A 58-year-old female with a history of colon cancer presents with abdominal pain, fatigue, nausea, and changes in bowel habits. Her vital signs show hypertension and tachycardia, and her laboratory results indicate elevated liver enzymes and an increased white blood cell count. Imaging reveals hepatic metastasis. Which nursing intervention is most appropriate to prioritize in her care plan?

C) Coordinate with the oncology team for potential adjustment in cancer treatment.

A) Administer anti-hypertensive medication to manage blood pressure.

B) Initiate dietary modifications to address gastrointestinal symptoms.

C) Coordinate with the oncology team for potential adjustment in cancer treatment.

D) Provide oxygen therapy to improve oxygen saturation levels.

A 58-year-old female patient with a history of colon cancer presents with new hepatic metastasis, hypertension, and diabetes. She reports abdominal pain, fatigue, nausea, and changes in bowel habits. Given her current health status, what should be the priority nursing intervention to address her immediate needs?

C) Coordinate with the healthcare team for palliative care services.

A) Initiate a low-sodium diet to manage hypertension.

B) Administer prescribed antiemetics to control nausea.

C) Coordinate with the healthcare team for palliative care services.

D) Educate the patient about lifestyle modifications for diabetes management.

A patient with metastatic colon cancer has developed a partial bowel obstruction due to tumor growth. Which nursing intervention is most appropriate to prioritize while awaiting surgical consultation?

C) Initiate nasogastric tube insertion to decompress the stomach.

A) Administer prescribed antiemetics to control nausea.

B) Prepare the patient for immediate surgical intervention.

C) Initiate nasogastric tube insertion to decompress the stomach.

D) Encourage oral intake to maintain nutritional status.

A patient with metastatic colon cancer has developed a partial bowel obstruction and is being managed with IV fluids and consideration for a nasogastric tube insertion. Which nursing intervention is most appropriate to prioritize in managing this patient's condition?

C) Monitor the patient for signs of complete bowel obstruction

A) Administer analgesics to manage abdominal pain

B) Encourage oral intake of clear fluids to maintain hydration

C) Monitor the patient for signs of complete bowel obstruction

D) Perform frequent abdominal assessments to check for bowel sounds

A patient with a partial bowel obstruction is being monitored for changes. After noting increased heart rate, decreased blood pressure, and lethargy, along with lab results indicating a drop in hemoglobin and rising lactate levels, which nursing intervention should be prioritized to address the patient's current condition?

C) Initiate blood transfusion and continue IV fluid administration.

A) Administer antiemetic medication to control nausea.

B) Prepare the patient for immediate exploratory surgery.

C) Initiate blood transfusion and continue IV fluid administration.

D) Increase the frequency of vital signs monitoring and notify the physician.

A patient with a partial bowel obstruction shows signs of hemodynamic instability and tissue hypoperfusion. After initiating a blood transfusion and IV fluid management, what is the nurse's priority action to ensure patient safety and support the treatment plan?

C) Continually assess vital signs and level of consciousness for signs of improvement.

A) Monitor the patient's nasogastric tube output closely for changes.

B) Assess the patient's abdominal girth hourly to detect further distension.

C) Continually assess vital signs and level of consciousness for signs of improvement.

D) Prepare the patient for immediate exploratory surgery without delay.

A patient with a high-grade bowel obstruction is being prepared for an exploratory laparotomy. Which nursing action is the most critical to ensure optimal perioperative outcomes?

B) Ensuring the patient is NPO and administering IV fluids as ordered.

A) Administering prescribed antibiotics to prevent surgical site infection.

B) Ensuring the patient is NPO and administering IV fluids as ordered.

C) Educating the patient about postoperative pain management strategies.

D) Monitoring vital signs and reporting any significant deviations to the surgical team.

A patient with a high-grade bowel obstruction secondary to cancer is being prepared for an exploratory laparotomy. Which nursing intervention is the most important to implement prior to surgery?

C) Insert a nasogastric tube to decompress the stomach

A) Administer a full liquid diet to improve nutritional status

B) Encourage ambulation to promote bowel motility

C) Insert a nasogastric tube to decompress the stomach

D) Initiate enteral feeding through a nasojejunal tube

A patient in the immediate postoperative period following an exploratory laparotomy reports increased abdominal pain and shows signs of abdominal distension. Her white blood cell count is elevated, and lactate levels are high. Which of the following interventions is the priority for the nurse to perform?

