Background
H.M. is a 62-year-old female patient who presented to our healthcare facility with complaints of a lump on her left breast. She revealed that she discovered the lump when taking a shower and was concerned; hence, she decided to visit our healthcare center. She was assessed by our healthcare team at the facility and sent for further scans that revealed she had breast cancer in the left breast.
For patients with breast cancer, the role of a nurse includes managing them preoperatively to manage anxiety and stress. Postoperatively, a nurse is expected to manage a patient’s pain and skin around the surgical area and ensure the timely administration of the prescribed drugs.
Pathophysiology
Breast cancer is caused by genetic alterations and DNA fragmentation, both of which can be impacted by estrogen exposure. Sometimes, Genetic flaws or cancer-causing genes like BRCA1 and BRCA2 are inherited (Alkabban & Ferguson, 2021). Hence, a positive familial history of ovarian or breast cancer predisposes one to the disease later in life.
Normally, the body functions to destroy abnormal cells or DNA and eliminate them from the system, guaranteeing health. In some cases, this natural mechanism of protection fails to confer its function on an individual, and the abnormal cells and DNA are allowed to thrive. This encompasses the development of cancerous cells, aids their spread to other body organs, and leads to the development of tumors.
Breast cancer spreads through local lymph nodes, the bloodstream, or both as it invades a specific area. The majority of frequently impacted organs by metastatic breast cancer include the lungs, liver, bones, brain, and skin. The majority of skin metastases happen close to the breast surgery site; scalp metastases are rare.
Certain breast cancers may recur more quickly than others, and tumor markers can frequently predict recurrence. For instance, people lacking tumor markers remain at risk of acquiring metastatic breast cancer in four years, while those who have estrogen-receptor-positive tumors may develop the disease more than ten years after the original diagnosis and therapy. Some breast tumors have estrogen and progesterone receptors, which are nuclear hormone receptors that encourage DNA synthesis and cell divisions when the proper hormones attach to them. Drugs that inhibit these receptors may, therefore, be effective in treating cancers that express these receptors.
The majority of postmenopausal cancer patients (around two-thirds) have tumors that are estrogen receptor-positive (ER+) (Choi, 2022). Those who are premenopausal have a reduced incidence of ER+ malignancies. The human epidermal growth factor receptor 2 (HER2, also known as HER2/neu or ErbB2) is another cellular receptor; its presence is associated with a worse prognosis at any given stage of cancer.
About 20% of breast cancer patients have an overexpression of HER2 receptors. The conventional course of care for these patients includes medications that inhibit these receptors. Breast cancer risk is increased by 70% by BRCA1 and BRCA2 genetic mutations. Women who have a BRCA mutation should be given the option of a prophylactic bilateral mastectomy, which minimizes the chance of developing breast cancer by 90% (Choi, 2022). A panel genetic test often includes testing for alterations in CHEK2, PALB2, ATM, RAD51C, RAD51D, BARD1, and TP53, as well as other genetic changes that raise the chance of developing breast cancer.
History
The patient presented with a breast lump identified during showering and subsequently identified at the healthcare center upon visitation. The patient could not pinpoint the exact time when the lump developed but remembered when she first noticed it on her breast. H.M. does not report any pain, swelling, or skin changes. She has not experienced an abnormal increase in body temperature, reduced body weight, migraines, vomiting, faintness, or bone aches.
H.M. is in generally good health despite being moderately overweight. She has never been diagnosed with breast cancer before or received any treatment for the condition. She had a routine mammography two years prior.
She had her first and sole kid at age 36, went through menarche at age 10, and went through menopause at age 55. Her hormone replacement therapy lasted from the age of 54 until the age of 59. There is no history of malignancy in first-degree relatives. H.M. has one sister, age 58, who is in good health. She teaches history at a university and is married. Her grown daughter resides close by. She does not consume more than three alcoholic beverages each week and has never smoked. She doesn’t check her breasts.
Nursing Physical Assessment
- VS (vital signs): T=98.2, HR (heart rate)=70, RR (respiration rate)=15, BP (blood pressure)=130/90.
- Neck: No JVD, no lymph node enlargement, normal deep arterial pulses, no abnormal vascular sounds.
- Lungs: On auscultation, normal breath sounds.
- Heart: regular rate, the normal rhythm of the heart, and peripheral pulses, S1/S2, were standard, with no additional abnormal cardiac sounds, rubs, or gallops (normal heart function and capabilities).
- Abdomen: moderately obese, soft, not tender, normal distension, bowel sounds within the normal count, no enlarged spleen or liver, no abdominal masses or enlargements.
- Extremities: warm, well-perfused.
- Neuro: A&Ox3 (alert and oriented to person, place, and time), CNII=XII grossly intact. Reflexes are normal and symmetric. Strength and sensation are normal.
- Breast/axilla: No obvious anomalies were observed on sitting or recumbent examination. The right breast and axilla are typical. The left breast had a ~ 3 cm firm, immovable mass with asymmetrical margins in the upper lateral quadrant, approximately. 6 cm from the areola. No palpable axillary or supraclavicular lymph nodes.
