Grammie dx'd recurrent BRCA today, need advice...

  1. My maternal grandmother was diagnosed with what is suspected to be a recurrence of BRCA. She has a h/o radical mastectomy of the left breast followed by chemotherapy and radiation, in 1981.

    This new tumour was detected on a mammogram, bx'd and came back positive for CA. Since my grandmother has not received a nuc med scan (she's scheduled for one tomorrow, Monday), we're not 100% sure that this is a primary and not a met from some other primary. I just received the news today b/c my mother wanted to keep it from me over the holidays--my mother had BRCA in 1994, my grandmother in 1981.

    So, here's the thing. My grandmother is 80 years old, a retired RN, relatively healthy except for severe arthritis (requiring a cane and/or walker), some thrombophlebitis and her prior bout with BRCA. She was a nurse in the days when doctors were God, and my biggest concern for her post-op--she's scheduled for a mastectomy of the right breast on Wednesday--is that she will be in pain, either from the surgery itself or from her arthritis, and won't ask for pain meds. Her hip pain is so bad after prolonged bed rest that she literally screams in the morning--but won't even take a Tylenol.

    Her doctor is a old-school guy, and is of the don't ask/don't tell school of pain management. He doesn't ask, and she wouldn't tell.

    So, I have a telephone call scheduled with him tomorrow (I have healthcare POA). My question is, what pain med would you recommend in the hospital after surgery? I was thinking PCA or other IV route--so that my grandmother wouldn't have to ask, it would just be there for her when she woke up in PACU. Alternatively, I am thinking about asking for a Fentanyl patch for her, for the same reason--no asking required for pain control.

    My grandmother has already decided to forgo chemotherapy and radiation--it nearly killed her the first time around, and then she watched it nearly kill her daughter. She doesn't have any interest in doing it again. Any suggestions for palliative type care would be appreciated.

    Also, if anyone is in the Cape Girardeau, MO area, that's where she is...and where I will be very soon, courtesy of United Airlines. The surgery is Wednesday, and I'll be leaving Tuesday for St. Louis and Cape Girardeau.

    I need to toddle off and cry now...thanks in advance, everyone.
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  2. 7 Comments

  3. by   DIPLOMATICRN4HIRE
    I suggest that you speak with the Dr and your headed down there anyway You can speak face to face with the Dr about her pain management. Speaking surgically.... she will have the same amount of pain as the past surgery for the mastectomy. But getting her up and moving will be her best defense in post of pain. I wouldnt suggest keeping her down too long with the other symptoms she has. The fent patch may help with both, but how well does she tollerate being in the daze? If she does get one I suggest you stay with her and help her about. She sounds strong willed and high tollerant or just too proud to ask for pain meds. I think the patch would be fine but sometimes we have a PCA post op for the first day.
    I hope you have a safe trip, my prayers are with you and your family. I went through this with my grandmother when I was posted in South Africa and the plane ride was long and hard. Keep us posted on her stats and how everything goes. You and your family are in my prayers.
    Zoe
  4. by   RN from OZ
    Fentanyl patches are used widely over here for analgesia post op in the elderly as well as in palliative care.
    We also use alot of it with epidurals.
    It is effective and does not cause the deleriums and constipation that other pain meds do in the elderly.
    Also she probably would not press the PCA if she wont take a panadol.
    So a patch or a regular charted dose of a slow release morp...like MS Contin seems like the best option.
    So Sorry to hear that it has re occured, I lost my grandmother to CA of the breast 2 years ago she was 91 and not healthy enough to withstand another round of chemo.
    I hope all goes well for your Gran.
  5. by   ShandyLynnRN
    I am so sorry to hear this! As an addition to the narcotic pain meds, what about routinely scheuled Toradol injections? I have never cared for post op mastectomy patients, but it works WONDERS for hysts and c-sections!
  6. by   aus nurse
    I think a PCA with a continous background infusion and prn demand doses would be the way to go.
    We have 2 different PCA sets here...one just has the demand button and the other is a pump which has the demand buttton and you can also set a background infusion. If you only have the demand type there then I would think IV infusion with orders for boluses would be the way to go.
    Personally I have seen a lot of confusion in the elderly using Fentanyl patches, and in my experience it is not used in the post-op patient. Remember it takes 12-24 hours to reach optimal plasma levels with absorption of Fentanyl in the patch form. After removal of the patch the fentanyl still has a half life of around 17 hours. So you can not quickly adjust the analgesia level in acute post-operative pain. They are excellent in chronic pain where you have that time to slowly adjust the dose, whilst using alternative analgesia.
    Remember too, it isn't the surgeon but the anaethetist who will be ordering her analgesia.
    I hope your grandma does OK and my thoughts are with you.
  7. by   RNFROG3
    prayers to you rn2b2005. My mom had breast Ca 2 years ago. It was much harder for me to be the daughter then it is for me to be the nurse. She had a PCA and our hospital uses PCA regularly for post-ops. Talk with the anesthetist and maybe they'll give her a demand and base rate. She'll need to get out of bed after her first day but she'll also need to be guarded closely when she is up --don't want to fall and break a hip cuz we got her pain under control and now shes a bit fuzzy. It sounds like you know her well though and will be a really big help. Good luck, I be thinking of you!
  8. by   2banurse
    ((((rn2b2005)))) My thoughts and prayers are with you and your grandmother. My mom was dx'd with BRCA last March and though she is doing well and finished now with the chemo and radiation, she has told us that if there is any recurrence, she would not go through that again. It's a scary thought.

    Wishing you all the best,
    Kris
  9. by   RN2B2005
    Thank you everyone...I needed some affirmation of what I was already thinking. I'm still just a nursing student, and only know about PCA's from what I've read; Fentanyl I'm familiar with from working with veterinary patients (we used it post-op).

    The hospital where my grandmother is having the surgery doesn't use PCA units--I called this morning and spoke with someone (an RN, I think) in admitting.

    So, I will be talking with Grammie's doctor later today and then I am going to try to reach the anesthesiologist scheduled on her case to request that they slap a Fentanyl patch on before she wakes up. If she's ORDERED to take pain meds, she'll take them--otherwise, she could literally be on fire and
    she'd only politely ask for a fire extinguisher, when the nurse has a minute.

    I'll try to keep updating the board, at least until tomorrow.:kiss

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