HAT 1 Task 2 Nursing Care Plan for the Thomas Family

Mr. and Mrs. Thomas are subjects of a case study on improving the quality of life and functioning in a terminal patient and her caregiver. Mrs. Thomas is a 56-year old female geriatric patient with metastatic breast cancer. After undergoing right and left mastectomies, the removal of 5 axillary lymph nodes, radiation and chemotherapy, there remains inoperable cancer in her lungs. Given the poor prognosis for recovery or remission, her doctor recommends palliative care as the best course of treatment at this time. Mrs. Thomas suffers from post-treatment lymphedema, pain in her dominant arm, chronic pain, and lack of adequate social support and care. Her primary caregiver is her husband Mr. Thomas. Because her female relatives have passed away, caregiving responsibilities have fallen upon Mr. Thomas: “at least 40 percent of caregivers are men, a growing trend demonstrated by a 50 percent increase in male caregivers between 1984 and 1994,” (Bemis, Given, Petlick, & Reinhard, 2008, pp. 341-342) many of them are the patient’s spouse. He works outside of the home and suffers from clinical depression which has intensified due to stress related to Mrs. Thomas’ health and his obligations as a caregiver. Mrs. Thomas’ two sons would like to play a role in her care, but they live far away and are alienated by her condition. Mrs. Thomas reports she does not like her pain medication because she fears addiction, and feels burdensome to her family.

The main objectives of a community health nurse in this situation will be to assess Mrs. Thomas and Mr. Thomas, evaluate which nursing diagnoses and interventions apply, set reasonable nursing goals to achieve, facilitating a plan of care which accounts for their individual histories and involves an interdisciplinary caregiving team to improve functioning and quality of life. Because of the sensitive nature of end of life care, a skilled hospice nurse under the supervision of a doctor would best understand the approach to treating Mrs. Thomas in order to improve her quality of life during the time she has left. By understanding the nursing diagnoses interventions, and evaluations that can improve Mrs. Thomas’ overall well-being, a thorough and comprehensive plan of palliative nursing care and other support services and resources can be developed by the community health nurse.

Personal Perceptions

As a nursing student, I definitely appreciate the suffering that many disease processes entail, especially chronic diseases such as depression and terminal illnesses such as cancer. The decision to continue a losing battle against cancer can entail unnecessary distress during the months or years before the inevitable. Anyone such as myself, who has witnessed a family member in pain during their last days wishes they could alleviate that pain and enable some quality of life even under the circumstances of a terminal diagnosis. Nurses strive to act as patient advocates, who will do anything within their scope of practice to mitigate pain and render treatment to prevent a condition from worsening. A positive patient outcome, in this case, does not have to entail medical improvement: hospice emphasizes palliative care which eases patients and assists families with caregiving and end of life issues. My personal perceptions of quality of life and health promotion make me inclined to support administering thorough, supportive, and pain-alleviating care to terminal patients. More importantly, I aspire to assist families and caregivers as they process emotions and needs related to their patients.

Strategies

There is a three-pronged strategy that a community health nurse could utilize to improve the Thomas’ quality of life. Address Mrs. and Mr. Thomas’ medical issues separately at first, and then coordinate nursing care to increase their comfort and reduce suffering and stress together. Mrs. Thomas needs additional resources in order to receive proper care: a community health nurse should, after an accurate assessment of her needs, provide patient education regarding available counseling and psychiatric care, the importance of taking her prescriptions as ordered and discussing alternative medications with her doctor, information about Medicare benefits, support groups and services such as meals on wheels. A good strategy in this situation is to treat the caregiver as a client (Bemis et al., 2008). Mr. Thomas should be assessed for depression based on his history of Mrs. Thomas’ statements and referred to a psychiatric specialist as well as caregiver and cancer support groups. Counseling and calls or visits to the home can relieve caregiver stress (Bemis et al., 2008). A nurse acts to bring people together to help the patient, and contacting family members such as the Thomas’ sons and alerting them of their ability to support their mother through this difficult experience would be a rewarding exercise. It is highly important to actively involve Mr. Thomas in decisions about Mrs. Thomas’ care, providing family and patient education as necessary and explaining medical jargon in a way he can understand. These “interventions can be aimed to help make the caregiver become more competent and confident, providing safe and effective care to the patient, which can indirectly reduce caregiver distress by reducing their load or increasing their sense of certainty and control” (Bemis et al., 2008, p. 345). Finally, if a skilled nurse or unskilled caregiver could take over some of Mr. Thomas’ caregiving duties, it would likely relieve stress for both Mr. and Mrs. Thomas, allowing them more time to enjoy together.

