Community Health Nursing

While evaluating my own perceptions about quality of life and health promotion when caring for a dying patient with a lingering illness such as cancer I found that I have a lot to work on. Being a strong “Alpha” female I do not find myself feeling sorry for myself and usually do not accept that type of attitude in other people. I am a person who finds the cup half full instead of half empty and have a strong sense of competitiveness in life. There are times in my life that things have not gone the way I planned but I also have a strong sense of faith, a true belief in God, and the trust that He has a greater plan than I do so I must put my trust in Him. People must help themselves in order to receive help, no one is just going to show up at the door and state, “I thought you were in need of something so here I am here to give it to you.” There are plenty of programs that are out there to help anyone who is struggling with many different things in life all most people have to do is some research and then ask. As I read the profile of the Thomas’s, as a cancer survivor myself I do understand how she is feeling but I was also slightly frustrated at her for just giving up, worse yet for putting a lot of this on her husband who is already probably feeling helpless as it is. Lying in bed crying all the time is not going to do any good to anyone.

There are many options for her, she is just choosing to ignore them and feel sorry for herself. So my main goal for myself is to remember that not everyone deals with these situations as I do and to listen to her and how she is feeling. Projecting my beliefs and feelings onto her is not going to help her as she might feel as if I am not listening to her and incorporating her into her own care – taking away her autonomy. Maybe instead of solving the problem for her or telling her what she should do I could ask her what she thinks and give her multiple options to choose from, including her husband in some of the choices will help as well, I believe. The first strategy I would use in the Thomas’s situation is to sit down with them and find out how they perceive their situation, understand their illness, and what options they think that they have. This is an important step because unless I am aware of where they are in their lives and situation than I cannot help them. For example, Mrs. Thomas is not taking her Vicoden for pain relief because she “does not want to get addicted to pain medication”.

This is a common misconception about the use of pain medication but I do understand her concern. There is a lot of media coverage about abuse of prescription pain medication and many people are concerned about taking them now because they feel they will become addicted. There are many alternatives to this that can be presented to her but I need to access how open she is to other forms of pain management. Also Mr. Thomas has been forgetting to take his medication because he is so worried about his wife, the need to access his understanding of the importance of his medication is imperative. Mr. Thomas will not be able to help take care of his wife and help maintain his other responsibilities not only at home but also at work if he is unable to take care of himself. His willingness to incorporate some simple techniques to help remind him to take his medication will need to be accessed as well. Not only does their thought processes and understanding need to be accessed but also their capabilities and available resources.

For instance, Mrs. Thomas is still able to walk and drive does she have transportation to take her to appointments for secondary level of care, they both still are covered with health insurance is that covering all of the medical bills, Mr. Thomas is currently employed and along with her small disability check they are able to pay the bills even though there is not much left over afterwards. Are they willing to apply for assistance that is available to them? Demonstrating both the positive as well as the negative is a strategy used so that they do not feel as I everything they are doing is wrong. They are already struggling trying to deal with both of their medical conditions, only showing them the negatives and not emphasizing the positives will only make them less willing to accept help. Often people are just not aware of where to start and how to research and find help. For example, although Mrs. Thomas may have used a computer at her clerical job, she may need some assistance in using the computer as a resource to find assistance and resources for both of them.

This step is a major part of the assessment because if either one of them does not understand, or is not willing to participate in the development or implementation of the plan, then the plan itself will not work. Both of them need to be involved together in this so that they both are able to hear how the other person is feeling as well. Mrs. Thomas is probably feeling guilty, as if she caused the problem and is making her husband’s medical condition worse. While Mr. Thomas is also probably feeling helpless as he is unsure how to help his wife while she sits in bed crying and incompetent because his paycheck at the police department is not enough to cover the bills and any extra expenses now that his wife is unable to work. Once the assessment is complete the process of exploring options and creating a plan begins. This is a two-step process since the needs of the Thomas’s are to be addressed and then the options that are available to them need to be discussed. Step one begins with asking both of them what they want and expect from setting up this plan.

Then to determine whether the expectation is realistic or not realistic and if it is not realistic how can we address this expectation and make it realistic. For example, Mrs. Thomas may say that a goal of hers is to live. This is not realistic as her disease is terminal, however, a more realistic goal may be to live each day to its fullest incorporating medical and holistic techniques to minimize pain and create a positive experience with each day. This is a more realistic and a measurable goal as she can write down or state one positive thing that happened each day. Having them develop these expectation and goals is crucial because people are more likely to stick with a plan if they are involved in forming it – keeping them in control of their autonomy. This also helps because you are able to find out things from them that you did now know prior like – what Mrs. Thomas enjoyed doing in her spare time prior to the diagnosis – did she like to sew or knit, was she a book reader, does she enjoy movies? What are some of the things that the two of them used to do together? What were things that they used to do with their friends? Once these are addressed giving the Thomas’s options is important because it allows them to make the choices for themselves.

