medicine department of the Korle-bu teaching hospital, Accra, Ghana on the 12th January 2016 at 12:30pm looking anxious. She was registered and her particulars were taken at the Registry Unit of the department. She was directed to the cashier to make payment of registration and consultation as the national health insurance does not have coverage of the oncology unit. After payment, she was directed to the Nurses Station at the out-patient department, she was warmly received and counselled to relieve her anxiety. Her vital signs were checked and recorded as follows;

Blood pressure -134/81mmhg
Pulse – 1120bpm
Respiration -18cpm
Temperature – 36.2 c
Weight – 60.6kg
Height – 159.4cm
Body surface area -1.68m2
Performance status -ECOG 0 (Eastern Corporative Oncology Group Scale)
She was then directed to consulting room where she was warmly received by a Medical Officer. Who clerked her and made the final diagnosis of Gestational Trophoblastic Neoplasm (Choriocarcinoma Type) StageII7 High Risk The Consultant Radiation Oncologist went over the Medical Officers’ notes and agreed with the final diagnosis. She prescribed the treatment plan, that is;

1. Client to have the following laboratory investigations conducted on her;
-full blood count
-blood urea and creatinine
-chest x-ray
-beta hCG
-abdominal and pelvic scan
-urine routine exam and
-liver function tests

2. Client to have the following prescribed cytotoxic medications if all laboratory results were within normal range;
Day 1;
Methotrexate160mg bolus then 320mg over 12 hours
Actinomycin D 0.8mg
Etoposide 160mg
Granisetrone 1mg
Dexamethasone 12mg
IVF 1.5liters

Day 2:
Leucovorin tablets15mg bd first dose 24 hr. after 1st dose of Methotrexate x2days
Etoposide 160 mg
Actinomycin D 0.8mg
IVF 1liter
Granisetrone 1mg
Dexamethasone 12mg

Day 8 Vincristine1.6mg Cyclophosphamide 960mg
Granisetrone 1mg
Dexamethasone 12mg
IVF 1liter Dexamethasone, Granisetrone, Motillium, Lorazepam

3. Client to have her full blood count, blood urea electrolyte and creatinine as well as liver function test monitored after each cycle of chemotherapy

4. Client to have beta hCG level monitored after each cycle of chemotherapy

Client signed a consent for commencement of chemotherapy and was directed to the nurse’s station of the chemotherapy suite for counselling, education, billing and chemotherapy administration.
This is where I met Miss R.B., I was intrigued by the interesting, rare and curable condition she presented. I educated her about her condition that it was no fault of her to get the diagnosis and allayed her anxiety that her condition was curable. I went on further to counsel her on how the treatment regimen is given, the days she will be having chemotherapy and laboratory investigations to be carried out before and after each chemotherapy session. I calculated her bill for each cycle of chemotherapy which was ghc 900 every 2weeks for about eight cycles and asked her plans she had in settling her bill. She stated that her boyfriend will be able to cater for the bills.
She was relieved of her anxiety as she voiced out to that effect, I assured her to come to me or any registered nurse on duty with questions bothering her.
I expressed my interest in choosing her case for my case study for academic purpose and that her identity will be protected, and she will receive individualized nursing care from me. She readily accepted and gave verbal consent for me to use her as a case study.
Miss R.B visited the department on following day 13th January 2016 to present her laboratory results and commencement of chemotherapy. The comprehensive nursing care rendered to client is documented as follows:

COMPREHENSIVE NURSING CARE RENDERED TO MISS R. B

“Nursing knowledge is the inclusive total of the philosophies, theories, research, and practice wisdom of the discipline. As a professional discipline this knowledge is important for guiding and practice.” Smith & Lier (2008).
Virginia Henderson (1955) defined Nursing as “The unique function of the nurse is to assist the individual, sick or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will and knowledge.”
The nursing profession has evolved greatly over time, moving from dependence upon total medical direction and providing basic care into an independent practice modality with its own nursing theory practice, nursing models, and distinct nursing interventions. Although the role of the Nurse has expanded in modern times, focus on the four paradigms on which nursing has been built hasn’t been lost, these are; Person, Environment, Health and Nursing.
Patricia Benner’s “Novice to expert theory” describes five (5) stages of skill acquisition in Nursing Practice; Novice, Advanced beginner, Competent, Proficient and Expert. Through structured clinical and didactic learning, I have gained expert clinical nursing skills of which I render comprehensive evidence based nursing care to clients.
From the first encounter I had with Miss R.B, I started rendering evidence-based nursing care to her and her family which led to quick recovery from her disease trajectory. The nursing care I render to Miss R.B is inspired by Florence Nightingale’s legacy of caring which focuses on “nursing and the patient environment relationship”,; Faye G. Abdellah’s typology of 21 nursing problems, which looks at “patients problems determine nursing care”; and Virginia Henderson’s “patient require help towards achieving independence.”
Health history is a holistic assessment of all factors affecting a client’s health status, including information about social, cultural, familial, and economic aspects of the client’s life as well as any other component of the clients lifestyle that affect health and well-being. The health history is designed to assess the effects of health care deviations on the client and the family to evaluate teaching needs, and to serve as the basis of an individualized plan for addressing wellness
Nursing history encompasses a comprehensive set of information about a client’s medical history, including the history of the present illness, as well as her psychosocial, nutritional, developmental and spiritual history; used as the basis for nursing diagnosis and development of a care plan. History taking is the first step in nursing care and valuable information is obtained.

PATIENT’S MEDICAL AND PERSONAL HISTORY INCLUDING REVIEW OF THE SYSTEM.
Patient particulars
Miss. R.B. is a 28 year old young woman born on the 9th of August, 1987. She hails from krobo-Odumasi in the Eastern Region of Ghana and resides in Somanya. She speaks English, Twi, Ga and Krobo. She is a first year student nurse at the Nurses and Midwifery School in Accra, Ghana. She was first seen at the National Center for Radiotherapy and Nuclear Medicine unit of the Korle-bu teaching Hospital on 12th January 2016. She states Miss W.B. her sister as her next of kin

Presenting complaints: 3 months history of bleeding per vagina

History of presenting complaints;
She was seen by the Gynecology team of the Korle-bu Teaching Hospital with a history of 3 months menorrhagia. Prior to presentation, she had seen a Traditional birth Attendant (TBA) for 2months amenorrhea of undesired pregnancy, for which herbal medications were administered to terminate the pregnancy. Subsequent bleeding per vagina did not subside and so she presented to Volta River Authority hospital. A diagnosis of incomplete abortion was made and Manual vacuum aspiration (MVA) was perfomed.Bleeding PV persisted and a second MVA was done, persisted PV bleeding prompted the referral to the Korle-bu teaching hospital where an explorative laparotomy was done at patients’ request. Pathology reported a Gestational Trophoblast Neoplasm (Choriocarcinoma type) and she was subsequently referred to the oncology unit for further management
On direct questioning, she stated that she was bleeding, she denied weight loss or cough, she had no symptoms of raised intracranial pressure i.e. headache, nausea, vomiting, double vision
General health; client states she is generally well except she feels pain in the lower abdomen of which she scores 6/10 on the numeric pain scale
Respiratory system; Normal
Cardiovascular system; Normal
Alimentary system; Normal
Urinary system; Normal
Nervous system; Normal
Genital system; Normal
Locomotive system; Normal
Past medical and surgical history; According to Miss. R.B there is no past medical history which is of any significance. She has never been admitted to a hospital and no surgery has been performed on her. She occasionally go to the pharmacy shop to buy over the counter drugs (Anti-Malarias and Paracetamol) if she thinks it’s a minor illness.
Past gynecological history; Menarche-14yrs,she has a regular 28day menstrual cycle Last menstrual period-4th May 2015, Nulliparous with three previous pregnancies, 3 induced abortions.
Drug history; not on any routine medication until she consulted a TBA who administered Herbal medications which she took for a month but has since stopped.

Allergies: No known allergies

Family history; No known family history cancers, this statement was confirmed by her mother. Neither is there any family history of diabetes, hypertension, heart disease, epilepsy or mental illness.

Social history; lives at Somanya in a single room rented apartment. She is the first of seven siblings of her parents. She comes from a low income family, her father is an electrical gadgets repairer and her mother is a food vendor .she is not married but has boyfriend who caters for financial needs, has had two previous sexual partners.Coitarche was at 16years. She is a first year student at the Nurses and Midwifery Training School in Korle-bu, she does not smoke nor take alcohol.

