Transcript Applying the Nursing Process to Patient #2

How to Effectively Apply the
Nursing Process to the
Cannabis Patient
Copyright, June 4, 2016:
Leslie Reyes Waddington, RN
How to Effectively Apply the Nursing Process to
the Cannabis Patient
› The nursing process can be effectively applied to a patient using cannabis therapeutics, if the nurse
understands a few basic things about the cannabis plant and the human endocannabinoid system.
› By the end of this workshop, the Nurse will be able to effectively apply the nursing
process to the cannabis patient.
› The following topics will be discussed in this lecture…
1. What is the Endocannabinoid System?
2. What are Cannabinoids?
3. What are Phytocannabinoids vs. Endocannabinoids?
4. What effects does THC have on the body?
5. What effects does CBD have on the body?
6. What is the difference between cannabis Indica and cannabis Sativa?
7. What is the “Entourage Effect”?
8. What are the benefits versus drawbacks of inhaled cannabis?
9. What are the benefits versus drawbacks of ingested cannabis?
10. What do I need to assess in order to determine if my patient is a good candidate for the legal
program in their area?
Why is this education needed
As of the date of this article lecture, some form of
medical cannabis is legal in twenty-four states, and
Washington D.C., and is legal for recreational
purposes in at least two states (National Conference
of State Legislature, 2016).
However, cannabis is still classified on a federal
level as an illegal schedule I drug, along with
heroin. (Drug Enforcement Agency, 2016)
The DEA defines cannabis as a highly addictive, toxic
substance with no medicinal value (DEA, 2016)
Why is this education needed?
› More and more people, particularly those who have not found
relief from standard western health care protocols, are looking
for alternatives, such as acupuncture, Ayurveda (traditional Indian
medicine), Chinese herbal medicine and cannabis therapies.
Currently, there are a lack of professional healthcare staff who
understand the application of cannabis as medicine.
› In 2013, high profile physician and CNN’s Chief Medical
Correspondent, Sanjay Gupta, published an editorial titled “Why I
Changed My Mind on Weed”, followed by documentaries which
showcased the potential healing properties of cannabis. This
brought knowledge of medical cannabis into the mainstream.
Why is this education needed?
›
Currently, there are no standard treatment protocols or formal
training on the endocannabinoid system in American Medical Schools
or in Canada (Allen, Stewart, Colombe, & Mullins, 2013).
›
Without standard protocols in place, our current healthcare institution
is unable to care for the cannabis patient in a responsible manner
(Ziemianski, Capler, Tekanoff, Lacasse, Luconi, & Ware, 2015).
› Furthermore, the health care providers’ current inability to answer
patients’ questions about delivery methods and dosing options leaves the
patient feeling distrustful of the health care provider, as well as the health
care institution in general.
› The more patients turn to people outside of the health care field for
answers about cannabis, the less they trust the traditional, western health
care institution.
Why is this education needed?
› David Allen, M.D., a retired cardiovascular surgeon from
Sacramento, California, held a survey to study the state of education
on ECS science in American medical schools.
› Dr. Allen’s team contacted 157 accredited Medical Schools across all 50 states, by
phone and then followed up by e-mail.
› The researchers asked these learning institutions three questions:
– If they had a department of endocannabinoid science with a director,
– If they taught endocannabinoid science as an organized course, and
– If they mentioned the endocannabinoid system in any ancillary classes.
› Out of the 157 surveyed accredited medical schools in the United States, not one of
them had a department of endocannabinoid science or an ECS director.
› None of the schools surveyed are teaching endocannabinoid science as an organized
course.
› Only 13.3% (21 of the 157 schools surveyed) mention the endocannabinoid system in
an ancillary course (such as neurology, pathophysiology, pharmacology, etc.)
Why is this education needed?
› This means, less than 14% of accredited medical schools in the United States of
America are teaching our future physicians and healthcare professionals about the
endocannabinoid system. (Allen et al., 2013)
› The education on ECS in Canada is not much better. Cannabis has been legal in Canada
since 1999, and yet, in an article published by BioMed Central of a nationwide survey of
Canadian physicians, there was a lack of knowledge regarding dosage, delivery options,
creating treatment plans, and a misunderstanding of the difference between cannabis
as an herbal medicine and using prescription synthetic cannabinoids. (Ziemianski et al.,
2015).
