Breast Cancer and Complications for One Patient

7/29/2019 Breast Cancer and Complications for One Patient

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Running head: BREAST CANCER 1

A Patient with Breast Cancer:

Complications and Co-morbidities

Sarah Firmin

University of North Florida


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BREAST CANCER 2

A Patient with Breast Cancer: Complications and Co-morbidities

F.T. is a 73 year- old African American female who has been in the hospital for 18 days

following a double mastectomy on August 10, 2012. After her surgery she experienced

complications including severe sepsis secondary to a urinary tract infection, anemia, gastritis,

formation of a pressure ulcer on her buttock, and generalized weakness. She is obese. Being

obese affects her recovery in many ways; she becomes short of breath upon minimal exertion,

has generalized joint pain, and has reported feeling tired on a consistent basis. Being obese also

increased her likelihood for the initial development of breast cancer (LeMone, Burke, &

Bauldoff, 2011).

She has a prior diagnosis of type two diabetes mellitus (DM) and has had periods in the

hospital when her glucose level has been over 200mg/dl. Surgical patients with blood glucose

levels over 200mg/dl have higher rates of infection (LeMone, Burke, & Bauldoff, 2011).

Controlling her glucose level has been difficult because F.T. has refused to eat at times, she is

inactive, and she has expressed feelings of emotional stress. As a result of type 2 DM, she has

i h l th Thi h i t d h F T h t h f t f


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BREAST CANCER 3

Breast Cancer

Heredity is a non-modifiable risk factor which causes breast cancer. Two genes, BRCA1

and BRCA2, are cancer susceptibility genes. A woman has an 80% chance of developing breast

cancer if one of these genes is inherited (Crowley, 2012). Family history has been identified as

the leading indicator for the risk of breast cancer; however, breast cancer can also be caused by

environmental, hormonal, and reproductive factors (LeMone, Burke, & Bauldoff, 2011).

Breast cancer begins as one cell mutates from being a regular cell to a cell that grows and

multiplies too rapidly and forms a tumor. The proliferation of cancerous cells is dependent upon

hormones (LeMone, Burke, & Bauldoff, 2011); estrogen, progesterone, growth hormone,

prolactin, and adrenal corticosteroids influence the action of the cells (Crowley, 2012). An

alteration in these hormone levels may slow the rate of cell multiplication. Estrogen and

progesterone initiate activity in nearly 60% of cancerous cells; the cells that respond to these

hormones have specific protein receptors and without the hormones the cells exhibit regression

(Crowley, 2012).

The HER-2 gene causes the proliferation of approximately 25% of tumor cells (Crowley,


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BREAST CANCER 4

cells is an area of necrosis. Calcium salts exit the bloodstream and enter the necrotic tissue, and

the calcium may be felt while performing a self-breast exam.

The cancer is noninvasive if there is no infiltration to the surrounding tissue. If the tumor

breaks through the ducts or lobules into the surrounding breast tissue, the tumor is invasive

(LeMone, Burke, & Bauldoff, 2011). Metastasis occurs when a tumor secondary to an original

tumor forms; the cancer spreads to an organ or a part of the body that was not associated with the

original tumor (LeMone, Burke, & Bauldoff, 2011). Breast cancer will often first metastasize to

the regional lymph nodes which are located above the breast towards the underarm before

metastasizing in more distant sites (Crowley, 2012). In addition to the lymph nodes, metastasis

commonly occurs in the bones, brain, lungs, liver, and skin (LeMone, Burke, & Bauldoff, 2011).

The proliferation of cell division will often trigger a response which initiates the

formation of excess fibrous tissue around the tumor. The fibrosis may be a protective attempt by

the body to contain the cancer from spreading (Crowley, 2012). This may make the cancer feel

hard; it may make the skin appear dimpled, and may have uneven borders that merge into the

bordering breast tissue. The cancerous lump in the breast may be nontender. The nipple may


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BREAST CANCER 5

in the liver release insulin into the blood stream which triggers skeletal muscles and fat to

increase the absorption of glucose, lowering the blood glucose level. Insulin resistance occurs

when skeletal muscle and fat tissue do not respond to insulin. When the body is in a of state

insulin resistance, glucose levels build up in the blood stream instead of going into the cells of

skeletal muscle and fat, creating a state of hyperglycemia (LeMone, Burke, & Bauldoff, 2011).

The liver also becomes resistant to insulin in type 2 DM (Mahler, & Adler, 1999).

Insulin is released from beta cells in the pancreas. In a healthy individual, insulin signals the

liver is to withhold excretion of glucose. Insulin resistance from the liver creates an environment

where glucose is excreted regardless of circulating insulin levels. Over time, the glucose

production is continually increased and is excreted after fasting and postprandial (Mahler, &

Adler, 1999). The liver begins to use glucose less as glucokinase activity decreases, and yet the

liver continues to overproduce glucose (Mahler, & Adler, 1999). In the pancreas, beta cell

function begins to decline before eventually ceasing action (Mahler, & Adler, 1999).

F.T. is obese and physically inactive, which are risk factors for type 2 DM. These are

also risk factors for her chief complaint of breast cancer. An additional risk factor for type 2 DM


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BREAST CANCER 6

pressure of 120-139 mm Hg over a diastolic pressure of 80-89 mm Hg, while hypertension is the

systolic pressure equal to or greater than 140 mm Hg over the diastolic pressure equal to or

greater than 90 mm Hg (Brashers, 2008). In order to diagnose a patient as hypertensive, the

diagnostic blood pressure measurement must be an average of the pressures taken on three

different instances (LeMone, Burke, & Bauldoff, 2011).