Physical examination;
Head to toe physical examination revealed, Young lady, who looked well, with performance status ECOG 0. She was not pale, jaundiced or cyanosed. Afebrile, hydration was adequate Weight-60.5kg Height159.4cm Body surface area- 1.68m2

Skin: Uniform color with warm temperature, dry and smooth. No scars and hairs are evenly distributed. No pallor, pigmentation, cyanosis and cutaneous eruptions

Hands: neatly trimmed nails, no pitting or clubbing of nails

Head and Face: The skull is proportionate to body size, no tenderness. Face is symmetrical with symmetrical facial movement. Eyes: symmetrical, pupil is black in color and equal in size.

Nose: septum is midline, mucosa is pale; both patent with dry mucous.

Mouth: the lips are pale, symmetrical, pale mucosa, tongue is in midline.

Neck: Had a normal range of motion of neck with no stiffness or pain. No distended neck veins, lymphadenopathy, scars or abnormalities observed.

Breast and Axilla: No masses and tenderness upon palpation

Legs: no peripheral lymphadenopathy, and no pedal edema.

Cardiovascular system; Pulse rate 120bpm, Blood pressure 134/81, Heart sounds 1&2 present and normal, no murmurs

Respiratory system; No respiratory distress, breath sounds were vesicular and air entry was adequate. There were no added sounds

Abdominal: on inspection Abdomen is mildly distended and moves with respiration, she had a well healed pfannenstiel incision scar, there is a palpable 24week cyesis looking mass arising from the pelvis. Liver, spleen and kidneys not palpable there was tenderness and guarding in the hypogastric, left and right iliac regions, there was no rebound tenderness.

Gynecological examination: Normal vulva, no vault mass on speculum examination, cervical os dilated and bleeding pv,vaginal mucosa smooth, bloody discharge on examining finger on digital examination

Rectal examination; Normal, no palpable lesions

Musculoskeletal; Normal

Central Nervous System; Normal

Diagnostic evaluation
This is any kind of medical test performed to aid in the diagnosis or detection of disease, injury or any other medical condition. For example, such a test may be used to confirm that a person is free from disease, or to fully diagnose a disease, including to sub-classify it regarding severity and susceptibility to treatment. The under listed laboratory and radiologic tests were requested and done for Miss R.B.
Full blood count-12.og/dl
Histopathology- confirmed gestational trophoblastic disease of choriocarcinoma type
Blood urea electrolytes and creatinine - NAD
Liver function tests-NAD
Chest x-ray- NAD
Beta hCG – 484,136mu/dl
Urine routine examination-NAD
Abdominal and pelvic ultrasonography-NAD

NUTRITIONAL ASSESSMENT
This is an in-depth evaluation of both objective and subjective data related to an individual’s food and nutrient intake, lifestyle and medical history. Once data on an individual is collected and organized, the practitioner can assess and evaluate the nutritional status of that individual. The assessment leads to a plan of care or intervention designed to help the individual either maintain the assessed status or attain a healthier status.
Collecting, integrating and analyzing nutrition-related data, including food-drug interactions, cultural, religious and ethnic preferences, age related nutrition issues and the need for diet counselling
Miss R.B’s treatment plan have direct correlation with her nutritional status, hence a nutritional assessment was done on her to counsel her on appropriate nutrient intake for her body to physiologically adjust to the cytotoxics which will be administered to her which has the potential of reducing her blood values.
Miss R.B. normally takes her breakfast of porridge, chocolate drink or cereal with milk. She is not a fun of snacks. She takes meals such as banku and palm nut soup, fufu and palm nut soup, rice and stew or ampesi and stew for lunch and super. Even though she usually takes balanced meals, she is moderately overweight (BMI 25.3) because she consumes carbohydrate and fats in excess. Her meals lacks adequate amounts of fruits and vegetables. She was educated on the need to increase the consumption of iron rich foods such as red meat, beans, dark green leafy vegetables such as kontomire and fruits to maintain appropriate hemoglobin levels which is a good indicator of chemotherapy administration.
She doesn’t drink alcohol but take moderate quantities of carbonated soft drinks. A 24-hour dietary recall of one of her normal days was recorded and has been attached.

PSYCHOSOCIAL ASSESSMENT
Miss. R.B is the 1st of eight siblings of her parents. Her second sibling is a hairdresser, the third sibling is in apprenticeship to learn dressmaking, the fourth born, a male helps their father in the electrical repairing shop, the fifth and sixth siblings have completed basic school and does petty trading, the seventh and eight born are in junior high and primary school respectively. She states that she helps her parent to cater for her siblings, it is an important role for her, and it has never been easy dealing with problems of her family.
She is assertive and maintains high ethical values as much as she can.She gets along well with her colleagues and family members and contributes well in discussions. She watches television to relax after super. She loves reading her bible and praying. She sometimes goes for walks as a form of exercise. She states that she goes to bed at 9pm and wakes up at 6:30am but she sometimes find it difficult staying asleep so she uses sleep aids (tab diazepam 10mg prn). She also attends weddings, parties and funerals as and when necessary. She is not married but have a boyfriend who caters for her needs. Her boyfriend is an accountant in one of the senior secondary schools in the country. She lives alone in a one room rented accommodation in Somanya. She is a Christian and attends church every Sunday. She scored 20 on the perceived stress scale which translates that she is moderately stressed.
Miss R.B views her diagnosis as a normal physiological mishap and believes strongly that with the prescribed treatment plan she will fully recover and return to her normal social functional state. She also believes she will in the near future get married and have her children.

DEVELOPMENTAL ASSESSMENT Miss. R. B. was born through spontaneous delivery at Somanya health center with the assistance of a trained midwife. She grew up normally and went through the developmental milestones at all age levels successfully without significant problems. She said her mother told her she was given all the needed immunizations at the right schedule. She completed her primary and Junior Secondary education at Somanya Methodist Basic schools where she sat and wrote the Basic Education Certificate Examinations and passed successfully, she had her secondary education at Modern Secondary school in Kpone, Somanya. After successfully passing the Secondary School Certificate Examination, she gained admission into the nurses and midwifery training school in Korle-bu, Accra.

SPIRITUAL ASSESSMENT
Miss R.B. said her parents are very religious and dedicated Catholics and so she was born into the Catholic faith. She was baptized into the Catholic Church at a tender age of 6months, received her first Holy Communion at 10years and confirmed at age 15.As he grew up into an adult, she changed her faith and has been attending the New Testament Baptist church for the past five years. She believes strongly in God the Father, God the Son and God the Holy Spirit. She is an usher at her church and also sings in the church choir. She says she loves reading her bible and prays first thing in the morning before she steps out of her room and last thing before she goes to bed. She said she believed in the healing power of God and that she believed she will recover fully after treatment so that she would go back to her normal daily activities.

QUALITY OF LIFE ASSESSMENT AND INDICATORS
Miss R. B. has been a very healthy person who hardly falls sick. She is physically healthy and moderately mentally stressed (she scored 20 on the perceived stress scale). She is very active and goes about her normal daily activities without assistance. She is able to take good care of herself. She doesn’t experience fatigue and has moderate abdominal pain due to her diagnosis. She is emotionally stable. She is able to attend social activities and she is able to play her social roles. She feels healthy and content with life .She has a boyfriend who loves her and caters for her needs, also her parents and siblings’ loves and care about her welfare. She expresses positive emotions and resillence.She is looking forward to completing nursing school and beginning her career as a Registered Nurse. Her favorite food is fufu and palm nut soup.

