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Running head: BREAST CANCER

A Patient with Breast Cancer: Complications and Co-morbidities Sarah Firmin University of North Florida

BREAST CANCER 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 peripheral neuropathy. This has impacted her recovery; F.T. has cuts on her foot from an unknown origin and has increased difficulty with ambulation. F.T. has hypertension and takes medication in order to control her symptoms. Her risk factors for hypertension include obesity, diabetes, race, and age (LeMone, Burke, & Bauldoff,

2011). Close monitoring of hypertension in the patient after a bilateral mastectomy is imperative due to impaired healing ability, which is a resulting factor from increased vascular resistance. Hypertension and diabetes were contributing factors to a cerebral vascular accident which occurred in 2009. She has residual right-sided weakness due to that event. Pathophysiology of Breast Cancer and Contributing Comorbidities

BREAST CANCER 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, 2012). Found on chromosome 17, this gene is responsible for the assembly of growth factor receptors. The growth factor receptors are located on the cell membranes and react to specific growth factors which instruct the cell to multiply. Cells affected by HER-2 produce more growth factor receptors, and therefore attach to more circulating growth factor. This causes the cells to rapidly multiply, creating breast tumors (Crowley, 2012). The proliferation of the cancerous cells takes place either in the mammary ducts or the mammary lobules, and the tumor may remain in the ducts or lobules for an extended period of time (LeMone, Burke, & Bauldoff, 2011). Often forming within the mass of multiplying tumor

BREAST CANCER 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 have a change of position, there may be a rash or flaking around the nipple and it may excrete an abnormal discharge (LeMone, Burke, & Bauldoff, 2011). Type 2 DM Type 2 DM is a metabolic disorder defined as the state of fasting hyperglycemia even though there is sufficient insulin inside of the body; the normal fasting plasma glucose level is a value less than 126 mg/dl (LeMone, Burke, & Bauldoff, 2011). When glucose enters the body by eating carbohydrates or by drinking sweetened drinks, it goes into the bloodstream. A function of insulin is to transport glucose across the cell membrane out of the blood. Beta cells

BREAST CANCER 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 is having family members with the condition; F.T. has a brother with type 2 DM. Being a minority in America places F.T. at a higher risk of type 2 DM as well. Additionally, having the comorbid factor of hypertension increases the likelihood of having type 2 DM. Hypertension Blood pressure is the result of several different mechanisms in the body reacting to internal and external stimuli, which then lowers or raises the pressure the blood exerts upon the vessels. Normal blood pressure exists when the systolic blood pressure is less than 120 mm Hg and the diastolic pressure is less than 80 mm Hg (Brashers, 2008). Prehypertension is a systolic

BREAST CANCER

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-angiotensinaldosterone 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 process involves increasing the size of the cardiac and vascular tissue cells and initiating scarring of the tissues (Brashers, 2008). Once remodeled, the tissue cannot revert to the prior state, resulting in an irreversible increase in systemic vascular resistance (LeMone, Burke, & Bauldoff, 2011). Often referred to as the system of fight-or-flight, the sympathetic nervous system (SNS) also impacts blood pressure (LeMone, Burke, & Bauldoff, 2011). The actions of the SNS stimulate and excite tissue. When the SNS is activated, fibers descending from preganglionic neurons stimulate neuroreceptor activity, which is responsible for regulating vasomotor tone

BREAST CANCER (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 (Brashers, 2008). The increase in sodium causes an increase in blood volume, which leads to increased blood pressure. Inflammation also impacts blood pressure. When tissues are injured, cytokines are released and cause vasodilation. While this action is needed to promote healing after injury, chronic injury and inflammation leads to ventricular remodeling (Brashers, 2008). Chronic inflammation also leads to a reduction in vasodilators and an increase in vasoconstrictors (Brashers, 2008).

