Patient Case Study: Mandibular Tumour

This presentation is focused on Mr Brown, a 72-year-old adult male patient who was admitted in an East of England hospital. He was diagnosed with mandibular tumour which is a type of oral cancer. Pseudonyms have been used and settings changed to maintain patient confidentiality in line with Nursing and Midwifery Council (NMC, 2018). The author seeks to discuss Mr Brown’s long-term health condition and critically analyse the progression and the effect of this condition and aging on his social life. Evidence based interventions for people with long term conditions (LTC) including pharmacological and non-pharmacological interventions will also be evaluated. An analysis will be made on the conflict between ethical, professional and legal principles and the role of the nurse within health promotion for patients with long term health conditions.

Mr Brown was first admitted in hospital a year ago due to tonsillectomy, resection of tumour on his left mandible and mild chronic renal failure. He was readmitted into hospital to remove his left side plate. Before his latest hospital admission, he lived alone in his two-bedroom flat and he was single. He was a retired warehouse worker and drank occasionally but never smoked cigarettes. He lived an active life, taking part in community activities and going on holidays abroad. His closest relatives were his older sister and her daughter who lived in another town. They arranged for him to be taken into a care home for the elderly once he was discharged from hospital.

Mr Brown’s left side plate was successfully removed through surgery but the wound on his cheek did not heal properly. He was referred to specialists for rehabilitation and was also fitted with a percutaneous endoscopic gastrostomy (PEG) feeding tube for nutritional support. Hashida (2017) and Ijichi and Murakami (2017) noted that after surgery, mandibular tumour patients suffer from complications including “osteoradionecrosis, infection of the soft tissue flap, bone exposure, gingival necrosis, plate exposure, abscesses, and fistulas”. They also reported that cancer patients normally suffer from weight loss and dysphagia, a complication arising from inability to swallow.

Carrier (2015) and Hökkä, Kaakinen and Pölkki (2014) explain that cancer is a long-term condition which affects individuals differently, from frequent visits to the GP/hospital, taking increased quantities of medication, money problems and social isolation. Hinz et al. (2019) added that LTC brings a permanent change to a patient’s life as the disease and its implications are constantly changing. This therefore calls for on-going and complex treatments. LTC affects the patient physically, socially and psychologically. Mr Brown must bear with associated problems such as depression and other aspects of life including social isolation, family relationships, and challenges in carrying out activities of daily living (Hinz et al. 2019).

Christenbery (2017) quoted Sackett et al. (1996)’s definition of evidence-based practice (EBP) as the “conscientious, explicit, and judicious use of the integration of current best evidence, clinical expertise, and patient values into the decision-making process for patient care” That is combining the nurse’s clinical expertise with best available externally researched clinical evidence. The purpose of EBP these days is to safeguard patient safety by providing quality healthcare that is based on comprehensive evidence whilst considering the individual patient’s needs and preferences (Christenbery, 2017). Schmidt and Brown (2017) concur by explaining the role of a nurse as that of using their critical thinking skills to asses research publications and other sources of information and apply their clinical expertise in caring for patients with LTC whilst respecting the patient’s needs and preferences

Taverner (2015) state that cancer patients suffer from a mixed-mechanism of pain, including neuropathic pain as a result of chemotherapy, radiotherapy, surgery, and musculoskeletal pain due to inactivity.

Attal et al. (2006

) describe neuropathic pain as chronic pain which is a result of a damaged or dysfunctional nerve. The patient usually obtains incorrect signals that are perceived as pain in addition to tingling sensation, pins and needles and numbness. This greatly affects the patient’s quality of life and requires both pharmacological and non-pharmacological interventions. Taverner (2015) further state that patients respond differently to explicit neuropathic pain drugs. This calls for nurses to recognise neuropathic pain, its appearance and appreciate the need for wide-ranging and ongoing patient assessment and management. It also means that Mr Brown may have to try several drugs before suitable ones are found which work for him. NICE (2019) also state that some cancer patients do not respond to conventional pain analgesic and may need to try several pain management strategies, including pharmacological and non-pharmacological interventions. Treatment plans should be developed in partnership with Mr Brown who should also be made aware of any complications or side-effect of the chosen intervention strategies (NICE, 2019)

Pharmacological interventions for pain reduction include use of drugs such as anticonvulsants, antidepressants and Opioids. Non-pharmacological interventions include rehabilitative treatment, transcutaneous electrical stimulation, and psychological therapy (Davies and D’Arcy, 2013; Taverner, 2015; and Wilkinson and Whiteman, 2017). British Pain Society (2013), NICE (2013) and WHO (1990) recommend a multi-modal approach using either a combination of both pharmacological and non-pharmacological interventions or one of these depending upon the patient’s preference and response to ongoing treatment.

All decisions made for Mr Brown’s treatment and care should be in his best interest, considering ethical and legal principles and informed consent (Mental Capacity Act 2005; Human Right Act 1998; Equality Act 2010; Allmark and Tod, 2009). Mr Brown had capacity and nurses should give him autonomy and freedom to make decisions about his care and those decisions should be respected. Nurses have a legal duty of care not to harm patients due to negligence, Nurses also have a duty to observe the NHS Constitution (DH, 2013), and applying the 6Cs of nursing (NHS, no date) in caring for Mr Brown.

