Carol And Her Cancer Problems - Essay Example

Assignment 2: Case study Carol is a 48 year old woman who lives with her husband Dean and three children. Carol’s three children, Josephine (15 years), Harry (12 years) and Sarah (8 years) are aware their mother has cancer, but have not been told of the development of secondary disease or the implications this carries. The family run a small general store in an outer suburb of Perth. Carol was diagnosed with breast cancer three years ago, originally undergoing a right lumpectomy with adjuvant chemotherapy. Last year Carol was diagnosed with bone secondaries. Since that time she has been receiving tamoxifen and attending the oncology clinic for follow-up. The community palliative care nurse visits Carol once a month to monitor her progress and provide emotional support. While visiting Carol the nurse notes that she appears to be in considerable discomfort, though she denies any pain. On questioning Dean, the nurse learns that Carol has been found crying and holding her hip, but refuses to seek medical attention. 1. Why do you think Carol is reluctant to seek medical attention and acknowledge her pain? Carol’s children are young and she has not informed them of her vulnerability to opportunistic diseases. She does not want her children to know that her health is failing quickly. Going to a physician for check up would draw attention to the fact that her condition is not well. People might also not seek medical attention if they put the care of others first, as inferred in Carol’s hesitation. Studies show that people do not acknowledge their pain because they have children to take care of and other family members and do not want to worry them (Geraghty, 2010). 2. As Carol begins to receive palliative care, which members of the palliative care team do you think need to be involved in her care? Briefly describe the role of each. Palliative care is aimed to improve the quality of life of the patient and hence each of the members of the palliative care team will work in concert to achieve it. Members of the care team would include doctors, nurses, social workers and counsellor (American Academy of Family Physicians, 2009). Doctors and family doctors are primarily responsible for patient’s treatment. Nurses can work collectively with colleagues to provide nursing care and assist the family doctor in making decisions about the patient and convey the problems of the patient to the doctors. The social worker can assist the patient and family deal with the social and personal issues of the illness. Counsellors can provide the patient and the family with positive advice and help Carol to deal with her situation. Investigations of Carol’s pain revealed bony secondaries. She was offered a course of radiotherapy, but refused as this would mean going to the city (55km away) every day, and she would be away from the shop at the busiest time of the year. Carol agreed to recommencing chemotherapy, and was commenced on regular panadeine forte (two every four hours) for her pain. Carol has been troubled by nausea and vomiting after each course of chemotherapy. On a follow up visit five days after Carol’s last chemotherapy, the community nurse discovers that Carol is constantly nauseated, vomiting several times a day and unable to keep any fluids down. 3. Identify the possible causes of Carol’s nausea and vomiting. Panadeine Forte can cause constipation and vomiting and nausea in some patients; constipation itself can lead to nausea and vomiting. Moreover, Carol is most likely experiencing nausea and vomiting due to chemotherapy. The body reacts to chemotherapy drugs in the blood by activating its chemoreceptor trigger zone (CTZ). Activation of CTZ will induce the vomiting centre in the brain to cause the person to throw up. Smells, anxiety and pain can also cause Carol to throw up 4. Describe the management strategies for the various probable cause(s) of Carol’s nausea and vomiting. Carol can be prescribed medicines for her nausea and vomiting like Anti-emetics like Phenergen and Compazine and Diphenhydramine (Benadryl). Panadeine Forte can also cause constipation, which can leads to nausea and vomiting, and so if Carol is constipated, she could be treated for constipation. If chemotherapy is the main cause of her vomiting, Carol needs to avoid foods that make her feel sick and should have edibles and drinks that are easy on the stomach like soups, fruits etc. Carol should also split her meals in to five or six per day and ask someone else to cook for her if the smell of food makes her feel queasy. On a follow-up visit, the community nurse discovers that Carol is only achieving two hours pain relief after her tablets and is taking them more frequently, but is reluctant to consider changing to stronger medication. 5. Identify the appropriate steps for assessing Carol’s pain. Carol needs to be asked if she her pain effects her daily activities and prevent her from sleeping at night. Pain needs to be assessed by asking testing its intensity by using a zero-to-ten pain scale. The next step would include asking the patient about the location, frequency of the pain (if she has it daily)and its quality. After consultation with the general practitioner, the community nurse discusses changing Carol’s analgesia to something stronger. Carol is very reluctant as she feels she will only become addicted to ‘hard drugs’ if she uses them now. Carol expresses concerns about having this type of medication in the house with young children around. 