BREAST CANCER 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, and the heart rate was 98 beats per minute while at rest. Her oxygen saturation rate was 94%, temperature was 99.0 degrees, and she had a blood pressure of 190/74 mm Hg. Her skin was dry, pale, ashy, and warm. The patient had two cuts on her right foot near the great toe. She had a wound on each breast from incisions made during her double mastectomy. The wounds held Jackson-Pratt (JP) drains. The dressings around the JP drains were clean, dry, and intact. The patient had a blister on her buttock, which measured approximately inch across. Her head position was midline and erect, and the trachea and neck muscles appeared symmetrical. The lymph nodes were not tender to palpation and did not appear swollen. Her

BREAST CANCER 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 90 degrees to the sides and forward. She was able to move her legs in a full range of motion (bend, raise, abduct, and adduct) without gravity. She had a full range of motion in fingers, and she performed slight up and down movements in her toes. She is non-weight bearing, and selfreported this as a new symptom beginning August 28, 2012. Cranial nerves 2-12 were tested and were intact. The patient was able to demonstrate coordination skills by performing finger opposition and by successfully performing the finger to finger test. She showed abstract thinking by explaining a metaphor. She was fully alert and has

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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 which found moderate left and right pleural effusions with bilateral atelectasis. There were no retroperitoneal masses or adenopathies. Images of the pelvis showed a moderate amount of free fluid in the pelvis, and a large amount of stool in the rectum. Laboratory data concerning blood chemistry, hematology, and glucose is displayed in Tables 1, 2, and 3, respectively. Low values are noted as (L), and high values are identified as (H). Table 1 Blood Chemistry Analysis August 26, 2012 Metabolic chemistry and Value

BREAST CANCER liver function tests Na K Cl CO2 Anion Gap Glucose BUN Creatine GFR BUN/Creatine CA Osmolality Calculated Total Protein Albumin AST ALK Phosphatase ALT Billi Total 146 (H) 4.1 112 (H) 29 5 123 (H) 9 0.97 <60 9 8.6 291 6.2 1.6 (L) 34 108 21 0.4

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Table 2 Hematology August 26, 2012 Blood component Value

BREAST CANCER WBC RBC HGB HCT MCV MCH MCHC RDW PLT NEUT % LYMPH % MONO % EOS % BASO % NEUT # LYMPH # MONO # EOS # BASO # 7.7 3.09 (L) 7.9 (L) 25.6 (L) 82.8 25.6 (L) 30.9 (L) 18.4 (H) 316 69.4 18.4 9.5 2.6 0.1 4.9 1.3 0.7 0.2 0.0

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Table 3 Glucose testing at the bedside Date and time Value

BREAST CANCER August 27, 2012 at 0348 August 27, 2012 at 0702 August 27, 2012 at 1126 August 27, 2012 at 1639 August 27, 2012 at 2024 August 28, 2012 at 0038 August 28, 2012 at 0247 102 107 176 (H) 122 (H) 234 (H) 162 (H) 134 (H)

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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 has many obstacles to overcome. Plans for future treatment include wound care and the implementation of techniques which promote wound healing. She requires continual monitoring for signs of sepsis, and needs encouragement to obtain adequate nutrition. She needs appointments with physical therapy in order to increase strength and confidence during ambulation. Detailed patient goals and outcomes are listed in Appendix B.

BREAST CANCER 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

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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 Journal, 38(3), 263-265.

Running head: BREAST CANCER

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Appendix A Medication Worksheet Patient Initials F.T. Date Seen August 27, 2012

MEDICATION NAME & CLASSIFICATION

DOSE, TIME, FREQUENCY & ROUTE

MECHANISM OF ACTION

MAJOR & COMMON SIDE EFFECTS

RATIONALE FOR THIS CLIENT

NURSING CONSIDERATIONS

Heparin Sodium 5000U Every 12 hours Anticoagulant 0900, 2100 Subcutaneous

Hydralazine HCL (Apresoline) Antihypertensive Vasodilator

25mg Every 8 hours 0600, 1400, 2200 Oral

Potentiates inhibitory effect of antithrombin on factor Xa and thrombin. Prevents the conversion of prothrombin to thrombin by its effects on factor Xa. Direct- acting peripheral arteriolar vasodilator which lowers blood pressure in hypertensive patients.

