breast cancer - Nursing Case Study

Pathophysiology

• Primary mechanism: Mutation in genes - Breast cancer primarily initiates through DNA mutations in the breast cells, leading to uncontrollable cell growth. The most common genes involved are BRCA1 and BRCA2. Mutations in these genes significantly increase the risk of breast cancer.

• Secondary mechanism: Hormonal influence - Estrogen and progesterone, female hormones, play a significant role in breast cancer development. These hormones can promote the growth of some types of breast cancer cells. Increased lifetime exposure to these hormones (early menstruation, late menopause) raises breast cancer risk.

• Key complication: Metastasis - This is when cancer cells spread from the primary site (breast) to other parts of the body, often via the lymphatic or blood vessels. Common sites for metastasis include the bones, liver, lungs, and brain. It complicates treatment and significantly affects prognosis.

Patient Profile

Demographics:

55-year-old female, high school teacher

History:

• Key past medical history: hypertension, type 2 diabetes

• Current medications: Metformin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent pain in the right breast and axillary region, shortness of breath

• Key symptoms: Right breast lump, skin changes over the right breast, fatigue, mild weight loss

• Vital signs: Blood pressure 150/90 mmHg, pulse 110 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air.

Section 1

Change in Patient Status:

Over the next few days, the patient's condition starts to deteriorate. She exhibits increased fatigue and shortness of breath even after slight exertion. Her vital signs show a persistent elevated blood pressure of 158/95 mmHg, pulse of 120 bpm, and a respiratory rate of 26 breaths per minute. Her oxygen saturation drops to 89% on room air, requiring supplemental oxygen. She also complains of a persistent dull ache in her right lower chest, rating the pain as 7 out of 10 on the pain scale.

Response to Interventions:

She is started on a low dose of morphine for pain management, which brings down her pain score to a manageable 4 out of 10. Her shortness of breath is managed with supplemental oxygen at 2 liters per minute via nasal cannula, improving her oxygen saturation to 94%. Her blood pressure remains elevated despite her Lisinopril dose being increased. She is also started on a diuretic, Furosemide, to help manage her blood pressure. Despite these interventions, she continues to exhibit signs of distress and her fatigue continues to worsen. This raises concerns about possible metastasis and the need for further diagnostic evaluation.

Section 2

New Diagnostic Results:

After a series of diagnostic tests, the results indicate a likely progression of the disease. A chest X-ray reveals a suspicious mass on the right lower lobe of the lung, which is possibly a metastatic lesion. In addition, abnormalities are found in her blood work; her red blood cell count has decreased to 2.9 million cells/mcL, and her hemoglobin level is at 9.2 g/dL, both indicative of anemia. The liver function tests show increased levels of Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) at 45 U/L and 50 U/L respectively, which are above the normal range and suggest potential liver involvement.

These findings suggest that the patient's breast cancer may have metastasized to other organs, which could explain her increased fatigue and persistent pain. The anemia could be contributing to her shortness of breath and elevated heart rate. Given these results, the healthcare team needs to reconsider the patient's treatment plan, adjust the management of her symptoms, and address the new findings related to potential metastasis. More diagnostic tests are needed to confirm these findings and to understand the extent of the disease spread.

Section 3

Change in Patient Status:

The patient's condition has noticeably deteriorated over the past few days. She reports increased fatigue, feeling more breathless and experiencing persistent right-sided chest pain. The pain has gradually progressed from a dull ache to a sharper, more constant pain which she rates as 7 out of 10 on the pain scale. Her vital signs show an elevated heart rate of 110 beats per minute, a respiratory rate of 22 breaths per minute, blood pressure of 138/86 mmHg, and an oxygen saturation of 92% on room air. On physical examination, the healthcare provider notes pallor, a palpable mass in her right lower chest, and hepatomegaly.

Given her worsening status and the recent diagnostic results, it is essential to expedite further diagnostic tests to ascertain the extent of metastasis. The healthcare team decides to order a Computerized Tomography (CT) scan of the chest, abdomen, and pelvis to identify any potential metastatic lesions. The team also plans to repeat her complete blood count and liver function tests to monitor her anemia and potential liver involvement. The patient's medications are also reviewed with a consideration to adjust her current pain management plan and possibly initiate treatment for her anemia.

Section 4

New Diagnostic Results:

The results of the CT scan reveal multiple metastatic lesions in the right lung and liver, explaining the patient's chest pain, breathlessness, and hepatomegaly. The liver function test results are also concerning, showing elevated levels of alanine aminotransferase (ALT) at 70 U/L and aspartate aminotransferase (AST) at 60 U/L, hinting at liver dysfunction. The complete blood count indicates the patient's hemoglobin levels have dropped to 9.5 g/dL, confirming the suspicion of anemia.

These findings provide a deeper understanding of the patient's deteriorating condition and demonstrate the aggressive progression of the disease. The metastatic lesions in the lung and liver suggest the need for immediate intervention, likely chemotherapy or targeted therapy, and careful monitoring of her liver function. The anemia, likely due to the cancer itself or a side effect of her current treatment, may require blood transfusions or the administration of erythropoiesis-stimulating agents. The healthcare team needs to consider these findings in their discussions about the patient's prognosis and the potential adjustments to her treatment plan.

Section 5

Change in Patient Status:

In the following days, the patient’s condition continues to deteriorate. She is now experiencing increased fatigue and her appetite has significantly diminished. Her pain level has escalated, with a consistent score of 8 on a scale of 0-10 despite her regular analgesia. She also reports experiencing bouts of nausea. Her vital signs are as follows: BP 135/85 mmHg, pulse 110 bpm, respiration rate 20 breaths/min, and temperature 37.8°C. On physical examination, her jaundice has worsened, and her abdomen is distended with marked hepatomegaly. She is also more lethargic than usual, with occasional periods of confusion.

The healthcare team is concerned about these developments, suspecting hepatic encephalopathy due to her liver dysfunction and altered mental status. They also worry about possible malnutrition, given her lack of appetite and ongoing weight loss. They plan to reassess her analgesia to better manage her pain, and consider antiemetic medications for her nausea. They also decide to consult a dietitian to address her nutritional needs. Her liver function and complete blood count will be rechecked to monitor the progression of her liver disease and anemia. The team understands that these new developments may require adjustments to her treatment plan and potential discussions about palliative care.