APPENDIX I COVER SHEET Reflections on the care of a patient with palliative care needs Name : Ms.R.

Anu Sarannya

Register Number : 08131302 Centre Date : JEEVODAYA HOSPICE INSTITUTE OF PALLIATIVE CARE : 19.12.13

I declare that this is wholly my work, except where acknowledged specifically, as the published or unpublished work of others Signature: Ms.Anu Sarannya

APPENDIX II CCEPC Registration Number : 08131302 SECTION A Introduction: a) What is the nature of your work? I dont work at present as I am doing my master degree in nursing (medical surgical department) first year. My professional work is caring for the sick in the hospital, providing basic care needed for carrying on the life comfortably and qualitatively. I was interested in attending the course as was taking care of cancer patients in our speciality hospital and planning to take oncology nursing for my speciality in my M.sc(N) II year. SECTION B Case summary: 1. What was the diagnosis? Name: Mrs.X Age: 54 years Education: M.A (English literature) Occupation: lecturer Diagnosis: Left side breast cancer with metastasis to lung and brain. Habits: Bad habit: Nil Diet history: non vegetarian, 3 meals per day, has food allergy to brinjal. Sleep history: She used to sleep 6 hours per night. During her hospital stay she was having sleep disturbance because of hospitalisation and fear of impending death. Elimination pattern: Her urine output is in positive balance, she is having constipation as she is bed ridden. Hobbies: she used to do gardening in her home during her leisure times Menarche history: attained menarche at the age of 13 years, had irregular menstrual cycle. Obstetric history: No of pregnancy:3 No of abortion:1 No of live delivery:2 Mode of delivery: LSCS History of breast feeding: didnt give breast feeding for both the children

Menopausal history: attained menopause at the age of 40 years , had severe menorrhagia before the onset of menopause. Family history: Her sister had the history of breast cancer, undergone mastectomy 10 years before. Her family members do not have the history of any communicable disease like tuberculosis, chicken pox etc. Social history: she is a shy person who doesnt communicate much with other people. She maintains good interpersonal relationship with the near and dear ones. Socio economic history: she is from a middle socio economic status. She is one of the bread winners of the family. She is living in her own house, in Chennai. Her house has all the facilities like adequate ventilation, drainage, water system etc. The community area in which she lives has all the facilities like market, hospital, transport etc within reach. Emotional history: She doesnt have adequate emotional maturity. She is very sensitive. She doesnt have adequate coping .She doesnt have adequate decision making capacity. She used to cry for simple problems. 2. Enumerate all the important clinical features, including physical findings? Findings Remark OBJECTIVE FEATURES Due to increase in size of tumour Inverted nipple cell in the breast Axillary and supraclavicular lymphnode enlargement Use of accessory muscles Grade 1 clubbing Due to Lymphnode metastasis

Due to breathing difficulty

Due to prolonged hypoxia and increased oxygen demand to the extremities Due to fear about death and unfinished chores of work in life

Emotional feature: the client became depressed hearing to her health status, she also broke out in tears hearing to her diagnosis

SUBJECTIVE FEATURES Severe headache Breathing difficulty Neuropathic pain radiating toneck and left hand Suicidal ideation

Due to brain metastasis Due to lung metastasis Due to compression of nerve by the growing tumor Due to economic burden that may be caused to the family members in spending for the treatment

3. What investigation did you do and why? Table showing the investigation Investigations done Serum cancer markers(CA-15-3) Chest x-ray Reason why the investigation was done To diagnose the cancer To r/o lung cancer, evidence of metastasis to the ribs or vertebrae. To know the extent of malignancy To confirm the presence of malignant cell histopathologically. To confirm the depth and extend of spread of malignancy. To know the changes in lung capacity.

PET scan Fine needle aspiration cytology(Biopsy)

MRI

Pulmonary function test

4. What treatment and other management plans did you consider and why? I.Chemotherapy: - Cisplatin(Alkalyting agent) - Vincristine(Anti microtubule agent) - Paclitaxel(Anti microtubule agent) II. Radiation therapy-IMRT(Intensity Modulated Radiation Therapy) III. Dyspnoea management: - Mechanical ventilator-vcv mode,PEEP-7 cm H2O,sedative-Inj.midazolam - Inj.Deriphylline -Neb.levolin 1ml bd -Breathing and coughing exercise -patient in Fowlers position IV. Pain management: Inj.tramadol 50mg iv bd Inj.fortwin 30 mg iv bd Inj.dexamethasone 4mg iv bd

4. What was the result? Was the result expected / anticipated? The result related to symptom management was expected.Patients symptoms got reduced to some extent. But the patient was very much anxious and depressed. Her psychological and social aspect is affected as she is in ICU and was not allowed to see her relatives. 5. Who else did you involve or consult in the care of this patient? Neurologist Pulmonologist Radiologist Nurse Physiotherapist Counsellor Dietician Family members Spiritual leaders 6. Were their contributions helpful? If yes, how? Yes. Their contribution was very useful in confirming and treating the patient appropriately. SECTION C 1. If you have to see and manage the same patient once again, how will you proceed with the management?

Psychosocial care

Symptom control

Disease management

DISEASE MANAGEMENT: Surgery with adjuvant therapy to improve patient survival. Chemotherapy with focussed medications that are having less side effects. Radiation therapy with pain relief management.

