The field of palliative care in nursing is so vast that a look through available materials is quite overwhelming. The field is multidisciplinary and not merely confined to a particular organ or disease. It requires the participation of the patient, his or her family, and a whole health care team. It is in this field that the nurse is given a venue for integration of knowledge and skills in different specialties. Moreover, it integrates innate beliefs and principles of the nurse and provides an opportunity for a “shared humanity” experience.
Although guides are rigid and very systematic, palliative care requires flexibility (Lo, Quill & Tulsky, 1999). The plan must be adapted to the particular patient, to the family, and to the health care team. The people participating in the care of a particular patient must feel a sense of ownership of the health care plan and must believe in the potential of the plan in alleviating the pain or discomfort felt by the patient (Bond, 1995). In the process conceptualizing the health care plan, it is important to have regular consultations with the patient, the family, and the health care team.
The health care plan must be dynamic. As such, it can undergo changes as it is being implemented. In the process of implementing the plan, the nurse should ready to share a part of one’s self with the patient. The nurse-in-charge will be confronted with issues about life and personal beliefs. The implementation of the plan will also be thought-provoking for the nurse. The experience may even serve as a reality check of his/her principles and beliefs. The purpose of this paper is to present an individualized palliative nursing care plan for a patient with Stage 4 Breast Cancer.
The patient is currently experiencing vomiting and bone pain from metastases. Various aspects of care are presented in the succeeding pages. The author will present a detailed history and physical examination of the patient. In connection with this, important laboratory and ancillary test results will also be reported. A profile of the spiritual and personal beliefs of the patient will also be discussed. In the second part, the author will talk about a pharmacological and a non-pharmacological plan for the patient. Aside from this, the author will also deal with pain management of the patient.
Detailed chemotherapeutic regimen, however, will not be discussed. Various alternative techniques such as application of aromatherapy, TENS, acupuncture and the use of imagery will be presented. The third portion of the paper will contain the involvement of the nurse in the care of the patient. Individual and family coping strategies in preparation for death will also be discussed in this portion. Section one – Palliative client assessment The profile of a particular patient is a very important tool for the palliative care team to establish a relationship with the patient and the family.
The detailed history and physical examination is carried out by the primary care consultant. However, for the nurse, frequent interaction with the patient and the family is vital. The medical history of the patient must be reinforced with a family profile of the patient. This will give the team an idea of the support system that the patient has (Alexander, Fawcett & Runciman, 2000). In this portion, the author will give a detailed description of the medical history and physical examination of the patient.
The family profile of the patient will also be elaborated. Personal profile The patient is A. M. , 58 years old, Right-handed, Female She is a housewife residing in Australia. Patient Activity The patient can do activities of daily living with the help of a care-giver Chief Complaint: Vomiting History of Present Illness: The patient was apparently well with good functional capacity until… 6 months prior to admission, the patient started to experience dull pain on her lumbar region. Initially, the pain was described as 3/10 on the Visual Analogue Scale (VAS).
The patient took over-the-counter non-steroidal anti-inflammatory agents (NSAIDs) which afforded partial relief of symptoms. 4 months prior to admission, the patient, despite medication, noted gradual increase of pain. The pain was described to be 6/10 to 8/10 on the Visual Analogue Scale. The patient had to take more NSAIDs per day. At around this time, the patient also started to experience difficulty in walking and easy fatigability. The patient’s daughter decided to take the patient to their family physician. The patient was subsequently referred to a rehabilitation doctor.
Upon consult a CT scan of the lumbar region was requested. Results of the scan revealed numerous densities on the lumbar area suggestive of tumours. The rehabilitation doctor thought that these were metastases. However, they still had to establish the site of the primary tumour. The rehabilitation doctor referred the patient back to the family physician. 3 ? months prior to admission, the patient underwent thorough physical examination by the family physician. Upon inspection of the patient’s right breast, the physician noted skin changes on the said breast.
The nipple appeared inverted and blood was expressed from the nipple. The family physician also noted a foul-smelling odor coming from the breast. The family physician palpated the breast. He was able to palpate a 4×4 cm hard, fixed, non-tender mass on the upper outer quadrant of the right breast. Further examination revealed matted lymph nodes on the right axilla. The family physician referred the patient to a surgeon who did a punch biopsy of the mass. Histopathological examinations showed that the mass was an invasive ductal carcinoma of the right breast.
Blood tests also showed involvement of the liver. On chest X-ray, multiple small masses were seen. These were suggestive of lung metastases. The surgeon likewise requested for bone scan. The results yielded positive involvement of the spine and some areas of the skull. The patient was diagnosed with Stage 4 breast carcinoma. The patient and the family were informed that the patient’s case was terminal. However, they were offered a choice of neo-adjuvant chemotherapy in the hope of reducing tumour burden. After a family meeting, the patient decided to undergo chemotherapy.
2 months prior to present admission, patient started to undergo chemotherapy sessions. The patient had hair loss, nausea and vomiting, and has lost significant weight. Nonetheless, she remained very optimistic about her treatment. Although weakened by the effects of chemotherapy, she continued to attend Sunday Church, and would occasionally attend meetings of the Homeowner’s Association in their village. She would also force herself to eat despite her nausea and vomiting. The patient was apparently doing alright despite side effects of chemotherapy.
Part of her medication was morphine, to alleviate the pain. 1 week prior to present admission, the patient was noted to be weak and pale. She would stay in bed all day. Frequently, she would take her meals on her bed. In instances when she felt better, however, she made sure that she ate with her husband and three daughters in the dining room. When she could not go to the dining area, she asked her family to join her in eating her meals in her bedroom. 2 days prior to admission, the patient started to experience nausea and vomiting. She also lost her appetite and would not finish her meals.
She also experienced bone pain more frequently and had to be started on morphine by the family physician. On the day of admission, the patient could no longer eat and was very weak. She was also very irritable and was experiencing excruciating bone pain. With the given situation, the family decided to have the patient admitted. On physical examination, the patient was weak-looking. She has lost significant weight—as compared to her weight 6 months ago which was 160 pounds. Her present weight is 115 pounds. She is afebrile, tachycardic and had normal blood pressure.
She was pale with slight icteresia. Her lungs and heart were normal. Her liver was enlarged. A 3×3 fixed, hard mass with ulceration was seen on her right breast. Blood can be expressed from her nipple. No pitting edema was noted. Slight papilledema was seen. The rest of the neurological examination done revealed satisfactory results. Blood tests were done. The liver function tests were elevated and the serum Calcium was normal. Electrolytes were a little below normal. The patient was anemic. The author was nurse-in-charge of the patient when the patient was admitted at the hospice ward.