COLLABORATIVE NURSING CARE.
The administration of chemotherapy is primarily the responsibility of the Nurse in consultation with the prescribing Oncologist. The nurse, as an important member of the multidisciplinary team, can implement the agreed plan; assessing and adjusting treatment as it progresses. However, it is vital that clients remain in contact with their oncologists at scheduled points in their treatment journey
The term chemotherapy which is sometimes shortened as chemo refers to the use of medications to treat cancer. In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions and reproduction. Chemotherapy is used primarily to treat systemic disease rather than lesions that are localized and amenable to surgery or radiation. Chemotherapy may be combined with surgery or radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively, or to treat some forms of leukemia. The goals of chemotherapy (cure, control, palliation) must be realistic because they will define the medications to be used and the aggressiveness of the treatment plan.
Chemotherapy nurses are respected for their drug knowledge, information-giving, communication skills, and assessment skills. This paper offers a comprehensive oncological nursing assessment of chemotherapy administered to Miss R.B., including the process of counselling, key information needs, and consent. It discusses in detail the common side effects of treatment and their management.
Chemotherapy is administered to Miss R.B as prescribed by the consultant oncologist. She had chemo on Days 1, 2 and 8 and this formed one cycle, this cycle was repeated every two weeks till she went into remission
I, together with the team of nurses at the National Center for Radiotherapy and Nuclear Medicine Department of the Korle-bu teaching Hospital, administered chemotherapy to Miss R.B. and is documented as follows;

Materials/ Equipment Needed
Chemotherapy drug Needles IV Set Alcohol wipe Syringe Adhesive plaster Protective equipment includes: Disposable surgical gloves Protective eye goggles Long sleeve gown

Procedure:
1. All chemotherapeutic drugs are prepared according to package insert under aseptic techniques.
2. Personal protective equipment includes disposable surgical gloves, long sleeves gown and eye goggles to minimize exposure.
3. Hands are washed before and after drug handling.
4. Access to drug preparation area is limited
5. Labelled drug spill kit is kept near preparation area.
6. Gloves are downed before drug handling.
7. Drug vials/ ampoules are opened away from body.
8. Absorbent pad is placed on work surface.
9. Alcohol wipe is wrapped around neck of ampoule before opening.
10. Tip of needle is covered with sterilize gauge when expelling air from syringe.
11. All chemotherapeutic drugs are labelled.
13. Any spill is immediately cleaned up.

Drug administration
Intravenous (IV) – It is the most common route of administration of cancer chemotherapy. May be given through central venous catheters or peripheral access. Absorption is more reliable. This route is required for administration of vesicants and it also reduces the need of repeated injection. Because the IV provides direct access to the circulatory system, the potential for infection and life threatening sepsis is a serious complication of IV chemotherapy. Miss R.B’s regimen required IV and oral administrations.

Prior to administration The importance of the procedure is explained to the patient. Privacy is provided. Client is taught how the procedure is done. A number of laboratory investigations are done before chemotherapy is started; these normally include
-Full blood count
-Blood urea and creatinine
-Liver function test Review
The chemotherapy prescriptions which should have
-Name of anti-neoplastic agent.
-Dosage
-Route of administration
-Date and time that each agent to be administered.
-Client is accurately identified
-Medications to be administered in conjunction with the chemotherapy e.g. antiemetic etc.
Client’s condition is assessed including;
-Most recent report of blood counts including hemoglobin, hematocrit, white blood cells and Platelets -Presence of any existing condition such as infection, severe stomatitis, decreased deep tendon reflexes, or bleeding which could contraindicate chemotherapy. -Physical status -Level of anxiety -Psychological status -Body surface area is recalculated Because Miss R.B’s chemotherapy treatment takes a long time (over 24 hours on day 1), she is advised to prepare for it by wearing comfortable clothes. Bringing a book to read or a tape to listen to ease the stress of receiving chemotherapy. She mostly came along with her mother or sister to provide support and company Miss R.B’s chemotherapy regimen have high emetogenic potential therefore she was educated on ways to prepare for chemotherapy and help lessen nausea which are;
-to regularly eat nutritious foods and drink lots of fluids. -to eat and drink normally until about two hours before chemotherapy. -to eat high carbohydrate, low-fat foods and avoid spicy foods.

During the procedure
Gloves are used when handling chemotherapy drugs.
Disposable long-sleeve gowns when preparing and administering chemotherapy are worn. Luer-lock fittings on IV tubing are used in delivering chemotherapy.
The 10 Rights of medication are observed
Client is monitored for symptoms of anaphylactic reaction such as urticaria, pruritus, phlebitis, sensation of lump in the throat, shortness of breath.

After the procedure
All equipment used in chemotherapy preparation and administration are disposed of in designated containers. All chemotherapy wastes are disposed as hazardous materials.
Client and family are taught to report the following:
-excessive fluid loss or gain,
-change in level of consciousness,
-increased weakness or ataxia,
-paresthesia,
-seizures,
-persistent headache,
-muscle cramps or twitching,
-nausea and vomiting
-diarrhea.

Client is taught -to increase fluid intake between 2500 to 3000 ml/day to aid excretion of drug metabolites. - To carry out requested post laboratory investigations on stated date Signs of renal insufficiency is monitored. - elevated urine specific gravity - Abnormal electrolyte values - Insufficient urine output (< 30 ml/hour) - Elevated BP, BUN, Serum Creatinine

Modern delivery of cancer services in Ghana is guided by clear Ministry of Health (MOH) policy. The past 19 years have seen a marked change in cancer services with the aim of improving outcomes to match those seen in Europe and the USA. Much of this policy direction call for specialization and a drive to develop services across professional boundaries rather than remaining in professional silos. Amongst other possibilities, this shift has created opportunities for nurses to be fully involved in the assessment and management of patients undergoing chemotherapy. However, implementation has been slow. The role of the chemotherapy nurse is much respected, and there is a wealth of knowledge within this group about side effects and their management.
Miss R.B undergoes clinical review before each cycle of chemotherapy, the purpose is to identify any toxicities experienced previously, assess her fitness to continue, and implement any planned changes in the treatment pathway. As a nurse undertaking this review in consultation with the oncologist, I possess the necessary knowledge about the specific chemotherapy Miss R.B. is receiving and its intent.
Chemotherapy has significant and predictable toxicities; the most serious of which are likely to develop while client is at home between treatment cycles. Usually these resolve with time. In the clinic, the nursing assessment establishes the presence of toxicities and determines the need for intervention. If client is fit, chemotherapy can continue. Importantly, I incorporated skilled communication to enable me obtain key information from the client regarding how she is feeling and not base my assessment only on observation . Advanced history-taking skills are undertaken because clients are often reluctant to describe how bad the side effects actually have been, for fear of their chemotherapy being stopped.
Miss R.B was educated on contraception options to prevent pregnancy whilst on treatment because the fetus will be exposed to the teratogenic effects of the cytotoxics been administered which will warrant an abortion should she get pregnant.
She was told condom (male/female) was the best option now as she was having chemotherapy because cytotoxics are excreted in body fluids of which she could expose her boyfriend to. Additionally, she was directed to the family planning department of the hospital if she felt the need to further explore the available options.
As well as physical assessment, psychological assessment is done as it has impact on diagnosis of cancer and its treatment. This includes how well client is coping with the impact of receiving chemotherapy on day-to-day life. Uncertainty regarding the outcomes of treatment can also add to distress by client and their families, therefore, client and her family are incessantly reassured.
Miss R.B is counselled that, chemotherapy could possibly cause permanent infertility and that she should consider adoption should she face such problems in the near future. Nevertheless she was encouraged to have hope as it’s been documented in the literature review that most women have successfully had children after treatment of Choriocarcinoma.
The presence of physical symptoms can often have a detrimental effect on an individual’s psychological well-being. Miss R.B experienced change in body image due to weight gain, hair loss, nail changes and potential for fatigue, which can confound the problems of psychological distress. Client’s perception of self is challenged, and a transition to a new self is needed. This I educated her that she could use wigs to camouflage the alopecia. She accepted and subsequently appeared in different wig styles and was looking cheerful. Miss R.B’s well-being assessments are undertaken at regular intervals because this is an important aspect of quality care. She adjusted well though she was moderately stressed, she therefore didn’t need referral to a psychologist General well-being of Miss R.B is recorded using performance status (ECOG) and holistic needs assessment tools, and toxicities are recorded using common toxicity criteria. This toxicity tool is embedded within clinical trials protocols, and so ensures consistency of practice.
The ongoing assessment of Miss R.B. is undertaken in a variety of setting and ways, varying from the more formal clinic setting in a hospital and by phone.
To enable Miss R.B. to make decisions regarding possible treatment options, appropriate up-to-date information regarding the aim of the treatment being recommended, possible side effects and how to manage them, the expected outcomes of the treatment, and also the outcome of not proceeding with treatment was given. Additionally, she was given information on cancer support groups (currently not available for gynecological cancers) she was therefore referred to reach for recovery Ghana, a breast cancer support group for socialization and support. She was also informed about financial support services such as UT bank and Indian Women’s Association and other relevant programs of which she could benefit from. Much time was invested to rehearse what Miss R.B. should do in the event of specific side effects, e.g., neutropenic sepsis. I educated client that, should she notice any sign of fever she should avoid any antipyretic, uncooked foods including fresh fruits and vegetables, pets, crowd and people suspected to be having colds or flu. She should call the telephone number I provided her with, walk into the clinic irrespective if she has been booked or not during working hours i.e. Mondays- Fridays from 8am to 5pm. However she should walk into a nearby clinic and inform the attending physician that she is receiving chemotherapy and has a fever during the night, weekends or holidays. Ensuring that client has understood the information provided, particularly in relation to oncological emergencies, is vitally important.