Anemia, thrombocytopenia, bleeding.

Patient is spending the majority of her days and nights in bed. This medication will help to prevent blood clots from forming.

Consistently assess for signs of bleeding and hemorrhage (bleeding gums, nose bleeds, black tarry stools, a fall in hematocrit or blood pressure).

Evaluation of Medication Effects Medication is having desired effect. Patient ptt is 2. Patient does not show signs of complications.

Tachycardia, sodium retention, drug induced lupus syndrome.

Patient has hypertension. This medication aids in controlling symptoms.

Monitor blood pressure and pulse frequently during therapy; note any changes. Monitor electrolytes

Blood pressure at 0735 was 197/77. 0900 blood pressure 190/74. 0600 medication was not given until 0900 due to nurse error. Blood pressure at 1000 was

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16 166/84. Medication administration had positive effect, however patient remained hypertensive. Patient lab value of sodium high (146). This is a possible side effect of the medication. Patient plan is to increase fluids to lower the value. No other side effects. Drug administration has desired effect, although blood glucose level remains high. On August 27, 2012 at 2024, the level was 234. Medication

Insulin Detemir (Levemir) Antidiabetics Hormones Pancreatics

4units 1x daily Bedtime Subcutaneous

Lower glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Onset: 3-4

Hypoglycemia, anaphylaxis

This medication is indicated for patients who have type 2 DM, which this patient has.

Assessment of symptoms for hypoglycemia, and hyperglycemia. Monitor weight periodically. May cause decrease in phosphate, magnesium, and potassium

BREAST CANCER hours. Peak: 3-14 hours. Duration: 24 hours. levels. Monitor glucose four times daily, and more commonly during stress.

17 was administered, and the level was checked again on August 28, 2012 at 0038. The level had fallen to 162. By 0237, the level had dropped further to 154. Patient does not experience negative side effect from medication. Patient needed 4u before breakfast on August 27, 2012 when blood glucose was 177. Patient does not have any adverse side effects, and the medication has a positive effect on overall health.

Insulin lispro (Humalog) Antidiabetic Hormones Pancreatics

Sliding Scale: Blood sugar <150: no coverage 151-200: 4u 201-250: 6u 251-300: 8u 301-350: 11u BS>350: call endocrinologist After meals and 1600 Subcutaneous

Lower glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Onset: 15-30 minutes. Peak: 2-8 hours.

Hypoglycemia, anaphylaxis

Controls insulin in patients with type one diabetes or type 2 DM. Patient has type 2 DM.

Assessment of symptoms for hypoglycemia, and hyperglycemia. Monitor weight periodically. May cause decrease in phosphate, magnesium, and potassium levels. Monitor glucose four times daily, and

BREAST CANCER Duration: 24 hours. Morphine Opioid analgesics Opioid agonist 2mg Every 4 hours as needed IV Binds to opiate receptors in the CNS. Alters the perception of and response to pain. Produces generalized CNS depression. Confusion, sedation, hypotension, constipation, respiratory depression. Patient has severe pain associated with her double mastectomy and infection. more commonly during stress. Use a pain scale before and after administration to quantify patient pain. Assess: level of consciousness, blood pressure, pulse, and respirations before, during, and after administration. Assess geriatric patient more frequently; this group is more susceptible to effects of opioids.

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Gabapentin (Neurontin) Analgesic adjunct

100mg 1x daily 0900 Oral

Mechanism of action not known. May affect the transport of amino acids

Confusion, depression, drowsiness, ataxia, paresthesia, facial edema.

An unlabeled use of this medication is for the relief of chronic pain. Patient has

Assess location, duration, and intensity of pain.

Medication has desired effect of lowering pain. Preadministration of medication, patient selfreported pain as a level 8 on a scale from 1 to 10. After an hour, the pain was reassessed and the pain level had dropped to a 5. The patient has constipation which is an adverse side effect of morphine; no other adverse side effects. The patient has diabetes, and due to the diabetes she has peripheral neuropathy.

