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  • Geria

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    JackRolunaBernales
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    Jane is an 84-year-old woman with metastatic breast cancer who has chosen to pursue hospice care instead of further active treatment. Her most pressing issue is adequate pain control. The oncologist prescribed hydrocortisone which lowered her pain from an 8 to a 6, but an adjuvant may help with bone pain, such as decadron. As the hospice nurse, the plan is to start morphine to control Jane's pain and allow her to participate in activities like shopping and lunch with her daughter.

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    Jane is an 84-year-old woman with metastatic breast cancer who has chosen to pursue hospice care instead of further active treatment. Her most pressing issue is adequate pain control. The oncologist prescribed hydrocortisone which lowered her pain from an 8 to a 6, but an adjuvant may help with bone pain, such as decadron. As the hospice nurse, the plan is to start morphine to control Jane's pain and allow her to participate in activities like shopping and lunch with her daughter.

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    76 views2 pages

    Geria

    Uploaded by

    JackRolunaBernales
    Jane is an 84-year-old woman with metastatic breast cancer who has chosen to pursue hospice care instead of further active treatment. Her most pressing issue is adequate pain control. The oncologist prescribed hydrocortisone which lowered her pain from an 8 to a 6, but an adjuvant may help with bone pain, such as decadron. As the hospice nurse, the plan is to start morphine to control Jane's pain and allow her to participate in activities like shopping and lunch with her daughter.

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    © All Rights Reserved
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    of 2

    Jane is an 84-year-old woman diagnosed with breast cancer 2 years ago, now with metastasis to

    the bone and lung. She has refused any further active treatment (i.e chemotherapy and radiation)
    and has asked her health care representative daughter Patty to help her talk to her oncologist
    about her wishes. After this discussion, the patient, daughter, and physician have agreed upon a
    hospice evaluation. Upon evaluation and subsequent admission to hospice services, the patient’s
    most pressing need was adequate pain control. Previously, she had tried scheduled Tylenol
    without relief-her pain rated at an 8 on a 0-10 scale. Her oncologist then prescribed
    Hydrocortisone 7.5/750 mg. 1-2 tabs every 4 hours as needed, which lowered her pain acuity to a
    6. At this point, an adjuvant might be considered for bone pain-possibly Decadron. If Jane
    experiences shortness of breath related to lung metastasis, the Morphine and Decadron are both
    helpful in alleviating this symptom.

    1. As the admitting hospice nurse, you recognize that 8 on the pain scale greatly impair
    Jane’s quality of life. Using the WHO step approach, what would be your plan on
    intervention?

     As hospice nurse I should recognized that the maximum dose of Tylenol would be
    exceeded by the hydrocodone combination, and so short-acting morphine was
    initiated in place of hydrocodone. Using a conversion chart comparing the two
    medications, I will calculate the amount of morphine that could safely be given
    every 4 hours, Jane received "around the clock pain medication for her around the
    clock pain," to keep the pain from getting out of control. The starting dose was at
    a conservative starting point of 5 mg every 4 hours. I will instruct the daughter to
    call me if the patient's pain was not managed at this dose. I will also educate her
    that Jane may be sleepy for 24-48 hours until her body adjusted to the new
    medication, and this would be a temporary side effect and not an adverse reaction.
    I will make plans to visit daily until the pain was controlled. 24 hours later, Jane
    reported, "It's better; I'm at a 5 most of the time." Asking Jane about her
    acceptable level of pain, she indicated, "If I could just get it to a 2, I could do the
    things I would like to do." The dose was then taken to 10 mg q 4 hrs. After 48
    hours, Jane reported, "You know, I think I could do a little shopping today and
    have some lunch with my daughter-of course she will have to drive." I will then
    calculate the therapeutic amount of morphine used in 24 hours, which was 60 mg.
    The 60 mg was divided by 2, as long-acting morphine lasts for 12 hours. The
    therapeutic dose would be 30 mg of extended release of morphine every 12 hours.
    A break-through dose of 10 mg (one-third of the 12-hour dose) immediate release
    morphine is available for prn use in case pain occurs between the 12-hour doses
    during Jane's shopping trip.

    2. Knowing that Jane probably has two types of pain due to the metastasis, what adjuvant
    might you consider for the bone pain?
     Adjuvant might be considered for bone pain-possibly decadron, 2-4 mg daily-
    because steroids are helpful for the inflammation of bone pain. At this time in
    Jane's life, steroids are appropriate for use, because her life expectancy is weeks
    or months rather than years, and long-term side effects are less of an issue.
    3. Looking to the future, what other comfort issues might Jane face as her metastasis
    impacts her life?
     If Jane experiences shortness of breath related to lung metastasis, the morphine
    and decadron are both helpful in alleviating this symptom.

    4. How could you keep Jane reach her goal of selected activities (e.g. shopping, lunch,
    church?)
     A variety of interventions can improve the quality of Jane's life, by
    allowing her the flexibility and freedom to continue some of her favorite
    activities.

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