Introduction
Malignant pleural effusion (MPE) is a complication of advanced cancer commonly encountered in the palliative care setting, and is often the cause of a significant reduction in the patient’s quality of life. This study will describe three cases and review the evidence regarding the management of MPE.
Case Presentation
Case 1
Mrs A is an 83 year old female. She initially presented with significant ascites and investigations revealed an elevated tumour marker (CA-125). Computed tomography (CT) imaging demonstrated a mass in the right ovary. She underwent therapeutic and diagnostic paracentesis which established a diagnosis of metastatic ovarian adenocarcinoma. Palliative chemotherapy was considered not to be indicated . Three months later she represented with worsening dyspnoea due to a large right pleural effusion. 1500mL of pleural fluid was drained by thoracocentesis. She represented again two weeks later with further dyspnoea from a recurrence of her right pleural effusion. An intercostal catheter was inserted by the cardiothoracic surgeons. Six weeks later she was referred to the palliative care service and admitted with dyspnoea. A chest x-ray showed a new large left sided pleural effusion, and this too was drained via thoracocentesis. Her right intercostal catheter was removed during this same particular admission as it had become infected and was discharging frank pus. No pleural fluid was sent for laboratory testing as it was presumed to be a malignant effusion given that she had previously had malignant ascites. In addition, the unilateral and sequential nature of the pleural effusions made them unlikely to be due to congestive cardiac failure. After a further five months at home Mrs YG was readmitted to hos...
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God tells his children, “He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away” (Revelation). Death is one of the most frightening and confusing times a person can go through. Watching a loved one pass away is also one of the hardest trials a person can experience. Many people assume that death is a time of pain and the only thing that they can do is mourn and watch their loved one fade away from the earth. This is wrong. There are ways that people can turn a bad situation to good. Dying doesn’t have to be painful and full of suffering. The County Hospice staff makes sure of this. The Hospice staff not only takes care of passing patients physically, but they also take care of the patients emotionally and spiritually. Hospice staff also plays a key role in helping families during the grieving process.
Pritesh has a previous medical history of asthma and has experienced right-sided haemothorax as he got hit by a hockey ball during a competition. Currently, the nurse suspects that Prithesh may be developing tension pneumothorax which is a life-threatening medical emergency (Brown & Edwards, 2012). Tension pneumothorax develops when a hole in the airway structures or the chest wall allows air to enter but not leave the thoracic cavity (Rodgers, 2008). The pressure in the intrathoracic space will continue increase until the lung collapses, place tension on the heart and the opposite lung leading to respiratory and cardiac function impairment, and eventually shock may result (Professional guide to pathophysiology, 2011; Rodgers, 2008). Tension pneumothorax usually results from a penetrating injury to the chest, blunt trauma to the chest, or during use of a mechanical ventilator (Brown & Edwards, 2012; Rodgers, 2008).
Healthy lung tissue is predominately soft, elastic connective tissue, designed to slide easily over the thorax with each breath. The lungs are covered with visceral pleura which glide fluidly over the parietal pleura of the thoracic cavity thanks to the serous secretion of pleural fluid (Marieb, 2006, p. 430). During inhalation, the lungs expand with air, similar to filling a balloon. The pliable latex of the balloon allows it to expand, just as the pliability of lungs and their components allows for expansion. During exhalation, the volume of air decrease causing a deflation, similar to letting air out of the balloon. However, unlike a balloon, the paired lungs are not filled with empty spaces; the bronchi enter the lungs and subdivide progressively smaller into bronchioles, a network of conducting passageways leading to the alveoli (Marieb, 2006, p. 433). Alveoli are small air sacs in the respiratory zone. The respiratory zone also consists of bronchioles and alveolar ducts, and is responsible for the exchange of oxygen and carbon dioxide (Marieb, 2006, p. 433).
Although lung cancer is generally operable, by using either traditional open surgery, or one of the less intrusive and more sophisticated video-assisted thoracoscopic surgeries (VATS), often it may not be considered to be the best option for a patient. Where ill-health is a factor, or either the size and location of the tumor is deemed to be a consideration, other forms of treatment may well have to be considered.
Christ, G., & Blacker, S. E. (nd). Social Work’s unique Contribution to Palliative Care. Council on Social Work Education, CWSE Gero-Ed Center, National Center for Gerontological Social Work Education. Retrieved from http://www.cswe.org/CentersInitiatives/CurriculumResources/MAC/Reviews/Health/22739/22741.aspx.
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings.
