Breast Cancer/Complications of Chemotherapy SKINNY Reasoning

Breast Cancer/Complications of Chemotherapy SKINNY Reasoning Jan Leisner, 50 years old Primary Concept Infection Interrelated Concepts (In order of emphasis) • Fluid and Electrolyte Balance • Cellular Regulation • Immunity • Stress • Clinical Judgment NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment □ Management of Care 17-23% • □ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% • Psychosocial Integrity 6-12% • Physiological Integrity □ Basic Care and Comfort 6-12% • □ Pharmacological and Parenteral Therapies 12-18% • □ Reduction of Risk Potential 9-15% • □ Physiological Adaptation 11-17% • SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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 have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: One year ago she noted a small palpable lump in her right breast about the size of an almond. Over the last month she has noted that this lump has been increasing in size. Her mammogram confirmed a 5 cm mass. This biopsy confirmed the presence of cancer cells in the tumor as well as in three of her lymph nodes most proximal to the tumor. The MRI scan revealed a 1 cm tumor on her lumbar spine. Any lump in the breast area has the potential to be cancerous and needs to be followed up. The majority of breast masses are benign, 10% are cancerous…Irregular fixed masses are suspicious for malignancy [Epocrates, 2015]. A rapidly growing lump is a clinical RED FLAG, a cause for concern, and must not be ignored! Though denial is a common coping mechanism, in this context it could be deadly! Cancer that has progressed to lymph nodes is a clinical RED FLAG that increases the likelihood of metastasis. Finding cancer cells in the lymph nodes is stage III because of their close proximity to the primary tumor. Metastasis from the primary site to a distant location meets the criteria for stage IV. This is the worst possible staging and makes this a terminal diagnosis. RELEVANT Data from Social History: Clinical Significance: Jan has 4 children under the age of 17. Jan is a Christian who has a strong faith and She is a mother with children whom she wants to see grow up. This complicates this scenario for both Jan and the nurse. The stakes are high, but the nurse can make a difference by choosing to ENGAGE in her experience and make the “art” of nursing a priority to support her holistically. With any serious illness, but especially a terminal illness such as cancer, to provide true holistic care, the nurse must be willing to trust in God who also believes in the power of prayer and believes that God can heal her. gently “go there” when appropriate and establish a trust relationship. I have found that any one of the following spiritual assessment questions can guide the nurse to support this patient’s spiritual needs: □ “What is your source of strength, peace, and hope in this illness? She chose to have a mammogram before her husband’s insurance plan expired because he just lost his job. • “Are you connected with a faith community?” • “How has this illness affected your faith?” • “What can I do to support your faith?” A lack of insurance also complicates this scenario! Social services must be consulted to see what state/federal health programs for which she may be eligible. Five Weeks Later… Jan is promptly started on chemotherapy of Cytoxan and Adriamycin every three weeks for the next three months. Two weeks after her first chemotherapy treatment she experiences persistent nausea and vomiting, and has been unable to keep anything down the past 24 hours. She has fatigue so severe she has been unable to move off the couch for the past three days, and has experienced night sweats with a fever last night. After contacting her oncologist, he arranges to have Jan admitted directly to the med/surg floor where you will be the nurse responsible for her care. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 101.5 F/38.6 C (oral) Provoking/Palliative: Eating/nothing P: 110 (regular) Quality: Sharp, ache R: 20 Region/Radiation: Mouth/tongue BP: 96/40 Severity: 5/10 O2 sat: 98% room air Timing: Persistent the past 3 days Orthostatic BP’s: Position: HR: BP: Lying 110 96/40 Standing 136 82/42 What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: T: 101.5 F/38.6 C (oral) P: 110 (regular) Fever in the context of likely neutropenia after chemotherapy has been started is a clinical RED FLAG! Further lab tests are needed to identify the source. The nurse will need to situate this knowledge to identify and anticipate current care priorities. WHY is her heart rate elevated? Elevated HR could reflect increased metabolic needs driven by fever; she likely has an infection. This has a RELATIONSHIP to fluid volume deficit that will also cause tachycardia. Bring back pathology….CO=SVxHR and BP: 96/40 Lying: HR: 110 BP: 96/40 Standing: HR: 136 BP: 82/42 explain why this must be understood and situated to clinical practice. The heart rate elevates to maintain adequate cardiac output and compensate for fluid volume deficit of any kind. We do not have a current baseline to TREND, but any systolic BP (SBP) <100 is a clinical RED FLAG unless it is the patient’s established baseline. This confirms fluid volume deficit or even the possibility of sepsis, especially because her temperature is elevated Review the definition of an abnormal orthostatic BP finding. Though even fundamental textbooks do not agree, from my clinical experience, an increase in the heartrate of 20 beats or more from lying baseline is by itself a POSITIVE finding and is usually seen in mild to moderate dehydration. If a decrease in 20 points or more of mm/Hg in SBP is seen from lying to standing in addition to the increase in heart rate, this reflects moderate to severe fluid volume deficit/dehydration. Because she has both a drop of BP and increase in HR as well as being symptomatic, this confirms that you are seeing moderate to severe fluid volume depletion. This data confirms the expected side effect of chemotherapy called mucositis. This data needs to be considered when establishing the nursing care priorities after nursing assessments have been completed. Provoking/Palliative: Eating/nothing Quality: Sharp, ache Region/Radiation: Mouth/tongue Severity: 5/10 Timing: Persistent the past 3 days Current Assessment: GENERAL APPEARANCE: Appears weak and uncomfortable with frequent facial grimacing. Constantly repositions self in bed RESP: Breath sounds clear with equal aeration bilaterally anteriorly/posterior, non-labored 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 are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: GENERAL APPEARANCE: Appears weak and uncomfortable with frequent facial grimacing. Constantly repositions self in bed. Must be noted, but too general to make any clinical assumptions. Need to investigate WHY? Fluid volume deficit is likely, but more information is needed. CARDIAC: Pale NEURO: Feels lightheaded when she stands up GI: Lips dry, oral mucosa tacky dry, severe nausea/dry heaves Most of the cardiac assessment is unremarkable, but the patient is pale. WHY? Knowing she had recent chemotherapy, how does this impact bone marrow? Anemia is expected, and the Hgb will need to be noted by the nurse to see if this is the obvious source of this clinical finding. Most of the neuro assessment is unremarkable except this finding. WHY? Fluid volume deficit must be anticipated as the most likely cause. Knowing her orthostatic BPs are positive, the nurse must make correcting this fluid volume deficit a priority. This is the best place to assess for fluid volume deficit/dehydration in most patients. Lips should be moist and oral mucosa is normally moist and shiny with saliva. This assessment finding reflects dehydration and confirms fluid volume deficit. 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- elastictents for 3 seconds Several small blisters/ulcers <1 cm. clustered underneath tongue and inner aspect of both lips Painful and frequency of urination are classic signs of a urinary tract infection that must be noted by the nurse! The color must be noted… WHY? Concentration of urine in fluid volume deficit is readily apparent. Confirms fluid volume deficit/dehydration Confirms the mucositis and the likely cause of her oral pain. 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. Normal CXR. Pneumonia is not the source of the infection. Diagnostic Results: Basic Metabolic Panel (BMP) Na K Gluc. Creat. Ca Current: 147 3.1 68 1.4 11.8 Most Recent: 138 3.9 95 0.8 11.5 Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 0.5 8.9 22 2 3 Most Recent: 8.5 14.5 289 72 1