Related Treatments
Breast-conserving surgery was conducted on H.M. so that only the portion of her left breast that was considered cancerous was removed. Upon removal of the lump, a biopsy was conducted for the surrounding tissue, and examinations were conducted to ascertain the presence of cancerous cells. Some cancerous cells were discovered, and further surgical excision of the surrounding flesh was done for her. To prevent the potential of breast cancer from spreading to other organs and the adjacent tissues through the lymphatic route, the lymph nodes supplying the region were excised surgically (NHS Choices, 2019).
The other alternative to conservative breast surgery would be mastectomy, which involves the removal of the entire breast. That decision was forfeited because the medical staff felt there was a portion of H.M.’s left breast that was salvageable.
Radiotherapy was conducted for the patient as an additional intervention, which strengthened the activity of the surgery. Radiation was projected on the excised region of the left breast to kill any remaining cancer cells, an action that would stop the spread of cancer. Additionally, H.M. was subjected to chemotherapy drugs, which would aid in killing the cancerous cells and stopping their division and spread to other body organs (NHS Choices, 2019). H.M. was additionally given trastuzumab, a hormone treatment that lowers estrogen and progesterone (NHS Choices, 2019). These two hormones are crucial for the growth and development of cancerous cells, hence the need to slow down their progress through the drug.
Nursing Diagnosis & Patient Goal
The main problems for this patient were the recurrent and uncomfortable pain they experienced, weight loss and malnutrition, fear and anxiety, and skin changes. The patient’s goals related to the interventions, such as surgery and chemotherapy implemented, include pain management. Pain management is a vital goal and is a consequence of the surgical procedure performed, and there is a need to manage the pain as the patient undergoes recovery (Schreier et al., 2019).
Nurses additionally ought to manage the fear and anxiety likely to arise after the start of the treatment plan. The integrity of the patient’s skin is also impaired during surgery, and one of the patient’s goals is to ensure the skin remains healthy and maintains its cosmetic appeal. Another patient goal during the recovery period is to observe their nutrition due to the capacity of the chemotherapy drugs to cause wasting.
Nursing Intervention
I must first evaluate the pain appropriately to gauge its severity and administer the prescribed drugs. I will additionally assess the vital signs of the patient, including temperature and pulse, to ensure that pain is managed and its effects on other systems are also established. Pain intervention involves the administration of the prescribed pain medication and regular evaluation of the effectiveness of the pain medication (Schreier et al., 2019).
Nonpharmacological pain management that I would employ includes massage, distraction, hot/cold compresses, and acupuncture for relief. Fear and anxiety first need to be assessed and the cause determined; hence, I would talk to the patient to establish her concerns. A nurse thereafter ought to assess coping strategies and ensure they are administered for wholesome recovery (Schreier et al., 2019).
I additionally provided a relaxing environment for the patient, promoted relaxation techniques, and educated her on their diagnosis. Nutrition is a vital intervention for the maintenance of skin integrity, and I would ensure she gets a balanced diet. Education on the effects of radiotherapy ensures the patient is not caught unaware when the changes occur.
Evaluation
The effectiveness of the nursing interventions implemented is evaluated through repeated history-taking and conversations with the patient. Decreased complaints about pain by the patient indicate the effectiveness of the recommended pain medication. An increased level of movement and activity additionally indicates comfort and freedom to engage in other daily activities (Schreier et al., 2019).
The patient’s anxiety should be evaluated through questions regarding how they feel about the interventions and their recovery. Decreased anxiety is determined during subsequent conversations with other healthcare professionals and family members. Skin condition is visible through physical examination of the progress and the comfort of the patient. Nutrition is evaluated through the measurement of the patient’s body weight, food intake, and general body health.
The nurse ought to continue administering the pain medication prescribed to continue the patient’s recovery. If the pain does not decrease during the management process, the nurse must suggest a review of the drugs so that more effective drugs can be administered (Schreier et al., 2019). Additional counseling therapies can be administered to the patient to eliminate anxiety and fear surrounding their treatment. These include behavioral counseling therapy that aims to improve the overall health of the patient and offer coping mechanisms. A thorough meal plan ought to be implemented and used to ensure the patient receives all types of nutrition and all the necessary nutrients.
References
Alkabban, F. M., & Ferguson, T. (2021). Breast Cancer. PubMed; StatPearls Publishing. Web.
Choi, L. (2022). Breast Cancer. MSD Manual Professional Edition. Web.
NHS Choices. (2019). Treatment – Breast Cancer in Women. NHS. Web.
Schreier, A. M., Johnson, L. A., Vohra, N. A., Muzaffar, M., & Kyle, B. (2019). Post-Treatment Symptoms of Pain, Anxiety, Sleep Disturbance, and Fatigue in Breast Cancer Survivors. Pain Management Nursing, 20(2), 146–151. Web.