MELE
Setting:
You are a district nurse who has been involved with Mele’s daughter, Siu and her
children.
This came about whilst you were caring for Mele’s granddaughter, Fai who has
Rheumatic Fever.
Siu’s oldest daughter, Maggie has brought home a slip for permission to have the
Gardasil vaccination. Siu does not know what Gardisal is.When you visit to give Fai
her injection, Siu asks you “what is Gardisal and is this a good thing?”
Action point
Outline the information that Siu needs to know to be able to make an informed
decision.
Gardasil vaccine targets the types of HPV responsible for most cases of cervical cancer (types
16 and 18) and genital warts (types 6 and 11). Clinical trials show Gardasil is highly
effective in preventing these types of HPV in young women who have not previously been
exposed to them.
The vaccine prevents future infection, but it does not cure an existing infection. However,
even if you have been sexually active, and have already been infected with one HPV type
contained in the vaccine, the vaccine still provides 95% to 100% protection against the other
three types in the vaccine. The vaccine may also reduce the likelihood that the existing HPV
infection progresses to a pre-cancerous change, although this is still being studied.
On going studies shows the vaccine protects against HPV infection for five years after
immunisation and suggest protection will last much longer. Gardasil does not protect against
all types of HPV that can cause cervical cancer and gardasil may not provide protection for
everyone who is vaccinated.
Girls born on or after 1 January 190 will be eligible for the HPV vaccine. From 1 September
2008, girls aged 17 and 18 years (born in 1990 and 1991) will be able to receive HPV vaccine
from primary care and health clinics. From 2009, HPV vaccine will be part of National
Immunisation Schedule for 12 year old girls (in primary care and health clinics) and girls in
school Year 8. HPV vaccine will be offered to girls aged 13 to 18 years.
The three doses of Gardasil are given over a six month period, 1st dose, 2nd dose is given 2
months after the 1st dose and 3rd doses is given 6 months after the 1st dose (4 months after the
2nd dose).
Action point
Discuss the aetiology of cervical cancer
Cervical cancer begins in cells on the surface of the cervix. Over time, the cervical cancer can
invade more deeply into the cervix and nearby tissues. The cancer cells can spread by
breaking away from the original (primary) tumor. They enter blood vessels or lymph vessels,
which branch into all the tissues of the body. The cancer cells may attach to other tissues and
grow to form new tumors that may damage those tissues. The spread of cancer is called
metastasis. See the Staging section for information about cervical cancer that has spread.
Cervical cancer is caused by infection with the human papillomavirus (HPV), which can lead
to abnormal cell changes and, over time, cancer. HPV is spread by sexual contact and is very
common. Many types of HPV are cleared by the body's immune system. However, some
women who have had HPV can go on to develop cervical cancer.
Preventive measures for cervical cancer include: Having regular cervical smears, so
abnormalities can be detected and treated early. The HPV vaccine helps prevent infection
with the most common types of HPV (vaccine is most effective if given before the onset of
sexual activity). Using condoms can help to reduce the spread of HPV infection, though
condoms are not a complete protection from HPV. Risk factors for cervical cancer include
having multiple sexual partners, and smoking.
http://www.everybody.co.nz/page-b4548ad7-5760-4324-aab7-2d29da290a4e.aspx
Action point
Discuss the issue of informed decision making and the rights of children.
In a recent paper to a Medico-Legal Conference, the Commissioner for Children made a
number of statements regarding childrens' and parents' rights. "I agree with the Commissioner
for Children that children should have the best treatment possible", says Health and Disability
Commissioner Robyn Stent. "The real question should be who makes the decision as to what
is the best treatment in the circumstances of each particular child - the child's current doctor
or a parent/legal guardian?"
"Should the parent take advice from the doctor? Absolutely! Who then makes the final
decision in the best interests of the child? The parent of course, because ultimately they
should care for the child - the child will be loved forever, and they will have to live with the
outcome of their decision."
Mr McClay cites one authority as saying, "it is, of course true that adults make mistakes ...
but having rights means being allowed to take risks and make choices". "I couldn't agree
more," says Robyn Stent. "I remind the public that the Code of Rights is New Zealand law
and gives all consumers of health and/or disability services the right to both be fully informed
and to make choices based on that information. This includes children."
In circumstances where a professional does not believe the parent is making the right choice,
they should continue discussions with parents or guardians. On the rare occasions when the
matter remains in dispute and is life threatening, then health professionals have an obligation
to go to the courts to seek a review. Court decisions, which may result in denying parents'
right to make this informed choice should be done in an open and transparent way. The
public must be aware of why the Court decided the health professional's view prevailed over
the parents' view and vice versa.
