Community Health Practice (0310)
October 20, 2013
A. Explain how your own perceptions about quality of life and health problems might affect your care for a dying patient with a lingering illness such as cancer. It is the nurse’s responsibility to remove their personal beliefs when providing care to the patient. If the nurse is persistent in their own beliefs and values there can be a disruption in the successful transition to palliative care. Nurses may feel that they are failing at their job when a patient chooses to go into palliative treatment. The nurse may question their performance as a nurse and have uncertainty regarding whether or not they could of done something more for that patient, so the patient would want to continue more aggressive treatment. Nurses might not understand why the patient has chosen to opt out of aggressive treatments or follow pain treatment regimes. It is imperative that the nurses realize that she/he is to provide treatment and education and the patient is not to be judged for their decisions. To treat someone in a palliative care environment the nurse needs to remove their personal beliefs to provide in depth assessments, teaching, and collaboration with other practitioners and agencies to provide a holistic plan of care that is tailored to the patient – not the nurses beliefs and values.
B. Discuss three strategies that you could use in the Thomas’s situation to improve the quality of life for Mrs. Thomas and her husband during this illness.
a) The first intervention to be initiated would be an in-depth assessment to address Mrs. Thomas’ needs. The nurse not only should start with a physical assessment, but should go further to address all of Mrs. Thomas potential and actual needs. Based on Mrs. Thomas’s intake information the nurse should anticipate the need for a thorough pain assessment. The nurse should assess Mrs. Thomas pain by identifying…
Mrs. Thomas has been prescribed Vicodin and has choosen not to take it, because she feels she will become addicted, she might be confusing tolerance and physical dependence as addiction (Ersek M. ,1999). Another integral part of the pain assessment is to identify if Mrs. Thomas has used any nonpharmacological physical or psychological treatments such as relaxation, massage, heat and cold, music, and exercise. In addition, it is imperative to identify if Mrs. Thomas has received surgical or nonsurgical treatments, such as acupuncture, nerve blocks, and / or neuroablation (Goudas , Carr, Bloch, et. al, 2001 ). Alternative treatment modalities could be of benefit to ease Mrs. Thomas’s pain.
2. Referral to a palliative care physician or a pain specialist. The nurse needs to assess whether or not the patient has seen palliative care physician or a pain specialist. Many other pain treatment options are available for end stage cancer that do not have addictives properties such as NSADISs and adjutant analgesics such as corticosteroids for neuropathic pain and biosphosphates for bone pain (Davies and Squi, 2002). Mrs. Thomas has knowledge deficit related to understanding pain therapy – and needs to understand the difference between addiction and treatment. A palliative care physician can help educate Mrs. Thomas to pain treatment options and other alternative interventions such as palliative radiation to shrink tumor that may be the source of her pain.
3. Referral to Social Worker
When the nurse completes a social dignity inventory he/she will note that the there is deficit related to the ability of the spouse to provide care due to the husband’s depression and lack of knowledge the disease process. A social worker can help identify agencies that can provide a patient care assistant (PCA) or respite to assist the spouse with caring for his wife. The social worker may be able to identify meal programs that will deliver food in the event the husband is unable to prepare foods while working and caring for his wife. Mr. Thomas is a police officer and the social worker may be able to identify fraternal police organizations that offer assistance to police officers and their families during time of illness. Mr. Thomas may be eligible for the Family Medical Leave Act (FMLA) to give him time to care for his wife while not having to work full time. In addition, the social worker can assist with identifying psychological services to help with the husband’s depression and anticipatory grief. Therapy may be of assistance to help with the impaired family coping wherein Mrs. Thomas two sons find it “too painful to visit”. Family therapy may help the children learn about death and dying so that that they may be more involved in their mother’s life.
