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NURS220 Concept 10 : Cellular Regulation Case Study

Diane is a married 45-year-old woman with four children who works part-time as a clerk. She is
58 and weighs 135 lbs. She has insurance through her husbands employer. She has never
smoked and has an occasional social drink. She has a PMH of breast augmentation in August,
2013. When she returned for her follow-up appointment, a 2.2 cm lump was discovered in her
right breast. When the biopsy was found to have cancer cells, she elected to have a lumpectomy
and axillary lymph node dissection. The pathology report found that some lymph nodes were
positive for cancer cells. She is scheduled for chemotherapy and radiation therapy. Her current
diagnosis is: infiltrating ductal carcinoma, stage T2, N1, M0, estrogen receptor (ER) 3+,
progresterone receptor (PR) negative and Her2-neu 3+.

1. What does T2, N1, M0 mean? Is this staging or grading the disease of cancer?
The tumor, node, metastasis system is a staging system developed by the American Joint
Committee on Cancer to describe the general anatomic extent of solid tumor-type cancers
(Ignatavicius & Workman, 2013). T represents the primary tumor, T2 is described as a
tumor >20mm but 50 mm in greatest dimension. N represents the regional lymph
nodes, N1 meaning metastasis to movable ipsilateral level I, II axillary lymph node(s).
M represents distant metastasis, M0 meaning there is no clinical or radiographic
evidence of distant metastasis. (Copstead & Banasik, 2013)
2. What does estrogen receptor (ER) 3+; progesterone receptor (PR) negative; and Her2-neu
positive at 1+ mean? Are these good (positive) or bad (negative) indicators for treating
the cancer?
ER 3+ means that the breast cancer cells have binding sites for the hormone estrogen and
are considered hormone receptor-positive, or sensitive. If the cancer is hormone sensitive,
it will respond to hormone therapy, (which is a positive indicator) in this case, tamoxifena medication that competes for estrogen binding sites to slow the growth of tumor. Breast
cancer cells that are PR negative, lack the receptor for progesterone and cannot be treated
by hormone therapy. However, since the cancer is ER +, hormone treatment is the same.
HER2-neu is a growth-promoting protein that appears on the surface of some breast
cancer cells. Having too many HER2 receptors may make the cancer cells grow and
divide faster and this type of cancer is considered aggressive because it grows and
spreads quickly (Simon, 2013). Immunohistochemistry is a test to determine HER2-neu

overexpression and is reported as a score of 0, 1+, 2+ and 3+. A score of 1+ implies very
little bound antibody and therefore, likely very small amount of HER2/neu, (Maltzman,
2003) or no excess of the gene to cause overexpression, which is a positive indicator.
3. Diane asks the nurse what her chances of survival are. Please provide 3-4 sentences (or
questions) that are appropriate for a response.
Each individuals prognosis can vary greatly based on a number of factors including age,
general health, the stage and grade of the cancer and their response to treatments being
used, such as chemotherapy and radiation. I would encourage you to talk to your
oncologist about any questions you may be having as he/she knows the most about your
cancer and your appropriate treatmentsThis must all be very difficult for you. Please
tell me more about how youre feeling.
4.

Diane is scheduled for six cycles of combination chemotherapy including doxorubicin


(Adriamycin), Docetaxol, and Fluorouracil (5-FU). What should the nurse prepare Diane
for with respect to this medication combination? (i.e. what are the most common side
effects)
Doxorubicin inhibits DNA and RNS synthesis by forming a complex with DNA. Its
action is cell-cycle S-phase specific. Docetaxol interferes with normal cellular
microtubule function required for interphase and mitosis, causing death of the cell.
Fluorouracil inhibits DNA and RNA synthesis by preventing thymidine production. The
most common side effects of all these medications, and things that the nurse should
prepare Diane for are diarrhea, nausea, vomiting, fatigue, weakness, alopecia, anemia,
leukopenia, and thrombocytopenia. (Vallerand, Sanoski, & Deglin, 2013) The nurse can
warn Diane about the nausea and vomiting and about administering an antiemetic to help
relieve the symptoms. The nurse should advise Diane that if she experiences leukopenia
and thrombocytopenia, she will be at an increased risk for infection and/or bleeding,
respectively, and should notify the doctor is she experiences any signs of infection, such
as sore throat or fever. She can have scheduled periods of rest if she has any fatigue or
weakness.