› A Lack of Education on ECS Science Affects Patients’ Attitudes and Trust. Patients who
live in one of the twenty-four states where cannabis is legal may have safe access to a
variety of medicinal products made from cannabis.
› Unfortunately, product availability, as well as legality of different forms, varies from
state to state (NCSL, 2016). In addition, the patients in these states still do not have
easy access to reliable information from true healthcare professionals, and are often
left to come up with their treatment protocols based on a dispensary worker or
“budtender’s” recommendations. (Allen et al., 2013)
Cannabis Basics: What Every Nurse Needs to
Know Before Working with the Cannabis Patient.
What is the Human Endocannabinoid System? (Sulak, 2015)
› The endocannabinoid system (ECS) is a major system of neurotransmitters and
receptor sites which exists in the human body and all living vertebrae (Sulak, 2016).
› Also known as the endogenous cannabinoid system, the ECS was discovered over
twenty years ago in July of 1990 by a group of scientists working for the National
Institute of Mental Health. (Grotenherman & Müller-Vahl, 2012).
› The entire human body contains receptor sites for cannabinoids, including major
organs, such as the brain, immune cells, and glands. Cannabinoids are chemical
compounds which interact with those receptor sites and help the body maintain
homeostasis (Sulak, 2016).
› CB1 and CB2 receptors are the most prominent cannabinoid receptors.
– CB1 receptors are involved in our sleep cycles, hunger and metabolism, memory, mood, and pain
sensory.
– CB2 receptor sites exist in our immune cells, and when activated, have the ability to fight
inflammatory disease responses, including the apoptotic cell death of cancer cells (Chakravarti,
Ravi, & Ganju, 2014).
Cannabis Basics: What Every Nurse Needs to
Know Before Working with the Cannabis Patient.
› Cannabinoids can be created by our own bodies
(endocannabinoids), created by plants (phytocannabinoids) such as
those found in the cannabis plant and other plants (Gertsch,
Pertwee, & Di Marzo, 2010), or those created in a lab (synthetic
cannabinoids), such as dronabinol, a synthetic form of
tetrahydrocannabidiol (THC) which is found in both the cannabis
plant (D9-THC) and made by the human body in the form of
“anandamide” (Grotenherman et al., 2012).
› The endocannabinoid system is believed to be responsible for
promoting homeostasis in the body, which would make it one of
the most important physiological systems involved in maintaining
human health. (Sulak, 2016)
Cannabis Basics: What Every Nurse Needs to
Know Before Working with the Cannabis Patient.
› What are Cannabinoids?
› Cannabinoids, the active compounds found in the cannabis
plant, promote homeostasis at every level of biological life,
from the sub-cellular, to the entire organism.
› These are the compounds which bind to the cannabinoid
receptors in the human cannabinoid system.
› There are over 130 compounds in the cannabis plant.
The two cannabinoids every health care professional should know about
are:
“Delta-9 Tetrahydrocannabidiol” (THC)
and
“Cannabidiol” (CBD)
Some of the Effects of THC:
Analgesic
Anti-emetic
appetite stimulant
anti-depressant
anti-proliferative
Some of the Effects of CBD:
Analgesic
Antibacterial
Anti-diabetic
Anti-ischemic (reduces risk of
artery blockage)
Treats psoriasis
Anti-anxiety
Neuroprotectant
What is the “Entourage Effect”?
o Cannabinoids do not work as well when synthesized and
isolated.
o For instance, CBD is not as effective without some THC, and
THC is not as effective without some CBD.
o Full plant extractions or full plant based medicines are the
most effective
o When the cannabinoids of the cannabis plant work together,
this is known as “The Entourage Effect”. (Sanjay Gupta, 2013)
What are Cannabinoid Receptors?
Cannabinoid receptors are present throughout the body, and are
believed to be more numerous than any other receptor system.