BREAST CANCER Mood stabilizer across and stabilize the neuronal membranes. chronic pain resulting from peripheral neuropathy.

19 This medication is primarily for the pain associated with that condition. Medication alone does not resolve all of the issues client has in relation to pain, however, when used in conjunction with other pain relief, the patient experiences less pain. Patient needs ongoing monitoring of pain. Medication is having desired effect and patient is not voiding due to stress incontinence. The patient is not taking in

Oxybutynin Chloride (Ditropan) Urinary tract antispasmodic Anticholergenic

5mg 1x daily 0900 Oral

Inhibits the action of acetylcholine at prostganglionic receptors. Has direct spasmolytic action on

Dizziness, drowsiness, constipation, dry mouth, nausea, urinary retention.

Patient has stress urinary incontinence.

Monitor voiding pattern and intake and output ratios, and assess abdomen for distention. In geriatric patients, assess

BREAST CANCER smooth muscle lining the GU tract, without affecting vascular smooth muscle. for sedation and weakness.

20 fluids, creating a low urine output. The patient is experiencing constipation. Patient is taking Colace 100mg daily at bed to counteract this effect. She has not complained of the other adverse effects. This Assess type, The medication medication is location, and has the desired indicated for intensity of pain effect of pain moderate to prior to and 1 relief when severe pain. hour after taken as Patient has pain administration. needed for due to recent Assess blood pain. This double pressure, pulse, medication mastectomy. and respirations requires before and consistent periodically monitoring during concerning administration. pain level. The If respirations patient showed <10 per minute, no sign of assess level of adverse side sedation. effects. This Assess bowel medication,

Oxycodone/ Acetaminophen (Percocet) Opioid Analgesic

5mg Every 4 hours as needed Oral

Binds to opiate receptors in the CNS. Alters response to and perception of painful stimuli, while producing generalized CNS depression.

Confusion, sedation, respiratory depression, constipation, orthostatic hypotension, urinary retention.

BREAST CANCER function regularly. Prevent constipation with increased fluids, fiber, and laxatives.

21 along with Hydralazine HCL, may cause urinary retention. The patient will need to increase fluids from her present intake (very low fluid intake). Input and output monitoring is beneficial in this case. Assess patient Medication is routinely for having the epigastric or desired effect abdominal pain and the patient and for frank or is not occult blood in complaining of stool, emesis, or GERD effects. gastric aspirate. The adverse side effect of hyperglycemia should be noted as a possible contributing factor for the patients present

Pantoprazole (Protonix) Anti-ulcer agent Proton pump inhibitor

40mg 1x daily 9am IV

Binds to an enzyme in the presence of acidic gastric ph, preventing the final transport of hydrogen ions into the gastric lumen.

Headache, abdominal pain, diarrhea, hyperglycemia.

Patient has Gastroesophageal reflux disease (GERD). Pantoprazole treats heartburn symptoms and is indicated for erosive esophagus associated with GERD.

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22 hyperglycemic condition. The patient is not experiencing any other adverse side effects. Patient has hyperlidiemia. I do not have cholesterol values in to evaluate medication effectiveness. LDL, HDL, and triglycerides must be monitored. Patient is not experiencing adverse medication effects.

Rosuvastatin Calcium (Crestor) Lipid lowering agent HMG-CoA reductase

40mg 1x daily Bedtime Oral

Inhibit an enzyme (HMG-CoA reductase), which is responsible for catalyzing an early step in the synthesis of cholesterol.

Abdominal cramps, constipation, diarrhea, flatus, heartburn, rashes, rhabdomyolysis.

Aid in the management of dyslipidemia. Patient has hyperlipidemia.

Monitor liver function tests. May also cause an increase in alkaline phosphatase levels and an increase in bilirubin levels. Monitor patient for muscle tenderness.

