NURS20023 Applied Nursing Practice 3
The paper will analyze and
describe the pathophysiology, clinical manifestations and evidence-based
treatment of invasive (infiltrating) ductal carcinoma (IDC). Further, the paper
demonstrates the holistic nursing care plan for Mrs. Rose Sharma (52) who
underwent a right modified radical mastectomy for her right breast IDC. Mrs.
Sharma is a practising Hindu who emigrated from India about 10years ago. She is
recently widowed and is living with her 13year old daughter and 18year old son
with some extended family members nearby. A cancer patient needs holistic care
in every situation with complete support of healthcare professionals,
especially nurses. This paper will critically examine the health condition and
current healthcare needs of Mrs. Sharma.
Clinical knowledge about the
pathophysiology states that IDC starts in the duct in the breast and further
breaks through into the breast’s surrounding fatty tissue. From the tissues,
IDC is able to spread to other body parts via the lymph or bloodstream. Over
80% of invasive breast cancers are found and reported to be IDC (Barroso-Sousa
& Metzger-Filho, 2016). IDC spreads beyond the ducts of the breast. Once
the cancer spreads into the blood vessels, it can possibly spread to distant
organs like the liver, lung, or bones. The invasive cancers occur through the
series of molecular changes at the cellular level. These changes lead to breast
epithelial cells having immortal features with uncontrolled growth (Chen,
Paulino, Schwartz, Rodriguez, Bass, Chang & Teh, 2014). The genomic
profiling illustrates the presence of discrete breast tumor subtypes along with
separate natural histories as well as clinical behaviour. The actual count of
disease subtypes as well as molecular changes through which the subtypes occur
remains elucidated (de Boer, Taskila, Tamminga, Feuerstein, Frings‐Dresen &
Verbeek, 2015). However, often they often align with the absence or presence of
estrogen receptor (ER), human epidermal growth factor receptor 2 (HER2), and
progesterone receptor (PR) (Barroso-Sousa & Metzger-Filho, 2016).
The clinical manifestations
(signs and symptoms) at first might not be present. Often, the abnormal areas are
seen on the mammogram screening (breast X-ray) that results in further testing
(Smeltzer & Bare, 2014). In some of the IDC cases,
the initial sign of IDC is a mass or new lump in the breast being felt by the
affected person or the doctor (Chen et al., 2014). The changes include breast
pain; skin irritation; skin dimpling (Gorman, Julian, Roberts, Romero, Ehren,
Krychman & Su, 2018); swelling of a part of all breast; nipple pain; inward
turning of nipple; redness, thickening, or scaliness of breast skin or nipple;
lump in the underarm area; and nipple discharge other than the breast milk (Barroso-Sousa
& Metzger-Filho, 2016).
The local treatments for IDC
are surgery (lumpectomy- only tumor removal and mastectomy- breast removal) and
radiation therapy (Chen et al., 2014). If cancer has spread to several lymph
nodes or other body parts, hormonal therapy and chemotherapy are necessary for
shrinking the cancer cells (Lavdaniti, 2017). The radiation therapy directs
high-energy rays reaching the breast, under the arm, chest area, or/and
collarbone area for destroying any types of IDC cells left behind and reduces the
chance of recurrence (Barroso-Sousa & Metzger-Filho, 2016).
The systemic treatments for
IDC are hormonal therapy, chemotherapy, and targeted therapies. The local
treatments focus on found IDC areas. The systematic treatments include the
whole body (Chen et al., 2014). These systematic treatments destroy the cancer
cells left by the original tumor to decrease the recurrence of IDC. The
chemotherapy includes anti-cancer medicines either injected into the vein or
through a pill. Hormonal therapy is done if the cancer tests positive for the
hormone receptors (Barroso-Sousa & Metzger-Filho, 2016). In IDC, hormonal
therapy is provided prior to surgery. Usually, this treatment begins after
other IDC treatments like radiation therapy and chemotherapy. The HER2-targeted
therapy is given if IDC is HER2-positive. It includes Herceptin, Tykerb, and
Perjeta medicines (Barroso-Sousa & Metzger-Filho, 2016).
For experienced nurses, the
intuition plays the critical role and nursing process must be efficient in
patient caring. The nursing process has seven key steps making goal-oriented care
(Miller, 2008). The first step is assessing patient data from all perspectives
and second step is health issues diagnosis (Lilley et al., 2014). The third
step is outcome identification from diagnosis and fourth step is planning on
how to manage the identified health issue and patient outcomes followed by
fifth nursing step of plan implementation (Smeltzer & Bare, 2014). The sixth step is
providing rationale for the plan of action with scientific reasons and evidence.