5.

How will the chemotherapy likely be administered? Please describe this apparatus as if
teaching the patient in 3-5 sentences.
You will be receiving combination chemotherapy and the doses will be calculated
according to your height and weight. The drugs will most likely be administered

intravenously through a central venous catheter (CVC) or portacath. The CVC can remain
in place for many months and will be used for each chemotherapy treatment. The long,
flexible, plastic line is inserted through a vein in your neck or through your chest and
ends up in the superior vena cava, a vein close to your heart. You wont have to be poked
each time you need treatment and you can move about normally. The line can also be
used to take blood for tests. (Cancer Research UK, 2013)
6. Cite five specific assessments that should occur between or after chemotherapy cycles.
Between chemotherapy cycles, the nurse should do a total patient assessment, including
vital signs, skin and mucous membrane assessment, lung sounds, mouth assessment and
venous access insertion sites to monitor for infection. During chemotherapy, the nurse
should closely assess and monitor the catheter site for infiltration or extravasation. Many
of the chemotherapy drugs are vesicants and when infiltrated can cause the patient pain,
infection and tissue loss. (Ignatavicius & Workman, 2013)
7. Following chemotherapy, Diane will undergo external beam radiation therapy to the right
chest and axillary area. Describe this form of radiotherapy and select two areas of
teaching providing 3-4 sentences for each topic for Diane.
A machine called a linear accelerator, delivers either a single or several beams of highenergy x-rays to the tumors, from outside of the patient. The beams are targeted at the
tumor site and deposits the x-ray dose to the tumor, destroying the cancer cells, while
sparing the surrounding tissues (Radiologyinfo.org, 2014). This type of treatment is
considered local treatment and is delivered over a period of 5-6 weeks (Ignatavicius &
Workman, 2013).
Preparation: When the exact location of the tumor is determined, the patient must always
be in the same exact position for each treatment. Position fixing devices and permanent
markings and outlines on the skin ensure proper position each time. The patient should
not remove any ink markings when cleaning the skin until the entire radiation course is
completed.
Side Effects: Skin changes are the main side effect of radiation therapy. The patient
should wash and rinse the irradiated area gently each day with either water or a mild soap
and use her hand rather than a washcloth. Wear soft clothing and use only lotions or
powders that are prescribed by the radiation oncologist. The patient should avoid

exposure of the irradiated area to the sun and heat exposure (Ignatavicius & Workman,
2013).
8. Cite five HCWs that would be beneficial for Dianes care (in and out of the hospital).
Include their role in supporting her care and lifestyle.
Case Manager- Possibly a nurse case manager who directs and oversees the patients care
through her diagnosis, treatment and recovery of cancer. The case manager can also help
to work with the insurance company and refer the patient to outside cancer resources and
support sources. (Cancer.org, 2014)
Dietician- A dietician will work with Diane during and after her cancer treatment to help
her maintain energy, keep from becoming malnourished and stay healthy. Her diet should
include at least 8 glasses of water, moderate sized portions of lean, protein rich and fiberrich foods. She should also avoid skipping meals and eat small, regularly spaced meals
throughout the day. (Thomson & Dyer, 2014)
Dosimetrist- works with the radiation team to generate dose distributions and calculations
for radiation treatment. He/She will come with a treatment plan to determine which
technique with deliver the prescribed radiation dose prescribed by the radiation
oncologist. (American Association of Medical Dosimetrists, 2014)
Radiation oncologist- medical doctor who uses and oversees radiation therapy to treat
cancers. The radiation oncologist along with the rest of her cancer team will coordinate
the best care and treatment for Diane. (Cancer.org, 2014)
Genetic counselor- a specially trained health professional who helps people understand
their risks of genetic disorders within a family and whether they should have genetic
testing done. Diane has an 18-year old daughter who might consider genetic testing
because having a first-degree relative (her mother) increases the risk for the disease.
(Cancer.org, 2014)

9. Dianes daughter (age 18) begs the nurse for information about her moms health. Can
the nurse offer this information to the daughter? Please explain why or why not this can
occur.
If Diane makes it clear, or signs a consent allowing the medical team to communicate
with her family regarding her medical care, then the nurse may share only what they need
to know about Dianes care. However, if Diane objects, the nurse is not allowed to share
private health information and is mandated by law to protect the privacy of her patient

according to the Health Insurance Portability and Accountability Act of 1996 (Cherry &
Jacob, 2014).