Blood pressure is affected by an elevated vascular volume, which may occur due to a

decrease in the excretion of salt. Persons with hypertension generally expel a lower amount of

salt in the urine than persons without hypertension (Brashers, 2008). The renin-angiotensin-

aldosterone system (RAAS) is responsible for controlling vascular tone and signaling the kidneys

to release or retain water and salt. An impaired RAAS system will result in an increase of

sodium and fluid, which increases the pressure on the vessel walls due to the heightened blood

volume (Brashers, 2008). Specifically, angiotensin II stimulates vasoconstriction, and the

sympathetic nervous system, and prompts aldosterone to manipulate the retention of sodium and

fluids by the kidney (Brashers, 2008).

Persistently high angiotensin II levels also contribute to ventricular remodeling. This


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BREAST CANCER 7

(Brashers, 2008). A goal of this action is to increase the contraction strength of the heart, which

increases the cardiac output and provides the muscles with more blood. Concurrently, the

adrenal medulla gland releases catecholamines which cause vasoconstriction (Brashers, 2008).

Continual excitation of the neuroreceptors leads to continual constriction of the vascular

system and a raised heart rate. Vascular remodeling occurs in this process, and procoagulant

effects can be seen (Brashers, 2008). The continual elevation of the SNS causes blood pressure

to become elevated.

Released from heart cells, atrial natriuretic peptide (ANP) also affects vasomotor tone

and blood volume (LeMone, Burke, & Bauldoff, 2011). This natriuretic hormone inhibits both

aldosterone secretions from the adrenal gland and anti-diuretic hormone from the pituitary gland.

This process allows for more water to be excreted in the urine (LeMone, Burke, & Bauldoff,

2011). Other natriuretic hormones such as brain natriuretic peptide and C-type natriuretic

peptide work to maintain a balanced relationship between salt and water in the body (Brashers,

2008). If a deficient intake level of potassium, magnesium, and calcium occurs, or if an excess

of sodium intake occurs, the balance is offset and too much sodium can be retained in the body


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BREAST CANCER 8

Contributing factors to hypertension also include resistance to insulin, hyperinsulinemia

and the functioning ability of endothelial cells (Brashers, 2008). Superfluous insulin contributes

to the retention of sodium by the kidneys and an increase in SAS action. In addition, vascular

smooth muscles become hypertrophic in the presence of excess insulin, and the ability to

transport ions across the cell membrane is impaired (LeMone, Burke, & Bauldoff, 2011).

Hypertension is the most common comorbidity in cancer patients (Mouhayar, &

Salahudeen, 2011). While the rate of hypertension is the same for persons that do not cancer and

those with cancer before chemotherapy, after chemotherapy the rate of hypertension rises

dramatically (Mouhayar, & Salahudeen, 2011). If hypertension cannot be controlled, the patient

may not be eligible for certain treatments. Blood pressure monitoring is critical throughout the

cancer treatment process in order to prevent end-organ damage (Mouhayar, & Salahudeen,

2011).

Physical Assessment

F.T. was sitting in the bed with the head of the bed at an 80 degree angle. Her weight is

196lbs. Her vital signs were taken at 0900. Her respiratory rate was 20 inhalations per minute,


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BREAST CANCER 9

nose was without drainage. The tongue was midline; the mucus membranes appeared dry and

light pink, and her dental hygiene was poor. Her pupils were equal, round, and reactive to light

and accommodation. The patient appeared to have been barrel chested. Her respiratory rate was

regular and unlabored. The lungs were clear to auscultation; diminished breath sounds were

noted bilaterally in the lower lobes. There was no cough or mucous discharge. Her heart rate of

98 beats per minute was regular and free of murmurs. S1 and S2 were auscultated. The carotid,

radial, and pedal pulses were regular however the radial and pedal pulses were weak (graded as a

+1). She had pitting +3 edema in her lower extremities. The skin under her fingernails and

toenails was tinged brown due to chemotherapy treatments; the capillary refill time was therefore

unable to be measured.

F.Ts abdomen was soft, obese, without visible peristalsis, and non-tender. Tympany

was heard upon percussion, and normal bowel sounds were present in all four quadrants. She

self-reported her last bowel movement as occurring on August 28, 2012; when possible she

ambulated to the bedside commode for bowel movements. A Foley catheter was removed on

August 26, 2012, and an adult brief was worn for urination. The patient was able to lift her arms


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BREAST CANCER 10

a score of 15 on the Glasgow Coma Scale. Her mood was congruent and appropriate. She stated

that she was depressed, tired, and sad. She also noted that she wanted to leave the hospital.

Diagnostic Testing and Laboratory Results

F.T. had a bilateral mastectomy on August 10, 2012. On August 8, 2012, after the patient

reported difficulty breathing, she had x-rays of the chest which showed mild cardiomegaly,

infiltrate in the right upper lung lobe, and shallow lung volume. A sonogram of the chest and

mediastinum was taken on August 16, 2012 which showed a mass in the region of the right

breast with heterogeneous echogenicity which measured 16cm by 7cm. She had a second mass

in the same area which measured 9.4cm by 3.7cm. These masses were found to most likely be

representative of hematomas. A chest x-ray was taken again on August 17, 2012; the lungs had

developed bibasilar atelectasis versus the prior infiltrate, and the cardiac silhouette was enlarged.

