Question

Case Study No. 1
Sue Kim, 49 years of age, emigrated from South Korea to the
United States 6 years ago. Her family came to the US to
educate their children and moved in with family members in
Los Angeles. Sue and her husband graduated from a top-ranked university
in South Korea, and her husband also had a master’s degree in
business. However, their English skills were not adequate for
them to get jobs in the United States. Instead, they opened a
Korean grocery store with the money they brought from South
Korea, and they managed to settle down in Los Angeles, where a number of Koreans are living. They have two children: Mina, a 25-year-old daughter who is
now the manager of a local shop, and Yujun, a 21-year-old
son who is a college student. Both children were born in South
Korea and moved to United States with Sue. The children had
a hard time, especially Mina, who came to the United States in
her senior year of high school. However, the children finally
adapted to their new environment. Now, Mina is living alone
in one-bedroom apartment near downtown, and Yujun is
living in a university dormitory. The Kim’s are a religious family and attend their community’s
protestant church regularly. They are involved in many church
activities. Sue and her husband have been too busy to have
regular annual checkups for the past 6 years. About 1 year ago, Sue began to have serious indigestion, nausea, vomiting, and upper abdominal pain; she took some
over-the-counter medicine and tried to tolerate the pain. Last
month, her symptoms became more serious; she visited a local
clinic and was referred to a larger hospital. Recently, she was
diagnosed with stomach cancer after a series of diagnostics
tests and had surgery; she is now is undergoing chemotherapy. You are the nurse who is taking care of Sue during this
hospitalization. Sue is very polite and modest whenever you
approach her. Sue is very quiet and never complains about any
symptoms or pain. However, on several occasions, you think
that Sue is in serious pain, when considering her facial
expressions and sweating forehead. You think that Sue’s
English skills may not allow her to adequately communicate
with health care providers. Also, you find that Sue does not
have many visitors -only her husband and two children.

NCM 100 TFN – Case Study 1 Topic: Transitions Theory by Afaf Ibrahim Meleis
You frequently find Sue praying while listening to some
previous songs. You also find her sobbing silently. About 2
weeks are left until Sue finishes chemotherapy. You think that
you should do something for Sue so she will not suffer
through pain and symptoms that could be easily controlled
with existing pain-management strategies. Now, you begin
some preliminary planning. Answer the following Questions:
1. Describe your assessment of the transition(s) Sue is
experiencing. What are the types and patterns of transition(s)?
What properties of transitions can you identify from her case?
2. What personal, community, and societal transition
conditions may have influenced Sue’s experience? What are
the cultural meanings attached to cancer, cancer pain, and
symptoms accompanying chemotherapy, in this situation?
What are Sue’s cultural attitudes toward cancer and cancer
patient’s? What factors may facilitate or inhibit her
transition(s)?
3. Consider the patterns of response that Sue is showing. What
are the indicators of healthy transition(s)? What are the
indicators of unhealthy transition(s)?
4. Reflect on how Transitions Theory helped your assessment
and nursing care for Sue. 5. If you were Sue’s nurse, what would be your first
action/interaction with her? Describe a plan of nursing care for
Sue.

Answer 1

1)

To develop an individually-tailored dynamic risk assessment model following a multistep, multifactorial process of the Correa’s gastric cancer model.

Methods

First, we estimated the state-to-state transition rates following Correa’s five-step carcinogenic model and assessed the effect of risk factors, including Helicobacter pylori infection, history of upper gastrointestinal disease, lifestyle, and dietary habits, on the step-by-step transition rates using data from a high-risk population in Matsu Islands, Taiwan. Second, we incorporated information on the gastric cancer carcinogenesis affected by genomic risk factors (including inherited susceptibility and irreversible genomic changes) based on literature to generate a genetic and epigenetic risk assessment model by using a simulated cohort identical to the Matsu population. The combination of conventional and genomic risk factors enables us to develop the personalized transition risk scores and composite scores.

Types of stomach cancer

About 90-95% of gastric cancers arise from the lining of the stomach, called adenocarcinoma. There are other cancers that can arise in the stomach, including gastrointestinal stromal tumors, lymphoma and carcinoid tumors, among others.

World Health Organization (WHO) classification recognizes four major histological patterns of gastric cancers: tubular, papillary, mucinous and poorly cohesive, along with some less uncommon histological variants .

2)Gastric cancer is one of the leadings cause of cancer worldwide. However, Koreans have the highest reported incidence of this deadly disease. Risk factors predisposing to the formation of gastric cancer include a combination of environmental risks, such as diet and infection (Helicobacter pylori), and, in some cases, genetic predisposition. Early screening and detection is essential to reduce gastric cancer mortality. The low prevalence and late onset of gastric cancer in Americans, compared to Korean Americans, however, has hindered our ability to risk stratify, screen, and improve early detection in Korean Americans, thereby contributing to the increasing mortality in this group. Gastric cancer control must focus on improved medical technology, in combination with community outreach, education, and awareness. Korean community services, church-based groups, media campaigns, medical communities, both academic and community based, and industry collaborations are essential to heighten awareness about gastric cancer in Korean Americans. Efforts to reduce the burden of gastric cancer in Korean Americans must focus on the dissemination of information to those most affected by the disease and those serving this community.

Regional high-risk groups are those from countries with high gastric cancer prevalence, in particular Koreans and AAPIs.

