Apr 12, 2018 in Case Study Examples

Medical Nursing Placement

Introduction

This case study focuses on Ms X. she is 50 years old, married with five children and lives in Bahrain with the entire family. For almost eight months, Ms X has had a medical problem to do with axillaries clearance from her left breast. As a result, she experiences a lot of pain in her left breast. Because of this illness, she underwent a mastectomy that left an open wound making Ms X vulnerable to nosocomial infections (Arriagada, Le, Rochard et al, 2006, p.110).

This was her first operation that causes a cute pain and constant temperature rise. She is currently on medication that includes: Amoxicillin, Metoclopramid, and Pethidine. According to Ms X’s medical history, she has breast cancer, a reason behind the initial admission of the mastectomy with axillary clearance for her left breast. Ms X’s condition requires that as a nurse, I should focus on interventions that are crucial in reducing the pain. As a result, this discussion will outline the pathophysiology of the disease, history, nursing physical assessment, related treatment, nursing care plan, nursing diagnosis and patient goal, nursing interventions, evaluation, and advice patient to prevent  any complication.

The Problem

According to the current research, it is evident that breast cancer has been a main problem for most women in the world (Department of Health, 2007, p. 13). Statistics indicate that this is the most prevalent form of cancers among American women after skin cancer. As a result, scientists have shifted their research to look at breast cancer, a rationale behind the current decrease in mortality rates resulting from breast cancer in the US. The problem has been detected early enough and timely treatment provided to the victims as well as changing their lifestyle. The illness became a menace to women after the Second World War. Literature shows that approximately one woman out of eight are infected with breast cancer during their lifetime. Data from research taken in 2012 reveals that about 226,870 cases of persistent breast cancer are associated with women, 63,300 new cases of growth in situ are detected among women, and out of this information, approximately 39510 die of the illness.  Although there is evidence that cancer prevalence has declined by about 2% yearly since 1999, this has been observed only in older women aged 50 years and above. This was the main reason as to why I decided to focus on breast cancer so that recommendations can be made on how to help women suffering from breast cancer get through the problem and at the same time reduce the menace significantly. 

Ms. X’s problem is with her axilla – a lymph gland under her arm – that sometimes drains the lymphatic fluid from the breast as well as the arm. Is left unchecked, the cancerous cells may spread other glands of the arm. These cancerous cells create a lump called a tumor, which refers to a swelling caused by abnormal growth of body cells. The tumor may be benign or malignant. The former is usually localized at on spot, but the latter may spread from one region to another making it the most dangerous type of tumor (Fisher, Anderson, Bryant et al, 2002, p. 35). Available medical records indicate that breast cancer starts in breast cells composed of mammary glands called lobules and the ducts linking lobules and the nipple. 

Studies show that there is no known cause of cancer, and therefore, there is no predestined etiology for breast cancer. There only exist myths on the etiology of breast cancer that may not be proven and help in treatment of the disease. Nevertheless, some assumptions linked to causes of breast cancer include age whereby, it is postulated that vulnerability to breast cancer increases with age, implying that older people are at higher risk than younger one. This supports the current case under investigation, Ms X, who is 50 years. The patient claims that her illness is as a result of a curse. Another potential cause of breast cancer may be hereditary in case there is a family member who had the same problem. However, Ms X’s family history has no such individuals who have ever suffered from breast cancer. Early menses or untimely menopause seems to be another etiological factor for breast cancer. According to the recent scientific research into the problem, radioactive rays pose the greatest danger to people getting any form of cancer. Furthermore, people using hormone replacement therapies are at high risk of getting the cancer (Early Breast Cancer Trialists’ Collaborative Group, 2005, p. 17). Delayed childbearing and other chemicals in the environment may make a person susceptible to breast cancer. 

In early stages, the disease may go undiagnosed. However, as the tumor continues to grow, symptoms become evident: swelling of the armpit, pain in the breast of tenderness, and development of lumps on the breast, which is the most obvious symptom (Khatcheressian, Wolff, Smith et al, 2006, p. 453). Other symptoms include flattening of the breast or indentation showing an unnoticed tumor, changes in the contours, texture change, temperature rise in the breast, and nipple among other signs. The nipple may be indrawn or may have scales, and at times abnormal discharge from the nipple may be a clear indication of breast cancer. 