SYMPTOM MANAGEMENT:

Would avoid intubation and mechanical ventlation as to provide a quality care to the patient. Would give priority to patient preferred treatment. Would give maximum pain management interventions with patient controlled analgesia. Would allow the patient attenders to spend the time with the patient. Would provide necessary aiding materials to improve the self confidence. o Hair loss(due to radiation and chemotherapy)-wig ,scarf provision to cover the exposure of scalp Rationale To reduce tissue sweeling and relieve nerve compression To block oestrogen receptor that stimulates the cancer cell growth To block the growth of cancer cells

Treatment Inj. Dexamethazone 32mg iv stat & 16mg bd

Inj.Tamoxifen (Hormone blocking agent)

Tab.Trastuzumab (Herceptin),

Tab.deriphylline 100mg bd Tab.lorazepam 1mg p.o p.r.n Tab.morphine 10mg 4th hourly Tab.vomikind bd

To reduce breathing difficulty To reduce anxiety To reduce pain To reduce nausea and vomiting To prevent episodes of convulsions

Tab.Sodium valproate 100 mg bd

Neb.duolin 1ml bd PSYCHOSOCIAL CARE:

To relieve breathing difficulty

Pulmonary and neuro rehabilitation therapy. Supportive care-help the patient and family members to cope up with their disease and treatment by teaching various coping strategies. spirituality Include the family member also in the care of client along with health care professional. Allow the family members to interact with the patient for some time.

Referral for hospice care is important in planning for comfortable and dignified end of life care for the patient and family.

2. What other issues will you consider in the same patient? -Physical issue -pain radiating to hand, back & neck due to compression. -side effects of radiation -Psychological issue- anxiety and fear, social isolation and spiritual isolation. 3. Be specific about the issues and mention why you would like to bring the changes? Physical issues: Weakness of left hand and severe pain in the back, hand may be due to nerve compression. If the nerve compression continues there is possibility of the person from losing his functional capacity of the area that may affect the quality of life of the patient so it should be taken into consideration and managed accordingly. Psychological issues: she has verbalised suicidal ideation, i would like to bring the change by giving adequate counselling because if not concentrated it may result in ending of her life by herself, which is more painful for her family members than dying of cancer. Social issues: She is isolating herself from the surrounding, i would like to bring change in it by improving the interaction and interpersonal relationship because when she is isolating herself from others it may increase the probability of increasing the psychological pain and suicidal thoughts. 4. Summarise briefly what you have learned from managing this patient, reflecting on his /her care, in the light of your learning from this course. By providing the care to this patient -I gained adequate knowledge about the breast cancer and its complications. -I improved my communication skill in how to break the bad news. -I was able to provide care by classifying it under physical, psychological, social and spiritual. -I completely understood the treatment strategies involved in the management of the client with such condition. -I understood that the pain management is the main in the patient with the advanced cancer. 5. Your personal insight about the way in which the patient was managed. My personal insight about the way the patient was managed is that, the patient even when treated adequately for the symptoms his social needs, psychological well being and quality of life was not taken care as the patient was in ICU.

6.Your professional knowledge and skills regarding the following: a) Physical care: Wound care Skin care Provide comfortable measures and position. Provide supportive care of daily living activities such as mouth care, bed bath etc. Pain assessment and management such as hot application, massage etc Encourage the patient to do active and passive exercise [ deep breathing exercise, range of motion exercise] Nutrition, bowel management. b) Psychosocial care: Counselling the patient Encouraging the client to interact with the all people. Educating about the personal care and health progress. Encourage the patient to ventilate the wishes. c) Spiritual care: Involving the patient in praying daily in the morning. Motivate the patient to think positively. Telling the patient some spiritual stories Teaching meditation and yoga. Motivating the patient to participate in spiritual meets. d) Issues of communication with patient and family: Language barriers As the patient and family member will be emotionally upset,they may exhibit it in the form of depression or anger The patient when hearing the bad news they will be denying to accept it Breaking the bad news when not with the appropriate words may divert the patient towards suicidal thoughts also. e) Ethical issues if present: Autonomy-patient refused MRI scan. Collision was present-they family members doesnt want the diagnosis to be revealed to the patient. Doctrine of double effect-consent from the relatives was got before starting the sedative(Inj.Midazolam) 7. How will you influence policy and innovations in your field of work based on this case reflection? Will change the policy if possible that, the relatives can be allowed to be with the patient at the end minutes. Patient controlled analgesia-Inj.morphine can be practised in hospital setup. Add palliative care as an essential chapter in Bsc programme.

APPENDIX III REFERENCE: BOOK: John Link Breast Cancer Survival Manual: A Step-by-Step Guide for the Woman with Newly Diagnosed Breast Cancerpublished 1998. Lillie Shockney Navigating Breast Cancer: A Guide for the Newly DiagnosedPrinted 2007Pages: 107 Brunner and suddarths.text book of medical surgical nursing. 12th edition.lippincott.670-678. Ettinger DS (2008).lung cancer & other pulmonary neoplasam.23rd edition.philadelphin saunders.1456-1465. Lewis. Medical surgical nursing.7th edition.mosby.613-617. CIMS JOURNAL: European journal on cancer- Borras jm.et.al Policy statement on multidisciplinary cancer care6th December 2013. Journal on cancer education-Nwoqu.c.et.al Promoting Cancer Control Training in Resource Limited Environments 2013 November 17th . Journal on wound care-Probst.S.et.al Coping with an exulcerated breast carcinoma 2013 July 22nd. NET REFERENCE: American cancer society (2013) http://www.cancer.org/acs/group/content/@epidemiology. American Journal of Hospice and Palliative Medicine http://www.sagepub.com/journalsProdDesc.nav?prodId=Journal201797 BMC Palliative Care http://www.biomedcentral.com/bmcpalliatcare/ European Journal of Palliative Care [TOC,A] http://www.ejpc.eu.com/ejpchome.asp