The United Nations Convention on The Rights of the Child gives children the right to
"medical treatment". The Commissioner for Children says, "their [children's] rights are
prescribed in the [Convention]?.there are no tags which say those rights must get the public
or even family's okay". A logical outcome of such a rigid interpretation could be that the
State could use the Convention to insist on mandatory immunisation programmes.
"As Health and Disability Commissioner, my concern is that parents will read and hear these
messages regarding inalienable rights of children and will interpret this as an inability to
exercise day to day choice," says the Commissioner.
"It is an important matter that parents continue to exercise their right to choose health care
and disability services on behalf of their children and not acquiesce to the health
professional's view which later becomes the source of complaints to me".
http://www.hdc.org.nz/publications/other-publications-from-hdc/media-releases/informedchoice-and-the-rights-of-children
Action point:
Identify all the immunisations on the free schedule and eligibility criteria.
Setting:
The two oldest girls are starting to rebel against their mother’s restrictions on their social
activities. Part of Siu’s concerns around the vaccinations for HPV centres around the church
telling them it is a bad thing because it will make the girls more sexually active.
Action point
How can you help Siu with this problem? What help can she find in the community?
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GP Practice
Family planning
Immunisation Awareness Society (IAS)
The IAS is a voluntary, non-profit organisation dedicated to promoting informed choice. The
IAS undertakes research and provides information on vaccination and vaccines. The IAS
encourages people to make informed decisions about vaccination and to take full
responsibility for their family’s health. The IAS liaises with similar overseas organisations
and aims to maintain up-to-date international information on vaccines, and the perceptions
and positions of medical professionals on vaccination.
The IAS does not advise people not to vaccinate but facilitates an informed decision making
process. The decision about whether or not to vaccinate is a personal one that should be made
after much research and consideration. The IAS provides support to people who choose not to
vaccinate, people who sometimes come under considerable pressure from health
professionals, and members of the community to vaccinate their children.
The majority of IAS members have made an informed decision not to vaccinate themselves or their
children. This difficult decision is generally made after considerable research and much soul
searching. It is a decision that is not made in isolation but is part of a broader philosophy
which sees IAS members taking responsibility for their health and the health of their children.
It almost always accompanies a decision to breastfeed their babies for an extended period of
time, to provide the best diet possible, to raise their children in a secure and loving
environment and limit the use of such things as antibiotics and over-the-counter drugs to such
times as they are truly medically necessary, rather than to use them as a quick fix for the
many mild discomforts that we and our children experience.
http://www.kiwifamilies.co.nz/Topics/Support+Groups/Illness/Immunisation+Awareness.ht
ml
Action point
If one of the girls did get pregnant, outline her legal rights, citing relevant legislation in
detail.
Setting:
There is considerable discussion about the fact that the two teenagers in the family have
become very conscious of their weight and want to conform to the peer accepted slim
image. Mele and her daughter express that this is not ok because then their friends would
accuse them of not feeding the children properly. They add that it is their way to be large.
Action point
How will you respond to these statements?
Teenage pregnancies in New Zealand
New Zealand has a very high teenage pregnancy rate (along with USA and UK). Of course, not all teenage
pregnancies are unplanned or unwanted, but they can cause a lot of stress both for the individual young parents
and their families.
Every teenager in New Zealand, like every other pregnant mother, is entitled to a Lead Maternity Carer (LMC),
who is usually a midwife or occasionally a family doctor or specialist. This LMC will ensure that you get the care
you need during pregnancy and that you understand choices available to you. See below for a link to find out
more about choosing the right LMC.
There are special considerations for health, during a teenage pregnancy 
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Nutritional needs of the growing teenagers and the growing baby have to be met
The pregnancy may be taking place at a time when you or your friends are experimenting with drugs and
alcohol
Teenage years can be emotionally stressful too – without the added burden of a pregnancy to cope with.
Teenage pregnancy – stressful decisions
You may be reading this article having already decided whether or not you are going to continue with your
pregnancy.
If you are undecided about what to do, remember you do have choices 
You can keep your baby and bring up your baby yourself, hopefully with some great support from friends
and family
 You can continue with your pregnancy and then have your baby adopted by another family
 You can continue with your pregnancy, but have your baby brought up by another family member.
 You may decide to terminate your pregnancy (have an abortion). In New Zealand this is legal at any age,
with or without your parents’ consent, so long as 2 doctors agree that continuing with your pregnancy
would be a danger to your physical or mental health. You are entitled to see another doctor if your own
doctor does not agree with abortion.
