Palliative Care Case Scenario - Nursing Assignment Help

Assignment Task

Palliative care case scenario
Patient name: Robert Miller
Handover report to Ward 8E Oncology Palliative care unit
Date of handover report: 5th September 2021 at 15.00 hours
MRN: 968 644 DOB: 27.05.1953
Weight: 53kg
Height: 170cm
BMI: 18.3 kg/m2 (underweight)

Introduction
Robert Miller a 68 year old male presented to the Oncology ward three days ago following deterioration over the last week. Patient is in the terminal phase of cancer and is experiencing severe pain. Robert and his family are not comfortable attending to end-of-life requirements at home. The patient wife and two children have accompanied the patient to the hospital for end of life care. The patient wife informs the nurse that the patient has not been sleeping well for the past week due to experiencing severe pain.

Situation
The patient is becoming less conscious and is no longer verbalising but opens eyes to pain. Vital signs prn have remained stable for the past three days. The patient is receiving regular subcutaneous morphine and hyoscine via an abdominal subcutaneous butterfly. The patient is NBM. Mouth care has been attended and Colostomy has minimal output.

Background
Robert has a four year history of Colorectal Cancer and has a Colostomy insitu following bowel resection surgery four years ago. Robert developed terminal metastases in his lungs and brain three months ago. The patient medical notes contain the required documentation for an Advanced Care Directive (ACD) which includes a do-not-resuscitate order and no other acute medical response or treatment. Medical staff discussed advanced care planning with the patient and family during a previous medical admission for radiotherapy six weeks ago. Robert lives with his wife and has two children with families of their own. 

Assessment Observations taken at 10am this morning:
BP: 105 / 72 mmHg
HR: 64 beats per minute
SpO2: 94% R/A
RR: 12 breaths per minute
On Auscultation: Fine crackles–bilateral lower lung fields
Cool lower limbs
Temp: 36.4 OC (oral)
Glasgo Coma Scale (GCS): 10/15 (Eye = 2, Verbal = 3, Motor = 5)
Pain score: 8/10
BGL: 4.8 mmol/L

Recommendations
Continue with end of life care and PRN subcutaneous morphine and hyoscine medications.
Pain assessment and management
Colostomy care
Patient comfort measures for palliative care

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