case reflection format

8/12/2019 case Reflection format

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APPENDIX I

COVER SHEET

Reflections on the care of a patient with palliative care needs

Name : Ms.R.Anu Sarannya

Register Number : 08131302

Centre : JEEVODAYA HOSPICE INSTITUTE OF PALLIATIVE CARE

Date : 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published or unpublished work of others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


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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 (medicalsurgical 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 havingconstipation 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


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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

Inverted nipple Axillary and supraclavicular

lymphnode enlargement

Use of accessory muscles Grade 1 clubbing

Emotional feature: the clientbecame 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 increase in size of tumourcell in the breast

Due to Lymphnode metastasis

Due to breathing difficulty Due to prolonged hypoxia andincreased oxygen demand to theextremities

Due to fear about death andunfinished chores of work in life

Due to brain metastasis Due to lung metastasis Due to compression of nerve bythe growing tumor

Due to economic burden that maybe caused to the family members in

spending for the treatment


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3. What investigation did you do and why?Table showing the investigation

Investigations done Reason why the investigation was doneSerum cancer markers(CA-15-3)

Chest x-ray

PET scan

Fine needle aspiration cytology(Biopsy)

MRI

Pulmonary function test

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 ofspread of malignancy.

To know the changes in lung capacity.

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


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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 youproceed with the 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:

Psychosocial

careSymptom

control

Disease

management


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Would avoid intubation and mechanical ventlation as to provide a quality care to thepatient.

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 theexposure of scalp

Treatment Rationale

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 4thhourly

Tab.vomikind bd

Tab.Sodium valproate 100 mg bd

Neb.duolin 1ml bd

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

To reduce breathing difficulty

To reduce anxiety

To reduce pain

To reduce nausea and

vomiting

To prevent episodes of

convulsions

To relieve breathingdifficulty

PSYCHOSOCIAL CARE:

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.
http://en.wikipedia.org/wiki/Trastuzumabhttp://en.wikipedia.org/wiki/Trastuzumab


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Referral for hospice care is important in planning for comfortable anddignified 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 thechanges?

Physical issues:Weakness of left hand and severe pain in theback, hand may be due to nerve compression. If the nerve

compression continues there is possibility of the person fromlosing 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, iwould 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, iwould 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, thepatient 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.


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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 mayexhibit it in the form of depression or anger

The patient when hearing the bad news they will be denying to acceptit

Breaking the bad news when not with the appropriate words maydivert 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 diagnosisto be revealed to the patient.

Doctrine of double effect-consent from the relatives was got beforestarting the sedative(Inj.Midazolam)

7. How will you influence policy and innovations in your field of work based on thiscase reflection?

Will change the policy if possible that, the relatives can be allowed tobe with the patient at the end minutes.

Patient controlled analgesia-Inj.morphine can be practised in hospitalsetup.

Add palliative care as an essential chapter in Bsc programme.


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APPENDIX III

REFERENCE:

BOOK:

John Link Breast Cancer Survival Manual: A Step-by-Step Guidefor the Woman with Newly Diagnosed Breast Cancerpublished 1998.

Lillie Shockney Navigating Breast Cancer: A Guide for the NewlyDiagnosedPrinted 2007Pages: 107

Brunner and suddarths.text book of medical surgical nursing. 12thedition.lippincott.670-678.

Ettinger DS (2008).lung cancer & other pulmonary neoplasam.23rdedition.philadelphin saunders.1456-1465.

Lewis. Medical surgical nursing.7thedition.mosby.613-617. CIMS

JOURNAL:

European journal on cancer- Borras jm.et.al Policy statement onmultidisciplinary cancer care6thDecember 2013.

Journal on cancer education-Nwoqu.c.et.al PromotingCancer Control Trainingin Resource Limited Environments 2013 November 17

th

. 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 Medicinehttp://www.sagepub.com/journalsProdDesc.nav?prodId=Journal201797

BMC Palliative Carehttp://www.biomedcentral.com/bmcpalliatcare/

European Journal of Palliative Care [TOC,A]http://www.ejpc.eu.com/ejpchome.asp
http://www.goodreads.com/author/show/42447.John_Linkhttp://www.cancer.org/acs/group/content/@epidemiologyhttp://www.cancer.org/acs/group/content/@epidemiologyhttp://www.sagepub.com/journalsProdDesc.nav?prodId=Journal201797http://www.sagepub.com/journalsProdDesc.nav?prodId=Journal201797http://www.biomedcentral.com/bmcpalliatcare/http://www.biomedcentral.com/bmcpalliatcare/http://www.ejpc.eu.com/ejpchome.asphttp://www.ejpc.eu.com/ejpchome.asphttp://www.ejpc.eu.com/ejpchome.asphttp://www.biomedcentral.com/bmcpalliatcare/http://www.sagepub.com/journalsProdDesc.nav?prodId=Journal201797http://www.cancer.org/acs/group/content/@epidemiologyhttp://www.goodreads.com/author/show/42447.John_Link

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