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?

Nurse Jacques: So, the decongestive therapist will work with you to reduce your symptoms using massage-like techniques to help move the fluid in your arm.

Then, a compression bandage is used to apply pressure and help reduce swelling. Elisapie: Okay, that's helpful.

What else can I do? Nurse Jacques: There are some things you can do at home to help with the swelling.

Nurse Jacques then goes on to explain that Elisapie should keep her arm elevated to promote drainage. During sleep, he suggests she elevate the arm on a pillow so it’s at the same level as the heart.

He stresses the importance of avoiding any trauma to the arm, including blood pressure measurements, venipuncture sticks, or injections in her left arm.

Nurse Jacques also teaches Elisapie how to care for her skin and that she should notify her health care provider for any signs of inflammation in her arm, like redness and warmth.One week later, Elisapie returns for her follow-up appointment and Nurse Jacques evaluates the outcome of his actions.

Elisapie’s vital signs are temperature 97.8 F or 36.5 C, heart rate 80 beats per minute, respirations 14 breaths per minute, blood pressure 124/84 mmHg, and oxygen saturation 98 percent on room air.

When asked about her pain level, Elisapie states that it’s zero out of ten. Nurse Jacques notes that Elisapie is currently wearing her compression bandage and her swelling has decreased from the last appointment.

Elisapie also states that her arm feels less heavy, and tingling has resolved.Alright, as a quick recap… Nurse Jacques recognized and analyzed cues related to Elisapie’s impaired tissue integrity, prioritized hypotheses, and generated solutions to address this problem.

Nurse Jacques then implemented measures to address Elisapie’s lymphedema, and evaluated Elisapie’s outcomes, comparing them to the expected outcomes.

Since Elisapie’s lymphedema symptoms were improved, Nurse Jacques determined the plan of care was successful.