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COMPLETION ASSIGNMENT ***Please note this is a required completion


"WIT" Guide Critical Thinking Worksheet

**** (Required to be Completed and turned in by day 4 of class) *****
Additional paper may be use to complete this assignment. Please note there will be exam
questions related to this material)

1. Describe the etiology and pathophysiology of Vivian’s cancer. (read and use your text book—Lewis,
Dirksen and Heitkemper) The BRCA genes which are tumor suppressor genes that inhibits tumor
growth when functioning normally, mutates and lose their tumor suppressor ability. This results in
an increased risk for women to develop ovarian or breast cancer. Ovarian cancer can metastasize
directly by shedding malignant cells, which frequently implant on the uterus, bladder, bowel, and
omentum. Also ovarian cancer can metastasize by lymphatic spread which drains primarily through
the retroperitoneal lymph nodes, but drainage also can occur through the iliac and inguinal lymph

2. How is this cancer diagnosed and treated? (Text Book)

• History and Physical examination
• Pelvic examination
• Abdominal and trans vaginal ultrasound
• CA-125 levels
• Color Doppler imaging

1. What assumptions did you make about Vivian and her perception of the care she was receiving
• Cold, Uncaring
• Degrading
• Disrespectful
• Humiliating
• Bewildering
• No autonomy
• They are treated her like a specimen

1. Give 2 specific examples of nontherapeutic communication

• Jason: “Hi Prof. Bearing, how are you feeling today?”
Vivian: “Fine, just shaking sometime from the chills.”
Dr, Jason: “That is fine; IV should kick in sometime, no problem!””Listen, I gotta go, keep
pushing the fluids, okay.”
• Dr. Keileken: “Dr. Bearing you must be very tough, do you think you can be very tough?”
Vivian: “You need not worry.”
• Jason: “Just to check I & O for 1 minute it takes me half an hour to put precautions.” Then
throws the clipboard back in the foot of the bed. About to leave the room *oops, sighs* then
turn around and asked, “Prof. Bearing how are you doing today.”
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• Talking in front of the patient in 3rd person is rude; her presence is not being acknowledged.
Like the rounds with DR. Keileken, Jason and other residents. Jason when Vivian was asleep
he was discussing about Vivian with Suzie even said that Vivian is out and can’t hear.

1. Give 2 specific examples of therapeutic communication.

• Suzie, the nurse used touch, massaged Vivian’s hand with lotion.
• Suzie offered herself and stayed with Vivian when she had an emotional breakdown.
• Suzie explained to Vivian the importance of having an advance medical directive explained
between DNR and a full code and told her that she can think about it. Vivian chose to be
• Suzie tries and explains to Vivian (even if she was asleep) before inserting the foley.

1. Describe the causes of each of the clinical manifestations listed below in a patient who has cancer.
Are there any lab tests that would be used to diagnose any of the manifestations? (Use L&H, and lab
text) List prescribed treatments and nursing management. Which symptoms was Vivian
experiencing? (Feel free to write on the back of this page)

Cause Lab test to Dx Nursing Management

Oral Mucositis Radiation History Maintaining Good OH
Drug induced Physical Exam ↑fluid intake
Assessment Soft bland food
Frequent rinse with water or suckin on ice chips
Avoid commercial mouth wash and hot or spicy
Severe cases- mixture of Benadryl and lidocaine
to rinse
Xerostomia Radiation History Maintaining Good OH
Drug induced Physical Exam Salagen (Pilocarpine Hydrochloride)
Assessment ↑fluid intake
non alcoholic mouth rinse
Chewing sugarless gum
Use of artificial saliva
Alopecia Destruction if hair History Patient education and preparation, cut hair
follicles by Physical Exam before therapy
chemotherapy or Assessment Ask patient preference- scarf, wig or cap
radiation to scalp Patient support
ACS “Look good, feel better” program referral
Diarrhea Denuding of Subjective and Antidiarrheal agents as needed
epithelial lining of objective symptoms Encourage low fiber, low residue diet
intestines due to Encourage fluid intake of at least 3L
chemotherapy agents Assessment
Radiation to History
abdomen, pelvis
lumbo sacral areas
Constipation ↓intestinal motility History Instruct patient to:
related to ANS Subjective symptoms Take stool softeners as needed
dysfunction Assessment Eat high-fiber foods
Neurotoxic effects of Increase fluid intake
plant alkaloids
Toxic effect of chemo
Fatigue (anemia) Bone marrow CBC Monitor H&H
depressed secondary Administer iron supplements and erythropoietin
to chemo/rad therapy Encourage intake of foods that promote RBC
Cause Lab test to Dx Nursing Management
Skin changes (e.g.) Desquamation/ Radiation Physical exam Alert patient to potential skin changes
Rash Chemotherapy Assessment Keep treatment field protected; do not apply any
Induced lotions, creams, cosmetics, or other products
unless prescribed by physician.
Symptomatic management
Avoid sun exposure
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N/V Release of History Teach patient to eat and drink when not
intracellular Subjective/objective nauseated
breakdown products symptoms Administer antiemetic prophylactically prior to
stimulates vomiting Assessment chemo and as needed
center in the brain Use of diversional activities (if appropriate)
Destruction of GI
lining from chemo
and radiation
Neutropenia Depression of bone CBC, ANC Monitor WBC count, esp neutrophils
marrow secondary to Teach patient to report tempt elevation and any
Chemo/rad therapy other manifestation of infection
Infection most Teach pt to avoid large crowds and people with
frequent cause of infection
morbidity and death Administer WBC growth factors