Researchers have identified two main cannabinoid receptors:
o CB1, predominantly present in the nervous system, connective
tissues, gonads, glands, and organs; and
o CB2, predominantly found in the immune system and its
associated structures.
o Many tissues contain both CB1 and CB2 receptors, each linked to
a different action. Researchers speculate there may be a third
cannabinoid receptor waiting to be discovered.
What are Endocannabinoids?
› Endocannabinoids are the substances our bodies naturally
make to stimulate these receptors.
› The two most well understood of these molecules are called:
•
Anandamide (from the Indian word “Ananda=Bliss”)
and
•
2-arachidonoylglycerol (2-AG).
Delivery systems: In what forms can a patient take
cannabis?
o Inhaled: Vaporized, Smoked
o Dried Flowers: “Joint” cigarettes, Water pipes “bongs”, pipes, vaporization
machines, vaporizer pens
o Oils and extractions (hash, trichromes) can be inhaled: E-cigarettes, oilvaporizers
o Ingested: Edibles, pills, oils
o Absorbed: Suppositories, topicals (lotions and oils on the skin),
tinctures (under the tongue)
o Cannabis cannot be injected or administered via IV.
What are the benefits of inhaled vs. edible cannabis?
Inhaled (vaporized or smoked):
› Benefits: Easy for the patient
to self-titrate the dose, Use
minimum dosage for
maximum effects, Difficult to
overdose, no evidence of
permanent lung damage, no
risk of lung cancer
› Drawbacks: Bronchial
irritation and infection, odor
from smoke/vapor, dry cough,
shorter duration of action
Edible or ingested:
› Benefits: No irritation to
lungs or respiratory tract,
longer duration of action
› Drawbacks: Hard to titrate,
easy to “overdose”,
unpleasant side effects if
taken too much, expensive
(need more plant material
when ingesting than if
inhaling)
Reviewing the Nursing Process:
A.D.P.I.E.
› Or: Assess, Diagnose (Nursing Diagnosis vs. Medical
Diagnosis), Plan, Implement, Evaluate
NURSING CARE PLANS
› For patients who may benefit cannabis therapeutics
Applying the Nursing Process and Treatment Plan
for Patient #1 “MJ”
› Client’s Primary
Medical Diagnosis
› Secondary Medical
Diagnosis
› Acute Renal Injury
› Microlytic Anemia
These are the Nursing Diagnoses related to this
patient’s disease process:
#1 Nursing Diagnosis: Less Than
Body Requirements: Weight Loss,
Nausea, Vomiting.
Related to: Acute Renal Failure
NSAID use (10x 200 mg tablets per
day x 2 weeks).
As evidenced by: Increased BUN
and serum creatinine, decreased
intake and output, weight loss of
10 lbs in two weeks.
#2 Nursing Diagnosis: Chronic Pain
Related to: History of neck injury,
car accident____
As evidenced by: Patient stating
pain above 5 on a 0-10 scale,
patient grimaces.
Nursing Care Plans for the Cannabis Patient:
Goals, Objective and Subjective Data
Patient #1 “MJ” (continued)
Goal(s):
› Patient will report an increase in appetite, and evidence of increased intake and output levels.
› Patient will report a decrease in nausea and vomiting and an increase in appetite
› Patient will achieve optimal urinary elimination as evidenced by: urine output greater than 30 mL/hr,
electrolytes and BUN within or near normal limits, and normal specific gravity.
› Patient will report pain less than 5 on a 0-10 pain.
Objective Data:
› Labwork: BUN levels, serum creatinine levels, electrolyte levels, urine specific gravity levels, decreased input
and output, kidney stones 2 years ago, vomiting. Loss of 10 pounds in two weeks.
Subjective Data:
› Patient states that she was taking 10 tablets of OTC ibuprofen (equivalent to 2,000 mg) per day for two
weeks.
› Patient states she suffered a neck injury during a car accident 1 year ago.
› Patient complains of chronic pain (5 or greater, usually an 8 on a scale of 0-10), vomiting, weight loss and
nausea. Patient states, and records show, that she has lost approximately 10 pounds in two weeks.
