case study

case study

Sandy is a 58 year old female with widely metastatic ductal carcinoma of the left breast diagnosed 8 years ago. Sandy has metastasis to her lungs and liver. Recent 3rd line chemotherapy has failed to decrease the size of the liver and lung nodules. Bone scan reveals hot spots in the thoracic spine, right ilium and right 5th and 8th anterior thoracic ribs. Sandy has experienced limited use of her left arm due to extensive lymphedema. Sandy is losing weight now weighing 115# instead of the 150# that she weighed 1 year ago and is experiencing level 8 pain in the RUQ and back. As the palliative care nurse practitioner, you are asked to see Sandy for evaluation of the unrelieved pain.

After a lengthy discussion with Sandy, she expresses her concerns about missing her daughter’s wedding which is scheduled for 4 months from now. She is anxious about the responsibilities she has to prepare for the wedding, the pain she is experiencing, her continuation with weight loss and the fact that she is non-responsive to chemotherapy. What are your priorities in managing this case? What approaches will you take to manage her care?

Sandy has been taking two Percocet every four hours to achieve the goal of pain an acceptable pain level of three. The doctor suggests increasing Percocet to two tablets q3hr around the clock. What is your concerns with this order?

What would be some possibilities if you were to do analgesic conversions to MS Contin? For MSIR? For hydromorphone?

Lymphedema is a very limiting complication of lymph node dissections. What are the possible ways to manage lymphedema?

Sandy is cachexic weighing 115# at 5’8” tall. Explain the causes of cachexia in the terminally ill patient. How will you manage the constipation and nausea experienced with the new shift in pain management?

 
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