Thrombocytopenia Bone marrow CBC, PT, PTT, INR Observe signs of bleeding
depression secondary • Observe for black, tarry bowel
to chemo • Black or bloody vomit
Malignant • Bruising or small red spot on skin
infiltration of bone • Bleeding in the mouth
marrow that crowds • HA or changes in vision
out normal marrow • Difficulty talking, weakness of arms,
Feeling confused.
Monitor platelet count
Do not blow nose forcefully
Do not puncture your skin ex. tattoo
Soft bristle toothbrush
Avoid using medication that can prolong bleeding
such as aspirin
Shave with electric razor
Don’t bend your head below your waist
Do not pluck your eyebrow or other body hair
Ask your physician before invasive procedure—
dental cleaning, manicure, pedicure
Role change experienced Chronic illness, Psychosocial Therapeutic communication
hospitalization, lack assessment Referral to chaplain for spiritual support
of information Assessing for psychoemotional problems related
Fatigue to cancer and assisting patients in getting
appropriate help if necessary
Psychologic support
Nonpharmacologic intervention

1. How would this type of cancer currently be treated? (may require for you to do some research-your
text may be dated)
According to NCI website, different treatments are available for cervical cancer: some are standard
and some are clinical trials.
Standard treatments used are:
A. Surgery- removing the cancer in operation
• Conization
• Total hysterectomy
• Radical hysterectomy
• Bilateral Salphingo-oophorectomy
• Pelvic exenteration
• Cryosurgery
• Laser
• Loop electrosurgical excision procedure (LEEP)

A. Radiation therapy uses high-energy x-rays or other types of radiation to kill the cancer cells
or inhibit growth. The way it is given depends on the type and stage of the disease.
• External – uses a machine outside the body to send radiation toward the cancer
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• Internal uses a radioactive device substance sealed in needles, seeds, wires or catheters
that are place directly into or near the cancer cells.
A. Chemotherapy- uses drugs to stop the growth of cancer cells either by killing the cells or
stop it from dividing. The way it is given depends on the stage of the cancer being treated.
• Systemic chemotherapy- when chemotherapy is taken by mouth or injected into a vein or
muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body
• Regional chemotherapy- when chemotherapy is placed directly into the spinal column,
an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in
those areas.
A. Palliative control still radical but local control help patient have a reasonably quality time
spent with family friends because of slow growth.

1. What assumptions did you make about care being administered by the doctor, and nurse caring for
In general, I think Vivian received a very poor care. No one had taken time to explain to her every
procedure, the course of treatment, results and what the next plan of action is. All was explained in
the beginning was that she is getting a full dose of chemo for 8 weeks and that’s it. It is a very long
treatment and expectations, choices might have changed along the way. Options should have been
presented carefully and she should have been given the chance to reevaluate her condition. Why is
there no case manager? It’s scary that she was put in the mercy of research without regards for her
being. This kind of patients who graciously volunteer for the sake of science should have the best
holistic care anyone can have. The team is made up of a specialist, a fellow and a nurse?

2. Describe at least 3 feelings elicited while you were watching the film.
I was sad that she did not get best quality of care, treatment and respect she deserves, angry that
research was more a concern than the patient condition, sorry that she chose to be alone and did not
have any support in such a critical time. If she had good family support, they could have helped her
explore other treatment modalities and not resigned to what was offered.

3. Name 3 cautions/advice/admonitions for a nurse caring for a patient with cancer like Vivian.
Cancer therapy patients are fragile, they are undergoing physical and emotional changes and so
nurses caring for these patients need to be compassionate, strong patient advocate, big on patient
teaching so they understand what is going on. Don’t assume because no matter how educated they
are they regress when they are sick, they become helpless and powerless. Promote patients self
preservation and dignity, be respectful.

4. What do you believe are some of the fears and barriers to discussions about death with a patient?
• Stage of coping and grief, if the family or the patient has not accepted the condition
• Different cultural beliefs- in some culture talking about it before it happens is like you are
asking for it.
• Impending death of love one may block comprehension-it is a very sensitive topic and you
need to have an open mind to discuss the issues
• Fear of showing emotions
• Lack of personal experience with death and dying can cause reluctance to discuss the topic
• Fear of not knowing the answer to questions or to be honest

1. What is the Patient Self Determination act? Did Vivian have an advanced directive? Would this have
changed the way she was cared for during her hospitalization? What is a health care proxy and why
is it important that this person be designated in addition to having an advanced directive.
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The Patient Self Determination act is a legislation that requires all health care agencies to give
written notice to patients upon admission of their right to
• Make a decision regarding their treatment.
• Accept or refuse own treatment
• Make an advance care directive

Vivian did not have an advance care directive until Suzy had talked to her. It was not explained to
her upon admission which is required by law. She did not seem to have anybody she wanted to notify
about her illness, but if somebody had explained to her about health proxy, she might have given it
some thought. She did finally have an order for DNR but it did not make a difference with an
unethical fellow worried about his research.

An advance health care directive is a kind of legal document that tells your doctor your wishes about
your health care. Advance directives can be general, with very few directions about your care, such
as a basic power of attorney for health care. The directive may just name a substitute person (proxy)
to make these decisions for you if you are unable to do so. Or it may include instructions along with
the proxy selection.

Health care proxy can be stated in the advance directive as a substitute person to make the decisions
regarding your care in the event that you are no longer capable of doing so.

One thing that is important and I am not sure of is that: was Vivian aware of her right to make
decision regarding her own treatment, whether to accept or refuse such. Had she known so, it may
have given her some strength, self preservation, power of being in control.