NRSG374: Clinical Practice Guidelines (CPG’s) - Fortunato (Frank) Rossi Case Study - Nursing Assignment Help

Assignment Task:

Consider the Patient Situation

(Levett-Jones, 2018)

Fortunato (Frank) Rossi, is a 60 year old male who was born in Italy and Migrated to Australia with his wife in 1952, both he and his 58 year old wife Sofia have dual citizenship in Italy and Australia. Frank and his wife practice a strong catholic faith. Frank has worked as a Secondary School Science and Mathematics teacher at a local Catholic Secondary School for over 20 years and loves his job.  He is well respected by his colleagues and students with his very "quick wit and sharp mind with problem solving" that he prides himself on

Sofia has been a stay at home mother and carer for their 2 daughters:

• Eldest Daughter: Anna married Phillip have 2 daughters Bella (6) and Emily (3 months)

• Youngest Daughter: Gabriella married Michael have 1 son (18 months old)

Together they have had a wonderful life, with supportive family visiting from Italy and the Rossi family themselves being able to go over to Italy for many family holidays.  Both Frank and Sofia are very excited and enjoying being grandparents, they are looking forward to Frank's decision for an early 'self funded retirement' to enjoy more time with the family. Frank has arranged with his school to be able to undertake a small amount of casual teaching if he and his family require some small income once he has retired, although he is very keen to work in his garden and spend time helping to raise the grandchildren and enjoy the many years of hard work that he and Sofia put in to support their family and the "good life" they have created in Australia.

Three months ago

Frank experienced some confusion at work and a seizure "of unknown origin" that was witnessed by his wife and grandchildren.  Sofia immediately called 000 and Frank was transported urgently under the care of paramedics to the emergency department (ED) of a major metropolitan hospital as they lived close to the city.

Collect Cues and Information

(Levett-Jones 2018)

Frank has now spent some time in a general medical ward at the Tertiary Level City Hospital that he was originally transferred to by ambulance 2 weeks ago following another seizure.  During his admission the following cues and information were collected and a diagnosis made. Prior to his transfer and admission to the palliative care unit in an outer city hospital closer to his family home

Past Medical Hx

• Tonsillectomy as a child

• Ex smoker (quit smoking 25 years ago was a packet a day smoker)

• Diet Controlled type 2 Diabetes

Current History

• Seizures of unknown origin

• Confusion

• Headache

• Blurred vision

• Difficulties with problem solving and decision making

• Gradual onset of speech disturbance

• Muscle Weakness

• Behaviour Changes

• Vomiting

• Sleepiness

• sluggish pupil response to light

Gathering new Information 

Frank's vital signs upon admission to medical ward 

RR : 18

HR: 84 bpm

BP: 185/95

SaO2: 96% on 3Lmin via N/P (For Comfort measures)

Raised Intracranial Pressure (ICP) - constant headache

GCS - 9/15 (eyes open to painful stimuli 2 / confused and disorientated verbal response 4 / Abnormal Flexion from painful stimuli 3)

Intermittent Patient Notes

"Patient transferred to medical ward following observed seizure of unknown origin by wife and grandchildren who called 000 for paramedic support. In ED patient's conscious state was altered with confusion and inability to recognise wife"

"Pupil size of both eyes was equal however pupillary light reflex is sluggish, positive babinski sign response bilaterally, renal function normal, patient experiencing double incontinence, normal FBE and U&E"

"Initial MRI clearly showed abnormalities in the frontal and temporal regions, with a differential diagnosis of metastatic tumors in the brain from an unknown primary"

Frank was experiencing Increased Intracranial Pressure likely from brain lesions and possible Diagnosis of a Glioblastoma Multiforme (GBM)

Differential Diagnoses had not yet been ruled out 

"Patient was administered mannitol every 12/24 over 16 days to reduce Intra Cranial Pressure (ICP,) Lyrica 150mg BD for seizure activity, and Diazepam 10mg PRN..... 5 days post initial seizure pt woke with normal cognitive responses and recognition of family members once ICP had begun to reduce. Progressively pt's ability to walk without deficit returned. Pt was fully continent, had good long term memory recollection, however short term memory was impacted"

"Pt's oral mucosa had multiple abrasions and thrush evident from possible injury during seizure, patient complained of mouth and throat pain, often refusing to eat and drink"

"Differential Diagnoses of ?Infection, ?metastaic cerebral tumors were discussed however following lumbar puncture for collection of cerebro-spinal fluid (CSF) specimen, and  further MRI results  showing rapid tumor growth particularly in Frank's frontal lobe just 18 days after his initial ED presentation, the diagnosis was highly indicative of a GBM"

"Patient and wife agreed to surgical tumor resection as a palliative measure with the knowledge that this was not a cure. Histopathology post surgical resection clearly identified a rapidly growing GBM with temporal lobe metastases as the definitive diagnosis. A family meeting was arranged with the neurosurgeon, oncologist, palliative consultant, social worker, nurse unit manager, Frank and his family to discuss options"

Confirmed Diagnosis, medical imaging and  histopathology results

Following  CT Brain and MRI it was concluded that Frank had a Glioblastoma Multiforme (GBM) in his frontal lobe which had likely metastasized in both temporal lobes, thus his prognosis was devastatingly a Stage IV GBM with a likely survival of 2 - 3 months without surgical resection and/or palliative radiation therapy.

"Family advised to discuss and complete an Advanced Care Directive whilst Frank was competent with the knowledge that his ICP was likely to increase again, and a decision on how to proceed with interventions was needed.  Palliative radiotherapy was offered to Frank, he and his wife refused and decided to be transferred to an inpatient palliative care unit closer to their family where he could go home on day visits and also spend more time with his family at the palliative care unit, rather than in a busy medical ward" 

Processing Information

Arrival and Admission to the Palliative Care Unit

Frank expressed some personal family history and wishes for his disease progression 

"Frank informed medical and nursing staff that his father had died from a GBM, restless, undignified crawling on the floor from terminal restlessness and his only desire was to not die like his father had"

"Nil Advanced Care Directive had been completed with Frank and Sofia as they thought they still had plenty of time when informed about an ACD on the Medical Ward. However, with Frank's fluctuating ICP and disorientation he is now deemed incompetent for any legal decisions or changes to his Will"

"Sofia was Frank's medical Power of Attorney, presenting paperwork to support this to the admitting palliative Care Team"

"Sofia stayed with Frank during his admission and together they communicated that they wanted him to be comfortable and dignified"

Medications Commenced once reviewed by Palliative Care Team

• Dexamethasone: 8mg BD oral or S/C (0800 and 1400) - To aid in reduction of ICP and Pain Relief from headache (Consider side effects and behavioural changes from dexamethasone - How can these be managed?)

• Lyrica : 75mg BD Oral (0800 and 2000) -  To manage seizure activity (consider side effects of Lyrica, are there other options that could be considered for Frank?)

• MS Contin 10mg BD Oral (0800 and 2000hrs) -  Analgesia

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