breast cancer case study for nursing students

Nursing Case Study for Breast Cancer

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Natasha is a 32-year-old female African American patient arriving at the surgery oncology unit status post left breast mastectomy and lymph node excision. She arrives from the post-anesthesia unit (PACU) via hospital bed with her spouse, Angelica, at the bedside.  They explain that a self-exam revealed a lump, and, after mammography and biopsy, this surgery was the next step in cancer treatment, and they have an oncologist they trust. Natasha says, “I wonder how I will look later since I want reconstruction.”

What assessments and initial check-in activities should the nurse perform for this post-operative patient?

• Airway patency, respiratory rate (RR), peripheral oxygen saturation (SpO2), heart rate (HR), blood pressure (BP), mental status, temperature, and the presence of pain, nausea, or vomiting are assessed upon arrival. Medication allergies, social questioning (i.e. living situation, religious affiliation), as well as education preference are also vital. An admission assessment MUST include an examination of the post-op dressing and any drains in place. This should be documented accordingly.
• The hand-off should be thorough and may be standardized. Some institutions have implemented a formal checklist to provide a structure for the intrahospital transfer of surgical patients. Such instruments help to standardize processes thereby ensuring that clinicians have critical information when patient care is transferred to a new team. The nurse should also prepare to provide education based on surgeon AND oncologist guidance

What orders does the nurse expect to see in the chart?

• Post-op medications, dressing change and/or drain management, strict I&O, no BP/stick on the operative side (rationale is to help prevent lymphedema – Blood pressure (BP) measurement with a cuff on the ipsilateral arm has been posed as a risk factor for the development of LE after-breast cancer therapy for years, regardless of the amount of lymph node excision.)
• Parameters for calling the surgeon are also important. The nurse should also check for an oncology service consult.

After screening and assessing the patient, the nurse finds she is AAOx4 (awake, alert and oriented to date, place, person and situation). The PACU staff gave her ice due to dry mouth which she self-administers and tolerates well. She has a 20G IV in her right hand. She states her pain is 2 on a scale of 1-10 with 10 being the highest. Her wife asks when the patient can eat and about visiting hours. Natasha also asks about a bedside commode for urination and why she does not have a “pain medicine button”. Another call light goes off and the nurse’s clinical communicator (unit issued cell phone) rings.

The nurse heard in report about a Jackson-Pratt drain but there are no dressing change instructions, so she does not further assess the post-op dressing situation in order deal with everything going on at the moment. She then sits down to document this patient.

Medications ordered in electronic health record but not yet administered by PACU: Tramadol 50 mg q 6 hrs. Prn for mild to moderate pain. Oxycodone 5 mg PO q 4 hrs. Prn for moderate to severe pain (5-7 on 1-10 scale) Fentanyl 25 mcg IV q3hrs. Prn For breakthrough pain (no relieve from PO meds or greater than 8 on 1-10 scale) Lactated Ringers 125 mL/hr IV infusion, continuous x 2 liters Naloxone 0.4-2 mg IV/IM/SC; may repeat q2-3min PRN respiratory rate less than 6 bpm; not to exceed 10 mg

BP 110/70 SpO2 98% on Room Air HR 68bpm and regular Ht 157 cm RR 14 bpm Wt 53 kg Temp 36.°5C EBL 130mL CBC -WNL BMP Potassium – 5.4 mEq/L

What education should be conducted regarding post-op medications?

• New post-op pain guidelines rely less on patient-controlled analgesia (aka “pain medicine button”) than in previous years. Most facilities will have an approved standing protocol (i.e., “Multimodal analgesia and Opioid Prescribing recommendation” guideline) or standing orders. The patient must be instructed on how to rate pain using facility-approved tools (aka “pain scales”). She should also report any medication-related side effects and reinforce there is a reversal medication in case of an opioid overdose.

What are some medical and/or non-medical concerns the nurse may have at this point? If there are any, should they be brought up to the surgeon?

• The nurse may request an anti-emetic such as ondansetron 4 mg IV q 6 hrs prn nausea vomiting (N&V) since it is not uncommon post-op for the patient to have N&V. The rate of LR is a little high for such a small patient and could cause electrolyte imbalances. The nurse may also inquire about the oncologist being on the case and ask if the surgeon has discussed reconstruction with the patient yet. She may also want to ask about dressing change orders.

Natasha sleeps through the night with no complaints of pain. Lab comes to draw the ordered labs and the CNA takes vital signs. See below.