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

BREAST CANCER Appendix B

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UNIVERSITY OF NORTH FLORIDA NURSING CARE PLAN FORM


1. Nursing Diagnosis / Related to As Evidenced By: Acute Pain related to post double mastectomy procedure. Page # in Ackley & Ladwig As Evidenced By: 601

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

Objective Patient displays observable pain responses including guarding of the breasts and crying. Respiratory rate 20 and heart rate of 98 beats per minute while at rest.

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1. By the end of the 8 hour shift, patient will use a self-report pain tool 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 is having on the quality of life. Patient was fully assessed at the start of the shift to determine a baseline for pain. She stated that she was in pain; the pain had lasted at least 2 hours, the pain radiated down her chest, and down her sides. She stated that it hurts the most when she moves, and she feels he best when she is laying still with the head of the bed tilted at 30 degrees. Having pillows under each arm, propping the arms up to the level of the chest also alleviates some of the pain.

1a. Determining the characteristic of pain is critical to determining the underlying cause of pain and effectiveness of treatment. Selfreport is considered the single most reliable indicator of pain presence and intensity.

1. Goal met. Patient was able to self-report her pain on a 0-10 numerical pain rating scale. She was also able to verbalize a pain level which would make her more able to achieve activities of daily life.

1b. Assess pain level in patient using a valid and reliable selfreport pain tool, such as the 0-10 numerical pain rating scale. The nurse posed this question to the patient, and explained that 0 signifies no pain, while 10 represents terrible pain. The patient state that she was at a level eight.

1b. Single dimension pain ratings (such as the 0-10 pain scale) are valid and reliable as measures of pain intensity level.

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1c. Ask the client to identify a comfort-function goal for a pain level on a self-report tool that would allow the patient to perform necessary activities easily. Patient stated that if her pain was at or near a level 5, she would be able to perform activities, and would not fear movement as she currently does.

1c. The relationship between pan level and functional goals should be a major focus of the development of the individualized pain management plan. Effective pain relief which allows function and movement is critical for decreasing risk factors for cardiopulmonary and thromboembolic complications after surgery. Immobilization is also a major risk factor for chronic hyperalgesic pain after surgery.

2. By the end of the eight hour shift, the patient will report that a pain management regimen achieves comfort-function goal without adverse effects.

2a. Manage acute pain using a multimodal approach. Patient had orders for Percocet oral 5mg as needed every four hours, Morphine 2mg IV as needed every four hours, and Nuerotin at 0900 daily. The patient complained of pain and was given Percocet at 0550 on Tuesday morning. At 0900, the patient took Neurotin. At 1208 the patient self-reported pain as a level 8 and was given Morphine 2mg IV. Morphine was administered again at 1600.

2a. Multimodal analgesia combines two or more medications from different pharmacological classes that target different mechanisms along the pain pathway. The advantage of this approach is that the lowest effective dose of each drug can be administered, resulting in fewer adverse side effects such as oversedation and respiratory depression.

2. Goal met. At the end of the eight hour shift, the patient did not report any adverse side effects from the pain medications. The patient was educated about the comfortfunction balance, and medications and pain levels will continually need reassessment, at least every four hours.

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2b. Assess pain level, sedation level, and respiratory status at regular intervals during pain management with opioid administration. Assess at least every four hours if patient has been stable without episodes of hypoventilation. Patient vitals were taken and recorded every four hours by the student nurse. Eyes were examined and pupils were equal, round, and reactive to light. Pupil size within normal limits. Respiratory rate remained within normal limits. Patient was tested for orientation to date, time, place, and self every four hours as well and was oriented x4. Pain level changed depending upon the activity level of the patient. Two hours after morphine administration the patient selfreported her pain as a level 4. An hour later when the care team assisted her in moving into the chair by the bed, she stated that her pain was increasing again due to the movement, and self-reported her pain as a 7. Patient was given time to rest and we did not try to move her again for an hour. She was instructed to alert the

2b. All patients receiving opioids or pain management are at risk for sedation that may progress to oversedation and lead to clinically significant opioid-induced respiratory depression.

