Question

Scenario

M.D. is a 50-year-old woman whose routine mammogram showed a 2.3- × 4.5-cm lobulated mass at the 3 o’clock position in her left breast. M.D. underwent a stereotactic needle biopsy and was diagnosed with invasive ductal carcinoma, estrogen and progesterone receptor positive, HER-2 negative. The staging workup was negative for distant metastasis. Her final staging was stage IIB. She had a modified radical mastectomy with axillary lymph node dissection. The sentinel lymph node and 4 of 16 lymph nodes were positive for tumor cells. An implanted port was placed during surgery.

1. What are the risk factors for breast cancer?

2. Describe the biopsy technique used to diagnose M.D.’s cancer.

3. Breast cancer is classified as noninvasive or invasive. Compare these terms.

4. Discuss the implications of a positive sentinel node.

5. What factors affect prognosis and treatment for breast cancer?

6. Is she a candidate for tamoxifen therapy? Explain your reasoning.

7. Surgical intervention is the primary treatment for breast cancer. Describe the surgical procedure that M.D. had.

8. Describe M.D.’s risk for lymphedema.

9. What actions will you teach M.D. to reduce her risk for developing lymphedema?

CASE STUDY PROGRESS

Eight weeks after surgery, M.D. is now beginning a prescribed chemotherapy regimen of 6 cycles of CAF (cyclophosphamide, doxorubicin, and fluorouracil).

10. M.D. asks you why she has to have chemotherapy with so many drugs if the surgeon removed all the cancer. How would you respond?

11. Name the common side effects experienced by patients receiving a chemotherapy regimen.

12. What information would you want to review with M.D. about the signs and symptoms of infection and when to seek treatment?

13. M.D. is ordered doxorubicin at 75 mg/m². Her height is 5 feet, 7 inches (170 cm), and her weight is 155 pounds. Calculate the dose she will receive.

14. M.D. is prescribed filgrastim (Neupogen) as part of her treatment regimen. You teach her filgrastim is used is to:

1. Improve the number and function of neutrophils

2. Help CAF be more effective in treating her cancer

3. Replace abnormal cells in the bone marrow with normal cells

4. Decrease the level of fatigue she will experience during treatment

15. However, after reviewing with her how to manage alopecia, you determine further teaching is needed after she says:

1. “I should go buy a wig now, before I start losing my hair.”

2. “Wearing a scarf or hat when outside will help to protect me.”

3. “My hair should begin to return 2 months or so after treatment ends.”

4. “I can prevent hair loss if I wash every other day with a gentle shampoo.”

CASE STUDY PROGRESS

M.D. has now completed three cycles of chemotherpy, with her last treatment 12 days ago. She comes to the emergency department with a 1-day history of fever, chills, and shortness of breath. On arrival, she is slightly confused and agitated. Vital signs are 100/60, 119, 26, 103.6° F (39.8° C), Spo₂ 86% on room air. The chest x-ray examination shows diffuse infiltrates in the left lower lung consistent with pneumonia. Her basic metabolic panel is within normal limits, except the blood urea nitrogen (BUN) 28 mg/dL (10.0 mmol/L) and creatinine 1.6 mg/dL (141 mcmol/L).

Chart View

Complete Blood Count

White blood cells (WBCs)	1200/mm3 (1.2 x 109/L)
Neutrophils	34%
Segmented (“polys”)	30%
Bands	4%
Lymphocytes	60%
Monocytes	3%
Eosinophils and basophils	2%
Hematocrit (Hct)	24.9%
Hemoglobin (Hgb)	8.7 g/dL (87 g/L)
Platelets	85,000/mm3 (85 x 109/L)

16. Interpret M.D.’s laboratory results and explain the reason for any abnormal results.

17. M.D.’s absolute neutrophil count (ANC) is calculated as less than 500/mm3, describe the significance of this value.

18. What is your nursing priority at this time?

19. What is the single most important nursing intervention for a patient with an ANC below 500/mm³?

20. When is neutropenia most likely to occur in a person receiving chemotherapy?

21. What type of isolation do you need to initiate for M.D.? Outline the guidelines for maintaining this type of isolation.

22. What collaborative care interventions do you expect for M.D.?

23. What immediate nursing interventions do you need to take?

24. What actions do you need to take because M.D. had a left axillary lymph node dissection and why?

25. The provider orders a 500-mL normal saline bolus now, with orders to infuse over 2 hours. You decide to use M.D.’s implanted port for IV access. After you access the port and connect the fluid, the infusion pump alarms that the line is occluded. What will you do?

CASE STUDY OUTCOME

M.D. is admitted to the intensive care unit, where she soon needs endotracheal intubation. She spends 3 days there receiving IV antibiotics and fluids with respiratory support. After she is extubated, she returns to the oncology unit, where she stays for a few more days before being discharged to home.

Answer 1

1.Risk Factors of breast cancer:

• Age
• Gender
• Menopause management medication
• Early menses
• Having children
• Breastfeeding
• Alcohol consumption
• Smoking

2.Diagnosis:

Sterotactic Needle Biopsy:

• Diagnose non palpable masses
• Locate by sterotactic mammography under fluroscopy to guide needle location.

