Situation: The client is a 50-year-old female teacher who was notified of an abnormal screening mammogram. Diagnosis of infiltrating ductal carcinoma was made following a stereotactic needle biopsy of a 1. 5 x 1. 5 cm lobulated mass at the 3:00 position in her left breast. The client had a modified radical mastectomy with lymph node dissection. The sentinel lymph node and 11 of 16 lymph nodes were positive for tumor. Estrogen receptors and progesterone receptors were both positive. Further staging work-up was negative for distant metastasis. Her final staging was stage IIB.
Her prescribed chemotherapy regimen is 6 cycles of CAF after a single-lumen central line was placed. 1. The client asks you to help her understand how big her tumor was. Draw a 1. 5 x1. 5 cm circle. This gives a good understanding of the size of the actual tumor. 2. Describe the biopsy technique used for this diagnosis. • Stereotactic needle biopsy includes aspiration of tumor cells through a special biopsy needle by immobilizing the breast, determining the exact location of the tumor through x-ray examination, and then inserting the needle into the precise location.
• The specimen is then analyzed by a pathologist and a diagnosis made. 3. Discuss the implications of a positive sentinel node. Before removal of the tumor, radioactive dye is instilled into the tumor bed. During surgery the surrounding lymph nodes are evaluated for the presence of the radioactive dye. The sentinel node is defined as the initial node that drains the tumor bed. The sentinel node is removed and evaluated by a pathologist for presence of cancer. Presence of cancer in the sentinel node is an indication that the disease is metastatic at the time of diagnosis. 4.
Using the TNM staging system, what would her classification be? T1N1M0 • Tumor size less than 2 cm: T1 • Lymph node involvement is positive: N1 • Metastasis is negative: M0 5. What is the significance of her hormone receptor status? When a tumor is hormone receptor positive—in this case both estrogen and progesterone positive—the tumor grows in the presence of these hormones. Reducing the level of these hormones will slow the rate of tumor growth. 6. Surgical intervention is called the primary treatment for breast cancer. Follow-up chemotherapy is called what kind of therapy?
Surgery is the primary treatment for breast cancer. Chemotherapy is the secondary therapy, making it the adjuvant therapy. 7. List the chemotherapy drugs used for her treatment. List any side effects and special considerations associated with the use of these drugs. Her treatment involves CAF (cyclophosphamide, Adriamycin [doxorubicin], 5-fluorouracil). •Cyclophosphamide is an alkylating agent. •Its major side effects are myelosuppression, alopecia, hemorrhagic cystitis, N/V, cardiotoxicity, pulmonary fibrosis, and hypersensitivity reactions.
•Ensure that the patient is aware to drink plenty of fluid and to urinate frequently to decrease the possibility of hemorrhagic cystitis. •Doxorubicin is an antitumor antibiotic. Its major side effects are myelosuppression, cardiotoxicity, N/V, alopecia, red urine, and dermatitis in previously radiated areas. •Doxorubicin is a vesicant, which means it can cause necrosis of tissue if the IV infiltrates during the infusion. Vesicants should only be given in IVs that are new (less than 24 hours) and exhibit good blood return. There is a maximum lifetime cumulative dose that must not be exceeded.
Inform the patient of the red urine. •5-Fluorouracil is an antimetabolite. Its major side effects include myelosuppression, diarrhea, oral and GI ulcerations, alopecia, and N/V. •Because all these chemotherapeutic agents cause myelosuppression, when her blood counts are low, she needs to be monitored closely for symptoms related to infection, anemia, and thrombocytopenia. 8. Calculate the client’s body surface area (m2). Her height is 5? 7? , and her weight is 155 pounds. 9. Calculate the dose of her doxorubicin at 75 mg/m2. 75 mg x 1. 82 = 136. 5 mg.
CASE STUDY PROGRESS: The client has now received 3 cycles of combination chemotherapy for her breast cancer. Her last treatment with doxorubicin, cyclophosphamide, and 5-fluorouracil was approximately 12 days ago. She came to the emergency room with a 2-day history of fever, chills, and shortness of breath. On arrival, she is disoriented and agitated. Vital signs are 86/43, 119, 28, 39. 8° C, SaO2 85% on room air. Laboratory data include WBC 1. 2 thou/cmm, Hct 24. 9%, Hgb 8. 7 g/dl, platelets 125 thou/cmm. Differential WBC count shows 37% granulocytes, 60% lymphocytes, 3% monocytes.
Chem 14 is within normal limits, with the exception of BUN 28 mg/dl, creatinine 1. 6 mg/dl, and lactic acid 2. 4 mg/dl. Chest x-ray demonstrates diffuse infiltrates in the left lower lung. • Granulocytes include neutrophils, basophils, and eosinophils. • Bands, or stabs, are immature neutrophils. • Nongranulocytes include lymphocytes and monocytes. The formula for absolute granulocyte count (AGC) is: AGC = Granulocyte count (%Neutrophils + %Bands)/100 X WBC AGC = 0. 37 X 1200 = 444/cmm 10. The client’s AGC is 444/cmm. What is the significance of an AGC of 444/cmm?
An AGC of less than 500/cmm puts a patient at a severe risk of infection. Some labs still report both neutrophils and bands, so this calculation is necessary. Modern labs report straight granulocyte. 11. What are the probable causes of the abnormal laboratory findings listed above? • Myelosuppression from the chemotherapy is the cause of the decreased WBC, Hgb, and Hct. • The elevated BUN and creatinine indicate probable dehydration due to N/V and indicate a potentially developing renal insufficiency. 12. What is the single most important nursing intervention for a patient with an AGC less than 500/cmm?
Handwashing is the most important intervention for the prevention of infectious organisms. 13. What is the significance of the lactic acid level? The Client has pneumonia in her LLL. When O2 is not available, cells are required to manufacture ATP using the anaerobic pathway. The by-product of anaerobic metabolism is increased lactic acid. CASE STUDY PROGRESS: The client’s oxygen requirements significantly increase. She is admitted into the ICU and requires endotracheal intubation. 14. Differentiate among sepsis, severe sepsis, and septic shock.
• Septic shock occurs along a continuum that begins with an inflammatory process in response to an infectious organism. • Sepsis occurs when 2 of the following 4 criteria are met: 1. Temperature over 38° C 2. Heart rate over 90 beats/min 3. Respiratory rate over 20 breaths/min or arterial blood CO2 level less than 32 torr 4. WBC over 12 thou/cmm, less than 4 thou/cmm, or containing more than 10% immature forms (bands) • Severe sepsis occurs when the patient meets the above criteria for sepsis and also has organ dysfunction, hypoperfusion, or hypotension manifested by lactic acidosis, oliguria, or mental status alteration among others.
• Septic shock meets the above criteria for severe sepsis and includes hypotension despite adequate fluid resuscitation. If septic shock progression is not stopped, multiple organ dysfunction syndrome (MODS) occurs. CASE STUDY PROGRESS: The client spends 3 days in the ICU receiving antibiotics and respiratory support. She is able to be extubated and returns to the oncology unit, where she remains for a few more days before being discharged home.