The Physician would like to offer a recommendation to the patient for
medical cannabis:
The Nurse Must Assess the following:
› Is there a legal cannabis program in your State?
› Is chronic pain a legal qualifying condition?
› Is the patient a good candidate for the medical cannabis program?
› Has patient used in the past and if yes, was the experience negative or positive?
› How much does the patient already know about cannabis and how to use it?
› Can the patient inhale vaporized cannabis or smoke? Or can the patient ingest or use a sublingual
tincture? Are these legal and available in your State?
› Is the patient capable of caring for themselves, or will they need a caregiver involved?
› Will the patient be able to afford the medicine needed under their State’s current medical cannabis
laws?
› Does the patient have a caregiver willing to help with the process of becoming a medical cannabis
patient?
Applying the Nursing Process to the Patient:
“Assess”
Assess the needs of the patient: The patient is suffering from
Acute Renal Injury from taking 30% or more over the
recommended dosage of OTC NSAIDs.
Patient is suffering from chronic pain and misuse of NSAIDs.
The doctor has ordered that the patient refrain from using
NSAIDs.
Applying the Nursing Process to the Patient:
Diagnose
What are the Nursing Diagnoses?
The medical diagnosis is acute renal injury, but the nursing diagnoses are
the symptoms related to the medical diagnoses which the nurse must help
the patient manage.
The patient is suffering from weight loss, lack of appetite, nausea,
vomiting, and chronic pain.
The Nursing diagnoses are: Less than body requirements, nausea and
vomiting, anorexia, and chronic pain.
How will the nurse help the patient manage her chronic pain?
• Cannabis is a good option because it does not cause to renal injury, even when used
above recommended dosages (citation needed).
How will the nurse help the patient manage her nausea, vomiting and
weight loss?
• Not only is cannabis good for pain management, it also helps with nausea, vomiting
and weight loss (citation needed).
Applying the Nursing Process to the Patient:
“Plan”
› Once the nurse assesses the patient and has determined that she is a good candidate for the State’s Medical cannabis program,
the nurse, and patient if possible, need to come up with a treatment plan.
a. Is the patient’s current attending physician qualified under the State’s program to write a recommendation for cannabis?
›
If Yes, the physician writes a Letter of Recommendation. At the time of this publication (June, 2015), Cannabis is still
listed as a Schedule I drug, and it is therefore still illegal to write a PRESCRIPTION for cannabis. It can only be
recommended, not prescribed. (In some States, Physicians Assistants and Nurse Practitioners may write a letter
recommending cannabis. )
›
If No, then a qualifying physician must be sought: In some States, physicians and patients may be required to register
onto a physician or patient registry and pay a registration fee.
b. Is the patient comfortable with using medical cannabis?
Social Stigma?
Negative past experiences?
Problem inhaling or ingesting medicines (cannabis based medicine cannot be given via IV or injection)?
Once it has been determined that the patient is a good candidate for the cannabis program, the patient has obtained a letter
recommending the use of cannabis from their physician, and has legally registered into the State’s Medical Cannabis Program (if
applicable), a source for medicine must be identified.
This patient in this scenario lives in the State of Colorado, where cannabis is legal in all forms for medical use and
recreational use. The patient has the option of becoming a medical patient, or obtaining medicine in a dispensary and
paying sales tax.
*Please note, in most States, Nurses and Physicians cannot identify or recommend a specific facility to a patient, as it is considered “aiding
and abetting”. Doctors and Nurses can educate the patient on where the resources are so they can find a facility themselves. PLEASE note the
local medical cannabis laws in your area.
Applying the Nursing Process to the Patient:
“Plan” (continued)
How will the patient obtain medicine?
 Caregivers/Private growers
 Collectives
 Dispensaries
Applying the Nursing Process to the Patient:
“Plan” (continued)
What products are available legally in your State?
 Tinctures
 Edibles
 Inhaled Full Plant Dried Flowers (smoked or vaporized)
 Tablets/Pills
 Oils
What products can the patient Tolerate?
 Can the patient eat?
 Can the patient inhale vapor or smoke?
 Does the patient have, or can they obtain, the appropriate delivery system tools?
