Analysis of a Colorectal Cancer Patient

In the case study John undergoes surgery. Following surgery John agrees to receive adjuvant chemotherapy that includes Fluorouracil. John returns for his third cycle of chemotherapy to an outpatient clinic (day patient only) and reports feeling 'not himself' and sometimes unwell since his last cycle of chemotherapy. In the nurse's discussion with John the following points are raised:
• He feels achy all over and lethargic. He notices it more for the few days following chemotherapy treatments but he has felt unwell other days as well. He takes a few 'Panadol' and 'Neurofen' when he feels this way and that helps a little.
• He tells you that some days he has no energy to go outside of the house and feels he is missing out on the activities he usually enjoys. He likes to help his daughter with her real-estate agency by doing maintenance work for the rental properties she manages. He also likes to walk his dog twice a day, but finds this difficult because he feels too tired. Before the cancer diagnosis he rarely took afternoon naps, but now he feels he can't miss having a two-hour nap every afternoon.
• He worries about his wife and his future. He doesn't want to discuss these feelings with his wife as she is often emotional when his cancer treatment is mentioned in conversation. Most nights he finds it difficult to fall asleep even though he feels tired. He often wakes at 3AM and cannot fall back asleep. When this happens, he usually gets up and plays solitaire on his computer.
John's other medications that he takes at home include:
– Dexamethasone 8 mg orally (PO) for 2 to 3 days post chemotherapy
– Metoclopramide 10 mg PO one to two tablets every 4 to 6 hours when required

PREPARING TO WRITE:
To prepare for writing the essay, complete the Clinical Decision Making Framework template for all of John's problems (refer to your module workbook for the template). This exercise should cover relevant assessment data that supports the identification of John's problems, goals, possible interventions and evaluation criteria, and will help you focus on one problem for the essay below. Include this template as an appendix to the essay. This does not need references and is not included in the word count

Introduction

Colorectal cancer is the cancer found in the colon and rectum of the large intestine.In this case John who is diagnosed positive for colorectal cancer undergoes a surgery followed by chemotherapy that includes the drug Fluorouracil. John who returns for review after three successful chemo therapies reports that he is not been keeping too well after the third chemotherapy. He felt lethargic accompanied by pain all over the body which was intense for first few days after therapy and continued for days. He also reported that taking in 'Panadol' and 'Neurofen' made him feel little better.

John could not cope with his routine due to lack of energy and found it hard to support his daughter's real-estate maintenance work as well as taking his dog out for walk twice a day. John reportedly had two hours nap in the afternoon which he barely did before his treatment for cancer. He felt stressful about his wife and himself more often and had sleepless nights in spite of tiredness. He often woke up at about 3 in the morning and got no sleep later on. As a part of his medication John took an oral dose of 8mg of Dexamethasone for two to three days post chemotherapy and one to two tablets of 10mg PO of Metoclopramide every four to six hours whenever required.

Side effects of chemotherapy especially fatigue is the reason behind the most inconveniences and discomforts felt by John.

Patient Problem

Fatigue is a persistent and distressing condition causing emotional, physical and cognitive tiredness or exhaustion as far as cancer treatment is concerned which doesn't have a link with the recent activity whereas interferes greatly with usual bodily functions (NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue , 2010).

Fatigue is the most debilitating side effect of chemotherapy that affects the quality of life of a patient to a large extent as well as interferes greatly with the ability of a person to perform on daily basis. The effect of fatigue is high on elderly patients since they are more vulnerable and reportedly present age-related changes in the multiple organ systems(Giacalone, et al., 2013).

In elderly patients cancer related fatigue is associated with depression, sleep disorders and anaemia. Fatigue could be caused as a result of metabolic, endocrine, cardiovascular or liver disorders (Giacalone, et al., 2013). Fatigue is the most prevalent as well as distressing symptom in patients suffering from colorectal cancer and is found to increase during the course of therapy and remained intense along first three cycles of chemotherapy(Berger, Grem, Visovsky, Marunda, & Yurkovich, 2010).

John who has had his third cycle of chemotherapy and vulnerable for his age is unable to cope with his daily routine, finds it hard to perform any physical activity as well as suffers sleepless nights because of fatigue.

