NUR 2065 WEEK 12 CASE STUDY BREAST CANCER.

NUR 2065 WEEK 12 CASE STUDY BREAST CANCER. Breast Cancer/Complications of Chemotherapy Jan Leisner, 50 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Infection 2. Pain 3. Fluid and Electrolyte Balance 4. Thermoregulation 5. Immunity 6. Cellular Regulation 7. Clinical Judgment 8. Patient Education 9. Communication 10. Collaboration © 2016 Keith Rischer/www.KeithRN.com 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: No previous medical history Noted small palpable lump in her right breast, sizeof an almond Lump is increasing in size Ultrasound confirmed cancer cells in the tumor as well as three of her lymph nodes most proximal to the tumor MRI revealed a 1 cm tumor on her lumbar spine VAD will be placed later this afternoon so that chemotherapy can be started as soon as possible Finding a lump is usually the first sign of breast cancer The lump is getting bigger so the cancer is spreading Now with it in the lymph nodes it will be harder to stop It is still spreading This is an attempt to stop the spread without surgery RELEVANT Data from Social History: Clinical Significance: 4 kids under the age of 17 No personal or family history of breast cancer Never smoked This is showing her kids need her to help take care of them There isn’t any history so she wasn’t constantly worried about getting it Devout Christian who has a strong faith and trust in God also believes in the power of prayer and believes that God can heal her. Chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job. This could help her get through her treatments with her faith and having something to believe in Without having insurance medical bills can become expensive and won’t get the treatment needed if they can’t afford it Education Priorities 1. What will be the most important education priorities the nurse will reinforce regarding the central port, chemotherapy, and expected side effects? Implanted VAD: This will be placed in the chest, abdomen or arm and it makes receiving the chemotherapy easier so the pt doesn’t have to keep getting poked by a needle. The needle placed into your port is attached to a lumen (clear tube) with a cap at the end and will be used to give the chemotherapy. A patient should look at his or her port site every day. You should call your provider if you have any signs of infection. If fluids administered into the port do not flow freely or the skin around the port is swelling, stop the infusion and call your care team. Contact your care team if you notice changes in the appearance of the area around the injection site or if the reservoir is moving around underneath your skin. Chemotherapy: Explain how chemo works, what the side effects will be. Let the pt know about self-care during it. Tell them all the medications and the effects they will have with the chemo. Chemo goes through the whole body so it can affect every part of the body especially the hair. Expected side effects: The most common side effects are hair loss, fatigue, Easy bruising and bleeding, Infection, Anemia (low red blood cell counts), Nausea and vomiting, Appetite changes and Constipation 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with Jan? You can ask her to repeat back to you what you said, have her list the potential side effects and have her ask any questions she may have about it. © 2016 Keith Rischer/www.KeithRN.com Caring and the “Art” of Nursing 1. What is Jan likely experiencing/feeling right now in this situation? She is probably feeling scared and anxious because she has children that need her and she doesn’t have insurance at the moment. 2. What can you do to engage yourself with Jan’s experience, and show that she matters to you as a person? Show her that you are there for her and you know what she is going through. Show empathy towards her and make yourself open to listening to her and let her know you are available. Tell her you have a listening ear for anything she has questions about or just want to talk about it. 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 is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: T: 101.5F (oral) Fever could indicate infection or neutropenia after chemotherapy has been started. P: 110 (regular) This could indicate hypotension BP: 96/40 Lying: HR: 110 BP: 96/40 Standing: HR: 136 BP: 82/42 A drop in her BP could indicate dehydration from vomiting for 24 hours Persistent sharp ache in the mouth and tongue the past 3 days, rated 5/10. Chemotherapy is known to cause mouth sores so this could be a result from the chemotherapy © 2016 Keith Rischer/www.KeithRN.com 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: GENERAL APPEARANCE: Appears weak and uncomfortable NEURO: feels lightheaded when she stands up GI: oral mucosa tacky dry, severe nausea/dry heaves GU: Voiding without difficulty, painful and frequency of urination the past day, urine clear/dark amber SKIN: Skin integrity intact, small blisters/ulcers 1 cm. present on tongue and inner aspect of both lips This indicates she is in pain and uncomfortable This is probably from being dehydrated Try lips with severe nausea and dry heaves indicate dehydration This indicates a UTI This is side effects from 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. This shows the cancer hasn’t spread to the lungs or the heart Lab Results: Complete Blood Count (CBC): Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 0.5 Low 8.5 Hgb (12–16 g/dL) 8.9 Low 14.5 Platelets (150-450 x103/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: WBC WBC, neutrophils and platelets are low due to chemotherapy All are worsening Hgb Hgb are