CBC HGB 7.2 g/dl HCT 21.6%

BMP Sodium 130 mEq/L Potassium 6.0 mEq/L BUN 5 mg/dL

BP 84/46 SpO2 91% on Room Air HR 109 RR 22 bpm

What should the nurse do FIRST? Is the nurse concerned about the AM labs? AM vital signs? Why or why not?

• Check the dressing and drain for bleeding (assess the patient). The patient should also sit up and allow staff to check the bed for signs of bleeding. Reinforce the dressing as needed. Record output from the drain (or review documentation of all the night’s drain output). Labs and vital signs indicate she may be losing blood.

Check the dressing and drain for BLEEDING (assess the patient). The patient should also sit up and allow staff to check the bed for signs of bleeding. Reinforce the dressing as needed. Record output from the drain (or review documentation of all the night’s drain output). Labs and vital signs indicate she may be losing blood.

What orders does the nurse anticipate from the surgeon?

• The nurse should expect an order to transfuse blood for this patient. Also, dressing reinforcement or change instructions are needed in the case of saturation)

How should the nurse address Natasha’s declaration? What alerts the nurse to a possible complication?

• First, the complication is that “Kingdom Hall” is the site of worship for Jehovah’s Witnesses. They do not accept ANY blood product, not even in emergencies. It is vital the nurse determines the patient’s affiliation and religious exceptions for medical care before moving forward. Next, employ therapeutic communication to elicit more details about Natasha’s concerns. Say things like, “tell me why you think you’re not attractive?” She may discuss reconstruction options or ask the patient to write down specific questions about this option to ask the provider later. Ask about getting family in to provide support. Seek information to give the patient about support groups and other resources available (as appropriate, ie. prosthetics, special undergarments/accessories, etc)

The surgeon orders 1 unit packed red blood cells to be infused. The nurse then goes to the patient to ask about religious affiliation and to discuss the doctor’s order. After verifying that Natasha is not a practicing Jehovah’s Witness, the nurse proceeds to prepare the transfusion.

What is required to administer blood or blood products?

• First, the patient’s CONSENT is required to give blood products. The nurse must also prepare to stay with the patient for at least the first 15 minutes of the transfusion taking a baseline set of V/S prior to infusion. Then, V/S per protocol (frequent). Education is also required. The patient should report feeling flushed, back or flank pain, shortness of breath, chest pain, chills, itching, hives. Normal saline ONLY for infusion setup and flushing: size IV 20g or higher. Always defer infusion time limits to “per policy” because this can differ vastly

How should the nurse respond to this question?

• Planning for post-op cancer treatment should have begun prior to the surgery. Ask the patient if she has discussed plans with her oncologist. Refer to any specialist documentation to see if this is mentioned. Remind the patient of the specialist’s assessment and planning information. Reinforce that testing of the tissue may change the course of treatment as well. Provide education AS PER THE PATIENT’S STATED PREFERENCE and/or resources based on what the plan includes (ie. chemotherapy, radiation, further surgery. Continually assess and reassess patient understanding. Include family and/or support with the patient’s approval.

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View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Breast cancer Case Study Jan Leinser

Nursing process iv: medical-surgical nursing (nur 411), borough of manhattan community college.

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Preview text, breast cancer/complications of, chemotherapy, jan leisner, 50 years old, primary concept, interrelated concepts (in order of emphasis).

• Fluid and Electrolyte Balance
• Thermoregulation
• Cellular Regulation
• Clinical Judgment
• Patient Education
• Communication 10

Unfolding Clinical Reasoning Case Study: STUDENT

Breast cancer history, of present problem:.

Jan Leisner is a 50-year-old Caucasian woman who has been healthy with no previous medical history. One year ago, she noted a small palpable lump in her right breast about the size of an almond. Because she has been healthy, she assumed it was nothing and ignored it. Over the last month she has noted that this lump has been increasing in size. Her mammogram confirmed a 5 cm mass. An ultrasound biopsy confirmed the presence of cancer cells in the tumor as well as in three of her lymph nodes most proximal to the tumor. An MRI scan that followed revealed a 1 cm tumor on her lumbar spine. She is not a surgical candidate at this time, so an implanted venous access device (VAD) will be placed later this afternoon so that chemotherapy can be started as soon as possible. You are the nurse responsible for her care on the oncology unit of a community hospital.