Problem Assessment Tool

In order to assess levels of fatigue in a patient Piper Fatigue Scale (PFS) is used. The PFS measure fatigue in four different dimensions they are sensory, behavioural severity, affective and meaning and cognitive and mood (Berger, Grem, Visovsky, Marunda, & Yurkovich, 2010).

Fatigue could be described by a patient as exhaustion, laziness, weakness, worn-out feel, slow, heaviness, weary, lack of energy to stand up or sit down. Fatigue can also be assessed with the presence of disturbance in mood, decline in physical functions, social interaction, work and cognitive performance, declined involvement in family care and community activities and losing sense of self (Fatigue–for health professionals, 2014).

Quick fatigue assessment survey (QFAS) was designed to assess cancer related fatigue in a patient. In QFAS about 17 techniques were used for the assessment that include intensity, duration, initiation, use of dichotomous questions for relieving or aggravating factors, ordinal ranking and open minded questions (King & Hinds, 2012).

The main factors that predict fatigue in case of colorectal cancer is performance status, sleep disturbance and disturbance. When all the three factors are present in a patient then it is indicative that the patient has 80% fatigue level and if all the factors are absence then the level of fatigue was 8 %. Performance status and sleep disturbance increase the risk of fatigue about threefold whereas depression reportedly increase fatigue risk by fourfold (MotaI, Pimenta, & Caponero, 2012).

Management Intervention

Usage of drugs for treatment of fatigue is the ideal intervention method when a patient is currently undergoing treatment for cancer especially chemotherapy. Methylphenidate is the drug of choice for treating fatigue in patients suffering from cancer(Minton O, 2013). John is under chemotherapy and is experiencing all the symptoms of fatigue including sleeplessness, inability to perform physical activities as well as depression. A drug that would help in treating or minimizing the effects of fatigue is necessary for John in addition to Dexamethasone and Metoclopramide.

Methylphenidate is the most promising pharmacological interventions of many drugs tested so far in treating cancer induced fatigue (Stone, 2013). John should be administered a dosage of 10 to 20 mg of Methylphenidate per day (Minton O, 2013). The dosage should be adjusted depending on the way John responds to the drug with a minimum of 10mg to maximum of 20mg per day. A dosage of 2.5 mg of Methylphenidate twice per day can also be taken by John instead of 10 to 20 mg once everyday (Scholefield, John; Eng, Cathy, 2014)

Taking in Methylphenidate could give John quite some relief from fatigue. The drug could improve John's quality of life. The drug could reduce the pain that John felt all over his body and also relieve him from the feeling of not being himself. The laziness or the lethargic feel he had experienced could also be reduced. The drug might help him indulge in physical activities like taking his dog for walk and help his daughter's business. Depression and sleeplessness that John experienced could decrease to certain extent.

It is to be noted that though Methylphenidate is the only drug effective in the management of cancer related fatigue, it is advisable to use the under the supervision of experts and possibly active monitoring (Gong, et al., 2014). There also evidences suggesting that Methylphenidate alone are combined with nursing telephone intervention had no effect on cancer related fatigue (Eduardo, et al., 2013).

Methylphenidate reportedly has minimal side effects on patients that consume the drug whereas drugs like Erythropoietin and Darbopoetin are not recommended for use in treating fatigue because of their adverse effects. On the other hand there is also warning that the contradictions of the drug should be reviewed by the physicians before they are prescribed for use (Minton O, 2013). The effect of Methylphenidate in treating fatigue is not clear since there are evidences standing for and against its efficiency. Some studies also suggest that non-pharmacological treatments and interventions like exercise and acupuncture are effective against fatigue than any of the prescribed drugs(Bower, 2012).

As far as John's health condition and his age are concerned it is advisable for him to take up Methylphenidate medication since there are chances for him to become vulnerable on further cycles of chemotherapy. As long as chemotherapy is given John's condition would remain the same and hence it becomes necessary to help John participate in day to day activities at ease as much as possible. Methylphenidate would help John indulge in physical activities gradually as well as improve his condition by reducing factors like depression and sleeplessness that would worsen fatigue.