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:
50 yo Caucasian woman. Confirmation of breast cancer to initiate treatment. Also we know that
Healthy no previous medical history it had spread.
1 year ago small palpable lump in her right breast
Last month noted the lump is getting bigger
Mammogram 5cm mass
Cancer cells in tumor
1cm tumor in her lumbar spine
VAD will be placed this afternoon for chemo
RELEVANT Data from Social History: Clinical Significance:
4 children under 17 She is taking care of her children so this could be relevant emotionally.
No history of breast cancer in family Need to make sure her religion is taken into consideration in her care.
Does not smoke
Lives with husband
Part time as a teacher
Religious
Husband lost his job

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: Venous access device will help the chemotherapy drug to be pumped all over the patient’s body.
This gives us access so that we will not have to poke the patient every time.

Chemotherapy: How chemotherapy works. Chemotherapy is given via IV and it targets cells that divide quickly.
Such as cancer cells and kills the cells. Since it is a systemic treatment, some healthy cells are affected such as hair,
bone marrow, and intestines.
 Expected side effects: Chemotherapy’s possible side effects are as follows: aches, pains, nausea and vomiting,
diarrhea, and the dreaded hair loss. You could also have some mouth sores and loss of appetite, taste, smell.

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with Jan?

Teach back method. Or have her repeat what you say or ask questions to see her level of understanding.
 Caring and the “Art” of Nursing
1. What is Jan likely experiencing/feeling right now in this situation?
Jan is probably anxious and sad. She just heard a heart-breaking news. She has kids that are not old enough and she
is probably worrying about them and she is also most likely thinking of the worst possible outcome.
2. What can you do to engage yourself with Jan’s experience, and show that she matters to you as a person?
I will be there to tell her and teach her all about the possible interventions that we could have for her to help her
and her family get through this tough time. Give her time and yourself whenever she needs somebody there with
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 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: 101.5 F Fever after the start of chemo is a huge red flag.
P:110 Elevated HR could indicate lack of fluids.
BP: 96/40 BP and orthostatic BP leaning towards lack of fluids
Pain 5/10 sharp ache in mouth. Side effect of chemotherapy.
 Current Assessment:
GENERAL Appears weak and uncomfortable with frequent facial grimacing, constantly repositioning,
APPEARANCE: 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:
Weak and uncomfortable Signs of dehydration
Pale Painful urination and dark urine sign of UTI. Need to be checked.
Feels lightheaded when she stands up Mouth sores could be side effect of chemotherapy.
Oral mucosa tacky dry, severe nausea/dry Paleness could also be caused by the chemo, suspect anemia.
heaves
Painful and frequency urination urine
clear/dark amber
Small blisters/ulcers <1cm present on
tongue and inner aspect of both lips

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 Pneumonia and cancer spread to the lungs could be nullified.
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.

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 They are all low because of chemo. Chemo Worsening
Hgb destroys cells in your body and it is not
Platelets selective. This is significant because patient
Neutrophils would be susceptible to infections and minor
infections can be severe.
 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 WNL 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 BUN and creatinine sign of kidneys are not functioning
Potassium properly.
Glucose Glucose and calcium being high are side effects of chemo.
Calcium Potassium being low is another verification of dehydration
BUN Sodium and potassium being inconsistent could be an
Creatinine indication of kidney problems

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:

Lactate Will show signs of sepsis 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 Low
WBC’s (<5) 58 WNL
Bacteria (neg) Neg WNL
Epithelial (neg) Neg WNL
 What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
Bacteria Bacteria and epithelial is negative so there is no major signs of UTI.
Epithelial Presence of LET and Nitrite are signs that the kidneys are not functioning properly.
Nitrite
LET

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
WBC 4.5 – 11 mm Patient is losing WBC Assess closely for any change in temperature. Assess closely
from chemo. Susceptible for hypotension.
to infections
Value: Critical Value:
0.5
<2.5 or >15

Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:

Neutrophils 2.5-7.5 /L Susceptibility to Assess closely for any change in temperature. Assess closely
infections. Neutropenia for hypotension.
Value: Critical Value:
0.5 Too High:
<7.5
Too Low:
<.5

Clinical Reasoning Begins…

1. What is the primary problem(s) that Jan is most likely presenting with?
Breast cancer
2. What is the underlying cause/pathophysiology of this primary problem?

Cancer growth, overgrowth of cells.

Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV Administration of medications and IV access IV establishment

0.9% NS 1000 mL IV bolus For dehydration and fluid replacement Rehydration will be better. Ortho
x 2 liters BP will be normal.

