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
Unfolding Clinical Reasoning Case Study: STUDENT
Breast Cancer History
of Present Problem:
© 2016 Keith Rischer/www.KeithRN.com
, 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, Any lump has potential to be cancerous and needs to be followed
size of an almond up; however, most breast masses are benign
Lump is increasing in size
A rapidly growing lump is a red flag and must not be ignored.
Ultrasound confirmed cancer cells in the tumor
Cancer that spread to the lymph nodes is also a red flag that can
as well as three of her lymph nodes most
proximal to the tumor increase metastasis.
MRI revealed a 1 cm tumor on her lumbar spine This has metastasized to a distant location and could indicate a stage
IV prognosis, making this a serious, terminal diagnosis
VAD will be placed later this afternoon so that
chemotherapy can be started as soon as An attempt to slow or stop the progression of disease
possible
RELEVANT Data from Social History: Clinical Significance:
4 kids under the age of 17 Jan is a mother with 4 children whom she wants to see grow up. As
nurses, we want to support her emotionally and holistically.
No personal or family history of breast cancer The patient does not have a clear understanding or significance of
breast cancer due to her good health and lack of family history.
Devout Christian who has a strong faith Jan has a strong spiritual foundation
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
Obtaining a mammogram may provide a baseline of her current
expired because he just lost his job.
status and may be used for comparison after treatment.
© 2016 Keith Rischer/www.KeithRN.com
, 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: Provide information and education on what the port is used for and how this will be placed and how the port
will aid in administering medication and accessing labs. Instruct the patient to inspect the port daily and report any signs of
infection. If fluids are administered through the port, it is important to inform her that it should not be done freely as this could
cause infiltration. The patient will need to be educated on S/S of infection, changes in appearance around the port or if the
reservoir is moving underneath the skin.
Chemotherapy: Explain how chemotherapy works and it goes through the whole body and affects every part of
the body. Educate on being immunocompromised and will need to assure that she is not around sick individuals.
Expected side effects: Anorexia, nausea and vomiting, fatigue, alopecia, possible neuropathy, easy bruising and bleeding,
infection, anemia (low red blood cell counts), appetite changes and constipation
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with Jan?
Ask Jan to reiterate what the possible side effects could be and ask her how she can mentally prepare herself. She will
voice understanding on when to notify provider or seek medical attention.
Caring and the “Art” of Nursing
1. What is Jan likely experiencing/feeling right now in this situation?
She could be in denial, angry, depressed, and hopeless. Angry at herself for not seeking medical attention sooner.
Scared of the unknown and how they will be able to afford treatment without insurance. Depressed that she is
terminally ill and feelings of hopelessness since the cancer has spread. Fear of dying and leaving her children without a
mother.
2. What can you do to engage yourself with Jan’s experience, and show that she matters to you as a person?
Encourage her to keep her faith. Provide names and locations for support groups. Speak in a soothing tone and make eye
contact and touch. Ask her to voice her fears and questions. Explain to her that there are no stupid questions, if I don’t
know the answer, I would find out for her.
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
© 2016 Keith Rischer/www.KeithRN.com
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
Unfolding Clinical Reasoning Case Study: STUDENT
Breast Cancer History
of Present Problem:
© 2016 Keith Rischer/www.KeithRN.com
, 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, Any lump has potential to be cancerous and needs to be followed
size of an almond up; however, most breast masses are benign
Lump is increasing in size
A rapidly growing lump is a red flag and must not be ignored.
Ultrasound confirmed cancer cells in the tumor
Cancer that spread to the lymph nodes is also a red flag that can
as well as three of her lymph nodes most
proximal to the tumor increase metastasis.
MRI revealed a 1 cm tumor on her lumbar spine This has metastasized to a distant location and could indicate a stage
IV prognosis, making this a serious, terminal diagnosis
VAD will be placed later this afternoon so that
chemotherapy can be started as soon as An attempt to slow or stop the progression of disease
possible
RELEVANT Data from Social History: Clinical Significance:
4 kids under the age of 17 Jan is a mother with 4 children whom she wants to see grow up. As
nurses, we want to support her emotionally and holistically.
No personal or family history of breast cancer The patient does not have a clear understanding or significance of
breast cancer due to her good health and lack of family history.
Devout Christian who has a strong faith Jan has a strong spiritual foundation
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
Obtaining a mammogram may provide a baseline of her current
expired because he just lost his job.
status and may be used for comparison after treatment.
© 2016 Keith Rischer/www.KeithRN.com
, 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: Provide information and education on what the port is used for and how this will be placed and how the port
will aid in administering medication and accessing labs. Instruct the patient to inspect the port daily and report any signs of
infection. If fluids are administered through the port, it is important to inform her that it should not be done freely as this could
cause infiltration. The patient will need to be educated on S/S of infection, changes in appearance around the port or if the
reservoir is moving underneath the skin.
Chemotherapy: Explain how chemotherapy works and it goes through the whole body and affects every part of
the body. Educate on being immunocompromised and will need to assure that she is not around sick individuals.
Expected side effects: Anorexia, nausea and vomiting, fatigue, alopecia, possible neuropathy, easy bruising and bleeding,
infection, anemia (low red blood cell counts), appetite changes and constipation
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with Jan?
Ask Jan to reiterate what the possible side effects could be and ask her how she can mentally prepare herself. She will
voice understanding on when to notify provider or seek medical attention.
Caring and the “Art” of Nursing
1. What is Jan likely experiencing/feeling right now in this situation?
She could be in denial, angry, depressed, and hopeless. Angry at herself for not seeking medical attention sooner.
Scared of the unknown and how they will be able to afford treatment without insurance. Depressed that she is
terminally ill and feelings of hopelessness since the cancer has spread. Fear of dying and leaving her children without a
mother.
2. What can you do to engage yourself with Jan’s experience, and show that she matters to you as a person?
Encourage her to keep her faith. Provide names and locations for support groups. Speak in a soothing tone and make eye
contact and touch. Ask her to voice her fears and questions. Explain to her that there are no stupid questions, if I don’t
know the answer, I would find out for her.
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
© 2016 Keith Rischer/www.KeithRN.com