After complaints of severe abdominal pain, her stomach was biopsied on August 21,

2012 and there was no evidence of intestinal metaplasia or dysplasia. She was found negative

for helicobacter organisms; an x-ray was taken to examine the abdomen and found no free

intraperitoneal air. On August 22, 2012 she underwent a Computed Tomography (CT) scan


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BREAST CANCER 11

liver function tests

Na 146 (H)

K 4.1

Cl 112 (H)

CO2 29

Anion Gap 5

Glucose 123 (H)

BUN 9

Creatine 0.97

GFR


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BREAST CANCER 12

WBC 7.7

RBC 3.09 (L)

HGB 7.9 (L)

HCT 25.6 (L)

MCV 82.8

MCH 25.6 (L)

MCHC 30.9 (L)

RDW 18.4 (H)

PLT 316

NEUT % 69.4

LYMPH % 18.4

MONO % 9.5

EOS % 2.6

BASO % 0.1

NEUT # 4.9


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BREAST CANCER 13

August 27, 2012 at 0348 102

August 27, 2012 at 0702 107

August 27, 2012 at 1126 176 (H)

August 27, 2012 at 1639 122 (H)

August 27, 2012 at 2024 234 (H)

August 28, 2012 at 0038 162 (H)

August 28, 2012 at 0247 134 (H)

Medications

F.T. is taking Heparin Sodium, Hydralazine HCL, Insulin Detemir, Insulin lispro,

Morphine, Gabapentin, Oxybutynin Chloride, Percocet, Pantoprazole, Rosuvastatin Calcium.

Medication purpose, mechanism of action, class of drug, potential side effects, and the

evaluation of each medication is in Appendix A.

Summary of Treatment and Plans for Discharge

F.T. has a strong desire to leave the hospital. Having motivation is important because she


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BREAST CANCER 14

References

Ackley, B.J., & Ladwig, G.B. (2011).Nursing diagnosis handbook: A guide for planning care.

(9th

ed.). St. Louis, MO: Mosby.

Brashers, V. (2008). Alterations in cardiovascular function. In S. Huether, K. McCance, V.

Brashers, & N. Rote (Eds.), Understanding pathophysiology (pp. 607-676). St. Louis,

MO: Mosby.

Cowley, L. (2010).An introduction to human disease. (8th

ed.).Sudbury, MA: Jones & Bartlett

Deglin, J. H., & Vallerand, A. H. (2009).Daviss drug guide for nurses (11th

ed.). Philadelphia,

PA: F.A. Davis

LeMone, P., Burke, K., & Bauldoff, G. (2011).Medical-surgical nursing: Critical thinking in

patient care (5th

ed.). Boston, MA: Pearson.

Mahler, R., & Adler, M. (2011). Type 2 diabetes mellitus: Update on diagnosis,

pathophysiology, and treatment. The Journal of Clinical Endocrinology &

Metabolism, 84(4), 1165-1171. doi: 10.1210/jc.84.4.1165

Mouhayar, E., & Salahudeen, A. (2011). Hypertension in cancer patients. Texas Heart Institute


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Running head: BREAST CANCER 15

Appendix A

MEDICATION

NAME &

CLASSIFICATION

DOSE, TIME,

FREQUENCY &

ROUTE

MECHANISM OF

ACTION

MAJOR & COMMON

SIDE EFFECTS

RATIONALE FOR

THIS CLIENT

NURSING

CONSIDERATIONSEvaluation of

MedicationEffects

Heparin Sodium

Anticoagulant

5000U

Every 12 hours

0900, 2100Subcutaneous

Potentiates

inhibitory

effect ofantithrombin

on factor Xaand thrombin.Prevents the

conversion of

prothrombinto thrombin

by its effectson factor Xa.

Anemia,

thrombocytopenia,

bleeding.

Patient is

spending the

majority of herdays and nights

in bed. Thismedication willhelp to prevent

blood clots

from forming.

Consistently

assess for signs

of bleeding andhemorrhage

(bleeding gums,nose bleeds,black tarry

stools, a fall in

hematocrit orblood pressure).

Medication is

having desired

effect. Patientptt is 2. Patient

does not showsigns ofcomplications.

Hydralazine

HCL

(Apresoline)

Anti-hypertensive

Vasodilator

25mg

Every 8 hours

0600, 1400,2200

Oral

Direct- acting

peripheral

arteriolarvasodilator

which lowersblood

pressure in

hypertensivepatients.

Tachycardia,

sodium retention,

drug inducedlupus syndrome.

Patient has

hypertension.

Thismedication aids

in controllingsymptoms.

Monitor blood

pressure and

pulse frequentlyduring therapy;

note anychanges.

Monitor

electrolytes

Blood pressure

at 0735 was

197/77. 0900blood pressure

190/74. 0600medication was

not given until

0900 due tonurse error.

Blood pressureat 1000 was

Medication Worksheet

Patient Initials F.T. Date Seen August 27, 2012
https://www.google.com/url?url=http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000626/&rct=j&sa=X&ei=DoZKUMvnFsPI2gWyyICICg&ved=0CB8Q8Q4wAA&q=Hydralazine&usg=AFQjCNE1uHUi0Oc-ycb5QLrpDNmRrS04aQhttps://www.google.com/url?url=http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000626/&rct=j&sa=X&ei=DoZKUMvnFsPI2gWyyICICg&ved=0CB8Q8Q4wAA&q=Hydralazine&usg=AFQjCNE1uHUi0Oc-ycb5QLrpDNmRrS04aQhttps://www.google.com/url?url=http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000626/&rct=j&sa=X&ei=DoZKUMvnFsPI2gWyyICICg&ved=0CB8Q8Q4wAA&q=Hydralazine&usg=AFQjCNE1uHUi0Oc-ycb5QLrpDNmRrS04aQ


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BREAST CANCER 16

166/84.