REFERENCE LIST

• Allmark, P. & Tod, A. 2009, “End of life care pathways: ethical and legal principles”,
  
  Nursing standard (Royal College of Nursing (Great Britain): 1987),
  
  vol. 24, no. 14, pp. 35-39.
• Attal N, Cruccu G, Haanpää M et al (2006) EFNS Task Force. Guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol 13(11): 1153–69
• British Medical Journal (BMJ) (2000) Patients as partners in managing chronic disease. British Medical Journal, 320, 526–527.
• British Pain Society (2013). Available from:
  
  https://www.britishpainsociety.org/static/uploads/resources/files/members_articles_npa_2013_safety_outcomes.pdf
  
  . (Date accessed: 26/08/2019)
• Carrier, J. (2015) Managing long-term conditions and chronic illness in primary care. Routledge Ltd.
• Christenbery, T.L. (2017),
  
  Evidence-based practice in nursing: foundations, skills, and roles,
  
  1st edn, Springer Publishing Company, New York.
• Davies, P. S. and D’Arcy, Y. M. (2013)
  
  Compact Clinical Guide to Cancer Pain Management: An Evidence-Based Approach for Nurses
  
  . New York, NY: Springer Publishing Company (Compact Clinical Guide Series). Available at: http://search.ebscohost.com.rcn.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=485655&site=ehost-live (Date accessed: 26/08/2019).
• Department of Health, 2013. The NHS Constitution for England. Available from
  
  https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
  
  . (Date accessed: 27/08/2019)
• Equality Act 2010, available at:
  
  https://www.legislation.gov.uk/ukpga/2010/15/contents
  
• (Date accessed: 27/08/2019)
• Hashida, N., Shamoto, H., Maeda, K., Wakabayashi, H., Suzuki, M. and Fujii, T., 2017. Rehabilitation and nutritional support for sarcopenic dysphagia and tongue atrophy after glossectomy: A case report.
  
  Nutrition,
  
  
  35
  
  , pp. 128-131.
• Hinz, A., Friedrich, M., Kuhnt, S., Zenger, M. & Schulte, T. 2019, “The influence of self‐efficacy and resilient coping on cancer patients’ quality of life”,
  
  European Journal of Cancer Care,
  
  vol. 28, no. 1, pp. e12952-n/a.
• Hökkä, M., Kaakinen, P. & Pölkki, T. (2014), “A systematic review: non‐pharmacological interventions in treating pain in patients with advanced cancer”,
  
  Journal of advanced nursing,
  
  vol. 70, no. 9, pp. 1954-1969.
• Human Right Act 1998. Available at:
  
  https://www.legislation.gov.uk/ukpga/1998/42/contents
  
• (Date accessed: 27/08/2019)
• Ijichi, K. & Murakami, S. (2017), “Surgical treatment of parapharyngeal space tumors: A report of 29 cases”,
  
  Oncology Letters,
  
  vol. 14, no. 3, pp. 3249
• Mental Capacity Act (2005). Available at:
  
  https://www.legislation.gov.uk/ukpga/2005/9/contents
  
• (Date accessed: 27/08/2019)

• NHS (no date). Introducing the 6Cs: Available at:
  
  https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf
  
  . (Date accessed: 27/08/2019)

• NICE (2019). Available at:
  
  https://www.nice.org.uk/guidance/cg173
  
  . (Date accessed: 26/08/2019)
• NMC (2018) Available at:
  
  https://www.nmc.org.uk/standards/code/read-the-code-online/#fourth
  
  . (Date accessed: 12/08/2019).
• Sackett, D. L., Rosenberg, W. M., Muir Gray, J. A., Haynes, R. B. and Richardson, W. S. (1996) Evidence-based medicine: what it is and what it isn’t. British Medical Journal, 312, 71–72.
• Schmidt, N.A. & Brown, J.M. (2017),
  
  Evidence-Based Practice for Nurses: Appraisal and Application of Research,
  
  Jones & Bartlett Learning, LLC, Burlington.
• 
  Stannard, C.F. Kalso, E. Ballantyne, J. (2010) Evidence-Based Chronic Pain Management. British Medical Journal.
  
• Taverner, T. 2015, “Neuropathic pain in people with cancer (part 2): pharmacological and non-pharmacological management”,
  
  International Journal of Palliative Nursing,
  
  vol. 21, no. 8, pp. 380-384.
• Wilkinson, P. MB BS BMed Sci MClin Ed MRCGP FRCA FFPMRCA, Whiteman, R. MBBS FRCA, (2017), Pain management programmes, BJA Education, Vol 17, (1), 1 January 2017, Pages 10–15,
  
  https://doi.org/10.1093/bjaed/mkw027
  
  .
• World Health Organization (1990) Cancer pain relief and palliative care. Report of a WHO expert committee. http://tinyurl.com/n98sj6h (Date accessed: 27/08/2019)