6. What are the possible reasons for Carol’s reluctance to change her medication, and how could this be overcome? Carol feels that taking stronger doses of medicines can cause her to become dependent on them, and she will have to take increasing amounts of it to satisfy her needs. Moreover, she is scared that if the drugs fall in the hands of her children, they can cause serious health issues. Her fears can be alleviated by telling her that these drugs can not cause addiction, since addiction occurs when the user gets a high feeling from the drug and so is a misconception (F. A. Davis Company, 2005). Moreover, her children can be advised to not to touch her medicines. Carol can also keep her medicines in an isolated place in her room and advise her children not to eat any of her medicines. Carol reluctantly agrees to a trial of oral morphine, initially in short-acting form until the dose is titrated. She is commenced on 10mg of oral morphine 4th hourly. 7. What education should the nurse give Carol about commencing and taking morphine? First of all, the nurse needs to tell Carol that morphine can cause dependence. The nurse needs to direct Carol clearly on the timings and amount of morphine that she needs to administer. She should instruct her on patient education, like the drug dosage should not be altered, nor the frequency of administration; Carol is also to be advised on not chewing or crushing the capsule. Carol needs to avoid alcohol, and drink lots of fluid. The nurse also needs to inform Carol about the likely side-effects of morphine like blurred vision, dizziness, loss of appetite, nausea, vomiting and constipation (Merck & Co., Inc, 2010). 8. When should Carol be considered for conversion to controlled (slow) release morphine, and how would the dose be calculated for this? If Carol’s pain returns before the four hour break between administrations of morphine, then she can be considered for controlled (slow) release morphine. The dosage can be given after every 12 hours (one-half dosage) or 8 hours (one-third dosage). Since Carol’s daily requirement would be less than 120mg per day, she would be given the 30mg tablet strength of MS CONTIN for initial titration period (RXList, 2010). The dosage can be increased subsequently when Carol has stable dose regimen for 30mg has been established and Carol is still not getting sufficient pain relief. 9. Identify adjuvant medication that may be helpful in Carol’s case. Since morphine can cause nausea and vomiting, which Carol already has, she can be given adjuvant medicine along with morphine like co-analgesics drugs that treat side-effects of morphine including anti-histamines, laxatives etc. Carol is reluctantly taking morphine 30mg every four hours and Naprosyn 500mg b.d. for her pain. When visiting Carol one day the community nurse finds Carol vomiting and complaining of catching a ‘gastro’ bug from one of the children. On questioning Carol states she has had small frequent amounts of diarrhoea for 5-6 days, and has not had a normal bowel motion for two weeks. Carol is notably dry, complains of thirst, has a coated tongue, and a distended abdomen. 10. What nursing investigations would you carry out? Firstly I need to identify the factors that can cause diarrhoea. I could proceed with nursing investigations like analysing how dehydrated Carol is, check her skin turgor and mucous membranes. I will take her blood pressure while she is lying, sitting, and standing. I will inspect the distention in the abdomen, and palpate for tenderness. I will also auscultate bowel sounds, check for tympany over the abdomen, take her temperature, record colour, odour, amount and frequency of stool and note any chills (Springhouse, 2005). I will inform her doctor as well to review her. 11. What nursing strategies would you implement to relieve Carol’s symptoms? Since she is dehydrated and her electrolyte balance is upset, I will ask her to consume more fluids, about ten to 12 glasses of water per day, and foods rich in protein and calories like bananas. I will advise the patient and the family to wash hands, and to reduce Carol’s exposure to the environment by limiting visitors. Carol’s appetite has decreased and she is eating only very small amounts of food. She is not nauseous. Dean is finding it hard to accept that Carol doesn’t need food and worries that without food Carol will die. 12. What will you tell Dean about Carol’s loss of appetite? I could tell Dean that this might be a consequence of her morphine intake. However, low intakes of food will cause weakness in her and Dean needs to encourage Carol to eat more food. 13. What strategies can you use to help Carol increase her intake? Carol’s family needs to be advised on increasing Carol’s intake. A dietary chart could be drawn up, and the meals split into smaller portions and devoured on a more frequent basis. Foods rich in carbohydrates and proteins need to be included in the diet, especially Carol’s favourites so that she is encouraged to eat. Carol has become increasingly bedbound and is spending many hours sleeping, and at times becomes restless. She has refused all further chemotherapy and blood tests and is aware her time is limited. Carol has told Dean that she would like to die at home. 14. What do you need to consider to ensure that Carol can be cared for at home (eg. equipment, care needs etc)? Carol is provided with adequate supply of the medications that she is taking, as well as clear instructions on self-administration. A care-attendant can be arranged to take care of light household work. I would aim to ensure the patient’s convenience, like less or no household work etc. Moreover, I can arrange for medical equipment that Carol would need, and ensure that she uses it appropriately. The community nurse is called late at night because Carol has become semi-conscious, but is calling out and very restless. On arrival the nurse finds Carol agitated and restless in bed, with an increased respiratory rate, an obvious frown and unable to respond to questions. On questioning Dean states that he was unable to administer her last two doses of morphine slow release tablets. Carol has not taken fluids for several days, nor passed urine for eighteen hours. 