CASE SUMMARY

28 year old female with diagnosis of carcinoma of left breast with metastatic relapce. She is a young female, house wife by profession and was diagnosed as a case of carcinoma of left breast in the year 2011 where she was treated at a local hospital and she underwent mastectomy followed by concurrent radiation therapy and chemotherapy. Although patient was responding well to the chemotherapy and radiation therapy in the initial stages, few months later the tumour has started to recur. Scan showed relapse with metastasis to bone, liver, lung and brain.

She was bought to hospital by the relative with chief complaints of

1. Back pain- is primarily because of secondary metastasis. The patient relatives explained her back pain is severe in intensity since 2-3 days with partial pain relief and taking tablet morphine 10 mg for every fourth hour.

2. Progressively worsening headache – may indicate secondary metastasis to the brain.

3. Abdominal pain can also be a symptom of secondary metastasis to the liver.

4. Appetite loss, nausea and vomiting- since 2-3 days due to the side effects of chemotherapy and radiation therapy and it may also indicate secondary metastasis to the liver.

5. Occasional chest pain.

· Past history – Nothing significant.

· Family history – My client has a daughter who is 1 yr old. She belongs to middle class family and there was no family history suggestive of genetic inheritance of carcinoma of breast.

Physical Examination

· Thin built, poorly nourished, dehydrated

· Pulse – 80 beats/ min, regular, low volume.

· B.P – 130/90 mm of Hg.

· Fasting blood sugar – 116 mg/dl.

· Cyanosis, clubbing of fingers, lymphadenopathy, pitting edema were absent.

· Chest – equal lung expansion, no symptoms of dyspnea, notenderness, normal vesicular breath sounds.

· Abdomen – soft, epigastric tenderness, slight hepatomegaly and spleenomegaly. Normal bowel sounds.

· Other systemic examination is normal.

Investigation done Reason why the investigation was done

Complete blood picture – to assess general condition, infection

Serum electrolytes – since client was dehydrated tired and agitated.

Fasting blood sugar – to identify the blood glucose level.

Liver function test – to identify the extend of metastasis and to decide regarding choice of medication.

Blood urea and serum creatinine – to check dehydration level and renal function.

4. Treatment and other Management plans

· Pain – to relieve the pain, patient was advised to take Inj. Morphine 2mg subcutaneous (sos), and Tab. Tramadol (BD). I advised and taught the client about various non pharmacological interventions such as diversional therapy, comfortable positioning, positive reassurance, psychological support.etc.

· Hydration – since the client was thin built, poorly nourished and poor skin turgor, it is very important to restore the hydration status of the client. Hence the physician advised for IV fluids such as Ringers lactate and normal saline along with Inj. Multivitamin.

· Monitoring – every 2 hrs vital signs monitoring and estimation of intake and output chart.

· Nausea and vomiting – the physician advised to take antiemetic such as Tab. Domestal (TID) and Inj. emeset 8mg IV (BD). Inj. Pantoprazole 40 mg IV (SOS).

· Sepsis – physician advised corticosteroids Inj. Dexona 4mg in 100 ml of NS IV and Inj. Clindamycin 600mg IV 8^th hrly.

· Constipation – advised the patient to take fiber rich foods, fruits and vegetables. To treat constipation the patient is on Tab. Dulcolax (2 Tabs).

· Exercise – taught patient about various active and passive exercise for better joint mobility and to prevent lymphedema.

5. Outcome expected / anticipated ?

The patient was symptomatically better, good pain control was achieved with morphine and other non pharmacological managements. Her hydration status improved as evidenced by improvement in skin turgor, better oral intake, patient is able to pass stools at least once a day. Her nausea and vomiting is reduced to a greater extend. There was an improvement in overall condition of the client. On request of family members patient got discharged on 7^th day with proper instructions.

6. Other consultants involved in care

Physiotherapist, radiation oncologist, psychologist, neurologist and urologist, dietician, radiation physicist were consulted on various aspects of client care. Cumulative efforts of these people help to provide better holistic care to the patient, and also to clear the doubts of the family and the patient.