Holistic Nursing Action Plan

Like many others who have suffered cancer, Mrs. Thomas suffers from pain, “the most common symptom associated with cancer” (Nettina, 2013, p. 155). If Mrs. Thomas’ pain can be effectively managed, she will face less difficulty participating in the ADLs and likely have more ambulatory time per day. According to Qaseem et al. (2008), her pain related to cancer treatment should be assessed properly: is it somatic (direct tumor involvement), neuropathic (nerve-related), or visceral (inflammation of the smooth muscle) (Nettina, 2013)? Different pharmacologic and non-pharmacologic strategies can be employed based on the type and quantity of pain Mrs. Thomas reports and exhibits (Bemis et al., 2008). Pharmacological interventions include the use of analgesics like NSAIDs, Cox-2 Inhibitors, and Opioids, along with adjuvant drugs such as bisphosphonates, corticosteroids and muscle relaxers (Qaseem et al., 2008). Chronic, cancer-related pain has elements of both lingering pain and acute “breakthroughs,” (Nettina, 2013, p. 155) these can be better managed by combining long and short-lasting medications. Perhaps Mrs. Thomas is apprehensive about taking pain medication orally. Spinal catheterization with morphine injections or a pain pump may be able to effectively manage serious pain at the end of life (Nettina, 2013).

Goals to be pursued in this area include reduced reporting of pain by 2 or more points on a universal pain scale, fifteen minutes of ambulation per day (with caregiver assistance if needed), and two fewer episodes of crying per week. Setting reasonable goals and evaluating progress can be tremendously helpful to nurse, patient, and family because it ensures that a plan of care is achieving its desired objectives during specific time frames. The nurse should “convey the impression that the patient’s pain is understood and that the pain can be controlled” (Nettina, 2013, p. 156). This will reassure the patient that they are being heard and doing the right thing by taking medication and following a nurse’s recommendations. Mrs. Thomas needs a reduction in pain and reduction in stress as she faces her journey, and this can only be provided by a holistic plan of care which looks at all aspects of daily life and includes the doctor, nurse and all medical staff, Mrs. Thomas herself, her family and most importantly, Mr. Thomas in both development and implementation. Noting that Mr. and Mrs. Thomas are struggling financially, a community health nurse should work to facilitate interventions that are affordable. Traditional inventories of caregiving which look at assistance with ADLs ignore “the frustrations of navigating the health care system for help of any kind” (Bemis et al., 2006, p. 342).

Functional Ability

In order to assess and improve Mrs. Thomas’ functional ability, the nurse should aim to evaluate and relieve pain and post-cancer therapy symptoms, encourage physical and palliative therapy and focus on helping Mrs. Thomas complete her ADLs and IADLs more effectively. Mrs. Thomas has both subjective and objective signs of chronic pain related to tumor progression and post-treatment after effects. She reports pain and also cries in bed, where she remains most of the time. She is being treated for pain with hydrocodone medication, but she does not take it because of apprehension related to addiction potential. This important fact indicates that Mrs. Thomas’s pain management plan is not currently effective and the community health nurse needs to assess Mrs. Thomas's pain levels, her feelings about taking medications, and her goals for pain management. Providing patient education to Mr. and Mrs. Thomas regarding the importance of following doctors’ orders, especially with medications, is key. “Information from specialty organizations can enhance learning and compliance…a formal support group or communication” with a fellow cancer patient is very helpful (Gulanick, 2013, p. 871). Mrs. Thomas’s feelings toward taking medications are valid and her cultural background factors into the nursing interventions which follow; it would be wrong to ignore her statements and desires, but pain management will nevertheless be an important part of her palliative care.

The community health nurse can explain Mrs. Thomas’ needs and suggest to her doctor that other medications might be tried which enhance the effect of opioid medications, have fewer side effects, or lack addictive potential (Nettina, 2013). Medication is only one way to treat pain, a holistic nursing plan accounts for all aspects of human experience in order to fully care for a patient’s unique background and desires. For example, Mrs. Thomas could be referred to a pain management specialist who tries to avoid the use of certain medications and favors biofeedback, meditation, or cognitive-behavioral interventions. Mr. Thomas is not alone in suffering increased stress due to Mrs. Thomas’ pain. According to Bemis et al., “pain management is an intractable problem for caregivers that results in substantial caregiver distress, as caregivers assist with both non-pharmacologic and pharmacologic pain-management strategies” (Bemis et al., 2008, p. 345). A holistic plan of care includes Mrs. Thomas’ physical, mental, and social health. Pain is currently the major factor impacting these three parts of Mrs. Thomas's quality of life. Additionally, lack of care resources and her caregiver\partner’s stress is having an impact on day-to-day outcomes. In order to ease some of Mr. Thomas’ stress as a caregiver, the community health nurse should engage him in considering support options such as a skilled nurse, home health aide, or long-term care.

