Reference no: EM133605539

Mrs. Sharp is a 74-year-old retired teacher with a history of esophageal cancer who is being admitted for weight loss and mucositis pain. She is alert and oriented and has been living at home with her husband of 40 years. On admission, she has a height of 162.56 cm (5 ft, 4 inches) and a weight of 46.36 kg (102 lb). She reports a 9.1 kg (20-pound) weight loss over the last several months. In addition, she is immunocompromised, with a white blood cell (WBC) count of 2.5. Her vital signs are within the expected parameters. During her screening, Mrs. Sharp stated that she hadn't had much of an appetite and that "everything tastes like cardboard." She also tells the nurse that "it hurts to swallow." Her pain rating is 7 on a scale of 1 (least pain) to 10 (most pain).

After completing the admission assessment, the nurse implements measures to provide comfort and control Mrs. Sharp's pain. The nurse also referred Mrs. Sharp for a dietary consult. The authorized healthcare provider orders a texture-modified-consistency, minced, and moist diet. Over the next several days, the nurses on the medical-surgical unit carefully recorded Mrs. Sharp's food and fluid intake while continuing to provide care and control her pain. They also allow flexible visiting hours and encourage her husband to remain at the bedside during her meals at Mrs. Sharp's request. Mrs. Sharp's pain is now more controlled (rating of 2), and her appetite has improved slightly. However, her intake is still not adequate, and she continues to lose weight. The authorized healthcare provider then decides to place a PEG tube for enteral feedings. Before the tube is placed, the nurse ensures that Mrs. Sharp consents to the PEG tube as well as to EN. After the PEG tube is placed, the nurses notice a small amount of serous drainage around the PEG tube exit site. Before the nurses initiate feedings, they verify the placement of Mrs. Sharp's PEG tube and prepare for her enteral nutrition. When Mrs. Sharp is discharged to home, the nurses provide teaching to Mrs. Sharp and her husband. They both express some anxiety about the PEG tube.

Case Study Questions

1. Considering Mrs. Sharp's nutritional screening and signs and symptoms on admission, what are the priorities regarding her care? What immediate interventions does the nurse do in this case to care for Mrs. Sharp? What additional measures could the nurse take?

2. The authorized healthcare provider places Mrs. Sharp on a texture-modified consistency, minced, and moist diet. Describe this type of diet and how it may help Mrs. Sharp.

3. In order to prevent further weight loss, the nurse does several things in this case to improve Mrs. Sharp's appetite and encourage eating. Describe these measures and any additional interventions the nurse could do to improve Mrs. Sharp's intake of food.

4. How would the nurse accurately monitor Mrs. Sharp's oral intake? Describe additional ways the nurse can assess. Sharp's tolerance and intake of food.

5. Because Mrs. Sharp's weight continues to decline, the authorized healthcare provider places a PEG tube for enteral feedings. Describe what a PEG tube is and where it is inserted. Why would a PEG tube be a better choice for Mrs. Sharp than a nasally inserted tube? Will it be possible for Mrs. Sharp to eat orally and receive oral care while she has a PEG tube?

6. After the PEG tube is inserted, the nurses observe a small amount of drainage around the insertion site. What are possible complications Mrs. Sharp might be at risk for? How can the nurse prevent these complications and provide optimal care for Mrs. Sharp?

7. Before initiating feedings, the nurses verify the placement of Mrs. Sharp's PEG tube. How often must the nurses check the placement of her tube, and what methods should they use? What is the gold standard for verifying the placement of enteral feeding tubes?

8. Before Mrs. Sharp is discharged to home, the nurses will be involved in teaching Mrs. Sharp and her husband how to make and self-administer her enteral feedings. Considering Mrs. Sharp's history, what teaching is critical to prevent complications?

9. Application of QSEN Competencies: One of the Quality and Safety Education for Nurses (QSEN) skills for Patient-Centered Care is to "Remove barriers to presence of families and other designated surrogates based on patient preferences" (Cronenwett et al., 2007). How did the nurse in this case honor Mrs. Sharp's preferences, and how did it help her? What other QSEN patient-centered skill did the nurse demonstrate before Mrs. Sharp's PEG tube was placed?