Available medical history shows that Ms X suffers from breast cancer. However, her family history has no incidences of breast cancer. Ms X has never been diagnosed with other related health complications. The surgery performed is in fact based on the fact that she lacks medical history. She was admitted for a left mastectomy with Axillary clearance due to the breast cancer that causes a lot of pain and discomfort to the patient. The surgery left her with a wound that makes her vulnerable to noscocomial infections (Gillis and Hole, 2006, p. 43). Currently, she is receiving necessary care to prevent occurrence of such an infection, and at the same time avoid compounding the surgery after effects. Ms X is under medication whereby the doctors prescribed the following drugs: cefazolin and enoxaparin to alleviate the pain and combat other conditions that could arise because of breast cancer, heart complications. It can be acknowledged that the patient is under good care of nurses that make sure that she is in a clean environment to promote faster healing of the wound. Ms X has a loving family that is ready to provider home care in which case the daughter has been assigned the responsibility of looking after her mother at home. This is evident from the constant presence of Ms X’s family members during her admission.

Ms X is 148cm tall, weighs 83kg, and has a BMI of weight/height ² - 83/148² = 28 kg/m². Her heart beat rate and regularity is 89 beat/min, which is considered normal. Furthermore, Ms X has a normal respiratory rate of 20 breath/min. The patient’s blood pressure (mmHg) of 147/57 mmHg is normal. There is no blood gas since she has an oxygen saturation of 95%, and a temperature of 38.1 ْC, which is high indicating analgesics, should be oral. Her bowel sounds between 5 and 10 seconds during each bowel emptying. Ms X has a sharp pain in the left breast at a severity rate of 7/10. This proves extreme especially when she moves around at night. 

As a result of the above specific conditions, Ms X is under medication prescribed to take: Amoxicillin and clavulanate potassium, 1 gram, and 1-gram acetaminophen codin and ceffein, intravenously. Ms X also receives 2 grams of cefazolin once daily and 10 grams of metaclopramid three times per day. She has been placed on 75grams of intramuscular pethidine three times. Lastly, she gets subcutaneous medication: 20 grams of enoxuparin (Dewar, Haviland, Agrawal et al, 2007, p. 89).

Since the patient has breast cancer, the nursing diagnosis is the left breast with axillaries clearance. She underwent surgery to remove the tumor that left her in acute pain resulting from the wound. The nursing goal for Ms X is to manage the pain effectively and eventually eliminate it. There is a need to apply management strategies that are efficient in alleviating surgical-associated pain. It is the responsibility of the nurse to ensure that Ms X is comfortable and is assisted when moving around to combat the acute pain, preferably at night. The nurse should also be keen to take any upcoming symptoms after every two hours until Ms X is stable. Her room and the general environment should be clean to avoid cases on infection from nosocomial infections since this seems to be the main risk factor for Ms X. the nurse should ensure that Ms X takes her drugs as prescribed by the doctor. Ms X requires activities like deep breathing using a spirometer and cough exercises. This is the sole responsibility of the nurse. To assure the patient’s quick recovery, it is imperative for the nurse to ensure that Ms X remain calm and complies with the therapy requirements.

According to Holland, Veling, Mravunac et al, (2005), the nurse can reduce the patient’s pain by administering analgesic that is important in alleviating pain. The choice of analgesic should be well to fulfill its purpose. For instance, it may be relevant to use drugs like opioids to alleviate pain in the case of Ms X. However, care should be taken since some of these drugs have after effects like respiratory depression such as narcotics. On the other hand, it is important that the nurse applies multimodal approaches to manage the pain. This may include the nurse getting pain prescriptions in accordance to the 0-10 scale. This will be helpful in managing the pain efficiently. This scale shows the level of the pain critical for the nurse to decide on the necessary management strategies. Ms X should remain in bed comfortably so that the nurse can stag her during pain. 

