Carol is a 48 year old woman who lives with her husband Dean and three children. Carols three children, Josephine (15 years), Harry (12 years) and Sarah (8 years) know their mother has cancer, but have not been told of the development of secondary disease or the implications this carries. The family run a little general store in an outer suburb of Perth. Carol was identified as having breast cancer three years ago, formerly undergoing the right lumpectomy with adjuvant chemotherapy. This past year Carol was diagnosed with bone secondaries. After that she's been obtaining 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 is apparently 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 won't seek medical attention.
Why do you consider Carol is reluctant to seek medical attention and acknowledge her pain?
ANSWER: Carol is reluctant to seek the medical assistance because she is fed up with the medical checkups and also she receives no positive improvement in her health so she herself concluded to not to waste the money on her health and let them safe for her three children (Matthews, 2008).
As Carol begins to get palliative care, which members of the palliative care team do you consider need to be involved with her care? Briefly describe the role of each.
ANSWER: The members of the family of Carol play an important role in the team of palliative care and especially the role of Dean was very crucial because he's the person who could fill the strength in Carol to fight against this dangerous disease ( Foley, 2001).
Investigations of Carol's pain revealed bony secondaries. She was offered a course of radiotherapy, but refused as this would mean going to metropolis (55km away) every day, and she would be from the shop at the busiest time of the entire 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 every course of chemotherapy. On the follow up visit five days after Carol's last chemotherapy, the city nurse discovers that Carol is constantly nauseated, vomiting several times each day and struggling to keep any fluids down.
Identify the possible factors behind Carol's nausea and vomiting.
ANSWER: Chemotherapy involves the killing of cancerous cells from the patient's body thus due to these heavier businesses on Carol's body would make her uneasy and so she has nausea and vomiting (Ferrell, 2006).
Describe the management approaches for the many probable cause(s) of Carol's nausea and vomiting.
ANSWER: Management strategies should be in order to provide her strict instructions to be from strong odours, never to lay flat after eating, have some light exercise after eating, to eat in small amounts & most importantly keep her mind relaxed and try to overlook the chemotherapy (Hesketh, 2005).
On a follow-up visit, the community nurse discovers that Carol is merely attaining two hours pain relief after her tablets which is taking them more often, but is reluctant to consider changing to better medication.
Identify the appropriate steps for assessing Carol's pain.
ANSWER: She should be checked for taking medicines on her behalf own i. e. someone from her family should take the duty to fetch her with medicines; also management should maintain a normal chart of the quantity of daily doses and enough time span of pain she have(McMann, 2009).
After consultation with the overall practitioner, the city nurse discusses changing Carol's analgesia to something stronger. Carol is very reluctant as she feels she will only become dependent on 'hard drugs' if she uses them now. Carol expresses concerns about having this type of medication inside your home with small children around.
What are the possible reasons for Carol's reluctance to improve her medication, and how could this be overcome?
ANSWER: Carol major reason for reluctance was that she wants to be with her family also she wants to save lots of money as she cannot spend the money for hospital's expenses and hence she wants the complete medication to be done at her home. This is overcome if and only if the management gives some relaxation in the expenses (Visel, 2006).
Carol reluctantly agrees to a trial of oral morphine, primarily in short-acting form before dose is titrated. She is commenced on 10mg of oral morphine 4th hourly.
What education if the nurse give Carol about commencing and taking morphine?
ANSWER: The nurse should tell her to take care of some pain and extend the period of taking the morphine from 2 hours interval to 4 hours interval so that she could develop some resistive powers in herself (Bruera, 2003).
When should Carol be looked at for conversion to controlled (slow) release morphine, and exactly how would the dose be calculated because of this?
ANSWER: When Carol feels that she has made enough resistive power then your controlled doses of morphine should be given and the period should be increased rose to the power of 2 i. e. 2, 4, 8, 16 and finally it ought to be stopped (Bruera, 2003).
Identify adjuvant medication which may be helpful in Carol's case.
ANSWER: Herceptin drug can be utilized as the adjuvant medication since it inhibits growth of cancer cells and slows their growth and spread in the torso (Knox, 2004).