Does the patient have a caregiver who can help them obtain and use these, if the
patient needs help?
Applying the Nursing Process to the Patient:
“Plan” (continued)
If Smoking has been chosen:
 Will they use rolled “joints”? Does the patient know how to roll a “joint?”
 Glass pipes, water pipes, bubblers “bongs”**: Does the patient know how to properly use these? If so, can the nurse educate
the patient? If not, can the nurse provide the appropriate person to educate the patient?
 **Please Note: In some states it is still illegal to refer to water pipes as “bongs” when shopping for delivery devices.
Please advise your patient accordingly.
If Vaporization is chosen:
o Will the patient use an e-cigarette?
o Will the appropriate oils for this system be available?
o Will the patient need a vaporizing machine which vaporizes dried plant material?
o Can the patient afford the necessary “paraphernalia”
o Vaporizers can range in price from $200-$600 and health insurance does NOT cover these.
If Edibles are chosen:
o Is the patient diabetic, suffering from high cholesterol, or on any special diets which might forbid them to eat pastries or
edibles high in fat, sugar or carbohydrates?
o Does the patient have a digestive issue which might make eating difficult?
o Does the patient understand the importance of “titration”
 The nurse must educate the patient that ingesting cannabis can be difficult, because the medicine must go
through the entire digestive system before effects are achieved.
 It is important that a patient who is new to edibles starts out slowly eating a very small amount, and waiting at
least a half-hour/30 minutes, before taking another dose
 Additionally, there is now a focus on using the lowest possible dosage to treat the problem. Lowest dose is
equivalent to 2.5 mg-10mg THC. “Start low and go slow”.
Applying the Nursing Process to the Patient:
“Plan” (continued)
Which cannabinoids/stains will be most effective in treating the
patient’s particular nursing diagnoses?
 It’s important for the nurse to at least have a basic understanding of
Indica vs. Sativa Strains, or CBD-dominant vs. THC-dominant Strains.
 High CBD strains, or “Indicas” generally work on physical pain, and help
the patient to relax.
 High THC strains or “Sativas” generally work as a stimulant, and help to
elevate mood. They are also used as appetite stimulants.
Applying the Nursing Process to the Patient:
“Implement”
Patient #1:
› The patient has been given a letter from her qualifying
physician recommending the use of cannabis and is legally
registered in her State’s medical cannabis program.
› Once all the above variables have been assessed and
considered, the treatment plan can be implemented.
Applying the Nursing Process to the Patient:
“Implement”
In Patient #1’s Scenario:
 The patient is familiar with smoking and vaporization methods, has no
contraindications to this method, and is comfortable with it, as it will allow the patient
to titrate the dose.
 The patient has obtained dried plant material for vaporization. The patient has also
acquired the appropriate equipment to vaporize the medicine.
 The patient will be using both Indica (CBD dominant) and sativa (THC dominant)
strains to treat her pain (Indica/CBD) and her loss of appetite and nausea/vomiting
(Sativa/THC).
 The patient has been instructed on the proper use of the vaporizer, and has effectively
demonstrated back to the health care staff how to operate the vaporizer
 Patient has been instructed to vaporize approximately 1-1.5 grams of dried cannabis
per day, prn (as needed) when symptoms occur.
Applying the Nursing Process to the Patient:
“Evaluate”
Evaluate: After treatment has been implemented, the nurse and the
healthcare team evaluates the effectiveness of the treatment.
Patient #1:
 Two weeks after utilizing cannabinoid medicine, the patient
follows up with her primary care physician and reports that her
pain levels remain below a 5 on 0-10 scale 75-90% of the time.
 Patient also reports that her appetite has returned. Patient has
gained 3 lbs in two weeks.
 Patient is no longer using NSAIDS and feels the cannabis effectively
controls her pain.
 Treatment plan is determined to be successful
Problem:
Recommendation
Recommendation
Recommendation
The patient reports feeling a
dry throat and cough
immediately following
vaporization.
Advise the patient to turn the
heat down on the
vaporization machine and to
drink plenty of water while
medicating
Advise the patient to try a
sublingual tincture, or
supplement inhalation with
an oral preparation to cut
down on amount of
vaporizing or smoking.