CHAPTER THREE

ANALYSIS OF DATA
Analysis of data is the second stage of the nursing process. It involves the making of conclusion of data collected from patient/family. During the analysis, data is compared with standards to determine any deviation from the normal physiological functions of the body. The collected and analyzed data help to arrive at nursing diagnoses and to draw the patient’s care plan. The components of this phase include:
Comparison of data with standards.
Patient/family’s strength.
Health problems.
Nursing diagnoses.

COMPARISON OF DATA WITH STANDARDS

SIGNS AND SYMPTOMS
The signs and symptoms exhibited by the patient in relation to those cited in the literature review are shown in the table below: SIGNS AND SYMPTOMS IN LITERATURE REVIEW | SIGNS AND SYMPTOMS EXHIBITED BY MISS.R.B | Vaginal bleeding | Present | Vaginal Infection | Absent | Abdominal swelling | Present | Vaginal mass | Absent | Positive urine pregnancy test but no fetus on Ultrasound | Present | Anemia | Moderate Anemia | Severe abdominal pain | Moderate Abdominal Pain- 6/10 | Vaginal discharge | Present | Pelvic cramps | Present | Fever | Absent | Signs and symptoms of distance metastasisBrain: Headache, vomiting, dizziness, seizures, paralysis | Absent | Liver: Abdominal pain, jaundice | Absent | Lung: Dry cough, chest pain, and dyspnea | Absent |

DIAGNOSTIC EVALUATION
Diagnostic evaluation requested for client in relation to those in the literature review Diagnostic evaluation in literature review | Diagnostic evaluation in clinic | Remarks | History/physical, including pelvic examination | Done | Confirmed diagnosis | Histopathology | Done | Confirmed diagnosis | Ultrasonography | Done | Confirmed diagnosis | Urine test for beta hCG | Done | Confirmed diagnosis | Blood for betaHCG | Done | Confirmed diagnosis | Chest x-ray | Done | No lung metastasis | Liver function tests | Done | No liver metastasis | Ct-scan of brain and abdomen | Not Done | - | Full blood count | Done | Moderate anemia | Blood urea electrolytes and creatinine | Done | | Pet scan | Not Done | - |

STAGING
Staging of client in relation to staging in literature review Stage I GTN is confined to uterus | Not applicable to Miss R.B | STAGE II GTN extends out of uterus but confined to genital structures | Applicable to Miss R.B | Stage | III GTN extends to the lungs, with or without genital tract involvement | | Not applicable to Miss R.B | Stage | IV All other metastatic sites | | Not applicable to Miss R.B | Final stage | Stage II |

Prognostic Factors | Score | | 0 | 1 | 2 | 4 | Age in years | <40 | >40 | - | - | Antecedent pregnancy | Mole | Abortion | Term | - | Interval (months)a | <4 | 4-7 | 7-10 | >13 | Pretreatment serum hCG (mIU/mL) | 1,000 | 1,00-10,000 | 10,000-100,000 | >100,000 | Largest tumor, including uterine | - | 3-5 cm | >5 cm | - | Site of Metastases | Lung | Spleen, Kidney | GI Tract | Brain, Liver | Number of metastases | - | 1-4 | 5->8 | >8 | Prior failed chemotherapy | - | - | Single drug | 2 or more drugs | | Miss R.B’S score0104020 | Total score | 7 |

OVERALL FINAL STAGING; STAGEII 7 –Implying Miss R.B’s condition is High Risk.

TREATMENT REGIMEN
Selected treatment protocol in relation to treatment regimen stated in literature review STANDARD PROTOCOL IN LITERATURE REVIEW | TREATMENT ORDERED FOR MISS R.B | PROTOCOL FOR EMA/CO REGIMEN | Day | Drug | Dose | 1 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | MTX | 100 mg/M2 IV push
200 mg/M2 by infusion over 12 h | 2 | Etoposide | 100 mg/M2 by infusion in 200 mL saline over 30 min | | ACTD | 0.5 mg IV push | | Folinic acid | 15 mg q 12 h — 4 doses IM or PO beginning 24 h after starting MTX | 8 | Cyclophosphamide | 600 mg/M2 by infusion in saline over 30 min | | Vincristine | 1.0 mg/M2 IV push | | EMA/CO PROTOCOL USED Same Ordered And ServedSame Ordered And ServedSame Ordered And ServedSame Ordered And ServedSame Ordered And ServedSame Ordered And ServedSame Ordered And ServedSame Ordered And Served |

Laboratory investigations carried out Date | Specimen | Investigation | Lab Results | Normal value | Remark | 12/01/2016 | Blood | Full blood count.Hemoglobin level estimationRBCWBC totalPlatelet | 12.0g./dl3.0x10^6/uL4.4 x10^6/uL214x10^3/uL | 13.5-16g/dl2.5-5.5x10^6/uL3.0-9.0x10^6/uL150-400x10^3/uL | Client has mild anemia. Iron diet recommended.Within normal rangeWithin normal rangeWithin normal range | 12/01/201612/01/2016 | BloodBlood | Renal Function testUrea Creatinine SodiumPotassiumChlorideLiver Function TestAlbumenTotal ProteinGlobulinDirect BilirubinIndirect BilirubinTotal BilirubinASTALPALTGAMMA GT | 4.3 mmol/L90 mmol/L139 mmol/L4.1mmol/L100.8mmol/L44.6mmol/L77.0mmol/L32.0mmol/L13.2mmol/L14.3.0mmol/L27.0mmol/L27.0mmol/L83mmol/L19.0mmol/L22.2mmol/L | 2.1-7.1mmol/L53-108 mmol/L136-145mmol/L3.5-5.1mmol/L98-107mmol/L38.0-55.0 mmol/L64.0-80.0 mmo9l/L20.0-40.0 mmol/L0.00-21.0 mmol/L1.70-17.0 mmol/L5.0-21.0 mmol/L0.00-40.0 mmol/L0.00-240 mmol/L0.00-40.0 mmol/L0.00-38.0 mmol/L | Within normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal rangeWithin normal range | 12/01/2016 | Urine | Urinalysis | No abnormality detected | Normal urinalysis | Normal urinalysis | 12/01/2016 | Chest | Chest X-Ray | Normal chest radiograph | Normal chest radiograph | Normal chest radiograph | 12/01/2016 | Abdomen and pelvis | Abdominal and pelvic ultrasound | Normal | Normal | No evidence of abdominal metastasis |

THE EPWORTH SLEEPINESS SCALE 0 = no chance of dozing | 1 = slight chance of dozing | 2 = moderate chance of dozing | 3 = high chance of dozing |

SITUATION | CHANCE OF DOZING | Sitting and reading | ______1______ | Watching TV | ___3_________ | Sitting inactive in a public place (e.g. a theater or a meeting) | ____1________ | As a passenger in a car for an hour without a break | ____1________ | Lying down to rest in the afternoon when circumstances permit | _____2_______ | Sitting and talking to someone | ______0______ | Sitting quietly after a lunch without alcohol | _____1_______ | In a car, while stopped for a few minutes in traffic | ____0________ |

1 - 6 | Congratulations, you are getting enough sleep! | 7 - 8 | Your score is average | 9 and up | Seek the advice of a sleep specialist without delay |

CLIENTS TOTAL SCORE=9
This translates client not getting enough sleep and should seek the help of a specialist without delay.