Another intervention approach may comprise informing the patient about pain management to involve her in the whole process of the therapy. This is a cognitive therapy approach. Ms X gets involved when she relaxes through techniques like taking a deep breath to control the pain. As a nurse, inform the patient to report on the onset of pain since managing the pain when it just starts require less medication to achieve analgesia. It is upon the nurse to teach Ms X comfort techniques like turning, repositioning, and therapeutic touch among other strategies. These approaches are paramount in relieving discomfort and enhance relaxation. Family members as well should be informed of the side effects of some medication so that they can report on any effects thereafter (Bishop, Blamey, Morris et al, 2009, p. 753). This enhances knowledge in addition to assisting initiate identification of adverse effects for medical attention.

Conclusion

The moment the above mentioned interventions are provided, Ms X will less likely complain about pains or paresthesias. This is because she will communicate beforehand any incidences of pain and ask for analgesics. Furthermore, her pain will be combated in good time and to her satisfaction. This will result into her attaining and sustaining normal perfusion of her body system. The moment this pain is controlled, other surgical-related infections may be managed easily. 

There is a need that in the future, women are sensitized on early detection of cancer so that treatment can commence timely. This is important in avoiding cases of performing mastectomy. One way should through understanding oneself in which case a woman can rub her breasts to feel if any lumps are developing (Hillner, Smith and Desch, 2000, p. 114). In the case of Ms X, it is imperative for her to go for occasional checkup to avoid the spread of the cancerous cells to her right breast. Considerations can be taken to restructure her left breast to make sure that Ms X leads a normal life. This will boost her self-esteem. It will be upon the nurses in future to set campaigns for early detection of cancers as well as treatment to get rid of adverse situations in their line of work. Screening campaigns should be the sole responsibility of the country to eliminate the menace of cancer among women.

Bibliography

  1. Arriagada R, Le MG, Rochard F, et al., 2006, Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow- up, J Clin Oncol 2006; 14:1558.
  2. Bishop HM, Blamey RW, Morris AH, et al., 2009, Bone scanning: its lack of value in the follow up of patients with breast cancer, Br J Surg 2009; 66(10): 752–4.
  3. Department of Health, 2007, Cancer Reform Strategy, London: Department of Health.
  4. Dewar JA, Haviland JS, Agrawal RK, et al., 2007, Hypofractionation for early breast cancer: first results of the UK standardisation of breast radiotherapy (START) trials, J Clin Oncol 2007; 25(18S):LBA518.
  5. Early Breast Cancer Trialists’ Collaborative Group, 2005, Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15 year survival: an overview of randomized trials, Lancet 2005; 366:2087–106.
  6. Fisher B, Anderson S, Bryant J, et al., 2002, Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer, N Engl J Med 2002; 347(16):1233–41.
  7. Gillis CR, and Hole DJ., 2006, Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the West of Scotland, BMJ 2006; 312(7024):145–8.
  8. Hillner BE, Smith TJ, and Desch CE, 2000, Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care, J Clin Oncol 2000; 18(11):2327–40.
  9. Holland R, Veling SH, Mravunac M, et al., 2005, Histologic multifocality of Tis, T1-2 breast carcinomas: Implications for clinical trials of breast-conserving surgery, Cancer 2005; 56(5):979–90.
  10. Khatcheressian JL, Wolff AC, Smith TJ, et al., 2006, American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guideline in the adjuvant setting, J Clin Oncol 2006; 24(31):5091–7.
  11. NICE, 2002, Improving outcomes in breast cancer e manual update, London: National Institute for Clinical Excellence.
  12. Sainsbury R, Haward B, Rider L, et al., 2005, Influence of clinician workload and patterns of treatment on survival from breast cancer, Lancet 2005; 345(8960):1265–70.
  13. The GIVIO Investigators, 2004, Impact of follow-up testing on survival and health- related quality of life in breast cancer patients, a multicenter randomized controlled trial, JAMA 2004; 271(20):1587–92.
  14. van Dongen JA, Bartelink H, Fentiman IS, et al., 2002, Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer, Eur J Cancer 2002; 801–5.
  15. Veronesi U, Saccozzi R,Vecchio Del, et al., 2001, Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast, N Engl J Med 2001; 305(1):6–11.

Related essays