In normal breathing, the lungs expand and contract easily and rhythmically within the ribcage. To facilitate this movement and lubricate the moving parts, each lung is enveloped in a moist, smooth, two-layered membrane (the pleura). The outer layer of this membrane lines the ribcage, and between the layers is a virtually imperceptible space (the pleural space), which permits the layers to glide gently across each other. If either of your pleurae becomes inflamed and roughened, the gliding process is impeded and you are suffering from pleurisy. Pleurisy is actually a symptom of an underlying disease rather than a disease in itself. The pleurae may become inflamed as a complication of a lung or chest infection such as pneumonia or tuberculosis, or the inflammation may be caused by a slight pneumothorax or chest injury. The pleural inflammation sometimes creates a further complication by causing fluid to seep into the pleural space, resulting in a condition known as pleural effusion. However, pleurisy is not the only condition that can lead to pleural effusion, it may also be produced by diseases such as rheumatoid arthritis, liver or kidney trouble or heart failure. Even cancer spreading from the lung, breast or ovary can cause pleural effusion. If you have pleurisy, it hurts to breathe deeply or cough, and chest pain is likely to be severe. Accompanying the pain are any other symptoms associated with the underlying disorder. The pain will disappear if a pleural effusion occurs as a consequence of pleurisy, because fluid stops the layers of the pleura from rubbing against each other; however, you may become breathless as the fluid accumulates. In most cases, the risks are those of the underlying cause. A big pleural effusion can compress the lungs and cause breathlessness. Any effusion may lead to empyema. A chest X-ray examination may be required.
...s. A pleural effusion is a collection of fluid next to the lung. When there are acids build up in your blood and urine, this is a complication of diabetes known as diabetic ketoacidosis.
...ents are diagnosed at a late stage when any curative method of treatment is not possible. Lung cancer is dangerous, it takes more lives per year than breast cancer, colon cancer, and prostate cancer combined. It’s harder to treat lung cancer than these other types of cancers. The last additional fact I learned was that every year in the United States about 200,000 people are diagnosed with lung cancer, and more than 159,000 die from this disease.
There are different types of pain which may be suffered by an individual with cancer, with some patients suffering only one type of pain, but others experiencing a range of all three types. Identifying the type of pain suffered is the first major step in ensuring effective treatment, as not all respond to different treatments in the same way (De Conno & Caraceni, 1996, p.9).
It is a common disorder that develops in cancer patients. According to the American Cancer Society, “Twenty-five percent of cancer patients develop depression, which is 7% of the general population” (qtd in Jennings). It can cause a loss of focus, feelings of sadness, and a sense of being “trapped”. Depression can also affect the recovery time of cancer patients after surgery or chemotherapy. Those who are trying to recover from surgery that have depression are more likely to have complications and have a more extensive visit to the hospital.. A study in Great Britain showed that those with moderate to severe depression or anxiety were more likely to have complications in their surgery and have a more extensive stay at the hospital (Britteon). The most widely used treatment for depression is antidepressant medications (ADM). ADM work by creating a balance of neurotransmitters in the brain that help improve mood, sleep, and appetite. Although, they can cause headaches and insomnia as well as “reduced blood clotting capacity because of a decreased concentration of the neurotransmitter seretonin in platelets” (What Are the Real Risks of Antidepressants?). ADM can also lead to a dependence on the medication or a drug tolerance where the brain does not respond to it over a long period of time. Although this is the largest treatment for treating depression, music therapy shows
In review conducted by the Cochrane Collaboration, it was found that performing airway clearance techniques on patients with an acute episode of COPD reduced the likelihood of mechanical ventilation, as well as the length of time ventilation was needed (2012, p. 2).
My earliest experiences of observing nursing in action occurred during my last two years of high school. My father was diagnosed with cancer during the spring of my junior year and died right before my senior year. During that short time I watched as the nurses cared for him and I could see compassion and empathy in the way they looked at him. It never occurred to me until after I had raised my children that I wanted to be able to help people in the same way those nurses helped my dad. But now when I tell people that I want to be an oncology nurse, people often respond by saying that they would never choose that type of nursing. They say that they could not stand to watch their patients die so frequently. Their reactions, along with this course in death and dying, have made me question how I might be able to bear the challenges of nursing in an area where death of my patients may be common. I believe that oncology will be a positive specialty to work in because of the consistent advances in prevention, early detection, and treatment of cancer. Furthermore, I believe that William Worden’s four tasks of mourning as presented in our text book is a good framework for the oncology nurse to use in order to cope with the repeated losses inherent in this type of nursing (Leming and Dickinson, 2011).
... that the nurse or family can do. The goal for palliative care is to make the patient’s passing as comfortable and relaxing, as possible. Medication management should be provided for every patient that is having pain to allow for a more comforting, pain-free, and peaceful death.
Hinkle, Janice, and Kerry Cheever. “Management of Patients with Chronic Pulmonary Disease." Textbook of Medical-Surgical Nursing, 13th Ed. Philadelphia: Lisa McAllister, 2013. 619-630. Print.