PERCIEVED STRESS SCALE
For each question choose from the following alternatives:
0 – never 1 - almost never 2 – sometimes 3 - fairly often 4 - very often
_4__ 1. In the last month, how often have you been upset because of something that happened unexpectedly?
_2____ 2. In the last month, how often have you felt that you were unable to control the important things in your life?
_4____ 3. In the last month, how often have you felt nervous and stressed?
_3____ 4. In the last month, how often have you felt confident about your ability to handle your personal problems?
_3____ 5. In the last month, how often have you felt that things were going your way?
_3____ 6. In the last month, how often have you found that you could not cope with all the things that you had to do?
_3___ 7. In the last month, how often have you been able to control irritations in your life?
_2__ 8. In the last month, how often have you felt that you were on top of things?
_2____ 9. In the last month, how often have you been angered because of things that happened that were outside of your control?
_1____ 10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress.
Scores ranging from 0-13 would be considered low stress.
Scores ranging from 14-26 would be considered moderate stress.
Scores ranging from 27-40 would be considered high perceived stress.

CLIENTS TOTAL SCORE=21
This translates that patient is moderately stress

24 HOUR DIET RECALL

Time | Activity | Type of food | Details of food & drink | 8th January 201612 midnight | sleeping | Nil | Nil | 9th January 20165:30am7:00am11.00am1:30pm7:00pm12 midnight | AwakeBreakfastSnackLunchDinnerSleeping | Beverage with breadDrink and biscuitFufu and palmnut soup Rice and stew- | 1 cup Milo beverage made with 3 tablespoons of Milo powder, 3 tablespoons of low-fat evaporated milk, 1 tbsp. sugar added and 500mls of plain warm water.2 slices of ¼ inches size white bread. 500mls of plain water 330mls of cold malt drink and four 1/8 inches size slices of salted cream cracker biscuits.1medium size cup of pounded cassava and plantain with 3 medium full ladles of palmnut soup made with palmnut concentrate,tomatoes,onion,pepper,2 medium sizes of herring fish and with salt to taste.500mls plain water 2 cups boiled white rice with 1 medium size ladle of stew made with 2 medium sizes fresh tomatoes, 1 small size onion, 2tablespoons vegetable oil, 2medium sizes red chilies and 2 medium size of eggs. 500mls plain water - |

ANALYSIS OF DIET RECALL

Client’s diet in relation the food pyramid shows that;

Miss R.B. had 3 servings of the bread, cereal, rice and pasta group which is adequate

She had 1 serving of the vegetable group which is inadequate of her body requirement

She had no serving of the fruit group, client nutritional status totally lacks this group

She had 2 servings of the meat, poultry, fish, eggs and nut group which is adequate She had 3 servings of the fats, oils and sweets group which is excess of her body requirement She had 1 serving of the milk, yogurt and cheese group, this is inadequate of her body requirement.

Client’s diet lacks adequate servings of the fruits and vegetables and have excessive servings of the fats, oils and sweets.

Monitoring of response to chemotherapy
Assessment of the response to treatment is crucial in daily oncological practice. Response evaluation criteria are used for different types of cancers, in GTN beta HCG is a reliable marker for monitoring response to chemotherapy. Miss R.B’s bHCg was measured at the end of each cycle of chemotherapy and recorded as follows;

DATE | CYCLE NO. OF CHEMO | BHCG LEVEL | 12th January 2016 | Nil | 484.136 | 27th January 2016 | One | 7130 | 9th February 2016 | Two | 1767 | 24th February 2016 | Three | 379.8 | 9th March 2016 | Four | 143 | 24th March 2016 | Five | 63.26 | 6th April 2016 | Six | 34.71 | 20th April 2016 | Seven | 18.11 | 4th May 2016 | Eight | 12.6 |

PHARMACOLOGY OF DRUGS USED FOR MISS R.B.

DATE | DRUG | ROUTE OF ADMINSTRATION | CLASSIFICATION | MECHANISM OF ACTION | SIDE EFFECTS | NURSING CONSIDERATIONS | 13/01/2016 | Etoposide | Oral, intravenous | Plant alkaloid | Inhibits DNA synthesis in the S and G2 so that cells do not enter mitosis. | Hypotension,malaise,alopecia,nausea,vomiting,diarhoea,mucositis,aneamia,leukopenia | Do no administer drug by means of rapid iv infusion or iv push to avoid hypotensionMonitor clients blood pressure during infusionMonitor for crystallization during infusion | 13/01/2016 | Methotrexate | Intrathecalintramuscularintravenousoral | Antimetabolite | Blocks the enzyme dihydrofolate reductase which inhibits the conversion of folic acid to tetrahydrofolic acid, resulting in the inhibition of the key precursors of DNA,RNA and cellular proteins | Mucositis,nausea,myelosuppression,oral ulceration, renal toxicity, liver toxicity, photosensitivity ,neurotoxicity associated with high-dose therapy | High doses must be followed by leucovorin and vigorous hydrationInstruct client on strict mouth careClient must take photosensitivity precautionsEnsure clients avoid taking multivitamins with folic acidMultiple drug interactions(alcohol,NSAIDS,asprin,warfarin) are possible | 21/01/2016 | Vincristine | intravenous | Plant alkaloid | Binds to microtubular proteins, thus arresting mitosis during metaphase | Peripheral neuropathy,amenorrhea,hypertension/hypotension,alopecia,bone marrow suppression, constipation, jaw pain, foot drop | Drug is a vesicantStool softeners may help to prevent constipationNeurotoxicity is cumulative but often reversible; conduct a neurologic evaluation before each dose. Withhold dose if sever paresthesia, motor weakness developReduce dose in the presence of significant liver disease | 21/01/2016 | Cyclophosphamide | Oral, intravenous | Alkylating agent | Causes crosslinkage in DNA strands, thus preventing DNA and cell division | Alopecia,nausea,vomitting,leukopenia,heamorrhagic cystitis, amenorrhea | Give dose early in the dayEnsure adequate hydration, if given per os,have client drink plenty fluids(2-3L/day)Have clients empty bladder frequently and before bed to prevent hemorrhagic cystitis | 13/01/201614/01/2016 | Dactinomycin | intravenous | Antitumor antibiotic | Binds to guanine portion of DNA and blocks the ability of DNA to act as a template for both DNA and RNA | alopecia,nausea,vomiting,Mylosuppression,mucositis,diarrhea,ovarian and sperm suppression | Drug is a vesicantDrug may be in micrograms, so check the dose carefully | 14/01/2016 | Leucovorin | Oralintravenous | Water soluble vitamin in the folate group | Acts as an antidote for methotrexate and other folic acid antagonists | Urticarial(rare) | | 13/01/201614/01/201621/01/2016 | Dexamethasone | Oral,intravenous | Glucocorticoid steroid | May inhibit prostaglandin release by stabilizing lysosomal membranes, thereby interrupting hypothalamic prostaglandin release and subsequent stimulation of nausea and vomiting | Hypertension,oedema,depression,psychoses,weight gain,osteoporosis,amenorrhea | Administer slowly over at least 10 mins to prevent perineal or vaginal burning or itching | 13/01/201614/01/201621/01/2016 | Granisetrone | Oralintravenous | Serotonin antagonist | Binds to vagal afferents adjacent to the entrochromaffin cells in the GI mucosa, thus preventing the stimulation of afferent fibers that would otherwise stimulate the vc and ctz. | Hypertension,headache,dizziness,constipation,fever,urticarial,insomnia,agitation | Can be administered by rapid bolusInstruct patient to take oral formulation with food or milk | | Domperidone | | | | | | 21/02/2010 | lorazepam | Intravenous,intramuscular, oral | benzodiazepine | Binds to benzodiazepine receptors in the CNS resulting in the following effects: anxiolytic, ataxia, anticonvulsant, muscle relaxation. | Hypotension,hypertension,drowsiness,ataxia.vertigo,dizziness,dry mouth, nausea | Use with caution in older adults clients or those with hepatic or renal dysfunctionGive first dose at night before treatment and the morning of chemotherapy for anticipatory nausea/vomiting |

CHAPTER FOUR

COLLABORATIVE PLAN OF CARE
Collaborative plan of care facilitates better patient outcomes. The healthcare team works as a group utilizing individual skills and talents to reach the highest of patient care standard. A multidisciplinary plan of care should be decided by all of the team members. Individual disciplines must be willing to work together, have the same objectives and goals and provide the plan of care which is individualized to the patient’s needs.
Five core principles define collaborative care and should inform every aspect of an implementation. If anyone of this is missing, effective collaborative care is not being practiced;
1. Patient centered team care; primary and behavioral health providers collaborate effectively using shared cared plans that incorporate patient goals.
2. Population based care; care team shares a defined group of patients tracked in a registry to ensure no one falls through the cracks
3. Measurement based treatment to target; each patient treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured by evidenced based tools
4. Evidenced based care; patients are offered treatment with credible research evidence to support their efficacy in treating the target condition
5. Accountable care; providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided.