Orthostatic BP To monitor her hydration level Normal ortho BP

Vancomycin 1000 mg IVPB Possible infection, help prevent infection because of her Get rid of infection or prevent
Every 24 hours low WBC and neutrophil count infection

Ondansetron 4 mg IV every For nausea and vomiting. Preventing from chemo No nausea or vomiting
4 hours prn

Acetaminophen 650 mg PO
Fever and pain Decrease pain
every 4 hours

Hydromorphone 0.5–1
Treatment for pain Decrease pain
mg IV push every 4 hours
prn

Avoid infections No infections

Neutropenic precautions

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:
1. Vancomycin 1000 mg Establish IV Establish IV site asap for medication intervention
IVPB Every 24 hours NS 1000 mL IV administration
2. Ondansetron 4 mg IV Vancomycin Fluids needs to be replaced asap for better medication
every 4 hours prn Acetaminophen metabolism
3. Acetaminophen (Tylenol) Ondansetron Fight and prevent infection
650 mg every 4 hours Hydromorphone Fever needs to be controlled
4. Hydromorphone 0.5–1 Neutropenic precautions Prevent nausea and vomiting caused by chemo
mg IV Pain relief from chemo
5. Neutropenic precautions Avoid infection
6. Establish peripheral IV
7.0.9% NS 1000 mL IV
bolus x2
 Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Infection control. Getting the patient stable and treating chemo therapy side effects.

4. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:
Monitor patient Monitoring the patient will help us evaluate No infections.
her and make sure everything is going
Administer medications per providers orders according to plan. That no infection happens
behind our backs.
Asepsis techniques
Help prevent infections. Since she is
susceptible, we need to make sure we take
proper precautions

5. What body system(s) will you assess most thoroughly based on the primary/priority concern?
Cardiovascular, endocrine, urinary system

6. What is the worst possible/most likely complication to anticipate?

Sepsis or chemotherapy complications

7. What nursing assessments will identify this complication EARLY if it develops?

Monitoring cardiovascular function and monitoring patient vitals and physical assessment

8. What nursing interventions will you initiate if this complication develops?

Let the provider know. Administer intervention per provider’s orders.

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Education about chemotherapy. Education about infection susceptibility.

10. How can the nurse address these psychosocial needs?

Teaching.
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:
Safely Administer:
Ondansetron Prevents nausea and 15-30 minutes IV infusion Report persistent vomiting. Monitor EKG in
vomiting patients with electrolyte abnormalities.
4 mg IV IV Push: Assess mental status.
4mg/2 mL vial Volume every 15 sec?
2-5 minutes

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:

Safely Administer:
Vancomycin Bactericidal Avoid other ototoxic, nephrotic medications
if possible. Monitor serum functions test,
1000 mg IVPB Hourly rate to set IV I&O. continue therapy for full length of
pump? treatment.
60 minutes or longer
(30 minutes for each
500 mg)

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% Timing: Persistent
room air (RA)

Current
Assessment:
GENERAL Resting comfortably, appears in no acute distress
APPEARANCE:
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 shinier, 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
 1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
All of her vitals Her vitals are showing improvement and stability.
Pain in her mouth of 1/10 is just a side effect of her treatment

RELEVANT Assessment Data: Clinical Significance:

All of physical assessment This is significant because we can see the treatment working and she is getting
better. Goals are being met.
Blisters in her mouth is due to side effect of chemo.

2. Has the status improved or not as expected to this point?

improved

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
No. Continue monitor patient and provide interventions as needed.

4. Based on your current evaluation, what are your nursing priorities and plan of care?

Monitor patient.
Administer intervention per provider’s orders.
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 yo

BRIEF summary of primary problem: Breast cancer

Background:
Primary problem/diagnosis:

Breast cancer

No relevant past medical history

RELEVANT past medical history:

Patient is married with kids. Family is supportive of her treatment. Patient has religious preference.

RELEVANT background data:

Assessment:
Vital signs:
T: 99.8 F, P:98, R:20, BP: 108/60, O2 stat 98%.
RELEVANT body system nursing assessment data:
Blisters in her mouth due to chemo. Everything WNL.
RELEVANT lab values:
Bacteria, Epithelial, Nitrite, and LET

How have you advanced the plan of care? Patient Response?

Yes, patient is now stable and showing signs of improvement

INTERPRETATION of current clinical status (stable/unstable/worsening):

Stable.
Recommendation:
Suggestions to advance plan of care: Continue to monitor patient for signs of infection. Monitor patient’s
assessment and VS. Continue current plan of interventions per provider’s orders.
 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?

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 from this scenario the seriousness of not being checked regularly for possible cancer or other illnesses. I
learned the side effects of chemo, such as the susceptibility to infections because of it’s effect in our immune
system.

2. How can I use what has been learned from this scenario to improve patient care in the future?
I can use what I learned to better care for future patients that will be going through the same thing such as cancer and chemo.
I will be able to educate and relate this scenario to theirs and have better patient interaction.