Medication

administrationhad positive

effect, howeverpatient

remainedhypertensive.

Patient lab

value ofsodium high

(146). This is

a possible sideeffect of the

medication.Patient plan is

to increasefluids to lower

the value. No

other sideeffects.

Insulin Detemir(Levemir)

Antidiabetics

Hormones

Pancreatics

4units1x daily

BedtimeSubcutaneous

Lowerglucose by

stimulatingglucose

uptake in

skeletalmuscle and

fat, inhibitinghepatic

glucose

production.Onset: 3-4

Hypoglycemia,anaphylaxis

Thismedication is

indicated forpatients who

have type 2

DM, which thispatient has.

Assessment ofsymptoms for

hypoglycemia,and

hyperglycemia.

Monitor weightperiodically.

May causedecrease in

phosphate,

magnesium,and potassium

Drugadministration

has desiredeffect,

although blood

glucose levelremains high.

On August 27,2012 at 2024,

the level was

234.Medication


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BREAST CANCER 17

hours.

Peak: 3-14

hours.Duration: 24

hours.

levels. Monitor

glucose four

times daily, andmore

commonlyduring stress.

was

administered,

and the levelwas checked

again onAugust 28,

2012 at 0038.The level had

fallen to 162.

By 0237, thelevel had

dropped further

to 154. Patientdoes not

experiencenegative side

effect frommedication.

Insulin lispro(Humalog)

Antidiabetic

Hormones

Pancreatics

Sliding Scale:Blood sugar

350: callendocrinologist

After meals and1600

Subcutaneous

Lowerglucose by

stimulating

glucoseuptake in

skeletalmuscle and

fat, inhibiting

hepaticglucose

production.Onset: 15-30

minutes.

Peak: 2-8hours.

Hypoglycemia,anaphylaxis

Controlsinsulin in

patients with

type onediabetes or type

2 DM. Patienthas type 2 DM.

Assessment ofsymptoms for

hypoglycemia,

andhyperglycemia.

Monitor weightperiodically.

May cause

decrease inphosphate,

magnesium,and potassium

levels. Monitor

glucose fourtimes daily, and

Patient needed4u before

breakfast on

August 27,2012 when

blood glucosewas 177.

Patient does

not have anyadverse side

effects, and themedication has

a positive

effect onoverall health.


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BREAST CANCER 18

Duration: 24

hours.

more

commonly

during stress.

Morphine

Opioid

analgesics

Opioid agonist

2mgEvery 4 hours

as needed

IV

Binds toopiate

receptors in

the CNS.Alters the

perception of

and responseto pain.

Producesgeneralized

CNSdepression.

Confusion,sedation,

hypotension,

constipation,respiratory

depression.

Patient hassevere pain

associated with

her doublemastectomy

and infection.

Use a pain scalebefore and after

administration

to quantifypatient pain.

Assess: level of

consciousness,blood pressure,

pulse, andrespirations

before, during,and after

administration.

Assess geriatricpatient more

frequently; thisgroup is more

susceptible to

effects ofopioids.

Medication hasdesired effect

of lowering

pain. Pre-administration

of medication,

patient self-reported pain

as a level 8 ona scale from 1

to 10. After anhour, the pain

was reassessed

and the painlevel had

dropped to a 5.The patient has

constipation

which is anadverse side

effect ofmorphine; no

other adverse

side effects.

Gabapentin

(Neurontin)

Analgesicadjunct

100mg

1x daily0900

Oral

Mechanism

of action notknown. May

affect thetransport of

amino acids

Confusion,

depression,drowsiness, ataxia,

paresthesia, facialedema.

An unlabeled

use of thismedication is

for the relief ofchronic pain.

Patient has

Assess location,

duration, andintensity of

pain.

The patient has

diabetes, anddue to the

diabetes shehas peripheral

neuropathy.


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BREAST CANCER 19

Mood stabilizer across and

stabilize the

neuronalmembranes.

chronic pain

resulting from

peripheralneuropathy.

This

medication is

primarily forthe pain

associated withthat condition.

Medicationalone does not

resolve all of

the issuesclient has in

relation to

pain, however,when used in

conjunctionwith other pain

relief, thepatient

experiences

less pain.Patient needs

ongoingmonitoring of

pain.

Oxybutynin

Chloride

(Ditropan)

Urinary tractantispasmodic

Anticholergenic

5mg

1x daily

0900Oral

Inhibits the

action of

acetylcholineat prostgan-

glionicreceptors.

Has direct

spasmolyticaction on

Dizziness,

drowsiness,

constipation, drymouth, nausea,

urinary retention.

Patient has

stress urinary

incontinence.

Monitor

voiding pattern

and intake andoutput ratios,

and assessabdomen for

distention. In

geriatricpatients, assess

Medication is

having desired

effect andpatient is not

voiding due tostress

incontinence.

The patient isnot taking in


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BREAST CANCER 20

smooth

muscle lining

the GU tract,without

affectingvascular

smoothmuscle.

for sedation and

weakness.

fluids, creating

a low urine

output. Thepatient is

experiencingconstipation.

Patient istaking Colace

100mg daily at

bed tocounteract this

effect. She has

not complainedof the other

adverse effects.

