Managing a patient diagnosed with breast Cancer Fungating
Care context- The patient assessment and care planning took place in a care home following the patient’s admission due to decline in health, as she was unable to manage independently at home.
In this reflective account of person-centred assessment, I will be comparing and contrasting the resident’s information that I undertook during my time at practical placement, associating it with the (Driscoll 2007) model, a well-known framework for reflection demonstrating (Discoll’s 2007) the three processes when reflecting on a resident’s person-centred assessment. These three processes include: what (description of the event), so what (an analysis of the event) and now what (proposed actions following the event). Driscoll’s model will help me apply theory to practice. In accord with the Nursing and Midwifery Council (NMC) Code of Professional Conduct, performance and ethics (2015) protecting confidentiality and privacy of staff members and the patient all names and the place where the person- centred assessment took place will remain unidentified, for this assessment the patient will be known as Mrs Woody.
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First, four weeks into practical placement at the care home, I discussed with my mentor who she thought would be a suitable patient, to carry out the person-centered assessment. To prepare for this I read through all the patients care notes, by the end of the week, me and my mentor discussed that Mrs Woody was a good patient to carry out the assessment, as I was involved in the care plan, being involved in the wound dressing, this got me involved with getting to know the different types of dressings and what they were used for. Mrs Woody was diagnosed with breast Cancer with Fungating tumour. Breast tumour is a chronic disease (Lawrence 2016) that causes depression, loneliness, but other days they might feel more positive about their self(MacMillan Cancer 2014). By the end of week 5, Mrs Woody was asked if she could be the person I used for a person-centred account, I wanted to find out more about Mrs Woody’s breast cancer, as I found it interesting. Mrs Woody is a patient who’s got capacity so she could give consent herself. It is important to obtain patient consent before undertaken their care notes, this informs Mrs Woody about how her information is being used (Bowrey and Thompson 2014).
When explaining things to Mrs Woody, both verbal and non-verbal communication was used. It is important that Mrs Woody knew every detail about the person-centred assessment, ensuring that her name, place and other personal details were confidential. (NMC 2015) I found it difficult talking to Mrs Woody who has been diagnosed with depression, quite difficult than I had expected, as I always made time to have a conversation with Mrs Woody, so she wouldn’t feel nervous about answering questions. Mrs Woody got agitated when I spoke to her in a clear calm voice asking her simple sentences, this gave Mrs Woody, the chance to talk directly to me, and to express her feelings. There were times when Mrs Woody pretended to have not hear what I said, so Mrs Woody started talking about what she was more interested in. I then brought her back to the questions, explaining them in more detail, by adding in things about her family, which got her attention again, which is more therapeutic towards her as it is vital to nursing.
I felt confident knowing that Mrs Woody was at ease when she interacted in the person -centred assessment. I interacted with Mrs Woody for the first four weeks of placement, which helped her get to know me better. This was to support and reassure Mrs Woody so she didn’t feel nervous about talking to me for the first time. It also helped me to get to know Mrs Woody before undertaken the assessment, while interacting I was accessing how long, I would have to spend with Mrs Woody, given her enough time to undertake the assessment, as I knew that she liked to talk about her family. Given Mrs Woody more time will help her gather her thoughts, without being rushed.
The information that I gathered from Mrs Woody did match against the information on the medical and nursing notes. The only question that was left blank in the patient and family perspective box was “systems assessment” when Mrs Woody was asked this question she didn’t fully understand what it meant, so I tried to simplify the question, by asking her about her physiological, psychological, sociological, and spiritual status, but Mrs Woody just looked at me and stated: that she did not want to answer that question. I respected Mrs Woody’s wishes and moved on to the next questions. It is very important that Mrs Woody could answer all the questions about herself, as if Mrs Woody couldn’t answer any of the questions about herself then, we would have had to make a review with the doctor to check out Mrs Woody’s signs and symptoms, this could have been a result of Mrs Woody being diagnosed with dementia. The questions Mrs Woody answered were straight forward questions, about her past and relevant questions.
After getting consent from Mrs Woody, I was able to collect relevant case notes under the supervision of my mentor, the case notes contained past medical history, dietitian,doctors notes and care plans. My mentor was involved in the whole interview of Mrs Woody, who was in her bedroom this interview was undertaken in a confidential place (NMC 2015) as it was personal towards Mrs Woody. I explained to Mrs Woody in an informal manner, what was going to happen, and if it was okay to carry out the assessment today. By asking Mrs Woody if it was okay to undertake the person- centred assessment, showed that I was respecting her rights, in what she wanted to do. To improve Mrs Woody’s care needs we could have carried out this assessment when her family was there, this way we could have got more information out of Mrs Woody about her past medical history.