Lastly, the nursing process evaluates the results of the implemented plan of
patient care (Blais, 2015).
On day 1 post-operation and
the first nursing process step is patient assessment. Mrs. Sharma has two
bellovac drains and will be discharged after 3 days, going home with the drains
insitu which will be removed after a week (Gorman et al., 2018). Rose Sharma is
worried about the development of the mastectomy-related complications after
this surgery of right modified radical mastectomy (de Boer et al., 2015). It is
true that her vital signs are stable, PCA, and IV therapy are insitu as
acknowledged from patient’s medical records and assessment of her vital signs (Smeltzer & Bare, 2014). However, she has been
teary regarding her diagnosis as well as future treatment of radiation therapy
and chemotherapy. She is quite concerned for the future and her children’s welfare
(Lavdaniti, 2017). The assessment need to focus on examining Mrs. Sharma’s
mental status examination because the experience of cancer surgery affects patient’s
mental stability on extreme note. It is also essential to review her lifestyle
and habits prior making the plan of care for improved survival (Miller, 2008).
The oncology nurse is the key healthcare to assess, and support and make the
holistic plan of care a success for the patient (de Boer et al., 2015). The
nurses give crucial contribution throughout this journey with the provision of
holistic care with consistent attendance of the patient along with family (de
Boer et al., 2015). The nursing holistic care needs to focus on patient’s
physical, psychological, financial, social, and information needs,
religious/spiritual issues, emotional concerns, family relationships, and
practical issues (Orgill et al., 2015).
The diagnosing stage reveals
that Mrs. Sharma’s key health issues are anxiety, activity intolerance, and
acute pain after the surgery. As the nursing philosophy is the adoption of the
nursing care integrating every life dimension, the nursing care must focus on improving
her quality of life in accordance with the holistic nursing approach (He, 2016).
The care needs to be personalized to meet Rose’s social, psychological,
spiritual, and physical needs (Kim, Loring & Kwekkeboom, 2017). It has been
analysed that the outcomes of these diagnosed issues are probable because cancer
treatments of surgery, radiation therapy, chemotherapy, biologic therapies,
targeted therapies, bone marrow transplantation, or hormonal therapies lead to
vast number of side effects (Gorman et al., 2018). Mrs. Sharma might experience
loss of appetite, fatigue, nausea/vomiting, suppression of bone marrow (causing
anemia, leukopenia), alopecia, constipation, diarrhea, skin changes, change in
body image, issues with memory and concentration, impaired sexual function (Smeltzer & Bare, 2014), and peripheral neuropathy
(Gultas, 2017). The more Rose will experience the distressing symptoms, the
more deterioration in quality of life will occur (He, 2016).
During the implementation of
the plan of care, the holistic patient care plan must enhance patient’s
spiritual status. Spirituality can positively make contribution to the
situational management, can provide hope and strength, and can enhance her
quality life (He, 2016). She is practicing Hindu religion and she can be
involved in traditional Hindu groups for conducting spiritual prays and singing
spiritual songs and can be involved in daily meditation (Kim et al., 2017). The
very first nursing diagnosis is anxiety as Mrs. Sharma is feeling worried,
tense, and unsure of her future due to breast cancer. Anxiety will disturb her
internal body functions and might also contribute in recovery delay (Gorman et
al., 2018). Such outcomes will negatively impact her cancer survival rate. After
the right modified radical mastectomy and further treatment necessity of
radiation and chemotherapy, Mrs. Sharma will experience change in her body
image which can also elevate her anxiety level (Bishaw & Coyne, 2015). It can
impact adversely on her psychological balance developing issues at workplace (receptionist
at the local TAFE) due to inability to work. All this will contribute to her
anxious behaviour and mental stress (Miller, 2008). Therefore, the plan of care
is aimed to help Rose be able to express her feelings of relief and get psychosocial
support (Barroso-Sousa & Metzger-Filho, 2016). The holistic nursing care
plan must be focused on encouraging Rose to share her thoughts and feelings
through mental exercises, events, and games like music, and relaxation
therapies (Smeltzer & Bare, 2014). The nurse needs to
communicate effectively with Rose on consistent manner and must understand how
she perceives it and how her relationships with others are impacting her
treatment decisions (Miller, 2008). This will examine her realistic fears and
diagnosis misconceptions. It is necessary to provide an
open and safe environment to Rose to feel free to communicate. This will make her
feel accepted without any feeling of judgment (Blais, 2015). This is termed as
the psychosocial care which is beneficial to decrease psychological distress
and enhancing the quality of life (Lavdaniti, 2017). The nurse-patient
relationship must be grounded on honesty, trust, respect, understanding, and
reciprocal objectives. Rose and her family needs to be educated (Kim et al., 2017).