If at all possible, your parents really are the best people to talk to. They may be angry with you to begin with, but
they love you more than anyone. Alternatively try your teacher or school nurse, your family doctor or a family
planning centre. These can be found in the Yellow Pages or on the web.
Whatever your decisions, the more support you have the better.
http://www.kiwifamilies.co.nz/Topics/Parenting/Teen-ParentsCorner/Teenagers+Pregnancy.html
Action Point:
BMI is usually used to determine if people are overweight or obese. Identify the drawbacks
of this system based on ethnic variations.
Are you able to identify any other measurements of healthy weight? If so, what are they?
Different Measurements Of Body Size
Weight and body fat can be measured in numerous ways, from scales to skin-fold tests. It’s
important to remember that people come in all different shapes and sizes and there is no
‘ideal’ body shape. The main thing is to ensure your height and weight are in proportion, and
that you’re not carrying too much fat around your waist.
Health professionals currently use Body Mass Index (BMI) to calculate healthy weight
ranges. The healthy BMI range for a European is between 18.5 - 25. For someone of Asian
descent the healthy weight is 18.5 - 22.9 and Polynesian descent has a maximum healthy
weight range of 26.
These variations are due to the differences in bone mass that are evident in individuals of
different ethnicities. If for your ethnicity you are above or below these ranges your risk of
developing health problems is increased. Your BMI can be calculated using the following
equation.
http://www.healthysteps.co.nz/inspiration/healthy-weight/different-measurements-ofbody-size.aspx
Action point
Church leader
Action point
Discuss the effects migration has had on the health of Pacific peoples.
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Loss of their cultural identity, food, customs, ritual and belief system.
Relying mostly on fast food and not fresh from their farm.
Modernised.
Setting:
Mele, who is Agnes’s friend and companion, has been persuaded to go to her GP. Agnes
and Mele’s daughter have noticed that she has a very nasty smell, even after a shower and
is losing weight. The GP finds that Mele has a suppurating mass on her Left Breast. This is
strongly indicative of advanced carcinoma. Mele is admitted to hospital but after family
conference with the oncologist she is returned home.
Action point:
Describe the more common types of breast cancer, also identifying when there is a genetic
factor.
Common types of breast cancer include
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infiltrating ductal carcinoma
o colloid (mucinous)
o Inflammatory
o Paget’s disease of the nipple
o Modularly
o Papillary
o Tubular
Infiltrating lobular carcinoma
Non-invasive
o Ductal carcinoma in situ
Non-invasive breast cancer
The increased use of screening mammography has led to more women being diagnosed
with non-invasive breast cancer. These non-invasive breast cancers include ductal
carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). DCIS tends to be unilateral
and has the potential to progress to invasive breast cancer if left untreated.
Approximately 10% of all breast cancers are hereditary, with genetic mutations causing up
to 80% of breast cancers in women younger than 50 years of age. Two breast cancer
susceptibility genes – BRAC1 on chromosome 17 and BRAC2 on chromosome 13 may
account for most inherited forms of breast cancer. BRAC1 is known to be involved in
tumour suppression. A women with known mutations in BRAC1 has a lifetime of ovarian
cancer. BRAC2 is another susceptibility gene that carries an elevated cancer risk similar to
that with BRAC1.
Action point:
Differentiate between benign and malignant growths
Growths on the cancer can be benign or malignant. Benign growths are not cancer. They are
not as harmful as malignant growths (cancer). Benign growths (polyps, cysts, or genital
warts) are rarely a threat to life and don't invade the tissues around them. Benign Neoplasm
are similar in structure to the cells from which it was derived, most are encapsulated in a
layer of connective tissue, have poor blood supply, does not invade surrounding tissue,
seldom recurs after surgical removal, obstruction, pressure and secretion and has slow growth
rate.
Malignant growths may sometimes be a threat to life, can invade nearby tissues and organs
and can spread to other parts of the body. Cells are undifferentiated and bear little
resemblance to the cells from which they arose, are not encapsulated and thus can spread to
other tissues, rob normal tissues of essential nutrients in an effort to grow causing destruction
of normal tissue, often recur following surgery and has rapid growth rate.
Action point:
Identify the three main treatment therapies for neoplasia.
Identify the three main treatment therapies for neoplasia.
Radiation therapy – uses radiation to kill cancer cells but normal cells are affected. Scaring
can lead to a loss of normal organ function. Lymphoma – need bone marrow transplant and
blood transfusion post radiation.
Chemotherapy is the administration of drugs to kill cells or prevent mitotic division. Severe
side effects include fatigue, anaemia, bleeding, infection, nausea and vomiting, hair loss.