C. Holistic Nursing Plan for Mrs. Thomas
a. Discuss ways to optimize Mrs. Thomas’s functional ability at this stage of her illness. The nurse would have an occupational therapist come into Mrs. Thomas’s home to complete an occupational assessment and in home safety assessment. The occupational therapist would be able to recommend adaptive equipment to help Mrs. Thomas so she will be able to maintain her independence. The occupational therapist may recommend items to assist with self care such as shower chairs and handles for the bathroom. Other useful adaptive equipment may include adaptive utensils and toothbrushes. These items are specially made for individuals who may have weakness and are easier to hold then traditional utensils. The occupational therapist can identify safety risks within the household to prevent any injuries when Mrs. Thomas may be experiencing problems and/or limitation in her gait.
The nurse will assist Mrs. Thomas in achieving optimal pain control. The nurse will interact with Mrs. Thomas more than any other practitioner. The nurse will have to continuously assess Mrs. Thomas pain control. Due to Mrs. Thomas’s advance stage in her illness her pain control needs will vary depending on her level of conscious and the disease process. Keeping Mrs. Thomas’s level of pain to a level where Mrs. Thomas can still maintain her functional ability will be an ongoing struggle. Too little or too much pain medicine will prevent Mrs. Thomas in participating in activities.
b. Discuss ways to provide care for Mrs. Thomas once self-care is no longer possible. In an optimal situation the nurse would has previously
identified in the patient’s intake assessment how Mrs. Thomas would of wanted to be cared for in the event she was no longer to care for herself. Mrs. Thomas may have verbalized that she did not want her husband or sons to provide any hygiene cares. In this event, the nurse may have arranged that a PCA attendant is responsible for all hygiene related cares. The nurse would have arranged for Mr. Thomas to receive training, so that he is able to transfer his wife safety from the bed to a chair. Educating Mr. Thomas to safely participate in his wife’s care will prevent caregiver and patient injuries and will help Mr. Thomas not rely on paid staff to help with such tasks. Also, the nurse had previously identified that Mrs. Thomas does not wish to have any supplemental feeding assistance once she is no longer able to tolerate solid foods. Her family has been educated regarding nutrition at the end stage of Mrs. Thomas’s disease process so they do not feel Mrs. Thomas is being starved to death. The nurse has identified Mrs. Thomas’s wishes in the management of her care before Mrs. Thomas reached the point in her disease when she could not make such determinations. Often, individuals do not have the time to make such declarations and family has to presume what their loved one may have wanted. It is important to have the discussion with the patient upon entering palliative care as to what their wishes would be in the event they are too ill to make decisions for themselves.
D. Explain how you, as the community health nurse, can intervene in this situation in the management of Mr. Thomas’s chronic depression. The nurse would have had the assistance from a social worker to help identify psychological therapy for Mr. Thomas and his sons. The nurse would assess Mr. Thomas at each visit to determine his level of depression to determine if any other intervention is needed. The nurse would have assessed at intake the family religious needs. The family may not be active members of their church, but in times of crisis may reach out to their faith. The nurse could make a referral for a chaplain to come and visit Mr. Thomas if needed. In addition, the nurse would have identified support groups whether online or in person to present information, provide comfort, teach coping skills, help reduce anxiety, and provide a place for Mr. Thomas to share common concerns and receive emotional support (Zabalegui , Sanchez,
Sanchez, Juando , 2005). The nurse must complete an in-depth assessment on the patient early in the disease process to identify any actual and potential needs. Continued assessment is imperative to identify any deficits in pain control or functional ability. The nurse needs to be cognizant of the members of the family and their functional and emotional well being and know when additional support may be warranted.
References
Davies M and Squi M. Living on the Outside: A Theory of Living with Advanced Breast Cancer. International Journal of Palliative Nursing. 2002;8(12):583-90. Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to analgesic use. Journal of Hospice & Palliative Nursing, 1(3), 87-96. Goudas L, Carr DB, Bloch R, . Management of Cancer Pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Oct. (Evidence Reports/Technology Assessments, No. 35.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK33664/ National Cancer Institute. Pain control: Support for people with cancer.(2012). Retrieved from http://www.cancer.gov/cancertopics/paincontrol/allpages. Zabalegui A, Sanchez S, Sanchez PD, Juando C. Nursing and cancer support groups. Journal of Advanced Nursing. 2005;51:369-381.