low due to dehydration Platelets Neutrophils © 2016 Keith Rischer/www.KeithRN.com Basic Metabolic Panel (BMP): Current: High/Low/WNL? Previous: Sodium (135–145 mEq/L) 147 High 138 Potassium (3.5–5.0 mEq/L) 3.1 Low 3.9 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 (8.4–10.2 mg/dL) 11.8 High 11.5 BUN (7–25 mg/dl) 38 High 18 Creatinine (0.6–1.2 mg/dL) 1.4 High 0.8 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable : Sodium 147 This indicates dehydration All are worsening Potassium 3.1 This suggests kidney problems Chloride 90 Could be from vomiting Glucose 68 This could be a side effect from chemo but could also be from inadequate nutrition Calcium 11.8 This being elevated in related to the cancer BUN 38 BUN and creatinine indicate the kidneys are malfunctioning due to her being dehydrated Creatinine 1.4 Misc. Labs: Current: High/Low/WNL? Previous: Lactate (0.5–2.2 mmol/L) 1.2 WNL 0.9 Magnesium 1.6 WNL 1.9 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: None They are within normal limits Both are stable Urine Analysis (UA): Current: WNL/Abnormal? Color (yellow) Yellow WNL Clarity (clear) Cloudy Abnormal Specific Gravity (1.015–1.030) 1.029 WNL Protein (neg) Neg WNL Glucose (neg) Neg WNL Ketones (neg) Neg WNL Bilirubin (neg) Neg WNL Blood (neg) Neg WNL Nitrite (neg) Pos Abnormal LET (Leukocyte Esterase) (neg) Pos Abnormal MICRO: RBC’s (<5) 3 WNL WBC’s (<5) 58 Abnormal Bacteria (neg) Neg WNL Epithelial (neg) Neg WNL © 2016 Keith Rischer/www.KeithRN.com What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Clarity: Cloudy This is associated with dehydration Positive Nitrite Indicates sign of UTI Positive LET Indicates sign of UTI WBC’s 58 This could be caused by having the UTI Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: WBC Value: 0.5 4.5–11.0 mm Critical Value: <2.5 or >15 mm Losing WBC from chemo makes her more susceptible to infections. Assess closely for any change of temp. Assess for signs of hypotension. Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Neutrophils Value: 0.5 2.5-7 mm Critical Value: Too High: >8mm Too Low: ≤0.5 mm 3 Susceptible to infection and neutropenia. Assess closely for any change of temp. Assess for signs of hypotension. Clinical Reasoning Begins… 1. What is the primary problem(s) that Jan is most likely presenting with? Breast cancer, UTI 2. What is the underlying cause/pathophysiology of this primary problem? Tumor with cancer cells. Breast cancer that has metastasized as the patient also has it in her lymph nodes and on the spine. © 2016 Keith Rischer/www.KeithRN.com Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV Will need aggressive IV volume replacement due to severe dehydration. Pt will get fluid and not be dehydrated 0.9% NS 1000 mL IV bolus x 2 liters Dehydration due to severity of N&V NS is an isotonic IV solution that is the most common IV Pt will not be dehydrated Orthostatic BP To see how it is trending. Monitor pt BP Vancomycin 1000 mg IVPB Every 24 hours Used to treat bacterial infections UTI will be treated and go away Ondansetron 4 mg IV every 4 hours prn Antiemetic that is commonly used to control nausea when aggressive control is needed. Pt nausea and vomiting will decrease Acetaminophen 650 mg PO every 4 hours Fever control. Pt fever will decrease Hydromorphone 0.5–1 mg IV push every 4 hours prn Binds to opiate receptors in the CNS, which alters the perception of and response to painful stimuli so it will help with the pain. Pt pain will decrease Neutropenic precautions Decreases their risk of acquiring an infection from outside source. Pt will not develop an infection PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1.Vancomycin 1000 mg IVPB Every 24 hours 2.Ondansetron 4 mg IV every 4 hours prn 3.Acetaminophen (Tylenol) 650 mg every 4 hours 4. Hydromorphone 0.5–1 mg IV 5. Neutropenic precautions 6.Establish peripheral IV 7.0.9% NS 1000 mL IV bolus x2 1. Neutropenic precautions 2. Establish peripheral IV 3. 0.9% NS 1000 mL IV bolus x2 4. Vancomycin 1000 mg IVPB q24h 5. Acetaminophen (Tylenol) 650 mg q4h 6. Ondansetron 4 mg IV q4h prn Prevents pt from getting more infections Establish IV site for medication admin. Used for fluid replacement therapy and to bring uo BP Fight and prevent infection. Decreases fever Prevents nausea and vomiting caused by chemotherapy 7. Hydromorphone 0.5-1 mg IV Manages pain due to chemotherapy © 2016 Keith Rischer/www.KeithRN.com Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Dehydration Treating chemo side effects 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 1. Establish IV…administer IV fluids as ordered 1. 0.9% NS most common isotonic solution for fluid resuscitation Fluid volume deficit/dehydration is corrected 2. Assess both BP and HR 3. Assess skin turgor, oral mucous membranes, temperature, and capillary refill every 2–4 hours and as needed 2. Remember the importance and relevance of CO. As volume deficit is corrected, CO will reflect this improvement by lowering HR first that is elevated. HR lowered to WNL Oral mucosa shiny with saliva 4. Administer Ondansetron (Zofran) IV as needed 5. Ice chips to clear liquids in small amounts initially. Assess response 3. Each of these assessments directly correlates to determining fluid volume status. Temperature is relevant because of an elevated temp increasing insensible water loss. 6. Advance diet slowly as tolerated– BRAT diet (bananas, rice, applesauce, toast) 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? Cardiac, GU, and Immune System 6. What is the worst possible/most likely complication to anticipate? Hypovolemic shock 7. What nursing assessments will identify this complication EARLY if it develops? Vitals, I&Os, skin turgor, LOC 8. What nursing interventions will you initiate if this complication develops? Administer oxygen, Monitor vitals closely, rapid fluid administration. 