The prevention of gastric cancer requires two steps: primary prevention, consisting of lifestyle modifications or chemoprevention, including the treatment of H. pyloriinfection; and secondary prevention, which includes screening and surveillance. The rationale for chemoprevention of gastric cancer is that between 50 and 80%, or more, of all cases of gastric cancer are associated with diet. Many studies have shown this link. Pickled foods, smoked foods, and highly salted and preserved foods can all release carcinogens once they are metabolized in the stomach. Constant exposure of the lining of the stomach to such foods allows for the production of carcinogens, which result in mutations and histologic changes. In addition to food products, the way in which food is consumed may also impact the risk of gastric cancer; for example, very hot-temperature foods and rapid food consumption may be detrimental.

At the same time, some foods may reduce the risk of gastric cancer. Diets high in fresh fruits and yellow and green vegetables have been shown to be effective in cancer reduction by reducing food-derived carcinogens. The roles of green tea and garlic are unclear. Nutritional supplements with beta carotene (30 milligrams/day) or vitamin C (1 gram/day) have shown a 5-fold regression of atrophic epithelium, while the treatment of H. pyloriinfection in the same studies showed a 4.8-fold regression. Many potential chemoprevention agents are being studied. Cox-2 inhibitors, which are commonly used for arthritis management, rofecoxib, celecoxib, other nonsteroidal anti-inflammatory agents such as ibuprofen, and aspirin may all be important in the prevention of gastric cancer.

Secondary prevention of gastric cancer is less clear cut. No randomized control trials have been done to show a decrease in mortality by screening for gastric cancer. Failure to identify early gastric cancer in the United States is most likely due to several factors, including low incidence in the majority population, the lack of risk stratification, and the lack of aggressive screening. Japan, on the other hand, has the lowest mortality rates for gastric cancer worldwide. In 1960, Japan instituted a national, mass gastric cancer screening program in which everyone older than 40 was screened for gastric cancer by x-ray. Most studies showed a two-fold decrease in mortality for those who were screened versus those who were unscreened, largely owing to the early detection of disease. Unfortunately, in the United States, less than 10 to 20% of all gastric cancers are found in the early stages, and the 5-year survival rate is equally low. In Japan, however, where mass screening is done, 40 to 50% of all gastric cancers are found in the early stages, with a 5-year survival rate of 53%. My conclusion is that, in the right setting, screening seems to make a big difference.

3)

This year, an estimated 27,600 (16,980 men and 10,620 women) in the United States will be diagnosed with stomach cancer.

It is estimated that 11,010 deaths (6,650 men and 4,360 women) from this disease will occur this year.

Stomach cancer occurs most often in older people. About 60% of people who are diagnosed are older than age 64. The average age of diagnosis is 68.

The incidence of stomach cancer varies in different parts of the world. Although stomach cancer has decreased in the United States by 1.5% annually over the last decade, it is still common in other countries and one of the top causes of cancer deaths worldwide.

The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. The 5-year survival rate for people with stomach cancer is 32%. This statistic reflects the fact that most people with stomach cancer are diagnosed after the cancer has already spread to other parts of the body. If stomach cancer is found before it has spread, the 5-year survival rate is generally higher but depends on the stage of the cancer found during surgery.

If the cancer is diagnosed and treated before it has spread outside the stomach, the 5-year survival rate is 69%. If the cancer has spread to surrounding tissues or organs and/or the regional lymph nodes, the 5-year survival rate is 31%. If the cancer has spread to a distant part of the body, the 5-year survival rate is 5%.

4)Transitions are triggered by critical events and changes in individuals or environments. The transi- tion experience begins as soon as an event or change is anticipated. Though human beings always face many changes throughout the lifespan that trigger internal processes, nurses come face to face with people going through a transition when and if it relates to their health, well-being, and their ability to take care of themselves. In addition, nurses deal with the environments that support or hamper per- sonal, communal, familial, or population transi- tions. To capture the definition, meaning, condi- tions, and outcomes of transitions, it helps to have frameworks that provide coherence and direction from which to ask questions and develop re- search programs.
Transitions have been defined many different ways. A common definition used in this text is that it is a passage from one fairly stable state to another fairly stable state, and it is a process triggered by a change. Transitions are characterized by different dynamic stages, milestones, and turning points and can be defined through processes and/or terminal outcomes.
This section presents theoretical articles that were published to describe transition, define transi- tion as a central concept in nursing, and detail the emerging middle-range theory of the transition ex- perience. I trace the beginning of the theory of transitions from conceptualizing the potential prob- lems that individuals may suffer from if they are not properly prepared for a transitional experience (role insufficiency), and describe the development of preventative as well as therapeutic intervention (role supplementation). The emergence of transi- tion as a nursing concern, the supporting centrality of the concept in nursing through an extensive liter- ature review, as well as the evolution of transition theory from concept to theory over 3 decades of thinking and writing about transitions are all re- flected here. The chapters in this section represent the development of transition theory over 3 de- cades. Therefore, the sequence of the articles in these two chapters reflects the historical evolution of the theory ending with an integrative review of literature related to transitions.

5)Try to understand suis problem and give her confidence and strength to over come the pain.

1. Monitor nutritional intake and weigh patient regularly.
2. Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin and prealbumin levels to determine if protein supplementation is needed.
3. Provide comfort measures and administer analgesics as ordered.
4. Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to protect skin, and to promote comfort.
5. Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.
6. Provide oral care to prevent dryness and ulceration.
7. Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral nutrition, if ordered.
8. When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and progress slowly.
9. Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping syndrome because of excessively rapid emptying of gastric contents.
10. Administer protein and vitamin supplements to foster wound repair and tissue building.
11. Eat small, frequent meals rather than three large meals.
12. Reduce fluids with meals, but take them between meals.
13. Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically induced pernicious anemia.
14. Encourage follow-up visits with the health care provider and routine blood studies and other testing to detect complications or recurrence.