Personal/Social History:

Jan has four children under the age of 17. She has no personal or family history of breast cancer. She has never smoked and lives with her husband in a suburban community. She works part-time as a substitute teacher. Jan is a devout Christian who has a strong faith and trust in God. She also believes in the power of prayer and believes that God can heal her. She chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job.

What data from the histories are RELEVANT and has clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance: 1. Ignored palpable lump on right breast for a year. 2. Lump has increased in size. Mammogram confirmed 5cm and biopsy confirmed cancerous cells in tumor and in lymph nodes. 1 cm tumor on lumbar spine 3. Not a surgical candidate VAD device will be placed.

• Patient did not seek medical attention when cancer was in the earlier stages.
• Cancer has spread into her lymph nodes and in her spine (further from initial lump). This can indicate that the cancer is in its late stages.
• Patient will have to be watched carefully for signs of infection from the VAD.

RELEVANT Data from Social History: Clinical Significance: 1. Four children < 2. Works part time as a teacher 3. Devout Christian 4. Husband lost his job and insurance plan expired.

• The patient has to deal with her own emotional needs as well as her children’s during this time.
• She may have to quit working while receiving treatment
• She will hopefully have support throughout this difficult time.
• Financial stresses will be increased if both her and her husband are not working.

Education Priorities

• What will be the most important education priorities the nurse will reinforce regarding the central port, chemotherapy, and expected side effects? Implanted VAD: The VAD will need to be flushed regularly, the patient might be put on medications in order to prevent the port from becoming occluded. Bruising, tenderness and swelling are common in the beginning. Teach the patient for signs of infection (warmth, redness, swelling, discharge/pus, odor) and to avoid heavy lifting. Chemotherapy: Chemotherapy kills and inhibits the reproduction of neoplastic cells and also kills normal cells. Chemotherapy will be given via the implanted VAD. The effects are systemic because chemotherapy is administered systemically. Several chemotherapy and other agents in combination therapy to increase therapeutic response.

Expected side effects:

Temp 101/38.

Pulse 110 (reg)

Change in orthostatic BP

Patient is in pain

The patient is immunosuppressed, and a fever may be a sign of infection which needs to be further investigated.

A fever increases metabolic needs which puts stress on the heart and an elevated HR is compensating for decreased cardiac output.

A low BP is concerning if the patient has an infection and increased metabolic needs, the patient may be experiencing fluid volume deficit.

The change in this patient’s BP when going from lying to standing supports the finding of dehydration (fluid volume deficit).

The patient being in pain is an expected side effect however nursing interventions should include comfort measures.

Current Assessment:

####### GENERAL

####### APPEARANCE:

Appears weak and uncomfortable with frequent facial grimacing, constantly repositioning,

self in bed RESP: Breath sounds clear with equal aeration bilaterally anteriorly/posterior, nonlabored respiratory effort CARDIAC: Pale, warm & dry, no edema, heart sounds regular–-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert & oriented to person, place, time, and situation (x4), feels light-headed when she stands up GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, lips dry, oral mucosa tacky dry, severe nausea/dry heaves GU: Urinary frequency and painful voiding the past day, 50 mL urine clear/dark amber, last void 2 hours ago SKIN: Skin integrity intact, non-elastic-tents for 3 seconds, several small blisters/ulcers <1 cm. clustered underneath tongue and inner aspect of both lips

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: 1. Patient appears weak and is constantly repositioning herself in bed. 2. Patient is pale 3. Patient is lightheaded when she stands up. 4. Dry lips, dry oral cavity, severe nausea and dry heaving 5. Urinary frequency and painful voiding, clear/dark amber. 6. Blisters/ulcers clustered underneath tongue and inside lips.

• Possibly linked to the patient being in pain and nauseated.
• Patient may have a decreased cardiac output.
• Related to fluid volume deficit.
• Related to fluid volume deficit and dehydration.
• Patient showing signs of having a urinary tract infection.
• May be a side effect of the chemotherapy.

Radiology Reports: Chest x-ray

What diagnostic results are relevant that must be recognized as clinically significant to the nurse, relevant results: clinical significance:.

The lung tissue looks normal. No growths or other masses can be seen within the lungs. No abnormal collection of fluid or air is seen. The heart looks normal in size, shape.

1. The patient is not showing signs of any infection which is a good

sign since the patient is immunosuppressed.

Lab Results:

Complete Blood Count (CBC): Current: High/Low/WNL? Previous: WBC (4–11 mm 3) 0 LOW 8. Hgb (12–16 g/dL) 8 LOW 14. Platelets (150-450 x10 3 /μl) 22 LOW 289 Neutrophil % (42–72) 2 LOW 72 Band forms (3–5%) 3 WNL 1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Relevant lab(s): clinical significance: trend: improve/worsening/stable:.