The plan of care of Miss R.B involved the collaboration of client and family and the various health team members which include; radiation oncologist, oncology nurses, pharmacist, radiologist, pathologist, laboratory technician and clinical psychologist for the successful treatment of client

Radiation oncologist prescribes treatment regimen and reviews patient mid cycle and at the end of treatment

Medical officer checks on laboratory values, reviews client after each cycle of chemotherapy and gives the go ahead for chemotherapy to be administered. Medical officer refers client to radiation oncologist should there be any deviations Nurse counter checks laboratory values, drug dose, mode of administration and general condition of client including vital signs especially weight, temperature and blood pressure, Nurse refer client to medical officer should any of the parameters deviate from normal. The nurse educates client on chemotherapy regimen and continuous monitoring of beta hCG levels.

Pharmacist counter checks drug dose, other medications client is on, laboratory values, route of administration and reconstitute drugs, but will refer to medical officer if he/she is not satisfied with any of the parameters.

Laboratory technician takes and runs samples for the requested investigations. Draws attention of medical officer should there be any deviations
Radiologist takes and reports on requested medical images.
Pathologist gives an accurate description and diagnosis of the disease
Clinical psychologist provides variety of clinical interventions to reduce the distress and improve the psychological wellbeing of client

PRESUMPTIVE MEDICAL DIAGNOSIS;
This refers to diagnosis based on reasonable grounds for conclusions established by previous and commonly accepted experience.it is used when diagnostic test are not available or cannot be obtained. From the signs and symptoms Miss.R.B. Presented, some of the presumptive diagnosis which can be drawn are:
Spontaneous abortion
Raptured ectopic pregnancy
First trimester pregnancy
Polyhydramnios
Other uterine malignancies (cancer of the endometrium, leimyosarcoma etc.)

Patient / Family Strength
Client could take care of her personal hygiene.
Client could communicate with health staff effectively.
Client co-operated with medical team concerning compliance with procedures and also provided relevant information on her condition.
Client’s boyfriend was very supportive and paid all medical bills
Client had effective family support.

NURSING DIAGNOSIS:
The following nursing diagnoses were made; * Knowledge deficit related disease process,

* Fear/Anxiety related to unfamiliar environment, lack of understanding of diagnosis, diagnostic tests, treatment, and financial concerns * Self-concept disturbance related to:
-changes in appearance associated with the side effects of chemotherapy (e.g. alopecia, excessive weight loss, skin and nail changes)
-possible alteration in usual sexual activities associated with weakness, fatigue, psychological factors, and vaginal discomfort (may result from mucositis and premature menopause if ovarian failure occurs)
-permanent infertility associated with gonadal dysfunction resulting from extensive therapy with cytotoxic drugs (particularly alkylating agents and nitrosoureas)
-changes in lifestyle and roles associated with effects of the disease process and its treatment.

* Nausea and vomiting related to
-Stimulation of the vomiting center associated with: the effect of cytotoxic drugs, the by-products of cellular destruction, and the foul taste created by some cytotoxic agents
-Stimulation of the visceral afferent pathways resulting from inflammation of the gastrointestinal mucosa if mucositis is present
-Stimulation of the cerebral cortex resulting from stress and a learned conditioned response to previous experience with nausea and vomiting after the administration of cytotoxic drugs.

* Imbalanced nutrition less than body requirement * Acute lower abdominal pain related to disease process * Sleep pattern disturbance related to side effects of cytotoxic administration

Objectives
The objectives set are grouped into two categories; short term objectives and long term objectives.
Short Term Objectives
1. Client and relatives will have good knowledge on gestational trophoblastic disease (choriocarcinoma) within 48 hours.
2. Client will be relieved of anxiety within 24hours.
3. Client will gain her normal sleep pattern within 24hours
4. Client will be relieved of lower abdominal pain within 12 hours
5. Client will be relieved of nausea and vomiting within 48hours

Long Term Objectives
1. To restore client to normal health by the end of hospitalization.
2. To help client achieve to her normal lifestyle after discharge and resume her normal daily routine.
3. Client will have adequate knowledge about gestational trophoblastic diseases (causes signs and symptoms and treatment)
4. Client will have balanced nutrition throughout treatment period