Providing Care

The community nurse should work with Mrs. Thomas and her husband\caregiver to develop a plan for potential hospitalization, entering a long-term care facility, or home health\hospice provider. “Advance care planning, including completion of advance directives,” is highly recommended by clinicians (Qaseem et al., 2008, pp. 141-146). This will ensure that Mrs. Thomas’ wishes are followed even if her advanced disease processes prevent them from being made known and help clarify the decisions family members take during her end of life. More immediate care requirements need to be met by engaging with a hospice care provider and inquiring the insurance provider and Medicare about providing for specialized hospice care (Qaseem et al., 2008, pp. 141-146). The six ADLs to assess for Mrs. Thomas are, according to the Katz index: bathing, dressing, toileting, transfer, continence, and feeding (Nettina, 2013). Mrs. Thomas shows deficits in her ability to care for her own ADLs because she is semi-bedridden. She is relying on Mr. Thomas for caregiving assistance, but she states she does not want to ‘burden’ her family. A skilled or unskilled aid needs to be placed in contact with the Thomas family by nursing referral. Mr. Thomas feels unable to fully provide for Mrs. Thomas's care financially, physically and emotionally, and the community health nurse is obligated to provide education and referrals on these facets of care. Palliative care does not aim to cure a disease but to reduce the negative effects and symptomology of a chronic or terminal illness. “Current palliative care guidance…places the individual in receipt of care centrally,” in other words, Mrs. Thomas herself is the focus of palliative care and should receive the most information about her condition and possible treatments (Reed & MacFarlan, 2012, p. 166). However, as her partner and caregiver, Mr. Thomas plays a central role in her palliative care.

Chronic Depression

A community health nurse is obligated to facilitate care for members of the community which may be overlooked by other medical services. “Caregiver burden and depressive symptoms are the most common negative outcomes of providing care for the elderly and chronically ill” (Bemis et al., 2008, p. 344). Many older adults are in a similar situation to Mr. Thomas because “recognition of depression is hindered by the coexistence of physical illness and social and economic problems common in late life” (Harvath, 2012, p. 151). Early detection of depression and immediate nursing referral is ideal. In treating Mrs. Thomas, Mr. Thomas’ role as a caregiver must be addressed: “Caregivers who are at risk of depression…are more likely to engage in neglect or abusive behaviors, such as screaming and yelling, threatening to abandon or use physical force, withholding food, hitting, or handling roughly” (Bemis et al., 2008, p. 344).

Mr. Thomas’ depression poses a risk to Mrs. Thomas’ quality of care, and he may need individual treatment alongside Mrs. Thomas’s nursing plan. He may be assessed with the geriatric depression scale, “because it takes approximately 5 minutes to administer,” and “has been validated and extensively used” in older adults (Harvath, 2012, p. 151). If his chronic depression and the effects of caregiver stress can be properly managed, it will enable him to be a better caregiver now and a supportive husband overseeing Mrs. Thomas's future care options. Mr. Thomas needs to address how his work is being impacted by the financial and time demands of caregiving. “Caregivers who are employed report missed days, interruptions at work, leaves of absence, and reduced productivity because of their caregiving obligations” (Bemis et al., 2008, p. 344). Tricyclic anti-depressants can be a possible course of action for both Mr. and Mrs. Thomas because of their backgrounds and symptoms according to Qaseem et al. (2012).

Patient education is the number one resource a nurse can provide in this instance. The psycho-educational approach “emphasizes both the provision of information and a psychological/counseling approach to decrease caregiver distress.” Randomized clinical trials indicate that this type of intervention has a “positive effect on reducing caregiver depression” (Bemis et al., 2008, p. 350). The ideal outcome will be for Mr. Thomas to report decreased depression symptoms and increased confidence and knowledge about Mrs. Thomas's condition and plan of care. An integrated approach is the only way to balance Mrs. Thomas’ needs against the realities of her care context (Reed & MacFarlane, 2012).

Mr. and Mrs. Thomas face a tough road ahead, but they do not have to face it alone or in combined suffering. A community health nurse has numerous strategies and techniques at her disposal to ease pain, increase functioning, and treat depression. By following the nursing process of assessment, diagnosis, planning outcomes, implementation and evaluation, both Mr. and Mrs. Thomas could see marked improvements in comfort levels.

References

Bemis, A., Given, B., Petlick, N.H., & Reinhard, S. C. (2008). Supporting family caregivers in providing care. In R. G. Hughes, Patient safety and quality: An evidence-based handbook for nurses (pp. 341-363). Rockville, MD: Agency for Healthcare Research and Quality, U.S. Dept. of Health and Human Services.

Qaseem, A., Snow, V., Shekelle, P., Casey, D. E., Cross, J. T., & Owens, D. K. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 148(2), 141-146.

Harvath, T. A., & McKenzie, G. Depression in older adults. In Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice (4th ed.) (pp. 135-162). New York (NY): Springer Publishing Company; 2012. p. 135-62.

Gulanick, M., & Myers, J. L. (2013). Nursing care plans: Nursing diagnosis and intervention (8th ed.). St. Louis, MO: Mosby.

Nettina, S. (2013). The Lippincott manual of nursing practice (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Redfern, S. J., & Ross, F. (2006). Nursing older people (4th ed.). Edinburgh: Elsevier Churchill Livingstone.

Reed, J., Clarke, & MacFarlane, A. (2012). Nursing older adults. Maidenhead, Berkshire, Angleterre: Open Univ.