BREAST CANCER healthcare team if she became dizzy, drowsy, or felt nauseas. 3. By end of eight hour shift, patient will describe nonpharmacological methods that can be used to help achieve comfort-function goal. 3a. Support the patients use of non-pharmacologic methods to help control pain such as the use of distraction, imagery, and relaxation to aid in pain relief. The television was changed from a loud news entertainment program to a calm cooking show. The lights in the room were dimed, and the door to her room was changed from being completely open to be approximately 90% closed. This environment was created in order to provide calm and quiet, and to provide distraction from the pain without creating barriers for relaxation. 3a. Cognitive-behavioral strategies can restore the patients sense of self control, personal efficacy, and can encourage active participation in her own care.

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3b. Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological methods. The nurse and student nurse practiced deep breathing with the patient. The method consisted of a slow, large inhalation, followed by pursed lip exhalation. The patient was educated around moving at her

3b. Nonpharmacological interventions should be used to supplement, not replace, pharmacological methods.

3. Goal met. The patient was able to verbalize how to communicate her needs to the healthcare team. She stated that she felt more comfortable telling the staff when she was feeling poorly. She admitted to feelings of hopelessness, and she cried talking about how she cant get up to use the bathroom. We discussed how feelings of hopelessness can make a person feel physically bad. Recognizing that she can have some control over her environment and practicing coping mechanisms for pain may accelerate her healing process.

BREAST CANCER own speed and to alert caregivers if she is being hurt during an adult brief change. The patient was encouraged to let others know when she was in pain so that caregivers can assist her.

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

2. Nursing Diagnosis / Related to As Evidenced By:

Impaired Skin Integrity related to obesity, immunological deficit post double mastectomy, immobility, impaired sensation.

Page # in Ackley & Ladwig

769

Subjective

Objective

BREAST CANCER Patient said she did not notice the two cuts on her right foot near her toenail. She stated that she does not wish to get out of bed. Patient is not eating. Stated she is tired 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 to aid in eliminating fluid post double mastectomy. She is not ambulatory. Patient is wearing an adult brief for urinary incontinence. Patient age is 73.

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Rationale Outcome Indicators (NOC) Nursing Activities (NIC) (from nursing references) Evaluation and Revision of Plan

1. Maintain integrity of skin surface surrounding JP drains, right foot, and left buttock during an eight hour nursing shift.

1a. Assess site of skin impairment and determine cause. Wounds on buttock are pressure ulcers. Wounds on sides of breasts are from incisions during the mastectomy. The wounds on her foot are from an unknown source.

1a. Cause of the wound must be determined before interventions can be implemented. This is the basis for additional testing and evaluation to start the assessment process.

1. Goal met. Sites were monitored throughout shift; client stated that she experienced no change in sensation.

1b. Monitor site of skin impairment at least Q12h for changes in color, redness,

1b. Systematic inspection can identify impending problems early.

BREAST CANCER swelling, warmth, or other signs of infection. Determine if the client is experiencing changes in sensation. The wounds were examined at the start and end of an eight hour shift.

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1c. Select a topical treatment that will maintain a moist woundhealing environment and that is balanced with the need to absorb exudate. Client treated with Sensicane on her buttock; Versiva sterile wound dressing protected the ulcer on her buttock. The suture site and around her JP drains was kept clean and dry. Dry gauze dressings with Silvadin secured with tape are around the JP drainage tubes. The cuts on her foot were cleaned with saline and left open to air.

1c. Choosing dressings that provide a moist environment, keep periwound dry, control exudate and eliminate dead space to promote wound healing.

BREAST CANCER

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2. By end of eight hour shift, client will demonstrate understanding of plan to heal skin and prevent injury.

2a. Implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can erode or strip the skin. The patient was assessed every hour and was asked if she wanted to get up and use the bedside commode. She was asked to call the nurse immediately if she urinated in the adult brief so that the brief could be changed. She was also offered the bed pain for bowel movements.