Date &time | Nursing diagnosis | Objective /outcome criteria | Nursing intervention | Date & time | Evaluation statement | 12/01/2016 | Knowledge deficit related to disease process | Client will be able to know about the disease process, care and treatment and may explain the return if asked Describe procedure for disease or symptom control.Identify needed alterations in lifestyle. | Assess clients knowledge about diseaseAssess clients educational backgroundAssess patient’s desire to learn by assessing emotional response to illness; Acceptance, Anger, Anxiety, Denial, DepressionAssess clients ability to learn or perform health related careAssess clients learning style;visual,auditoryExplain to the client/family about disease process,progression,what to expect and answer all questions honestlyDiscuss about therapies and optionsDiscuss lifestyle changes that may be used to prevent complications.Ask the client's knowledge about the disease, nursing procedures and treatmentEvaluate patient behaviors as evidence that learning outcomes have been achieved | 14/01/2016 | Goal fully met as client was able to answer questions about disease process and treatment regimen and co-operated well with healthcare staff. she was empowered with knowledge of ranges of her laboratory results where chemotherapy could or could not be administered | 12/01/2016 | Fear/Anxiety related to unfamiliar environment, lack of understanding of diagnosis, diagnostic tests, treatment, and financial concerns | Client will experience a reduction in fear and anxiety as evidenced byVerbalization of feeling less anxious | Assess client for signs and symptoms of fear and anxiety (e.g. verbalization of feeling anxious, insomnia, tenseness, shakiness, restlessness, diaphoresis, tachycardia, elevated blood pressure, self-focused behaviors).Implement measures to reduce fear and anxiety by: orient client to environment, equipment, and routinesintroduce client to staff who will be participating in care; if possible, maintain consistency in staff assigned to his/her careassure client that staff members are nearby; respond to call signal as soon as possiblemaintain a calm, supportive, confident manner when interacting with clientencourage verbalization of fear and anxiety; provide feedbackreinforce physician's explanations and clarify misconceptions client has about the diagnosis, treatment plan, and prognosisexplain all diagnostic testsprovide a calm, restful environmentinstruct client in relaxation techniques and encourage participation in diversional activitiesassist client to identify specific stressors and ways to cope with theminitiate social service referral and/or assist client to identify and contact appropriate community resources if indicatedprovide information based on current needs of client at a level he/she can understand; encourage questions and clarification of information providedencourage significant others to project a caring, concerned attitude without obvious anxiousnessinclude significant others in orientation and teaching sessions and encourage their continued support of the clientAdminister prescribed antianxiety agents if indicated.Consult appropriate health care provider if above actions fail to control fear and anxiety | 14/01/2016 | Goal fully met as client walked in out of the department freely to assess anything she needed and she voiced to this effect | 9/02/2016 | Self-concept disturbancerelated to:changes in appearance associated with the side effects of chemotherapy (e.g. alopecia, excessive weight loss, skin and nail changes) possible alteration in usual sexual activities associated with weakness, fatigue, psychological factors, and vaginal discomfort (may result from mucositis and premature menopause if ovarian failure occurs)potential permanent infertility associated with gonadal dysfunction resulting from extensive therapy with cytotoxic drugs (particularly alkylating agents and nitrosoureas)Changes in lifestyle and roles associated with effects of the disease process and its treatment. | Client will verbalize and demonstrate feelings of self-worth and sexual adequacy as evidenced by;maintenance of relationships with significant othersactive participation in activities of daily livingverbalization of a beginning plan for adapting lifestyle to changes resulting from the disease process and residual effects of chemotherapy | Assess for signs and symptoms of a self-concept disturbance (e.g. verbalization of negative feelings about self, withdrawal from significant others, lack of participation in activities of daily living, lack of a plan for adapting to necessary changes in lifestyleDiscuss with client improvements in appearance and functioning that can realistically be expected.Implement measures to assist client to adapt to the following changes in body functioning and appearance if appropriate: Alopecia: inform client that hair loss can be expected approximately 2 weeks after initiation of chemotherapy; may be sudden, gradual, partial, or complete; and can include scalp hair, pubic hair, beard, eyebrows, and eyelashesreassure client that hair loss is temporary (regrowth sometimes occurs before cessation of treatment but usually occurs 2-3 months after it)inform client that hair regrowth may be a different color, texture, and consistencyencourage client to cut hair very short to decrease the anxiety related to seeing large quantities of hair fall outinform client that he/she can reduce rate of scalp hair loss by: brushing hair gently using a soft bristle brushshampooing hair only once or twice a week and using a gentle shampoo and lukewarm wateravoiding use of equipment/products that dry hair (e.g. hot rollers, hair dryers, curling iron, dyes)avoiding hair styles that create tension on hair (e.g. ponytails, braids)encourage client to wear a wig, scarf, hat, false eyelashes, or makeup if desired to camouflage hair lossskin and vein hyperpigmentation: inform client that skin and vein hyperpigmentation may occur if he/she is receiving cytotoxic drugs such as methotrexateinform client that skin and vein discoloration is usually temporaryinstruct client to avoid exposure to sunlight and to use sun screen to prevent an increase in hyperpigmentation and photosensitivity reactionsassist client to identify types of clothing that can be worn to camouflage hyperpigmented areas nail changes: inform client that his/her nails may thicken and stop growing, develop ridges, darken, and detach from nail bed during treatment with certain cytotoxic drugs (e.g. cyclophosphamide, doxorubicin, bleomycin, fluorouracil)reassure client that normal nail growth will resume when chemotherapy is completedinfertility: clarify physician's explanation that infertility is a possible permanent effect of chemotherapyDiscuss alternative methods of becoming a parent (e.g. artificial insemination, adoption) if of concern to clientAssist client with usual grooming and makeup habits if necessary.Support behaviors suggesting positive adaptation to changes that have occurred (e.g. interest in personal appearance, maintenance of relationships with significant others).Assist client's and significant others' adjustment to changes by listening, facilitating communication, and providing information.Encourage significant others to allow client to do what he/she is able so that independence can be re-established and/or self-esteem redeveloped.Encourage client contact with others so that he/she can test and establish a new self-image.Encourage visits and support from significant others.Consult appropriate health care provider (e.g. psychiatric nurse clinician, physician) if client seems unwilling or unable to adapt to changes that have occurred as a result of cancer and its treatment. | 25/02/2016 | Goal fully met as client purchased different hair wig styles and always appeared nicely groomed | | Sleep pattern disturbance related to side effects of cytotoxic administration | Client will demonstrate an optimal balance of rest and activity and statements of feeling well rested | Assess for signs and symptoms of a sleep pattern disturbanceExplore with client potential contributing factorsMaintain bedtime routine per clients preferenceProvide comfort measures to induce sleep; back rub, pain medication if neededLimit nighttime fluidsAsk client to void before retiring to bedCoordinate treatment to limit interruptions during sleep periodIncrease daytime activityServe prescribed sedatives | | | 13/01/2016 | Nausea and vomitingrelated to stimulation of the vomiting center associated with:the effect of cytotoxic drugs, the by-products of cellular destruction, and the foul taste created by some cytotoxic agents;stimulation of the visceral afferent pathways resulting from inflammation of the gastrointestinal mucosa if mucositis is present;Stimulation of the cerebral cortex resulting from stress and a learned conditioned response to previous experience with nausea and vomiting after the administration of cytotoxic drugs. | Client will experience reduction in nausea and vomiting as evidenced by;Verbalization of decreased nauseaReduction in the number of episodes of vomiting | Assess client for nausea and vomiting. Determine whether nausea and vomiting are acute, delayed, or anticipatory; the frequency of occurrence; what factors improve or worsen it; and if the nausea and vomiting interfere with activities.Assess client's perception of the severity of nausea using a scale of 1-10 or the terms mild, moderate, or severe.Implement measures to reduce nausea and vomiting: perform actions to reduce fear and anxiety and promote psychological adjustment to the diagnosis of cancer and treatment with chemotherapyconvey an attitude that nausea and vomiting might not occur (not every client experiences nausea and vomiting every time)administer intravenous cytotoxic drugs slowly unless contraindicated to decrease stimulation of the vomiting centerif feasible, administer the cytotoxic drugs at night so client will sleep and experience less nauseaprovide sour, hard candy for client to suck on if he/she can taste the drugeliminate noxious sights and odors from the environment (noxious stimuli can cause stimulation of the vomiting center)encourage client to take deep, slow breaths when nauseatedencourage client to change positions slowly (rapid movement can result in chemoreceptor trigger zone stimulation and subsequent excitation of the vomiting center)provide oral hygiene after each emesis and before mealsprovide carbonated beverages for client to sip if nauseateddelay meals until 3-4 hours after chemotherapy administrationavoid serving foods with an overpowering aroma; remove lids from hot foods before entering clients roomprovide small, frequent meals; instruct client to ingest foods and fluids slowlyencourage client to eat dry foods (e.g. toast, crackers) and avoid drinking liquids with meals if nauseatedinstruct client to avoid foods/fluids that irritate the gastric mucosa (e.g. spicy foods; caffeine-containing beverages such as coffee, tea, and colas)Encourage the use of non-pharmacologic measures (e.g. self-hypnosis, relaxation, biofeedback, imagery, acupressure, music therapy) to control nausea.administer the following medications as ordered 1-24 hours before initiating chemotherapy and routinely for the expected period of nausea and vomiting for the specific chemotherapeutic agents being administered: serotonin antagonists (e.g. dolasetron, granisetron, ondansetron)phenothiazines (e.g. prochlorperazine)butyrophenones (e.g. droperidol, haloperidol)gastrointestinal stimulants (e.g. metoclopramide)benzodiazepines (e.g. lorazepam, diazepam) to decrease anxiety and/or induce amnesia in order to lessen the possibility of client's developing a conditioned response to chemotherapycorticosteroids (e.g. dexamethasoneConsult appropriate health care provider (e.g. oncology nurse specialist, physician) if above measures fail to control nausea and vomiting. | 9/02/2016 | Goal fully met as client verbalized absence of nausea and vomiting. | | Imbalanced nutrition less than body requirement | Client will maintain an adequate nutritional status as evidenced by; normal Hb levels | Asses for an report signs and symptoms of malnutrition;weakness,fatigue,abnormal hb,pale conjunctivaMonitor percentage of meals and snacks clients consumes and report a pattern of inadequate intakeimplement measures to maintain an adequate nutritional status;Ensure that meals are well balanced and high in essential nutrients; offer high protein, high caloric dietary supplements if indicated. | | | | Acute Lower abdominal pain related to disease process | Client will be relieved of pain as evidenced by client expressing pain to be at tolerable levels and decreased discomfort | Monitor vital signsMaintain bedrest in a comfortable positionAssess intensity, location, and type of painApply warm water bottle on the lower abdomenLet client assume comfortable positionsServe prescribed analgesic | | |

EVIDENCE-BASED INTERVENTIONS
Evidenced based interventions are treatments that have been proven effective (to some degree) through outcome evaluations. There are three basic principles for establishing when an intervention can be deemed ‘evidenced based’
1. The best available research evidence bearing on whether and why a treatment works
2. Clinical expertise (clinical judgment and experience) to rapidly identify each patients unique health state and diagnosis, their individual risks and potential interventions and
3. Client preferences and values
From the above listed principles, all medical and nursing interventions implemented for Miss R.B. were evidenced based.