15. Identify the possible cause(s) for Carol’s restlessness and suggest treatments. One of the primary causes of restlessness is morphine. Morphine can cause a person to feel restless sleep and increased respiratory rate, with the symptoms aggravating since the time of the withdrawl of treatment (Editorial Board, 2007). When morphine administration was discontinued suddenly, the body reacted by making Carol feel more restless and hyperventilate. Carol needs to be administered fluids so that her urine output increases. She also needs to be given her dose of morphine. The community nurse suggests insertion of a subcutaneous butterfly needle to administer Carol’s morphine for pain control. Dean becomes distressed, questioning the need for morphine when his wife is almost unconscious. He accuses the nurse of trying to “hurry things along”. 16. What is an appropriate nursing response to Dean’s concerns? The nursing response should be to tell Dean that a probable reason for Carol’s restlessness is her discontinuation of the dose. He needs to be counselled that if Carol is not administered morphine, her symptoms would reach their peak in the next 36 to 72 hours since the discontinuation of the dose (Editorial Board, 2007). Also Dean can be counselled that Carol is already in a poor state of health as she has not urinated in the past 18 hours, so she needs to be dealt with immediately to prevent anymore complications due to morphine withdrawl. Carol remains unconscious for several days. Josephine expresses concern that her mother has not had any fluids for several days and questions whether she should be admitted to hospital so intravenous fluids could be commenced. Josephine questions if it is cruel to let her mother die of dehydration? 17. What explanation could the nurse give in response to Josephine’s concerns? Josephine could be counselled that sufficient levels of hydration are much lower for her mother than for healthy individuals. The nurse could tell Josephine that dehydration is not causing her mother distress and might even by a protective mechanism of the body (Gunten, 2010). 18. What nursing actions will ensure that Carol is comfortable despite no oral intake? Carol can be given subcutaneous route of hydration if the family insists that she needs to be hydrated. This method is feasible in the household setting and is not expensive either. Fluids and food should not be forced since that can cause discomfort (Rakel, 2007). Dean approaches the palliative care nurse for assistance the next day. He states the children, in particular Sarah, are asking questions he doesn’t know how to answer. Sarah asks detailed questions about what will happen to Carol before and after she dies, and appears to have a morbid interest in the details of death. 19. Identify strategies to assist children dealing with death. Children need to be shown care and attention, and the concept of death explained to them in their language. Children would feel guilty and to avoid that, they need to be encouraged to be open about it and share their grief with their loved ones. Children need to be observed keenly for depression and anger and their feelings dealt by their loved ones by having grief counselling. Productive coping strategies such as social support and positive thinking need to be promoted (Frydenberg, 2008). Carol died at 4.30 p.m. on a Sunday afternoon, with Dean, the three children and her mother by her side. Her death was described by the palliative care nurse as peaceful, but her dying as a struggle. 20. What bereavement follow up could be put in place for this family? The nurse needs to give her condolence to the family and offer words of empathy like Carol fought hard, and she was a very kind woman. A funeral needs to be organised. Carol’s medical treatment and medicines need to be stashed away in an isolated place until they are removed. The nurse and palliative care nurse should attend the funeral and offer condolence notes. They should also inform the Bereavement in-charge about the family members and help the family in the grief management process. Reference List American Academy of Family Physicians (2009). Cancer: Palliative Care. Retrieved from http://familydoctor.org/online/famdocen/home/common/cancer/treatment/722.html F. A. Davis Company (2005). Common misconceptions of Pain and Barriers to Pain Treatment. Retrieved from http://www.fadavis.com/related_resources/27_1885_654.pdf Frydenberg, E. (2008). Adolescent coping: advances in theory, research and practice (2nd ed.). New York, NY: Taylor & Francis. Geraghty (2010). When Minutes Matter: Why Do Patients Wait to Seek Treatment Following a Stroke or Heart Attack? Retrieved from http://www.clinicalcorrelations.org/?p=2356 Gunten, A. (2010). End-of-life care. Retrieved from http://www.nci.cu.edu.eg/lectures/ASCO-SEMCO,%20MCMC_PDF/05-%20Session%20V%20(Cancer%20Screen&Prevention)/Andrea_Cairoshortendcare.pdf Merck & Co., Inc, (2010). Morphine Sulfate Drug Information Provided by Lexi-Comp. Retrieved from http://www.merck.com/mmpe/lexicomp/morphine%20sulfate.html#N13D9F8 Editorial Board (2007). Morphine Withdrawal Symptoms. Retrieved from http://www.softlandingrecovery.com/articles/morphine_withdrawal.html Rakel, D. (2007). Integrative medicine (2nd ed.). Philadelphia, PA: Elsevier Health Sciences. RXList (2010). MS CONTIN. Retrieved from http://www.rxlist.com/ms-contin-drug.htm Springhouse, (2005). Handbook of Signs and Symptoms, Third Edition (3rd ed). Lippincott Williams & Wilkins. Read More