Oxycodone/

Acetaminophen(Percocet)

Opioid

Analgesic

5mg

Every 4 hoursas needed

Oral

Binds to

opiatereceptors in

the CNS.Alters

response to

andperception of

painfulstimuli, while

producing

generalizedCNS

depression.

Confusion,

sedation,respiratory

depression,constipation,

orthostatic

hypotension,urinary retention.

This

medication isindicated for

moderate tosevere pain.

Patient has pain

due to recentdouble

mastectomy.

Assess type,

location, andintensity of pain

prior to and 1hour after

administration.

Assess bloodpressure, pulse,

and respirationsbefore and

periodically

duringadministration.

If respirations


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BREAST CANCER 21

function

regularly.

Preventconstipation

with increasedfluids, fiber,

and laxatives.

along with

Hydralazine

HCL, maycause urinary

retention. Thepatient will

need toincrease fluids

from her

present intake(very low fluid

intake). Input

and outputmonitoring is

beneficial inthis case.

Pantoprazole(Protonix)

Anti-ulcer agent

Proton pumpinhibitor

40mg1x daily

9amIV

Binds to anenzyme in the

presence ofacidic gastric

ph,

preventingthe final

transport ofhydrogen

ions into the

gastric lumen.

Headache,abdominal pain,

diarrhea,hyperglycemia.

Patient hasGastro-

esophagealreflux disease

(GERD).

Pantoprazoletreats heartburn

symptoms andis indicated for

erosive

esophagusassociated with

GERD.

Assess patientroutinely for

epigastric orabdominal pain

and for frank or

occult blood instool, emesis, or

gastric aspirate.

Medication ishaving the

desired effectand the patient

is not

complaining ofGERD effects.

The adverseside effect of

hyperglycemia

should benoted as a

possiblecontributing

factor for the

patientspresent


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BREAST CANCER 22

hyperglycemic

condition. The

patient is notexperiencing

any otheradverse side

effects.

Rosuvastatin

Calcium

(Crestor)

Lipid loweringagent

HMG-CoA

reductase

40mg

1x daily

BedtimeOral

Inhibit an

enzyme

(HMG-CoAreductase),

which isresponsible

for catalyzingan early step

in the

synthesis ofcholesterol.

Abdominal

cramps,

constipation,diarrhea, flatus,

heartburn, rashes,rhabdomyolysis.

Aid in the

management of

dyslipidemia.Patient has

hyperlipidemia.

Monitor liver

function tests.

May also causean increase in

alkalinephosphatase

levels and anincrease in

bilirubin levels.

Monitor patientfor muscle

tenderness.

Patient has

hyperlidiemia.

I do not havecholesterol

values in toevaluate

medicationeffectiveness.

LDL, HDL,

andtriglycerides

must bemonitored.

Patient is not

experiencingadverse

medicationeffects.

Source: Deglin, J. H., & Vallerand, A. H. (2009).Daviss drug guide for nurses (11th

ed.). Philadelphia, PA: F.A. Davis


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Appendix B

UNIVERSITY OF NORTH FLORIDA NURSING CARE PLAN FORM1. Nursing Diagnosis /

Related to

As Evidenced By:

Acute Pain related to post double mastectomy procedure.

Page # in

Ackley &

Ladwig

601

As Evidenced By:

Subjective Objective

Patient self-reported being in pain Described the pain as throbbing and

stabbing

Patient displays observable pain responsesincluding guarding of the breasts and crying.

Respiratory rate 20 and heart rate of 98 beats perminute while at rest.


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BREAST CANCER 24

1. By the end of the 8 hour shift,

patient will use a self-report paintool to identify current pain level

and establish a comfort- function

goal.

1a. Conduct and document a

comprehensive pain assessment.Determine location, temporal

profile, aggravating and alleviating

factors, and the effects that pain ishaving on the quality of life.

Patient was fully assessed at thestart of the shift to determine a

baseline for pain. She stated thatshe was in pain; the pain had

lasted at least 2 hours, the pain

radiated down her chest, and downher sides. She stated that it hurts

the most when she moves, and she

feels he best when she is layingstill with the head of the bed tilted

at 30 degrees. Having pillowsunder each arm, propping the arms

up to the level of the chest also

alleviates some of the pain.

1b. Assess pain level in patient

using a valid and reliable self-

report pain tool, such as the 0-10numerical pain rating scale. Thenurse posed this question to the

patient, and explained that 0

signifies no pain, while 10represents terrible pain. The

patient state that she was at a level

eight.

1a. Determining the characteristic

of pain is critical to determiningthe underlying cause of pain and

effectiveness of treatment. Self-

report is considered the singlemost reliable indicator of pain

presence and intensity.

1b. Single dimension pain ratings

(such as the 0-10 pain scale) arevalid and reliable as measures of

pain intensity level.

1. Goal met. Patient

was able to self-reporther pain on a 0-10

numerical pain rating

scale. She was alsoable to verbalize a pain

level which wouldmake her more able to

achieve activities of

daily life.


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BREAST CANCER 25

2. By the end of the eight hourshift, the patient will report that a

pain management regimenachieves comfort-function goal

without adverse effects.

1c. Ask the client to identify acomfort-function goal for a pain

level on a self-report tool that

would allow the patient to performnecessary activities easily. Patient

stated that if her pain was at ornear a level 5, she would be able

to perform activities, and would

not fear movement as she

currently does.

