Video Case Study - Care of the Patient with Breast Cancer

Nurse Jacques works at an outpatient oncology clinic and is caring for Elisapie, a 55-year-old female with a history of breast cancer who presents with severe left arm swelling. After settling Elisapie in her room, Nurse Jacques goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Elisapie’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Jacques recognizes important cues, including Elisapie’s vital signs, which include temperature 98.6 F or 37 C, heart rate 92 beats per minute, respirations 18 breaths per minute, blood pressure 128/82 mmHg, and oxygen saturation 98 percent on room air. Elisapie reports a pain level of 6 out of 10 in the left chest wall and upper arm and mild tingling in her fingers and a feeling of heaviness in her arm. Nurse Jacques’ assessment reveals a healing surgical wound to the left chest. He also sees that Elisapie’s left arm is edematous, has limited range of motion, and that the skin is shiny and red.

Next, Nurse Jacques analyzes these cues. He reviews the electronic health record, or EHR, and notes that Elisapie is recovering from a left mastectomy with axillary lymph node dissection, or ALND for short, and has undergone radiation therapy. Nurse Jacques knows that having ALND, plus radiation therapy, can cause obstruction of lymph fluid flow, causing it to accumulate in the soft tissue of the arm. This puts pressure on the veins, preventing venous return and adding to the edema. He understands that the extra fluid causes a feeling of heaviness in Elisapie’s arm and the tingling in her fingers. Nurse Jacques recognizes that Elisapie needs management of her lymphedema.

Now, using the information he’s gathered, Nurse Jacques chooses a priority hypothesis of impaired tissue integrity. 

Then, he generates solutions to address Elisapie’s impaired tissue integrity that will include nonpharmacologic interventions; and he establishes the expected outcome that after intervening, Elisapie’s lymphedema symptoms will improve by her follow-up appointment.  

Nurse Jacques then takes action to implement these solutions. After the health care provider discusses the treatment plan for decongestive therapy with Elisapie, Nurse Jacques follows up with her.

Nurse Jacques: Hello again, Elisapie. Do you have additional questions about your treatment plan? 

Elisapie: Could you explain to me why I have to see a decongestive therapist?