For instance some options to give Mrs. Thomas in place of the pain medication that she does not want to take could be things like Yoga or Pilates to help strengthen her and teach her meditation practices, non-narcotic pain medications like Toradal or Ultram, herbal teas and aromatherapy, education about walking and exercise and its benefits on cancer pain. Primary education about how to use the internet to research optional pain management techniques or locate local Yoga/Pilates classes, and how different types of aromatherapy for pain management can be used, also where to get them. Also Mrs. Thomas can be given some options for enjoyment as well by using the information gained about what she liked to do prior to being diagnosed. She can choose from a list of activities. Mr. Thomas can use this strategy as well for his medications with options like using a daily pill container to place his medication in so he remembers to take it, placing his medication bottle next to the coffee pot so he remembers to take it when he makes himself his daily cup of coffee, or placing a sticky note on the back of the front door that states, “Did you remember to take your medication?” so he sees it and is reminded prior to leaving for work to take his medication.

Financially, the internet and the American Cancer Society are great resources for them to use to get help. They can contact the American Cancer Society who has tremendous contacts and places for them to apply and receive assistance. Support groups can be introduced to both of them for psychosocial help with Mrs. Thomas being able to talk with people who are experiencing the same feelings and situations that she is going through and Mr. Thomas can access support groups for spouses where he can talk with spouses who are going through his experiences and frustrations as well, they can also help him cope with some of the needs that he has or guide him to resources available. Giving him some areas to express his feelings is important too, whether it is writing in a journal, exercise, or just letting him know that it him to do some things for himself is just as important as him being there for his wife.

Nutrition for both of them is other area that needs to be addressed and goals can be formed about this, helping them make better decisions about groceries. Another strategy that can be used here is the sons. Even though they are far away and are unable to visit often Mr. and Mrs. Thomas can set up a Skype account on the computer and then they can visit with the family on a more face to face basis. Letting the family reassure both parents about the positives that can occur in their lives and the support they will be receiving from them will help to motivate both about their situations. Positive motivation is key to helping these two recover from their situation and improve the quality of their lives. This also will help them to maintain these goals and overcome new challenges in their lives. It will also help address the grief process that is going on with not only the children, knowing that their mother has a terminal illness but also for the parents being able to spend the remaining period of her life in contact with her children and grandchildren allowing her to accept her diagnosis.

Accepting help will hopefully open the door so they are able to accept the fact that they are going to need help and be willing to continue to request assistance. With the key here being to make their goals, simple, realistic, and measurable. At the tertiary level of care, when Mrs. Thomas is no longer able to provide self-care for herself, the options available to her should be addressed prior to that occurrence. She has multiple options like a home health nurse or hospice. If they live in a multilevel house provisions need to be made for her to stay on the lower level with things like a beside commode, an installation into the shower, or a medical bed, if needed. Hospice is a vital resource that provides end of life care and support not only for the terminally ill patient but also for the family members with helping make final arrangements, counseling, and other vital decisions that need to be made and are often difficult to make like the making of a living will and/or Do Not Resuscitate Order. The use of many resources at this stage in the development of the illness is open as well, such as the use of food delivery services like Schwann’s who will deliver meals straight to the home eliminating the need for grocery shopping.

Books on tape can be used if she enjoys reading but is unable to read the books anymore, she can listen to them. The family can also make audiotapes telling her how much they love her, what is going on in their lives, and let her know that they are there and still very supportive of her. During this time attention needs to be paid to Mr. Thomas as well. He will have numerous decisions to be made, as well as consideration for his frame of mind and history of chronic depression. The disposal of her clothing, jewelry, personal items is just a few of the things that he is going to have to deal with. Providing him with avenues for this should help, for instance the clothing. Shoes and personal items can be donated to the Salvation Army or local Women’s Abuse Shelter. The jewelry can be given to the children. Renting the medical supplies that were needed for her care is also a good thought so that a call to the company can be made and they can pick the supplies back up.

Since these two have been married for 31 years living without his wife is going to be quite a change for him. He needs to prepare to experience this and have a plan of how to deal with it. Counseling may be an option, continuing to write in his journal, contact and support of his children, continuing at his job all need to be explored. His support group can help with this as well; even hospice can help him deal with his loss. His doctor can also be consulted as a change in medication might be warranted. Dealing with terminal illness is difficult in itself alone, adding to it emotions, denial, and lack of support can lead to total breakdown of not only a system but a family as well. It is the job of the Community Health Nurse to facilitate communication, provide options, and give control back to the family to make these decisions. If the community health nurse does an effective and efficient job the transition from life to death will still be painful but the outcome will be successful and smoother.