This holistic care approach will also promote her sense of control and dignity
in life about which she is confused and unsure. The nurse can psychologically
keep her anxiety under control by providing consistent and accurate data about
prognosis (Bishaw & Coyne, 2015). The nurse can stay with her during
anxiety-producing consultations and procedures. This will permit Rose to deal
efficaciously with her reality (Barroso-Sousa & Metzger-Filho, 2016).
The second relevant nursing
diagnosis is activity intolerance. Mrs. Rose has undergone mascetomy surgery
and she would probably suffer from insufficient psychological or physiological
energy for completing her desired daily activities. Generalized weakness is a
key impact post-surgery (Lilley et al., 2014). Moreover, she will remain with two
bellovac drains insitu. This will enhance her activity intolerance as her
movements will be restricted. The holistic nursing process must focus on
improving her activity level (Gultas, 2017). The nurse must assess history of
Rose’s level of mobility and nutritional status post-surgery to set realistic
goals and define the level of assistance she needs. This can be improvised by
involving Rose in all the decisions (Nickel, Wallace, Warren, Ball, Mines,
Fraser & Olsen, 2016). Rest will surely heal her more. The nurse must also
encourage Rose with her family members to attain positive attitudes through
relaxation techniques like guided imagery for better learning (Orgill, Sheldon,
Godwin, Robinson & Kaushik, 2015). This will further enhance her sense of well-being.
This will inculcate the holistic principle of self-care in Mrs. Sharma (Gorman
et al., 2018). This must be combined with careful physical assessment of Mrs.
Sharma. She will also feel empowered. Moreover, this must also include the
mobility examination and preparing her diet chart with the consultation of
dietician/nutritionist for better health outcomes (Nickel et al., 2016).
The third nursing diagnosis
is acute pain. Mrs. Sharma can experience this unpleasant sensory (pain) as
well as emotional experience due to potential or actual tissue damage. The pain
could be related to surgical procedure, nerves’ interruption, dissection of
muscles, or tissue trauma (Smeltzer &
The holistic nurse care must help her in pain reduction with relaxed living
through both medical and other therapies (Kim et al., 2017). Mrs. Rose must be
encouraged to make daily report/diary of pain and stiffness by noting down the
location, intensity (0-10 scale), and duration. Both her verbal and non-verbal
cues need to be considered. This will assist her in timely identification of
degree of discomfort and analgesia effectiveness (Orgill et al., 2015).
Moreover, the nurse must initiate and maintain the friendly discussion of
normality of phantom breast to reassure her that the sensations are not
imaginary and relief is possible (Kim et al., 2017). She must be educated and involved in practicing relaxation
techniques, therapeutic touch, and guided imagery to promote her relaxation and
enhance her coping skills. This must be consistent with the administration of
narcotics or analgesics as defined (Lavdaniti, 2017).
The evaluation of this care
of plan is possible by conducting qualitative interview with Mrs. Sharma both
prior and after the plan of care shared with her. It is to discover her
situations, views, and experiences in terms of cancer prior the plan
implementation and after becoming educated (Gultas, 2017). It is also necessary
to discover her abilities towards successful transition as a breast cancer
survivor. Her mental condition/status must be assessed consistently at defined
intervals like on monthly basis to evaluate the impact of holistic approach on
her mental stability and her acceptance of her new life (Kim et al., 2017).
It is clearly stated that
the holistic nursing care plan is most essential for Mrs. Rose’s current
nursing care as she is to be prepared for her discharge in 3 days’ time. The
three key issues diagnosed in this case are anxiety, activity intolerance, and
acute pain that needs efficient plan of care. The holistic nursing approach is
necessary to present Mrs. Sharma’s survivorship care plan and implementation.
It should be based on the continuous healing relationship established between
the nurse and Mrs. Sharma. It is to help her attain smooth transition.
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