2a. Manage acute pain using amultimodal approach. Patient had

orders for Percocet oral 5mg as

needed every four hours,Morphine 2mg IV as needed every

four hours, and Nuerotin at 0900daily. The patient complained of

pain and was given Percocet at0550 on Tuesday morning. At

0900, the patient took Neurotin.

At 1208 the patient self-reportedpain as a level 8 and was given

Morphine 2mg IV. Morphine was

administered again at 1600.

1c. The relationship between panlevel and functional goals should

be a major focus of the

development of the individualizedpain management plan. Effective

pain relief which allows functionand movement is critical for

decreasing risk factors for

cardiopulmonary andthromboembolic complications

after surgery. Immobilization isalso a major risk factor for chronic

hyperalgesic pain after surgery.

2a. Multimodal analgesia

combines two or more medicationsfrom different pharmacological

classes that target different

mechanisms along the painpathway. The advantage of this

approach is that the lowesteffective dose of each drug can be

administered, resulting in feweradverse side effects such as

oversedation and respiratory

depression.

2. Goal met. At the endof the eight hour shift,

the patient did notreport any adverse side

effects from the pain

medications. Thepatient was educated

about the comfort-function balance, and

medications and pain

levels will continuallyneed reassessment, at

least every four hours.


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2b. Assess pain level, sedationlevel, and respiratory status at

regular intervals during pain

management with opioidadministration. Assess at least

every four hours if patient hasbeen stable without episodes of

hypoventilation. Patient vitals

were taken and recorded everyfour hours by the student nurse.

Eyes were examined and pupilswere equal, round, and reactive to

light. Pupil size within normal

limits. Respiratory rate remainedwithin normal limits. Patient was

tested for orientation to date, time,place, and self every four hours as

well and was oriented x4. Painlevel changed depending upon the

activity level of the patient. Two

hours after morphineadministration the patient self-

reported her pain as a level 4. An

hour later when the care teamassisted her in moving into the

chair by the bed, she stated thather pain was increasing again due

to the movement, and self-reportedher pain as a 7. Patient was given

time to rest and we did not try to

move her again for an hour. Shewas instructed to alert the

2b. All patients receiving opioidsor pain management are at risk for

sedation that may progress to

oversedation and lead to clinicallysignificant opioid-induced

respiratory depression.


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BREAST CANCER 27

3. By end of eight hour shift,

patient will describenonpharmacological methods thatcan be used to help achieve

comfort-function goal.

healthcare team if she became

dizzy, drowsy, or felt nauseas.

3a. Support the patients use of

non-pharmacologic methods to

help control pain such as the useof distraction, imagery, and

relaxation to aid in pain relief.The television was changed from a

loud news entertainment program

to a calm cooking show. Thelights in the room were dimed, and

the door to her room was changedfrom being completely open to be

approximately 90% closed. This

environment was created in orderto provide calm and quiet, and to

provide distraction from the painwithout creating barriers for

relaxation.

3b. Teach and implement

nonpharmacological interventionswhen pain is relatively well

controlled with pharmacologicalmethods. The nurse and student

nurse practiced deep breathing

with the patient. The methodconsisted of a slow, large

inhalation, followed by pursed lip

exhalation. The patient waseducated around moving at her

3a. Cognitive-behavioral strategies

can restore the patients sense ofself control, personal efficacy, andcan encourage active participation

in her own care.

3b. Nonpharmacological

interventions should be used to

supplement, not replace,pharmacological methods.

3. Goal met. The

patient was able toverbalize how tocommunicate her needs

to the healthcare team.

She stated that she feltmore comfortable

telling the staff whenshe was feeling poorly.

She admitted to feelings

of hopelessness, and

she cried talking abouthow she cant get up touse the bathroom. We

discussed how feelings

of hopelessness canmake a person feel

physically bad.Recognizing that she

can have some control

over her environment

and practicing copingmechanisms for pain

may accelerate her

healing process.


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Ackley, B.J., & Ladwig, G.B. (2011).Nursing diagnosis handbook: A guide for planning care. (9

th


2. Nursing Diagnosis /

Related to

Impaired Skin Integrity related to obesity, immunological deficit post double

mastectomy, immobility, impaired sensation.Page # in

Ackley &

Ladwig

769

As Evidenced By:


own speed and to alert caregivers

if she is being hurt during an adult

brief change. The patient wasencouraged to let others know

when she was in pain so that

caregivers can assist her.


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BREAST CANCER 29

Patient said she did not notice the twocuts on her right foot near her toenail.

She stated that she does not wish toget out of bed.

Patient is not eating. Stated she istired of hospital food, and that she

doesnt like the way it tastes.

Patient has type 2 DM. She has two cuts on her right foot. There is a stage 2 pressure ulcer on her left

buttock.

Patient has two openings in skin for JP drains toaid in eliminating fluid post double mastectomy.

She is not ambulatory. Patient is wearing an adult brief for urinary

incontinence.

Patient age is 73.

Outcome Indicators (NOC) Nursing Activities (NIC)

Rationale

(from nursing references) Evaluation andRevision of Plan

1. Maintain integrity of skinsurface surrounding JP drains,

right foot, and left buttock during

an eight hour nursing shift.

1a. Assess site of skin impairmentand determine cause. Wounds on

buttock are pressure ulcers.

Wounds on sides of breasts are

from incisions during themastectomy. The wounds on her

foot are from an unknown source.

1b. Monitor site of skinimpairment at least Q12h for

changes in color, redness,

1a. Cause of the wound must bedetermined before interventions

can be implemented. This is the

basis for additional testing and

evaluation to start the assessmentprocess.