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Spiritual support, anxiety and how to cope with the stress 10. How can the nurse address these psychosocial needs? Contact the chaplain Contact social work about finances Give them pamphlets with support groups © 2016 Keith Rischer/www.KeithRN.com Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Ondansetron selective 5-HT3 4 mg/2 min IV Push: Volume every 15 sec? 0.5mL/15 sec Inform patients that it may cause 4 mg IV receptor antagonist; binds to 5-HT3 hypersensitivity reactions 4mg/2 mL vial receptors both in Monitor cardiac status periphery and in CNS, with primary effects in GI tract Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Vancomycin Inhibits cell-wall 200mL/24hr Hourly rate to set IV pump? 8mL/hr Assess patient for infection 1000 mg IVPB biosynthesis; blocks glycopeptide polymerization by Obtain specimens for culture and sensitivity prior to initiating therapy. . binding tightly to D-alanyl-D-alanine Monitor IV site closely. Rotate infusion portion of cell wall site. precursor Monitor BP throughout IV infusion. 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: 99.8 F/37.7 C (oral) T: 101.5 F/38.6 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: 1/10 O2 sat: 98% RA O2 sat: 98% room air (RA) Timing: Persistent Current Assessment : GENERAL APPEARANCE : 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 © 2016 Keith Rischer/www.KeithRN.com 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: T: 99.8F (oral) P: 98 (regular) BP: 108/60 Persistent sharp ache in the mouth and tongue rated at a 1/10 that is provoked by eating with no relieving factors. Temp, pulse and BP have decreased to normal limits but temp could still indicate there is still infection present Her pain has decreased from a 5 to 1 but it is still persistent due to the mouth sores RELEVANT Assessment Data: Clinical Significance: Skin: non-elastic-tents for 1 second, several small blisters/ulcers 1 cm clustered underneath tongue and inner aspects of both lips All have improved Still have small blisters due to the chemo side effects 2. Has the status improved or not as expected to this point? Yes, status has improved 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Plan of care should remain the same 4. Based on your current evaluation, what are your nursing priorities and plan of care? Continue to monitor vital signs Continue with current treatment plan Continue fluid replacement therapy © 2016 Keith Rischer/www.KeithRN.com It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: Jan Leisner, 50 y.o. female BRIEF summary of primary problem: Pt was diagnosed with breast cancer five weeks ago. She had an An MRI scan that revealed a 1 cm tumor on her lumbar spine and had a VAD placed. She started 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 here. Background: Primary problem/diagnosis: Breast cancer, dehydration and possible UTI RELEVANT past medical history: Pt 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 that she ignored. 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 had a VAD placed for chemotherapy. RELEVANT background data: There is no no personal or family history of breast cancer. She has never smoked. Has four children under the age of 17. She works part time as a substitute teacher. She doesn’t have insurance and her husband lost his job. Assessment: Vital signs: Current T is 99.8 F decreasing from 101.5 F. Current P is 98 decreasing from 110. Current R is 20 and remained the same. Current BP is 108/60 increasing from 96/40. Current O2 sat remained the same at 98% RA. Her pain in the mouth and tongue has decreased from a 5 to a 1on a 1-10 pain scale but is still persistent, sharp and aching and it is provoked with eating. RELEVANT body system nursing assessment data: Pt has non-elastic-tents for 1 second, several small blisters/ulcers <1 cm. clustered underneath tongue and inner aspect of both lips RELEVANT lab values: Her labs from this morning were CBC- WBC 0.5, Hgb 8.9, Platelets 22, Neutrophil 2 and Band forms 3. BMP- Sodium 147, Potassium 3.1, Chloride 90, Glucose 68, Calcium 11.8, BUN 38 and Creatinine 1.4. UA- Clarity: cloudy, positive with Nitrite and LET, WBC 58. How have you advanced the plan of care? Patient Response? Pt care has remained the same. Pt has been responding well to current plan and vitals have improved. INTERPRETATION of current clinical status (stable/unstable/worsening): Improving and on path to stable Recommendation: Suggestions to advance plan of care: I would recommend to continue monitoring vital signs and repeat labs but other than that keep the same plan of care. © 2016 Keith Rischer/www.KeithRN.com Education Priorities/Discharge Planning 1. 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? Providing them with information on the patient’s treatments, risks, advantages, and support groups for the patient as well as the family. 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 some signs and symptoms of breast cancer, and there are a lot more side effects of chemotherapy than I originally thought. 2. How can I use what has been learned from this scenario to improve patient care in the future? Now that I know what to look for as in signs and symptoms from the effects of chemotherapy then I will know what to look for and know that it is a side effect not something new that is just popping up. © 2016 Keith Rischer/www.KeithRN.com