Surgery is used for diagnosis, the staging of cancer, tumor removal and palliation when a
cure cannot be achieved. Surgery is curative if the tumor is localised, has not matastasised or
invaded major organs.
Hormone therapy consists of administration of hormones eg androgens or hormones blocking
drugs eg tamoxifen.
Setting:
Mele has never had breast screening because she says she didn’t really understand what it
did and whether it was painful. She also said she was too shy and embarrassed.
Action point:
Identify government and non-government initiatives in place to address these issues within
the pacific community.

The Breast Cancer Aotearoa Coalition (BCAC) is an Incorporated Society
representing thirty of New Zealand’s breast cancer related organisations. We offer
free membership to those organisations and

'Ala Mo'ui - Pathways to Pacific Health and
Government initiatives to increase Pacific attendance in early childhood ,for
community initiatives in Pacific communities aimed at increase the proportion of
eligible Pacific women who have a breast cancer screen.
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Central Cancer Network
The purpose of the Central Cancer Network is to take a proactive leadership, facilitation and
coordination approach to ensure all providers of cancer care in the network area work
together with the community to:
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manage the implementation of the New Zealand Cancer Control Strategy and
associated Action Plan 2005-2010. The dual aims are:
to reduce the incidence and impact of cancer
to reduce the inequalities with respect to cancer
improve the journey of cancer patients and their family / whānau through the complex
pathway of care, ensuring equitable, high quality, patient centred, evidence based and
multidisciplinary care.
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NZ BREAST CANCER FOUNDATION(NGO)
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The Cancer Society of New Zealand is the leading organisation dedicated to reducing
the incidence of cancer and ensuring the best cancer care for everyone in New
Zealand. We are the leading cancer patient advocate in New Zealand, providing a
voice on all kinds of issues including cancer detection and treatment. We have a
National Office located in Wellington, six regional offices and 15 centres, all involved
in raising their own funds and providing local support services.
Ealt
h Trust was recognisedSetting:
Mele has been referred to the District Nurse for management of her malodorous wound. Her
GP has advised the family that they would benefit from a referral to the Hospice.
Action point:
Write a wound care plan for the management of this wound. Include in this issues of
evidenced based practice and economics. What charge is there to the patient for the wound
care products?
Malodorous Wounds
I have been slowly making my way through the symptoms experienced at the end-of-life. The
next symptom I would like to address is the malodorous wound.
People may have malodorous wounds for various reasons throughout their life. However,
there are certain wounds seen more often at the end of life. Some of the malodorous wounds
seen at the end of life include bedsores and fungating breast cancer lesions. The odor is
caused by anaerobic bacteria in necrotic (decaying) tissue, which release volatile fatty acids
as a metabolic by-product.
The odor can impact the quality of the patient's life and may lead to social withdrawal,
embarassment, shame, and psychological distress.
Some possible interventions for managing these wounds include:
-Cleanse the wound with water or normal saline.
-Metrogel 1% applied to breast cancer lesion daily and covered with an occlusive dressing
(such as vaseline gauze). Metronidazole (the active ingredient in Metro-gel) may also be
taken orally. The oral form is less expensive, but the few studies that have been performed
have shown marked improvement in odor with its use.
-activated charcoal / odor-absorbing dressings. These dressings should be changed daily or
more often if the odor becomes noticeable before the next dressing change is due.
-Peppermint oil - many pharmacies carry this oil. You can place gauze in the top with the lid
off and it works as an air deodorizer. Peppermint oil is a much more tolerable air freshener
than most air deodorizers. Do NOT apply peppermint oil directly to the wound. You can also
apply peppermint oil to a wash cloth and drape over a fan or air conditioning vent.
Peppermint oil should not be used alone, as it may become associated with the smell of the
wound and lose effectiveness.
-Palliative radiation is another option and may help to heal the wound.
Although this post focuses on odor, always remember to treat the pain associated with any
wounds.
http://deathmaiden.blogspot.com/2006/04/symptomatology-malodorous-wounds.html
Action point:
Identify services provided by the Hospice.
The services offered by hospice include the following
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Medical and nursing care
Pain and symptom control
Rehabilitation
Therapies, including physiotherapy and complementary therapies
Spiritual support
Practical and financial advice
Bereavement care
Action point:
Differentiate between services offered by District Nursing and the Hospice and the referral
system for both.
Setting:
Mele is dying and has only hours to live. Her family is concerned about costs related to her
funeral and want to know what help they can get from Government Agencies.
Action point:
What assistance is available and under what circumstances?