1b. Systematic inspection can

identify impending problems

early.

1. Goal met. Sites weremonitored throughout

shift; client stated that

she experienced no

change in sensation.


30/39

BREAST CANCER 30

swelling, warmth, or other signs of

infection. Determine if the client

is experiencing changes insensation. The wounds were

examined at the start and end of an

eight hour shift.

1c. Select a topical treatment thatwill maintain a moist wound-

healing environment and that isbalanced with the need to absorb

exudate. Client treated with

Sensicane on her buttock; Versiva

sterile wound dressing protectedthe ulcer on her buttock. Thesuture site and around her JP

drains was kept clean and dry.

Dry gauze dressings with Silvadinsecured with tape are around the

JP drainage tubes. The cuts on herfoot were cleaned with saline and

left open to air.

1c. Choosing dressings that

provide a moist environment, keep

periwound dry, control exudateand eliminate dead space to

promote wound healing.


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BREAST CANCER 31

2. By end of eight hour shift,

client will demonstrateunderstanding of plan to heal skin

and prevent injury.

2a. Implement an incontinence

management plan to preventexposure to chemicals in urine and

stool that can erode or strip theskin. The patient was assessed

every hour and was asked if she

wanted to get up and use thebedside commode. She was asked

to call the nurse immediately if sheurinated in the adult brief so that

the brief could be changed. She

was also offered the bed pain for

bowel movements.

2b. Maintain the head of the bed atthe lowest possible degree of

elevation.

2c. Assess the clients nutritional

status. The patient was refusing to

eat because she was did not likethe taste of the food. She ate

approximately one scrambled eggfor breakfast and did not eat any

lunch. We discussed this with her

2a. Implementing a plan with the

use of a skin protectant cansignificantly decrease skin

breakdown and pressure ulcer

formation.

2b. Lowest possible elevation willaid in the reduction of sheer and

friction.

2c. Optimizing nutritional intake,including calories, fatty acids,

protein, and vitamins, is needed to

promote wound healing.

2. Ongoing. Client was

able to verbalize theimportance of changing

her brief andeliminating the

moisture after the brief

becomes soiled. Shestated that she would

use the call bell forassistance, and she did

perform that action.

She stated that sheknew why the head of

the bed should be at alow angle to prevent

excess pressure on her

buttock, although shedid not always keep it

there because it made itdifficult to see the

television. She statedthat she has requested

that her daughter bring

her food from home;her daughter would be

bringing her dinner.


32/39

BREAST CANCER 32

doctor; her doctor stated that food

from outside of the hospital is

permitted if she feels like a changeof menu would perk her appetite.

We discussed the importance of

eating in order to support healing.

Ackley, B.J., & Ladwig, G.B. (2011).Nursing diagnosis handbook: A guide for planning care. (9th


3. Nursing Diagnosis Risk for falls

Risk factors: cluttered environment, unfamiliar room, polypharmacy, impaired

balance, neuropathy, post-operative condition.

Page # in

Ackley &

Ladwig

355



As Evidenced By:


Patient stated that she is feeling tired,weak, and has been dizzy at times.

She is not able tolerate weight bearingactivity.

Patient is taking 2mg Morphine as neededQ2h for pain, and 5mg Ditropan. Both

medications have a possible side effect of

dizziness.


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BREAST CANCER 33

Stated that this was the first day thatshe felt that she was not able to

support her own body weight for

ambulation.

Cluttered environment in an unfamiliarand dimly lit hospital room.

Patient is anemic. Patient has peripheral neuropathy

secondary to type 2 DM.


Rationale

(from nursing references) Evaluation and

Revision of Plan


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BREAST CANCER 34

1. Client will remain free of falls

for an eight hour shift.

1a. Use a high-risk fall armband

and Fall Room sign to alert stafffor increased vigilance and

mobility assistance. Place the calllight and fluids in reach of the

patient. Encourage the patient to

call the nurse as much as neededto assist with toileting, or getting

items for the patient.

1b. Screen for balance andmobility skills (supine to sit,

sitting supported and unsupported,

sit to stand). Patient was able tomove from supine to sitting

supported and unsupported. She

did not feel comfortable placingany weight on lower extremities.

Student nurse and patient care techassisted the patient to a wheelchair

to change position. Patient criedand stated that she was unable to

feel her legs.

1c. Evaluate client for mental

health and neurologic function.Tested patient for orientation in

relation to time, place, self, andlocation. Client was able to

explain a metaphor.

1a. These steps alert the nursing

staff of the increased risk for falls.Placing the call light in reach of the

patient and creating an environmentwhich encourages communication

prevent the patient from needing to

ambulate without assistance.

1b. It is helpful to determine the

clients functional abilities and thenplan for ways to improve problem

areas or determine measures to

improve safety.

1c. Mental health status has beenfound to significantly influence the

rate of falls.

1. Nursing activities

implemented. Plan met;at the end of eight hour

shift, the patient did not

have any falls.


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BREAST CANCER 35



2. By the end of eight hour shift,

client will be able to recognize an

environment which minimizes the

risk of falls.

2a. Place a fall prone patient in a

room that is near the nursing

station.

2b. Teach patient to assess forhazards to increase safety

including eliminating clutter,

slippery floors, scatter rugs, andother potential hazards. Even

though she was unable to stand atthis time, the patient stated that

she generally ambulates to the

bathroom or the bedside

commode.