The patient using edible
forms of cannabis complains
of feeling too “high”.
Advise the patient eat smaller
amounts and leave more time
between dosages
Assess the patient for inhaled
forms, explaining that it is
easier to titrate, harder to
overdose, and smoking and
vaporization are not linked to
permanent lung disease or
cancer.
Patient may want to try a
sublingual tincture
The patient states she
become paranoid even when
only inhaling small amounts
of medicine.
Assess if this happens after
patient uses Indica or Sativa,
suggest alternative strain
Sativas may cause paranoia,
advise patient to stick with
Indica or Indica hybrids if
Sativa is the cause
Remind patient that negative
side effects (both physical
and psychoactive) of cannabis
are temporary and will
eventually wear off.
Continued use of cannabis
lessons the psychoactive
effects as patients become
adjusted.
Applying the Nursing Process and Treatment Plan
for Patient #2 “TC”
Client’s Primary Medical
Diagnosis
Intraductal Breast Carcinoma,
right breast, ER+
Client’s Secondary Medical
Diagnoses
Anxiey, Depression, Pain
These are the Nursing Diagnoses related to this
patient’s disease process:
#1 Nursing Diagnosis: Body
Image Disturbance __
Related to: Positive breast
cancer diagnosis, scheduled
mastectomy
As evidenced by: Positive Biopsy,
Positive Scan for Intraductal
Breast Ca, ER+
#2 Nursing Diagnosis: Anxiety,
Depression, Insomia, Pain
Related to: Cancer diagnosis
As evidenced by: Patient stating
that she is depressed and having
trouble sleeping at night.
Patient anxious about diagnosis,
non-compliant, looking for other
options before undergoing
surgery.
Nursing Care Plans for the Cannabis Patient:
Goals, Objective and Subjective Data
Patient #2 “TC” (continued)
Goal(s):
Patient will verbalize understanding of disease process.
Patient will be involved in creating treatment plan, and verbalize understanding of the pros and cons of
treatment plan, and verbalize the importance of treatment compliance
Patient will report feeling less anxious about treatment plan.
Patient will report pain less than 5 on a 0-10 pain.
Patient will report sleeping through the night.
Objective Data:
Biopsy and labwork, pathology report: positive for stage 1 breast carcinoma in right breast, intraductal, ER+.
Patient’s speech is rapid. Patient becomes tearful easily.
Patient has cancelled and rescheduled surgery for her mastectomy once and Is stating that she wants to cancel
her surgery again.
Subjective Data:
Patient states that she has met some people who say they effectively treated their cancers with “cannabis oil”.
Patient states she has been unable to sleep through the night, and had suffered suicidal ideations.
Patient is concerned about being “disfigured” by the surgery.
Applying the Nursing Process and Treatment Plan
for Patient #2 “TC
Physician Orders:
 Patient should follow through with surgery.
 Physician has asked that the nurse assess the patient to see if
she is a good candidate for the State’s Medical Cannabis
program.
The Physician would like to offer a recommendation to the patient for
medical cannabis:
The Nurse Must Assess the following:
› Is there a legal cannabis program in your State?
› Is chronic pain a legal qualifying condition?
› Is the patient a good candidate for the medical cannabis program?
› Has patient used in the past and if yes, was the experience negative or positive?
› How much does the patient already know about cannabis and how to use it?
› Can the patient inhale vaporized cannabis or smoke? Or can the patient ingest or use a sublingual
tincture? Are these legal and available in your State?
› Is the patient capable of caring for themselves, or will they need a caregiver involved?
› Will the patient be able to afford the medicine needed under their State’s current medical cannabis
laws?
› Does the patient have a caregiver willing to help with the process of becoming a medical cannabis
patient?
Applying the Nursing Process to Patient #2:
“Assess”
Patient #2 “TC”, is suffering right intraductal breast carcinoma, stage
I, ER+, as well as anxiety, insomnia, and depression
a.
Assess if the physician could offer the patient medical
cannabis :
Is there a legal cannabis program in your State?
