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31 Mar 2019 14 Views Sarah

NURS20023 Applied Nursing Practice 3

Assessment 1


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 & Bare, 2014). 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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Bishaw, S., & Coyne, E. (2015). The role of the cancer nurse coordinator: An observational reflective study. The Australian Journal of Cancer Nursing16(2), 38.

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Nickel, K. B., Wallace, A. E., Warren, D. K., Ball, K. E., Mines, D., Fraser, V. J., & Olsen, M. A. (2016). Modification of claims-based measures improves identification of comorbidities in non-elderly women undergoing mastectomy for breast cancer: a retrospective cohort study. BMC health services research16(1), 388.

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