Case Study 3

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) 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.

Why do you think Carol is reluctant to seek medical attention and acknowledge her pain?

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.

Investigations of Carols 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 Carols last chemotherapy, the community nurse discovers that Carol is constantly nauseated, vomiting several times a day and unable to keep any fluids down.

Identify the possible causes of Carols nausea and vomiting.

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.

Identify the appropriate steps for assessing Carols pain.

Case Study 3

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After consultation with the general practitioner, the community nurse discusses changing Carols 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.  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.

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.

What nursing strategies would you implement to relieve Carols symptoms?

Carols 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 doesnt need food and worries that without food Carol will die.

What strategies can you use to help Carol increase her intake?

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.

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.

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?

What nursing actions will ensure that Carol is comfortable despite no oral intake?

Dean approaches the palliative care nurse for assistance the next day. He states the children, in particular Sarah, are asking questions he doesnt 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.

Identify strategies to assist children dealing with death.

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.

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