I gathered accurate information on my one-to-one talk, to support Mrs Woody’s clinical care needs, I will be researching nutrition for Anorexia Cachexia Cancer. Doing this condition for Mrs Woody’s clinical care, allows me to see what the problems can cause and how the illness can result in different parts of the body, for example, this can cause loss of appetite due to Mrs Woody having Cancer, Mrs Woody is losing electrolytes and proteins from the wound, as nutrition has a big impact on the wound healing. I felt that doing this type of cancer was good as if I didn’t understand something about the condition I could go back and ask my mentor, this support was good for a student as your learning off another member of staff, in the care setting instead of reading journals.
In conclusion, it is seen that I have mentioned the (Driscoll 2007) model of reflection. Stating the reasons why this framework was chosen as well as why reflection is important in Nursing. By using the three stages in the (Driscoll 2007) model of reflection this has helped to develop a therapeutic relationship with Mrs Woody by using interpersonal skills. This shows that Mrs Woody feels safe and happy within the care setting, and gets on well with staff members, as Mrs Woody was unable to manage independently at home due to her being diagnosed with breast Cancer Fungating. Mrs Woody communicated well with me and the nurse, during the assessment, this is very important. This shows that Mrs Woody feels comfortable and has a good relationship with the health professional staff, when talking to professionals about her personal care plan. Overall, I feel that getting to know the patient before doing the assessment, made it easier for me to communicate with Mrs Woody, as having a relationship with her made the conversation flow more easily, making Mrs Woody not feel nervous. This skill is essential towards nursing, as I found Mrs Woody felt comfortable talking to professionals.
If I was to undertake this person-centred assessment again to make it better, I would get the family involved in the person- centred assessment, by getting the family involved they could have supported, what Mrs Woody was saying, by expanding on what she was asked, this could have given me more detail about her past and relevant medical history. This makes it clear why Mrs Woody kept on getting distracted and talking about her family. If Mrs Woody’s family was in the room this might not have happened. When consent was given from Mrs Woody within the end of week 4, I could have given her a date when the assessment was going to be done and should have given her a choice if she wanted her family to be present when the assessment was being done. By given Mrs Woody the choice this was respecting Mrs Woody’s rights.
The main learning that I as a student Nurse, can take from this reflecting practice is that (Driscoll 2007) model is effective on health professionals, as the three reflective questions make you think more as what you have to develop, and analyse what you just done. This model helped me to develop my learning skills. (Driscoll 2007) model can identify weaknesses and strengths when it comes to someone’s care. Developing new skills reflecting on past experience can help me achieve my highest potential, as with the (Driscoll 2007) model it has outlined my weaknesses and strengths.
Part 3 – Using information and data gathered during the assessment process identify one clinical care need for your patient and discuss the evidence based rationale for this choice.
The clinical care need that I have chosen to reflect on within the person-centred assessment is nutrition, for patients with Cancer Anorexia Cachexia.
With Cancer Anorexia Cachexia symptoms it is a metabolic disorder (Tazi and Errihani 2010). Cancer Anorexia Cachexia happens when a patient like Mrs Woody, losses weight, fatigue and feels weak, with increase weight loss resulting in loss of fat mass. This is not the patient’s choice in wanting to lose weight as weight loss is involuntary, it can not be even prevented by nutritional support (Mondello 2015). This condition can be seen as an end of life or chronic condition, such as, ‘infections, acquired immunodeficiency syndrome (AIDS), chronic pulmonary disease and renal disease’ (Tomoyoshi 2015).
Nutriment is important in helping patients with Cancer treatment and the development to become better (Reeves et al. 2007). Having a poor diet when having Cancer Anorexia Cachexia is a common problem with most Cancer patients, as it has been known to have vital symptoms of poor outcomes, such as decreased quality of life, making them weak and losing their ability to mobilise. Cancer patients needs a good balanced diet for the body to store nutrition, and maintain their body weight, a good balanced diet, this will have an effect on good quality life (American Cancer Society 2015). While if cancer patients have a poor diet, this can cause undernutrition, which leads to the patient having a high factor of infections, increasing their end of life care (Vigano et al. 1994)
With Mrs Woody having Cancer Anorexia Cachexia at the age of 83 years old unfortunately, there is no treatment for anyone with this condition (Fearon 2013) having this condition it is vitally important that Mrs Woody’s clinical status is took into consideration when caring for her, as due to the factor that she is 83 and has this condition it does not only lead to weight loss, but can also affect other symptoms, Â Promoting positive outcomes from the health professionals for Cancer Anorexia Catherxia by increasing dietary needs, and minimising symptoms which will influence the patient’s quality of life (Bauer 2007).
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Due to not having enough nutrition in the body, this has effected Mrs Woody’s mobility making her need assistance with two people. This condition affects the skeletal muscle wasting, and body weight as nutrition has been decrease. Lacking appetite is a problem for Cancer Anorexia Cachexia patients as this might have a different mindset on therapeutic options. Decrease weight loss, could be due to being diagnosed with cancer, causing the patient to have not only have decreased nutritional intake, but swallowing can also be a problem (Bauer 2007) It is important that health professionals detect and treat Mrs Woody with other causes that Cancer Anorexia Cachexia brings to her, such as depression, Mrs Woody is a palliative patient, depression can effect Mrs Woody differently some days, she might get up one morning feeling content, or other mornings it might affect her my getting up feeling depressed and an inability for her mood to be lighted. Pain is another factor effecting Mrs Woody, pain is common in cancer patients, and in lifelong illnesses (Higginson and Costanantins 2008). With Mrs Woody having Cancer Anorexia Cachexia her pain should be well controlled as there is medicine to prevent her feeling in discomfort.