Carol is reluctantly taking morphine 30mg every four hours and Naprosyn 500mg b. d. on her behalf pain. When visiting Carol 1 day the community nurse finds Carol vomiting and complaining of catching a 'gastro' bug in one of the kids. On questioning Carol states she has had small frequent levels of diarrhoea for 5-6 days, and hasn't had a standard bowel motion for two weeks. Carol is notably dry, complains of thirst, has a coated tongue, and a distended abdomen.
What nursing investigations do you perform?
ANSWER: The problem is been spreading in her family because of the contact of virus released by the vomiting of the Carol. Hence personal hygiene should be maintained (Yarbro, 2005).
What nursing strategies might you implement to alleviate Carol's symptoms?
ANSWER: For relieving Carol's symptoms the basic nursing strategies should ensure that the toiletry area should properly cleaned using diluted bleach, she must wash her hand after using the toilet, her clothes must be washed in warm water, and lastly the nurse should suggest her the BRAT food i. e. Banana Rice Applesauce and Toast as the key food every once in awhile and drink the maximum amount of liquid as she discharges in her stools (Yarbro, 2005).
Carol's appetite has decreased and she is eating only really small levels of food. She actually is not nauseous. Dean is finding it hard to simply accept that Carol doesn't need food and worries that without food Carol will die.
What will you tell Dean about Carol's loss of appetite?
ANSWER: We will tell him never to panic because this loss of appetite is merely because of the gastro effects and it'll be removed when the medicines perform their proper function (Ko, 2008).
What strategies do you require to help Carol increase her intake?
ANSWER: After giving her enough liquid food we will ask Carol to execute light exercises that could help her to burn up more calories therefore she will feel a good hunger for obtaining a good nutrition (Ko, 2008).
Carol has become increasingly bedbound which 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'd like to die at home.
What do you need to consider to ensure that Carol can be cared for at home (eg. equipment, care needs etc)?
ANSWER: The main consideration would be predicated on finding ways so that she should never get any complication in terms of medical facility. Hence important equipments must be installed with a good experienced nurse who remains with Carol in her house for 24 hours (Keir, 2002).
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 elevated respiratory rate, an obvious frown and struggling to react 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 many days, nor passed urine for eighteen hours.
Identify the possible cause(s) for Carol's restlessness and suggest treatments.
ANSWER: Carol's restlessness is only due to improper metabolism of her body so she should get liquids just as much as she could take and finally she must be produced to discharge the urine (smith, 2006).
The community nurse suggests insertion of your subcutaneous butterfly needle to manage Carol's morphine for pain control. Dean becomes distressed, questioning the necessity for morphine when his wife is almost unconscious. He accuses the nurse of aiming to "hurry things along".
What can be an appropriate nursing respond to Dean's concerns?
ANSWER: Nurse should send Dean beyond your room and simply tell him to keep patience and keep faith, she will do the correct nursing of Carol (Kearny, 2006).
Carol remains unconscious for many days. Josephine expresses concern that her mother has not had any fluids for many 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?
What explanation could the nurse surrender reaction to Josephine's concerns?
ANSWER: Nurse should give condolence to Josephine and not to be concerned because she will look after her mother atlanta divorce attorneys aspects of medical concern (Alexander, 2000).
What nursing actions will ensure that Carol is comfortable despite no oral intake?
ANSWER: The essential nursing action a nurse should check Carol's pulse rate and blood circulation pressure, if everything is normal then there it is ensured that Carol is comfortable despite of experiencing no oral intake (Alexander, 2000).
Dean approaches the palliative care nurse for assistance the very next day. He states the kids, in particular Sarah, are asking questions he doesn't learn how to answer. Sarah asks detailed questions in what may happen to Carol before and after she dies, and appears to have a morbid affinity for the facts of death.
Identify strategies to assist children dealing with death.
ANSWER: While assisting children dealing with death the kids of small age should be taken away from the home and make them busy in a few games while elder children should understand itself how to control with the problem (Schaefer, 2002).
Carol died at 4. 30 p. m. on the 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.
What bereavement follow-up could be placed in place because of this family?
ANSWER: Carol was a solid fighter and she fights with her disease with silence and a lot of courage, this death would keep soul clear of the struggles that she had faced during her illness. God bless her soul Amen (Schaefer, 2002).