ADDITIONAL DIAGNOSTIC PROCEDURES WARRANTED BUT NOT DONE:
Additional diagnostic procedures are carried out to establish a diagnosis in symptomatic patients, Screen for disease in asymptomatic patients, Provide prognostic information in patients with established disease, Monitor therapy by either benefits or side effects and to confirm that a person is free from disease.
Factors that may inhibit carrying out of all diagnostic test may include:
When there is more than one option
When no option has a clear advantage
When risk-benefit profile may be valued differently
When cost involved cannot be met by the client
When the diagnostic procedure is not available at the facility/area

With reference to the literature review, the following diagnostic tests were warranted but not done due to one or more of the reasons listed above
1. Computed tomography scan of brain to rule out brain metastasis
2. Computed tomography scan of abdomen to rule out abdominal metastasis
3. Positron electron tomography scan of abdomen

MEDICATIONS TO BE ORDERED;

Day 1;
Methotrexate160mg bolus then 320mg over 12 hours
Actinomycin D 0.8mg
Etoposide 160mg
Granisetrone 1mg
Dexamethasone 12mg
IVF 1.5liters

Day 2:
Leucovorin tablets15mg bd first dose 24 hr. after 1st dose of Methotrexate x2days
Etoposide 160 mg
Actinomycin D 0.8mg
IVF 1liter
Granisetrone 1mg
Dexamethasone 12mg

Day 8 Vincristine1.6mg Cyclophosphamide 960mg
Granisetrone 1mg
Dexamethasone 12mg
IVF 1liter Dexamethasone, Granisetrone, Motillium, Lorazepam

CHAPTER FIVE

DISCHARGE PLAN, TO INCLUDE COMMUNITY SERVICES AND RESOURCES NEEDED

Preparation of client and relatives towards discharge began at the moment she was admitted. She looked worried about how long the treatment regimen will last, she was reassured and made to understand that, she was not going to have treatment forever but she would be discharge based on recovery evidenced by hCG level reading zero (0). The discharge plan included the following: i. Community services and resources and resources needed ii. Client education plan iii. Plans for follow-up of care
COMMUNITY SERVICES AND RESOURCES NEEDED Community-based health education programs may be helpful in improving health outcomes in patients with chronic illnesses. Because client will need to be supervised and encouraged to comply with treatment and follow medical directives as advised there is the need for community health workers, family and friends involvement in the after hospitalization care to maintain an optimum health. She was also referred to the public health nurse and the health promotion nurse for follow up. She was also furnished with the telephone number of the radiotherapy department to call during working hours on any issue bothering her. I also conducted one home visit to assess client’s environment and identify community resources which could be beneficial to client. This is the Somanya health center; oncological emergencies could be managed at the facility in case client experienced one. Interactive education workshops may be also be an effective strategy in community-based health promotion education programs for women of child bearing age in improving clients knowledge on gestational trophoblastic disease but this was not organized in the community as this service is not yet available in the community. However the visit by the health promotion nurse focuses on the improving patient’s knowledge on drug compliance, lifestyle changes, contraception, prevention of sexually transmitted diseases, and future consideration of child adoption to ensure client recovers fully and return to her normal daily activities and school schedule with ease. Client had a good family and societal support as her friends visited her regularly and encouraged her to comply with treatment.
CLIENT EDUCATION PLAN Client and relatives were educated on the disease condition (Gestational trophoblastic disease). Its causes, signs and symptoms and the treatment regimen. She was educated on the importance of contraception, sexually transmitted disease including HIV/AIDS.
She was further educated on the need to promptly report for ante-natal care at a health facility should she conceive in the near future. She was further educated on options of adoptions in the future should she face infertility. She was counseled not to allow the disease experience to put a strain on her relationship with her boyfriend but to practice safe sex

PLANS FOR FOLLOW-UP OF CARE Follow-up visit is a very essential process in the care of the patient. This is the continuity of the nursing care process where the nurse visits the patient and family at home. This gives the nurse the first hand information regarding the social status of the patient and the home environment. One home visit was conducted and documented as follows;
Home Visit
A nursing home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities.
The purposes of the planned visit I made to Miss R.B’s home were to
-To assess the living condition of the patient and his family and their health practices in order to provide the appropriate health teaching.
-To give health teachings regarding the prevention and control of diseases.
-To establish close relationship between the health agencies and the public for the promotion of health and
-To make use of the inter-referral system and to promote the utilization of community services
I visited Miss R.B on 30th January 2016 at her home in Somanya at 10:00am, I was warmly received and my mission was explained to them after exchanging greetings.
I got to know that, she lived in a single room rented house. There are three other tenants in the house. Her room is well furnished and there is one water closet toilet and bathroom of which the four tenants shared, they are kept very clean. They had a continuous flow of treated water that flowed from an overhead water tank even when the taps were not flowing. The whole house is fenced with solid brick walls and a gate. They had a dust bin with cover at the back of their house where they dispose off their refuse. I also realized that, the environment was in good hygienic condition so I encouraged them to keep it up and also educated them on the importance of avoiding types of lifestyles such as smoking and excessive intake of alcohol.
Miss R.B. stated that her boyfriend lived about five kilometers from her residence, he visited her regularly. Her parents’ home is also about 10 kilometers from her home. Her siblings and mother also visited her regularly. Her boyfriend met me at her residence when he came visiting, he welcomed and thanked me for the support I rendered to Miss R.B as we exchanged pleasantries. It was my first interaction with him. I seized the opportunity to educate them about contraception as discussed with Miss R.B, he accepted and promised he was going to take precautions in their sexual life.
In identifying community resource which could be beneficial to Miss R.B, I asked for the direction to the health center, this is about 3 kilometers from her house. I reminded client of the rehearsal we had in case she had neutropenia and explained to her that the health center could be beneficial to her in case she gets into such crises. With verbal consent and permission from Miss R. B and her boyfriend, we went to the health center where I met the physician assistant in charge of the facility. I educated him about how he could manage client in case she reports to the facility with an oncological emergency. I thanked them for the visit and took my leave .

CHAPTER SIX

EVALUATION PLAN
Statement of evaluation
For effective nursing care to be rendered to the client, a nursing care plan was drawn and implemented.
Objectives include the following:
1.Goal set on 13th January 2016 at 8am, that client will be able to know about the disease process, care and treatment and may explain the return if asked to describe procedure for disease or symptom control. Identify needed alterations in lifestyle was fully achieved on 24/03/2016 at 8am as evidenced by client verbalizing that she understood how treatment regimen was administered, and co-operated well with healthcare staff.
2. On 13th January 2016 at 8:30am, goal set for patients to Client will experience a reduction in fear and anxiety as evidenced by client Verbalization of feeling relaxed in the department’s environment
3. On 18th January 2016 at 8:30am, objective set for client feelings of self-worth and sexual adequacy, maintenance of relationships with significant others active participation in activities of daily living evidenced by client verbalization of a beginning plan for adapting lifestyle to changes resulting from the disease process and residual effects of chemotherapy was fully achieved on 20th February 2016 as client acquired different hairstyle wigs and looked cheerful
4. On the 18th January 2016, goal set to Client will experience reduction in nausea and vomiting as evidenced by; Verbalization of decreased nausea Reduction in the number of episodes of vomiting was fully achieved

Amendment of nursing care plan for partially met goals or unmet outcome criteria
All clients goal’s set were fully achieved within the specific period they were targeted to be achieved. As such, there was no amendment of nursing care plan.

Termination of care Termination of care started on the admission day. Client and relatives were educated on the disease condition, causes, signs and symptoms, and treatment. She was further educated on importance of practicing safe sex and contraception. She was encouraged to eat well balanced diet so as to help maintain her blood values in good ranges
It was during her visit for the 9th cycle of chemotherapy on 11th may 2016 that she was finally made aware that, the therapeutic relationship between us had ended. However she could count on me anytime she needed my help or advice. Client was also reminded to that chemotherapy will be administered to her till the hCG got to zero then she will have two more cycles to terminate treatment, then she will have scheduled reviews. Miss R.B. and her relatives expressed their gratitude and appreciation for all the care rendered to them and wished me well in my studies.

Summary Miss R.B is a 28 year old student nurse who was admitted on 12th january2016 with a pathological diagnosis of gestational trophoblastic disease. She was managed with a two weekly chemotherapy regimen which lasted for five months with good response. Nursing care plan was drawn and implementation started and was completed which led to client’s speedy recovery with limited side effects. Client and relatives were educated on disease process causes, signs and symptoms, treatment regimen, compliance to treatment, and monitoring of hCG levels during admission and at home. One home visit was made to familiarize myself with client’s home environment and identify resources which could be beneficial to client
The therapeutic relationship between us was terminated on 11th May 2016 when client completed her 8th cycle chemotherapy with hCG reading of 12mu.

References
Bagshawe, K. D., Dent, J., Newlands, E. S., Begent, R. H. J., & Rustin, G. J. S. (1989). The role of low‐dose methotrexate and folinic acid in gestational trophoblastic tumours (GTT). BJOG: An International Journal of Obstetrics & Gynaecology, 96(7), 795-802.

Bower, M., Newlands, E. S., Holden, L., Short, D., Brock, C., Rustin, G. J., ... & Bagshawe, K. D. (1997). EMA/CO for high-risk gestational trophoblastic tumors: results from a cohort of 272 patients. Journal of Clinical Oncology, 15(7), 2636-2643

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