2a. Implementing a plan with the use of a skin protectant can significantly decrease skin breakdown and pressure ulcer formation.

2b. Maintain the head of the bed at the lowest possible degree of elevation.

2b. Lowest possible elevation will aid in the reduction of sheer and friction.

2c. Assess the clients nutritional status. The patient was refusing to eat because she was did not like the taste of the food. She ate approximately one scrambled egg for breakfast and did not eat any lunch. We discussed this with her

2c. Optimizing nutritional intake, including calories, fatty acids, protein, and vitamins, is needed to promote wound healing.

2. Ongoing. Client was able to verbalize the importance of changing her brief and eliminating the moisture after the brief becomes soiled. She stated that she would use the call bell for assistance, and she did perform that action. She stated that she knew why the head of the bed should be at a low angle to prevent excess pressure on her buttock, although she did not always keep it there because it made it difficult to see the television. She stated that she has requested that her daughter bring her food from home; her daughter would be bringing her dinner.

BREAST CANCER doctor; her doctor stated that food from outside of the hospital is permitted if she feels like a change of menu would perk her appetite. We discussed the importance of eating in order to support healing.

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Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: A guide for planning care. (9th ed.). St. Louis, MO: Mosby. 3. Nursing Diagnosis Risk for falls Risk factors: cluttered environment, unfamiliar room, polypharmacy, impaired balance, neuropathy, post-operative condition. Page # in Ackley & Ladwig 355

Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: A guide for planning care. (9th ed.). St. Louis, MO: Mosby. As Evidenced By: Subjective Patient stated that she is feeling tired, weak, and has been dizzy at times. She is not able tolerate weight bearing activity. Objective Patient is taking 2mg Morphine as needed Q2h for pain, and 5mg Ditropan. Both medications have a possible side effect of dizziness.

BREAST CANCER Stated that this was the first day that she felt that she was not able to support her own body weight for ambulation. Cluttered environment in an unfamiliar and dimly lit hospital room. Patient is anemic. Patient has peripheral neuropathy secondary to type 2 DM. Rationale Outcome Indicators (NOC) Nursing Activities (NIC) (from nursing references)

33

Evaluation and Revision of Plan

BREAST CANCER 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 staff for increased vigilance and mobility assistance. Place the call light and fluids in reach of the patient. Encourage the patient to call the nurse as much as needed to assist with toileting, or getting items for the patient. 1b. Screen for balance and mobility skills (supine to sit, sitting supported and unsupported, sit to stand). Patient was able to move from supine to sitting supported and unsupported. She did not feel comfortable placing any weight on lower extremities. Student nurse and patient care tech assisted the patient to a wheelchair to change position. Patient cried and stated that she was unable to feel her legs. 1a. These steps alert the nursing 1. staff of the increased risk for falls. Placing the call light in reach of the patient and creating an environment which encourages communication prevent the patient from needing to ambulate without assistance.

34 1. Nursing activities implemented. Plan met; at the end of eight hour shift, the patient did not have any falls.

1b. It is helpful to determine the clients functional abilities and then plan for ways to improve problem areas or determine measures to improve safety.

1c. Evaluate client for mental health and neurologic function. Tested patient for orientation in relation to time, place, self, and location. Client was able to explain a metaphor.

1c. Mental health status has been found to significantly influence the rate of falls.

BREAST CANCER 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.

35 2.Goal met. Patient was able to verbalize the need for a clean and clutter free room. She used her call light several times during the shift, and was able to verbalize the best placement for furniture and medical equipment in her hospital room. The room was repositioned, and client stated that she would tell the next shift of healthcare members how the room should be kept for her safety. Her room however, was not changed.

2a. Such placement allows more frequent observation of the client.

2b. Teach patient to assess for hazards to increase safety including eliminating clutter, slippery floors, scatter rugs, and other potential hazards. Even though she was unable to stand at this time, the patient stated that she generally ambulates to the bathroom or the bedside commode.

2b. Clients suffering from impaired mobility are at risk for injury from common hazards.