References
American Association of Medical Dosimetrists. (2014). What is a Medical Dosimetrist?
Retrieved from Medical Dosimetry.org:
http://www.medicaldosimetry.org/generalinformation/medical_dosimetrist.cfm
Cancer Research UK. (2013). Intravenous Chemotherapy. Retrieved from Cancer Research UK:
http://www.cancerresearchuk.org/about-cancer/cancers-ingeneral/treatment/chemotherapy/having/iv-chemotherapy#central
Cancer.org. (2014). Health Professionals Associated with Cancer Care. Retrieved from
www.cancer.org:
http://www.cancer.org/treatment/findingandpayingfortreatment/choosingyourtreatmenttea
m/health-professionals-associated-with-cancer-care
Cherry, B., & Jacob, S. R. (2014). Contemporary Nursing. St. Louis: Elsevier.
Copstead, L.-E., & Banasik, J. (2013). Pathophysiology. St. Louis: Elsevier.
Ignatavicius, D., & Workman, M. (2013). Medical-Surgical Nursing. St. Louis: Elsevier.
Maltzman, J. (2003). Her-2/neu significance: science in action part 1. Abramson Cancer Center
of the University of Pennsylvania.
Radiologyinfo.org. (2014). External Beam Therapy. Retrieved from Radiologyinfo.org:
http://www.radiologyinfo.org/en/info.cfm?pg=ebt#part_two
Simon, H. (2013). Breast Cancer. Retrieved from New York Times:
http://www.nytimes.com/health/guides/disease/breast-cancer/prognosis.html

Thomson, C., & Dyer, D. (2014). Nutrition. Retrieved from Breastcancer.org:


http://www.breastcancer.org/tips/nutrition
Vallerand, A., Sanoski, C., & Deglin, J. (2013). Davis's Drug Guide. Philadelphia: F.A. Davis
Company.

Oncology Case Study Rubric

SLO (based on
course/program
SLOs)
1. Ethical/legal
practice

3. Evidenced-based
practice

5. Collaboration

7. Client-centered
care

Met - 2 points

Partially met - 1 point

Did not meet - 0 points

Carefully considered legal


dilemma as presented to the
nurse. Considered clients
perspective
Located information from 3
or more current sources and
incorporated into document.
Cited in references.

Partially considered
legal components

Did not consider legal


component.

Located information
from 1-2 current sources
or did not incorporate
into document or did
not cite.
Identified more than one
HCP that could assist in
optimizing care for the
client or did not
correctly identify HCP
role.
Partially completed all
items reflecting
Oncology care found in
required resources.
Partially considered
clients age, medical
history, and living
conditions in planning
care.
Partially demonstrated
therapeutic
communication in case
study
Partially identified and
applied cancer
classification systems or
the application of
chemo- and
radiotherapy in care of
the client.
Mostly used correct
grammar and medical
terminology. Mostly
correct APA format.

Did not locate current


source.

Identified five HCPs that


could assist in optimizing
care for the client. Correctly
identified their role in her
care. Demonstrated
thoughtful planning.
Completed all items
reflecting Oncology care
found in required resources.
Considered clients age,
medical history, and living
conditions in planning care.

8. Therapeutic
communication

Fully demonstrated
therapeutic communication
in case study

9. Planning to
provide safe,
quality care

Identified and applied TNM


system and other means to
identify cancer cell type.
Thoroughly reviewed
chemo- and radiotherapy in
care of the client.

Correct writing
using APA format

Wrote using correct


grammar and medical
terminology. Cited using
proper APA format.

Identified only one


HCP that could assist in
optimizing care for the
client.

Did not consider


Oncology care found in
required resources or
clients age, medical
history, and living
conditions in planning
care.

Did not consistently


demonstrate therapeutic
communication in case
study.
Did not identify or
apply cancer
classification systems or
the application of
chemo- and
radiotherapy in care of
the client
Many grammatical or
medical terminology
items. Many errors with
APA format.