7. Works carried out by other consultants

The ENT surgeon evaluated thoroughly and excluded any further intervention. Radiation oncologist, radiation physicist suggested radiotherapy to reduce the secondary metastasis. Physiotherapist taught patient about various active and passive exercise to overcome any complications that develop due to immobility. Dietician prescribed diet plan for the client to overcome her constipation. psychologist helped client and family members to overcome stress and coping related to client condition.

Palliative Care Principles and Practice.

The most challenging part while providing care for this client was to console the family members and make them to realise that one of their loved ones had carcinoma. Since my client was very young and she had a daughter it was very difficult for both the client and family members to accept the reality. Being a health team member, it was difficult for me to cope with such a situation.

Majority of my care was concentrating on disease management and neglecting other important aspects of care which are truly essential and vital. After undergoing training in palliative care, I understood the importance of not only disease management, equal importance should be given on symptomatic treatment and psycho social care which are vital to cope with such a situation. I also felt need for interdisciplinary team approach is vital to take care of client with carcinoma.

After attending the course in palliative care, it has helped me to understand the importance of early identification of illness, importance of assessment, symptomatic management and supportive care to the patient and family to cope with the disease and treatment.

Today in the new light of palliative care, my horizons of palliative care have widened to see client as a holistic individual not merely caring distressing physical symptoms. It helped me to understand the importance of psychosocial aspects which are very crucial in the management of client and understood various common ethical issues which are often neglected in day to day delivery of care.

a. Physical care:

Good pain care was achieved through analgesics and non pharmacological management, nausea and constipation was resolved with antiemetics and laxatives and various other interventions. Client diet improved, hydration status was restored. Client was given mouth care, hygienic care on a regular basis. Intake and output was monitored. Back care was given and change in position was initiated. Wound dressing was done to combat infection.

b. Psychosocial issues:

In my client the most important psycho social issue was body image disturbance. She was worried about future of her daughter and how the relatives and society will receive her. I educated client and family members about various rehabilitative measures that are available to be utilised to tackle the body image disturbance. I also arranged meeting with other individuals who had undergone same surgery and adapted various rehabilitative measures to overcome hopelessness.

c. Spiritual issues:

The family has expressed spiritual distress to some extend during hospitalisation. The client expressed their spiritual distress by asking question to the god regarding the disease which she is suffering which has brought so many changes in her physical appearance. The family members also spiritually distressed and were asking questions regarding is it a disease which comes because of sins, what I have done...so on. I arranged counselling sessions for them to overcome the spiritual distress in a greater extend.

d. Communication issues of the patient and the family:

The family members were quite educated. They were always well informed and were aware about the various problems and treatment options that were readily available. As a care provider i had no major communication issues when dealing with adult members of the family except this small child.

e. Ethical issues:

The patient was constantly refusing to undergo further treatment after the secondary metastasis to the other organs of the body. It was very difficult to convince the client about the importance of symptomatic treatment and essentials of dealing psycho social issues of the client. Family members were of the opinion that alternative system of medicine will be better option to treat disease like this. The family members tried alternative medicines for betterment but the therapy added more distressing physical symptoms rather than relive to the patient (autonomy versus beneficence).

CONCLUSION:

We need to improve at recognizing the psychosocial and spiritual needs of the family and active involvement of the family members while delivering care to the client. We also recognized the importance of early palliative care team work will help the cancer patient will help to elevate physical and other symptoms quite efficiently. We need to recognize the need for good living environment, comfort while dying and support the grieving with compassion and dignity. All the small efforts in this direction are like the every drop of water saved for future.

ACKNOWLEDGEMENT:

I am an associate professor working in college of nursing since 7 years. As a teacher my role is to supervise the students in the clinical area and guide the students for the holistic care of a client by taking into consideration of individual clients needs. As a vital member of health care team, it is important to take care of clients needs by giving adequate emphasis on various aspects of care which ranges from physical to physiological, psychological, spiritual aspects. The client whom I have selected for my case study is a young female with just 28 yrs old who made me to think on focussing the need for good nursing care, psychological support, better communication skills and various ethical issues involved in client care.

REFERENCES:

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Received on 14.07.2015 Modified on 01.08.2015

Asian J. Nur. Edu. and Research 5(3): July- Sept.2015; Page 443-446

DOI: 10.5958/2349-2996.2015.00089.0