2c. Thoroughly orient client to environment. Keep the bed in the low and locked position. Place the call light within reach and show how to call for assistance. Explain that nurse will answer call light promptly. Personal items were placed near the patient, as well.

2c. Limiting the need for the patient to get out of bed unassisted will lower the likelihood that the patient will incur injuries due to a fall.

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

BREAST CANCER 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 As Evidenced By: Subjective 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. Objective 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).

36 575

Rationale Outcome Indicators (NOC) Nursing Activities (NIC) (from nursing references) Evaluation and Revision of Plan

BREAST CANCER 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 and consult with a dietitian to establish a minimal calorie intake. The nurse and student nurse made notes about the food intake for the first day. Patient ate only a scrambled egg for breakfast and did not eat any lunch. She was offered snacks as well, but declined them also. The nurse stated that she would put in an order for the dietitian to meet with the patient concerning intake. 1a. Use of a food diary is helpful for the patient and the nurse, to examine food eaten, patterns of eating, and presence of deficiencies in the diet.

37 1. Ongoing. The food intake journal was started, but will need entries over three days to establish a pattern. Additionally, the dietitian had not yet consulted with the patient. The patient is having a family member bring in snacks and favorite food items. It will be important to note if the new food selections can prompt an increase in intake. The patient was not currently able to participate in long periods of activity. Building the length of time in which she is active may encourage the patient to eat.

1b. A nurse must make food 1b. Having food available as available as desired between early desired can increase nutritional evening and breakfast. The patient intake. was offered graham crackers and pudding as snacks after lunch. The snacks were declined. The doctor was consulted and the patient may have a family member bring foods from home which may trigger an appetite. 1c. Work with the patient to develop a plan for increased activity. The patient was moved from laying to supported sitting, and then to unsupported sitting. 1c. Immobility leads to negative nitrogen balance that fosters anorexia.

BREAST CANCER The patient was then transferred into the wheelchair. The patient stated that these activities took a lot 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 patient would be in the bed sitting and resting at least 30 minutes before lunch was served.

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2. By the end of the eight hour shift, the patient will identify fluid and nutritional requirements.

2a. Recognize that patients with wounds and a recent surgery need increased calories to maintain nutrition. The nurse and student nurse discussed the importance of protein in the diet, and linked it to wound healing. The patient then described her desire for her wounds from her double mastectomy to heal quickly. Patient education around protein allowed the patient to make a concrete connection between diet and health.

2a. An increase in nutrient and protein rich nutrition encourages faster healing.

2b. Assess intake calcium and vitamin D. Teaching centered on the purpose of calcium for bone strength. The patient was

2b. The elderly adult needs 1200mg calcium and a minimum of 800IU of vitamin D daily.

2. Ongoing. The patient was able to identify reasons to eat protein and calcium rich foods; she did not eat the foods. She took sips of her fluids, but never reached the 10mL/hour goal. She stated that she didnt like to go to the bathroom because she was wearing an adult brief and she didnt like getting it wet. She also felt as though she did not have the strength to go to the commode, so she did not want to eat. The nurse and student nurse made a plan to

BREAST CANCER educated about the importance of eating dairy, and was then able to explain why dairy products are an important part of the diet. The patient was then offered pudding. The pudding was declined. 2c. Assess for factors contributing 2c. Elderly individuals need at to an acute illness, such as least 1600mL/day to ensure dehydration. The patient was not adequate hydration. drinking water or ginger ale. The patient was given a fluid challenge. The patient was encouraged to drink a minimum of 10 ounces of fluid an hour. While this would still be under her fluid requirement, it would be a marked improvement over the patients current status. Drinks were poured by the student nurse, and during the hourly rounds the amount of fluid drank was noted. The patient was also encouraged to eat foods that were high in fluid, such as green beans.

39 encourage use of the brief, and to assist the patient with selfesteem. The issues with going to the bathroom must be rectified before the patient can feel comfortable eating the proper amount of food to maintain adequate nutrition.

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