####### 1. WBC 0.

Neutrophils 2%

Cancer and chemotherapy cause immunosuppression which causes a low WBC count (although patient has an infection and WBC count should be higher).

Anemia is commonly seen in patients with cancer.

Chemotherapy may damage bone marrow and decreases the production of platelets. Antibodies may also attack platelets.

1. Worsening

2. worsening, 3. worsening, 4. worsening.

Basic Metabolic Panel (BMP): Current: High/Low/WNL? Previous: Sodium (135–145 mEq/L) 147 HIGH 138 Potassium (3–5 mEq/L) 3 LOW 3. Chloride (95–105 mEq/L) 90 LOW 102 CO2 (Bicarb) (21–31 mmol/L) 22 WNL 25 Anion Gap (AG) (7–16 mEq/l) 10 WNL 12 Glucose (70–110 mg/dL) 68 LOW 95 Calcium (8–10 mg/dL) 11 HIGH 11. BUN (7–25 mg/dl) 38 HIGH 18 Creatinine (0–1 mg/dL) 1 HIGH 0.

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/worsening/stable:.

Patient has hypernatremia; this occurs when there is a deficit of total body water. Hypernatremia involves dehydration.

Potassium tends to have an inverse correlation to sodium.

1. Cloudy Urine

2. nitrate (pos), 3. let (pos), 1. abnormal findings consistent with urinary tract infection, 2. indicates high presence of e. coli (may be the cause of uti), 3. indicates the presence of wbcs in the urine, 4. white blood cells in the urine indicate uti., lab planning: creating a plan of care with a priority lab:.

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: WBC

Critical Value: <4 or >

Patient is immunosuppressed and WBCs are decreasing.

The patient must be monitored closely for opportunistic infections, Assess VS for signs and symptoms of infection.

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Neutrophils

####### 2 – 7.

Critical Value: Too High: <7. Too Low: <.

Neutropenia especially in extremely low value increases the risk of life-threatening infection (significant)

Assess VS for signs and symptoms of infection, patient is highly suspectable for infections.

Clinical Reasoning Begins...

What is the primary problem(s) that Jan is most likely presenting with? Patient has neutropenia and a UTI

What is the underlying cause/pathophysiology of this primary problem? Breast cancer metastasizing

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV

0% NS 1000 mL IV bolus x 2 liters

Orthostatic BP

Vancomycin 1000 mg IVPB Every 24 hours

Ondansetron 4 mg IV every 4 hours prn

Acetaminophen 650 mg PO every 4 hours

Hydromorphone 0–1 mg IV push every 4 hours prn

IV access allows for medication and fluid infusion and a site for blood tests.

To address the patient’s fluid volume deficit/dehydration.

To monitor the patient’s response to therapy (FVD)

Tx of potentially life-threatening infections when less toxic anti-infectives are contraindicated.

Prevention of nausea and vomiting associated with chemotherapy and radiation therapy.

Treatment of mild pain and fever

Treatment of moderate to severe pain

Decrease the patient’s risk of opportunistic infections due to increased susceptibility.

Patent IV access at all times.

Patient’s VS and blood work no longer indicate dehydration / FVD

Patient no longer has UTI and no other infections are present

Patient is not nauseous

Patient is afebrile

Patient’s pain level is decreased

No new infections are acquired.

Antipyretics decrease fever and fluid loss from sweating

Patient HR will decrease, and BP will increase

Patient will not have insensible water loss due to fever.

What body system(s) will you assess most thoroughly based on the primary/priority concern? Cardiovascular, Urinary, and Circulatory system

What is the worst possible/most likely complication to anticipate? Shock/Sepsis

What nursing assessments will identify this complication EARLY if it develops? Cardiovascular monitoring, slight neurological changes, respiratory distress, decreased urine output, fever

What nursing interventions will you initiate if this complication develops? Sepsis protocol: 2 large bore IVs, 2 blood cultures from different sites , Lactic acid levels, rapid infusion of fluids, broad spectrum antibiotics, vasopressors

What psychosocial needs will this patient and/or family likely have that will need to be addressed?

