Answer KEY Breast Cancer- Skinny Reasoning PDF

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Download Answer KEY Breast Cancer- Skinny Reasoning PDF

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Breast Cancer/Complications of Chemotherapy

SKINNY Reasoning

Jan Leisner, 50 years old

Primary Concept Infection Interrelated Concepts (In order of emphasis)  Fluid and Electrolyte Balance  Cellular Regulation  Immunity  Stress  Clinical Judgment NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies  Reduction of Risk Potential  Physiological Adaptation © 2018 Keith Rischer/www.KeithRN.com

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

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6-12% 12-18% 9-15% 11-17%

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Jan Leisner is a 50-year-old Caucasian woman who has been healthy with no previous medical history. One year ago, she noted a small palpable lump in her right breast about the size of an almond. Because she has been healthy, she assumed it was nothing and ignored it. Over the last month she has noted that this lump has been increasing in size. Her mammogram confirmed a 5 cm mass. An ultrasound biopsy confirmed the presence of cancer cells in the tumor as well as in three of her lymph nodes most proximal to the tumor. An MRI scan that followed revealed a 1 cm tumor on her lumbar spine. She is not a surgical candidate at this time, so an implanted venous access device (VAD) will be placed later this afternoon so that chemotherapy can be started as soon as possible. You are the nurse responsible for her care on the oncology unit of a community hospital.

Personal/Social History: Jan has four children under the age of 17. She has no personal or family history of breast cancer. She has never smoked and lives with her husband in a suburban community. She works part-time as a substitute teacher. Jan is a devout Christian who has a strong faith and trust in God. She also believes in the power of prayer and believes that God can heal her. She chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: One year ago she noted a small palpable lump Any lump in the breast area has the potential to be cancerous and in her right breast about the size of an almond. needs to be followed up. The majority of breast masses are benign, 10% are cancerous…Irregular fixed masses are suspicious for malignancy [Epocrates, 2015]. Over the last month she has noted that this lump has been increasing in size. Her mammogram confirmed a 5 cm mass.

A rapidly growing lump is a clinical RED FLAG, a cause for concern, and must not be ignored! Though denial is a common coping mechanism, in this context it could be deadly!

This biopsy confirmed the presence of cancer cells in the tumor as well as in three of her lymph nodes most proximal to the tumor.

Cancer that has progressed to lymph nodes is a clinical RED FLAG that increases the likelihood of metastasis. Finding cancer cells in the lymph nodes is stage III because of their close proximity to the primary tumor.

The MRI scan revealed a 1 cm tumor on her lumbar spine.

Metastasis from the primary site to a distant location meets the criteria for stage IV. This is the worst possible staging and makes this a terminal diagnosis. Clinical Significance: She is a mother with children whom she wants to see grow up. This complicates this scenario for both Jan and the nurse. The stakes are high, but the nurse can make a difference by choosing to ENGAGE in her experience and make the “art” of nursing a priority to support her holistically.

RELEVANT Data from Social History: Jan has 4 children under the age of 17.

Jan is a Christian who has a strong faith and trust in God who also believes in the power of prayer and believes that God can heal her.

© 2018 Keith Rischer/www.KeithRN.com

With any serious illness, but especially a terminal illness such as cancer, to provide true holistic care, the nurse must be willing to gently “go there” when appropriate and establish a trust relationship. I have found that any one of the following spiritual assessment questions can guide the nurse to support this patient’s spiritual needs:  “What is your source of strength, peace, and hope in this illness?

   She chose to have a mammogram before her husband’s insurance plan expired because he just lost his job.

“Are you connected with a faith community?” “How has this illness affected your faith?” “What can I do to support your faith?”

A lack of insurance also complicates this scenario! Social services must be consulted to see what state/federal health programs for which she may be eligible.

Five Weeks Later… Jan is promptly started on chemotherapy of Cytoxan and Adriamycin every three weeks for the next three months. Two weeks after her first chemotherapy treatment she experiences persistent nausea and vomiting, and has been unable to keep anything down the past 24 hours. She has fatigue so severe she has been unable to move off the couch for the past three days, and has experienced night sweats with a fever last night. After contacting her oncologist, he arranges to have Jan admitted directly to the med/surg floor where you will be the nurse responsible for her care.

Patient Care Begins: Current VS: T: 101.5 F/38.6 C (oral) P: 110 (regular) R: 20 BP: 96/40 O2 sat: 98% room air

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Eating/nothing Sharp, ache Quality: Mouth/tongue Region/Radiation: 5/10 Severity: Persistent the past 3 days Timing:

Orthostatic BP’s: Position: Lying Standing

HR: BP: 110 96/40 136 82/42

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: T: 101.5 F/38.6 C (oral)

Clinical Significance: Fever in the context of likely neutropenia after chemotherapy has been started is a clinical RED FLAG! Further lab tests are needed to identify the source. The nurse will need to situate this knowledge to identify and anticipate current care priorities.

P: 110 (regular)

WHY is her heart rate elevated? Elevated HR could reflect increased metabolic needs driven by fever; she likely has an infection. This has a RELATIONSHIP to fluid volume deficit that will also cause tachycardia. Bring back pathology….CO=SVxHR and explain why this must be understood and situated to clinical practice. The heart rate elevates to maintain adequate cardiac output and compensate for fluid volume deficit of any kind.

BP: 96/40

We do not have a current baseline to TREND, but any systolic BP (SBP)...