3.Invasive:

• Spread to other areas
• Most of breast cancers are Invasive

Noninvasive:

• It will stay with in the breast

4.Implications:

Presence of cancer in the sentinel node is an indication for the diasease is metastatic at the time of diagnosis.

5.Factors affect prognosis and treatment for cancer:

• Tumor size
• Axillary node involvement
• Tumor differentiation
• Estrogen/ Progesterone receptor status
• Genetic expression
• Metastasis

6.Her tumor is estrogen receptor positive that means tumor grows in the presence of estrogen,she is candidate for tamoxifen therapy.Tamoxifen blocks estrogen receptor on breast cancer cells for preventing receptor activation by estradiol the principal endogenous estrogen.Hence, in the absence of estradiol influence the rate of tumor cell proloferation decrease and tumor decreses in size.

7.Modified radical mastectomy: Takes entire breast, fatty tissue and axillary lymph nodes but leaves pectoral muscle and surrounding nerve in tact.

Radical Mastectomy: Removal of entire breast along with the underlying chest muscle and axillary lymph nodes.

8.Risks of lymphedema:

• Associated with amount of lymph removal
• Presence of obesity
• Past axillary surgery

9.Counselling points:

• Decongestive therapy
• Don't sleep in dependant positionProtect from trauma
• No bloodpressure measurement, venipuncture,injection on that arm
• Compression sleeves
• No heavy lifting

Case study progress:

10.Combination of chemotherapeutic drugs are more effective than single drugs. Each and every drug effective against the type of cancer being treated.When combined chemotherapeutic agents destroy more malignant cells and produce fewer side effects because each drug strikes the cancer cells at a diffrent point of the ceell cycle.

11. Side effects:

• Risk of infection
• Alopecia
• Nausea
• Fatigue
• Mouth sores
• Risk of bleeding
• Decreased fertility
• Joint pain
• Bladder irritation

12.Signs and symtoms of infection and when seek treatment

• High temperature
• Tachycardia
• Tachypnea
• Hypotension
• Sore throat
• Flu like symptoms

13. Chemotherapy dosing for Doxorubicin at 75 mg/m2

• Body surface area is calculated in squaremeters.
• Height:5 ft, 7 in =170 cm
• Weight:155lb/2.2= 0.3 kg
• According to an elsctronics BSA calculator, the BSA is=1.82 square meters

                     =1.82*75mg=136.5 mg

The dose she will receive is 136.5mg

14. a. Improve the number and function of neutrophils.

15.d.I can prevent hair loss if i wash every other day with gentle shampoo.

Case study progress:

16.The elevated Blood urea nitrogen and creatinine indicate probable dehydration due to the high temperature and vomiting.

• They indicate a potentially developing renal insuffieciency.
• The elevated lactic acid level is a by product of anaerobic metabolism.
• With pneumonia in her left lower lobe and decreased availabilty of oxygen cells require of manufacture adenosine triphosphate using the anaerobic pathway.
• Mylosuppression from the chemotherapy is the cause of decreased WBCs,Hgb,Hct and platelet count.
• Her lymphocyte count is high because of infection.

17.Absolute neutrophil count:

• Used to determine level of neutropenia.
• Calculation:ANC= WBC*(% Segmented neutrophils+% bands
• ANC=1200(30/100+4/100)= 408/mm3
• Because the NAC is less than 500/mm3 mary is at a severe risk of infection.
• Depending on the patient clinical situation chemotherapy might also be stopped untill the ANC count is higher.

18. Cardiac monitoring

• ECG changes, LV dysfunction, Heart failure
• Will see this manifest as stiffening of the left ventricle.

19.Strict hand washing is the main intervention to prevent risk of infection.

20. 7-14 days of chemotherapy

21.Reverse isolation guidelines:

• Guest of patiients must wear mask and not have any communicable diseasea
• Strict hand washing Keep medical equipment in room
• Cook food well

22.

• Respiratory support and administer of humidified oxygen
• You would obtain blood cultures and sputum cultures with gram statin and IV antibiotics.
• Fluid support would be initiated.

23.

• Monitor M.D's vital signs pulse oximetry, neurological statius, fluid and electrolyte balance.
• Arterial blood gas might be obtained.
• Fluid support

24.Actiona to take:

• Pink wrist band to make sure blood draws, injection, BP don't happen on that side.
• Elevate arm pillow to promote drainage

25.

• Assess the equipment and make sure the line is patent and without kinks.Have mary cough and deep breath and raise her arm.
• Reposition her.
• Check for blood return.
• If you meet resistance do not continue to flush.If necessary re access the port and verify placement of the HUber needle.
• Check for blood return.
• If not return notify the provider.
• Chest X ray results can be reviwed.
• You would follow agenct policy regarding the installation of antithrobolytic therapy and obtain venous access by another means.
• Note if mary has any discomfort or pain at the insertion site or in the shoulders,neck or arm.