It should be recommended that every patient with Cancer Anorexia Cachexia, to see about nutritional counselling as this will help patients who have this condition, being seen by a nutritional will help a patient like Mrs Woody to establish her physical function and body weight (Ravasco 2007). When attending a nutritional counselling for Cancer Anorexia Cachexia that a patient gets full support out of attending, which will include different nutritional aspects, eating problems and clinical history. This allows the patient with Cancer Anorexia Cachexia to keep a food diary, keeping a diary will help them see if there is any dietary changes, the diary will show the intake of caloric and show if there is any energy deficit. With the increase of caloric intake and nutrition, patients with Cancer Anorexia Cachexia have to understand that sometimes it does not work, with the increase of caloric it is known to help cancers. (Norleena 2011)
Being diagnosed with cancer it is known that having treatment can cause nutrition symptoms. Nutrition systems can cause obstruct oral intake, which then leads to the patient losing weight. This includes, different symptoms like, nausea, sore mouth, problems with swallowing, depression and changes in the smell and taste (Wojtaszek et al 2002) With having any of these symptoms it can impact the patients quality of life. It is advised that patients go and see a Dietician, Oncology, or even a nurse, as having any of these symptoms can affect the patient’s ability to eat. Getting the help from a health care professional will decrease the side effects in some way, as well as helping the patient to eat again and enjoy their food.
Health care professionals, within the care setting are involved in sending Mrs Woody to nutritional screening assessment. There are a variety of assessments that can be carried out for patients who are at a risk of nutrition, they use different assessment like skin testing, hypersensitity (delayed) and guidelines to institution- specific.
With the clinical care need of nutrition for patients being diagnosed with Cancer Anorexia Cachexia this condition is a metabolic disorder. It is important that for the best clinical care for patients being diagnosed with this condition, that they stick with the nutritional assessment of Cancer Anorexia Cachexia. Also having this condition the patient can talk to a health care professional, if they are having problems with eating or swallowing, also professionals help patients to set goals appropriately, which then improves quality of life for the patient. Some researchers have seen Cancer Anorexia Cachexia as an end of life condition, if they don’t have a good nutrition
Identify an outcome focused goal for this clinical care need, ensuring the goal involves the patient and is SMART (Specific, Measurable, Achievable, Realistic, Timely).
The goal that I will be focusing on for Mrs Woody is a 45 diet plan, for patients with Cancer Anorexia Cachexia which will involve the SMART assessment. The SMART assessment is what goal you want to achieve, there are five main parts to this goal and they include “Specific, Measurable, Attainable, Relevant and Timely. “(Haughey. 2015)
A specific goal for a Cancer patient in a care home setting is to improve the increase of calorie, by improving calorie this will improve quality of life to symptom manage nausea . The increase to calorie are different for each patient, this is due to everyone being different sizes, people being taller than others, treatment and side effects. A high calorie should be recommended for the patient, as it prevents the patient losing weight (Wickham et al 2015).
The goal for Measurable in a Cancer patient is weight management. With the increase of calories into the diet will help to maintain some body weight, if the patient is well enough it is vital that they get referred to the dietician, for supplements and weekly weight. The UK guidelines do not have a set guideline for doing physical exercise after treatment (Cancer Research UK 2015). But it is recommended by the (Macmillan Cancer Support 2012) that exercise is a good way to help control weight by muscle strength, and cardiovascular exercise. This will improve the patient’s quality of life, keeping their mind of their condition.
Achievable goals for a Cancer patient, is necessary when on a 45 diet plan, increasing a Cancer patients appetite, sometimes the psychological aspect of Cancer, appetite can be affected by mood, general health and ability to fight infection, soÂ using a MUST tool will help improve the patients appetite, which will be documented in a food diary. In the food diary the health care staff will keep an eye on the intake of fortifying diet, adding calories and high calorific snacks to the diet. Smoothies are good for adding in calories, as they have a range of vitamins in them. Vitamins are important nutrient for Cancer patients as it will decrease side effects, and helps the immune system (Parker 2017).
A realistic goal for a Cancer patient when on the 45 diet plan, is to increase weight, and not to lose weight. With a patient being underweight it can cause infections. These infections can be hair falling out, or/and decrease body muscle. When a patient is underweight there is a high risk of the patient being diagnosed, with Osteoporosis, being underweight people find it hard to absorb minerals and vitamins (Meghan 2008).
The timely goal will be the end result, which will be then reviewed in 4 weeks to see how well the patients get on, with the 45 diet. The focus within the 4 weeks is to see if there is any improvement in weight.
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