Introduction:

Many patients with a chronic, terminal illness are cared for in the home. The community nurse is a key resource to these patients both in providing a link to

healthcare and in promoting quality of life.

Scenario:

Mrs. Thomas is a 56-year-old female with a history of breast cancer. Three of Mrs. Thomas?s five female relatives died before the age of 50 from the same illness.

After identification of a malignant mass in her right breast one year ago, Mrs. Thomas underwent a right mastectomy with the removal of five axillary lymph nodes,

followed by chemotherapy and radiation therapy. She subsequently suffered moderate lymphedema and pain in her dominant right arm. At that time, the BRAC (Be Ready

Against Cancer) analysis was positive, revealing a higher than average chance of the disease recurring.

Six months ago, Mrs. Thomas felt a pea-sized, hardened lump in her left breast. A biopsy was positive for malignancy. She underwent a second mastectomy with

chemotherapy and radiation. After treatment, the cancer was found to have metastasized to her lungs, and further surgery was not determined to be a viable option. She

has been given a poor prognosis for recovery, and palliative care is now recommended.

After the last chemotherapy, Mrs. Thomas experienced a moderate degree of pain on most days. Even though she had been prescribed Vicodin (hydrocodone/paracetamol),

Mrs. Thomas endured the discomfort without pills most of the time because she says she did not want to become "addicted to drugs." Lately, however, her pain

level has been increasing and she spends much of the day crying in bed. She can no longer hold the clerical job that helped to supplement her husband?s income, and

they find it difficult to make ends meet, even though she is receiving a small disability check each month. Mrs. Thomas has medical insurance but no long-term

healthcare insurance. Since all of her close female relatives have died, she has few people to help her. She does not want to call on friends or coworkers for support.

Mrs. Thomas lives with her husband of 31 years in a private home in the suburbs of a large city. Mr. Thomas has suffered from chronic depression that has been managed

with medication. He is a police officer who is extremely supportive of his wife and is attempting to provide for her care at home. However, Mr. Thomas is now showing

increased signs of depression because of difficulties at work and because of the stress of his wife?s condition. He often forgets to take his medication due to the

stress. Mrs. Thomas has become concerned because she fears he is suicidal. This, in turn, is causing Mrs. Thomas even more distress, as she feels her husband is

suffering because of her illness. Because of Mrs. Thomas?s condition, the couple does not go out and does not have friends over to visit.

Mrs. Thomas has two sons, aged 28 and 30. Both live out of state with their wives and children and are very upset about their mother?s condition. Even though they

phone regularly, they find it too painful to visit her in person. The lack of personal contact with her immediate family makes Mrs. Thomas even sadder, yet she says

she does not want to "bother" them with her problems.

As the community health nurse, you have been asked to visit the Thomas family to assess their support needs. After reviewing Mrs. Thomas?s case history, you recognize

that the family is under a great deal of physical and emotional stress due to the chronic and terminal nature of Mrs. Thomas?s cancer.

Task:

Create an appropriate nursing plan (suggested length of 5?7 pages) in which you do the following based on the scenario above:

A. Explain how your own perceptions about quality of life and health promotion might affect your care for a dying patient with a lingering illness such as cancer.

B. Discuss three strategies that you could use in the Thomas?s situation to improve the quality of life for Mrs. Thomas and her husband during this illness.

C. Create a holistic nursing action plan appropriate for managing Mrs. Thomas?s care at home.

1. Discuss ways to optimize Mrs. Thomas?s functional ability at this stage of her illness.

2. Discuss ways to provide care for Mrs. Thomas once self-care is no longer possible.

D. Explain how you, as the community health nurse, can intervene in this situation in the management of Mr. Thomas?s chronic depression.