– In this Scenario, the patient lives in Pennsylvania, a State where medical
cannabis has not yet been legalized.
– The patient lives near the New Jersey state border, and stated that she
would be willing to move to New Jersey, where medical cannabis is legal.
› Is breast cancer a legal qualifying condition in the State of New
Jersey? Yes
› Are behavioral health issues a qualifying condition in the State of
New Jersey? No
Applying the Nursing Process to Patient #2:
“Assess”
Is the patient a good candidate for the medical cannabis program?
In patient #2 “TC”’s scenario:
– Has patient used in the past and if yes, was the experience negative or positive?
› Patient states she has never used recreational drugs in her entire life, and rarely uses prescription
or over the counter medications.
› Patient has tried legal herbal remedies in the past (i.e. chamomile, St. John’s Wort, Echinacea)
– How much does the patient already know about cannabis and how to use it?
› Patient states she “doesn’t know anything about it, except a few people I know had tried using
cannabis oils illegally and their doctors have told them they are cancer free now.”
– Can the patient inhale vaporized cannabis or smoke?
› The patient reports that she does not suffer from any chronic respiratory issues.
› Inhaled cannabis could treat symptoms related to the patient’s primary diagnosis (pain, depression,
insomnia), however, anecdotal evidence shows that cannabis oils with a 1:1 THC to CBD to 4:1 THC
to CBD ratio oils are preferred. In ER+ cancers (estrogen receptor positive cancers), anecdotal
evidence shows that a cannabis oil with at least a 1:1 CBD to THC (OR HIGHER CBD to THC ratio) is
preferred.
Applying the Nursing Process to Patient #2:
“Assess”
› In this patient’s Scenario:
› THE PATIENT’S BREAST CANCER IS ER+, AND THEREFORE, SHE
NEEDS A HIGHER PERCENTAGE OF CBD TO THC. THIS IS NOT
LEGAL IN PA OR NJ AT THE TIME OF THE PATIENT’S DIAGNOSIS.
– Or can the patient ingest or use a sublingual tincture? Are these legal and
available in your State?
› Oils, tinctures, edibles, extractions, etc. are all illegal under NJ’s medical cannabis
program.
› Only dried plant material is available
› THE PATIENT’S TYPE OF CANCER IS BEST TREATED WITH A FULL
PLANT CANNABIS OIL WITH A 1:1 CBD:THC RATIO. THIS IS NOT
LEGAL IN PA OR NJ AT THE TIME OF THIS PATIENT’S DIAGNOSIS
Applying the Nursing Process to Patient #2:
“Assess”
› The nurse concludes that “TC”, patient #2, will not benefit from the current
medical cannabis programs which are available to her at the time of diagnosis.
› The nurse reports to the physician that the patient will not be able to obtain
the correct medicine legally under the medical cannabis programs currently
available to the patient at the time of the diagnosis.
› The physician asks the nurse if Marinol would be a viable legal alternative for
the patient:
– Patient has a history of anxiety and insomnia. Some of Marinol’s potential side effects
include racing thoughts, anxiety and paranoia.
– The patient has ER+ carcinoma. Because ER+ cancers do not respond well to higher
doses of THC than CBD, Marinol is not favored.
› The nurse and physician determine they cannot offer any medically effective,
legal options to the patient which involve cannabinoid medicines.
› Under the current laws at the time of the patient’s diagnosis, patient would be
unable to legally obtain the proper medication.
Conclusion: How To Effectively Apply The Nurisng
Process to the Cannabis Patient
Conclusion:
There is a need for physicians, nurses, and other healthcare professionals
to understand the complexity of the needs of the patient who qualifies for,
or is already using, cannabis therapeutics. Delivery systems and titration
methods when dealing with herbal medications is so different from what
most people in Western society are comfortable with. Health care
professionals need to understand the proper way to assess and implement
a treatment plan so that the patient will be comfortable with their
treatment options, and for their treatment be most effective. It’s
important that the health care provider understand why certain delivery
systems may be favored over others, as well as effectively communicate
risks and benefits of using cannabinoid medicine.
References
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