• Emotional distress over the terminal diagnosis of the patient
• Financial stress of losing insurance and patient’s husband losing his job
• Distress over change of family roles
• Child care for underaged children while patient is receiving treatment

How can the nurse address these psychosocial needs? The nurse can have a social worker come and speak to the patient. The nurse can teach the patient and give the patient handouts/pamphlets. The nurse can also give the patient information about support groups, particularly ones that are of the same beliefs as the patient.

Medication Dosage Calculation:

Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Ondansetron

4mg/2 mL vial

0 mg/kg (up to 16 mg) 30 min prior to chemotherapy (repeat 4 and 8 hours later) IV Push: Volume every 15 sec? Administer over < sec, preferably over 2- mins

Ax for N/V, abdominal distention, bowel sounds, extrapyramidal effects, monitor ECG, S/S of serotonin syndrome (mental status changes) and rash

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:

Safely Administer:

1000 mg IVPB

Binds to cell wall resulting in cell death. Bactericidal action against susceptible organisms.

500 mg q6h or 1g q12h Hourly rate to set IV pump? 500mg/30 min

Ax patient for S/S of infection, monitor IV site closely, monitor intake/output, monitor BP, Monitor CBC and BUN levels, monitor renal function

Evaluation:

Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.

One Hour Later...

Current VS: Most Recent: Current PQRST:

T: 99 f/37 c (oral) t: 101 f/38 c (oral) provoking/palliative: eating, nothing, p: 98 (regular) p: 110 (regular) quality: sharp, ache, r: 20 r: 20 region/radiation: mouth/tongue, bp: 108/60 bp: 96/40 severity: 1/, o2 sat: 98% ra o2 sat: 98% room, timing: persistent, assessment:.

Resting comfortably, appears in no acute distress

RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, oral mucosa more shiny, no c/o nausea GU: Voiding without difficulty, 300 mL urine clear/yellow the past 2 hours SKIN: Skin integrity intact, non-elastic-tents for 1 second, several small blisters/ulcers <1 cm. clustered underneath tongue and inner aspect of both lips

• What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance:

Pulse 98 (reg)

Patient has a low grade fever, however it is an improvement from previous 101 F

Patient’s pulse is now WNL

Patient’s BP is increased, FVD has been addressed

Patient is in less pain than previously

RELEVANT Assessment Data: Clinical Significance:

Name/age: Jan Leisner, 50 year old, Female BRIEF summary of primary problem: Patient presented with metastasized breast cancer (spread into her spine and lymph nodes).

Background:

Primary problem/diagnosis: Breast Cancer

RELEVANT past medical history: No previous health history RELEVANT background data: No personal or family history of breast cancer. Has 4 children under age of 17, husband lost his job & they lost insurance.

Vital signs: T: 99 F/37 P: 98 (reg) R: 20 BP: 108/ SaO2: 98% RA RELEVANT body system nursing assessment data: Patient’s overall appearance reflects improvement. Her BP has increased and is WNL, patient has been able to void without difficulty. Patient is rating pain lower than previously. The several small blisters/ulcers <1 cm. clustered underneath tongue and inner aspect of both lips are a normal side effect of chemotherapy. RELEVANT lab values: 1. LET 2. Neutrophils 3. WBC 4. Nitrate

How have you advanced the plan of care? Patient Response? The patient has responded well to the plan of care, her UTI was addressed as well as pain levels; fluids and prophylactics were administered.

INTERPRETATION of current clinical status (stable/unstable/worsening): The patient is responding well and is stable.

Recommendation:

Suggestions to advance plan of care:

Maintain the patient’s level of pain as low as possible and ask the doctor about an oral rinse for oral

blisters. Have the social worker talk to the patient about her insurance options/therapy.

Education Priorities/Discharge Planning

• What will be the most important discharge/education priorities you will reinforce with Jan’s medical condition to prevent future readmission with the same problem? I would make sure to teach the patient about trying to avoid exposure to bacteria and germs that can possibly cause opportunistic infections. I would teach the patient about how to avoid UTIs. I would also teach her about signs and symptoms of dehydration and how to avoid it. Medication and pain relief advice will be taught too.

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? I learned about how quickly and quietly cancer can spread and the importance of teaching our patients to seek medical attention regardless if whether or not they have previous health issues.

• How can I use what has been learned from this scenario to improve patient care in the future? I can incorporate about addressing the symptoms rather than the diagnosis as a whole, especially one where the diagnosis might not have a cure or the treatment might create more symptoms.
• Multiple Choice

Course : Nursing Process IV: Medical-Surgical Nursing (NUR 411)

University : borough of manhattan community college, this is a preview.

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