2c. Thoroughly orient client to

environment. Keep the bed in thelow and locked position. Place the

call light within reach and showhow to call for assistance. Explain

that nurse will answer call lightpromptly. Personal items were

placed near the patient, as well.

2a. Such placement allows more

frequent observation of the client.

2b. Clients suffering from impairedmobility are at risk for injury from

common hazards.

2c. Limiting the need for the patient

to get out of bed unassisted willlower the likelihood that the patient

will incur injuries due to a fall.

2.Goal met. Patient

was able to verbalize

the need for a clean andclutter free room. She

used her call light

several times during theshift, and was able toverbalize the best

placement for furniture

and medical equipmentin her hospital room.

The room was

repositioned, and clientstated that she would

tell the next shift of

healthcare membershow the room should bekept for her safety. Her

room however, was not

changed.


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BREAST CANCER 36

4. Nursing Diagnosis /

Related to

Imbalanced Nutrition: less than body requirements related to loss of appetite as

evidenced by aversion to eating, lack of interest in food, and reported altered taste

sensation.

Page # in

Ackley &

Ladwig

575

As Evidenced By:


Patient stated that she is not hungry. Patient stated that food seems to have

no taste. Patient is refusing to eat the meals in

the hospital.

Low electrolyte lab values: potassium (3.5),glucose (58), total protein (6.2), albumin (1.6),

calcium (8.1), magnesium (1.6)

Complete blood count low levels: red blood cells(2.92), hemoglobin (7.8), hematocrit (24.2).


Rationale

(from nursing references) Evaluation and

Revision of Plan


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1. During the eight hour shift,

patient will consume adequate

nourishment.

1a. Monitor food intake and record

percentages of food that is eaten.

Keep a three day food diary andconsult with a dietitian to establish

a minimal calorie intake. The

nurse and student nurse madenotes about the food intake for thefirst day. Patient ate only a

scrambled egg for breakfast and

did not eat any lunch. She wasoffered snacks as well, but

declined them also. The nurse

stated that she would put in anorder for the dietitian to meet with

the patient concerning intake.

1b. A nurse must make food

available as desired between earlyevening and breakfast. The patient

was offered graham crackers andpudding as snacks after lunch.

The snacks were declined. The

doctor was consulted and the

patient may have a family memberbring foods from home which may

trigger an appetite.

1c. Work with the patient todevelop a plan for increased

activity. The patient was moved

from laying to supported sitting,and then to unsupported sitting.

1a. Use of a food diary is helpful

for the patient and the nurse, to

examine food eaten, patterns ofeating, and presence of

deficiencies in the diet.

1b. Having food available as

desired can increase nutritional

intake.

1c. Immobility leads to negative

nitrogen balance that fosters

anorexia.

1. Ongoing. The food

intake journal was

started, but will needentries over three days

to establish a pattern.

Additionally, thedietitian had not yetconsulted with the

patient. The patient is

having a familymember bring in snacks

and favorite food items.

It will be important tonote if the new food

selections can prompt

an increase in intake.The patient was notcurrently able to

participate in long

periods of activity.Building the length of

time in which she isactive may encourage

the patient to eat.


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BREAST CANCER 38

2. By the end of the eight hour

shift, the patient will identify fluid

and nutritional requirements.

The patient was then transferred

into the wheelchair. The patient

stated that these activities took alot out of her. She was given

time to rest and relax in the chair

before transferring back to the bed.The nurse assured that the patientwould be in the bed sitting and

resting at least 30 minutes before

lunch was served.

2a. Recognize that patients with

wounds and a recent surgery need

increased calories to maintainnutrition. The nurse and studentnurse discussed the importance of

protein in the diet, and linked it to

wound healing. The patient thendescribed her desire for her

wounds from her doublemastectomy to heal quickly.

Patient education around protein

allowed the patient to make aconcrete connection between diet

and health.

2b. Assess intake calcium andvitamin D. Teaching centered on

the purpose of calcium for bonestrength. The patient was

2a. An increase in nutrient and

protein rich nutrition encourages

faster healing.

2b. The elderly adult needs

1200mg calcium and a minimum

of 800IU of vitamin D daily.

2. Ongoing. The

patient was able toidentify reasons to eat

protein and calcium richfoods; she did not eat

the foods. She took

sips of her fluids, butnever reached the

10mL/hour goal. Shestated that she didnt

like to go to the

bathroom because shewas wearing an adult

brief and she didnt likegetting it wet. She also

felt as though she did

not have the strength togo to the commode, so

she did not want to eat.The nurse and student

nurse made a plan to


39/39

BREAST CANCER 39

educated about the importance of

eating dairy, and was then able to

explain why dairy products are animportant part of the diet. The

patient was then offered pudding.

The pudding was declined.

2c. Assess for factors contributingto an acute illness, such as

dehydration. The patient was not

drinking water or ginger ale. Thepatient was given a fluid

challenge. The patient wasencouraged to drink a minimum of

10 ounces of fluid an hour. While

this would still be under her fluidrequirement, it would be a marked

improvement over the patientscurrent status. Drinks were poured

by the student nurse, and duringthe hourly rounds the amount of

fluid drank was noted. The patient

was also encouraged to eat foodsthat were high in fluid, such as

green beans.

2c. Elderly individuals need at

least 1600mL/day to ensure

adequate hydration.

encourage use of the

brief, and to assist the

patient with self-esteem. The issues with

going to the bathroom

must be rectified beforethe patient can feelcomfortable eating the

proper amount of food

to maintain adequate

nutrition.



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Breast Cancer and Complications for One Patient