C) Initiate nasogastric decompression to relieve distension

A) Administer prescribed analgesics for pain management

B) Prepare the patient for a contrast-enhanced CT scan

C) Initiate nasogastric decompression to relieve distension

D) Increase IV fluid rate to address potential dehydration

A patient is in the immediate postoperative period following an exploratory laparotomy and limited bowel resection. The patient is experiencing increased abdominal pain, abdominal distension, and has an elevated white blood cell count and lactate level. Which nursing action is the priority?

C) Initiate nasogastric decompression to relieve abdominal distension.

A) Administer prescribed opioid analgesics to manage pain.

B) Prepare the patient for a contrast-enhanced CT scan.

C) Initiate nasogastric decompression to relieve abdominal distension.

D) Contact the physician to report the elevated white blood cell count.

breast and colon cancer - Nursing Case Study

Pathophysiology

Breast Cancer:

• Primary mechanism: Hormonal influence - Estrogen and progesterone can stimulate breast cell proliferation, leading to mutations and cancerous growths in cells with estrogen receptors (ER-positive tumors).

• Secondary mechanism: Genetic mutations - BRCA1 and BRCA2 gene mutations significantly increase the risk by impairing DNA repair mechanisms, leading to genomic instability and malignancy.

Colon Cancer:

• Primary mechanism: APC gene mutation - Loss of function in the APC tumor suppressor gene leads to unchecked Wnt signaling, causing abnormal cell proliferation and polyp formation, a precursor to cancer.

• Secondary mechanism: Inflammatory processes - Chronic inflammation, as seen in conditions like ulcerative colitis, can cause DNA damage and increase the risk of malignant transformation.

• Key complication: Metastasis - Both cancers can spread to distant organs, complicating treatment and worsening prognosis.

Patient Profile

Demographics:

58-year-old female, retired school teacher

History:

• Key past medical history: Diagnosed with stage II breast cancer two years ago, currently under treatment for stage III colon cancer diagnosed six months ago, hypertension for ten years

• Current medications: Tamoxifen, Capecitabine, Lisinopril, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent abdominal pain and fatigue

• Key symptoms: Nausea, loss of appetite, changes in bowel habits, shortness of breath on exertion

• Vital signs: Blood pressure 145/90 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 37.8°C, oxygen saturation 93% on room air

Section 1

As the medical team conducts an initial assessment of the 58-year-old female patient, her symptoms and vital signs point to potential complications arising from her ongoing treatment for colon cancer. The abdominal pain and fatigue, coupled with nausea and changes in bowel habits, suggest a possible progression or complication related to her gastrointestinal system. Her vital signs reveal hypertension with a blood pressure of 145/90 mmHg, a heart rate of 105 bpm, and a respiratory rate of 22 breaths per minute, all indicative of physiological stress. The slight fever of 37.8°C and oxygen saturation of 93% on room air further hint at an inflammatory or infectious process.

Upon further investigation, laboratory results reveal an elevated white blood cell count and a marked increase in C-reactive protein (CRP), suggesting an inflammatory response or infection. Liver function tests show elevated liver enzymes, which could indicate hepatic involvement, possibly due to metastasis or liver congestion. Imaging studies, including an abdominal CT scan, identify multiple hepatic lesions consistent with metastatic disease, correlating with the elevated liver enzymes and providing insight into her persistent abdominal pain and fatigue.

The confirmation of hepatic metastasis represents a significant change in the patient's status, necessitating a re-evaluation of her current treatment regimen. The healthcare team must consider the implications of this development on her overall prognosis and the management of her colon cancer. This new complication requires careful clinical reasoning to balance her cancer treatment, manage her hypertension and diabetes, and address the potential for further metastatic spread. The focus will shift towards optimizing symptom control, evaluating the potential for additional systemic therapies, and coordinating palliative care interventions to improve her quality of life.

Section 2

Following the confirmation of hepatic metastasis, the medical team decides to initiate a more aggressive treatment plan aimed at slowing the progression of metastatic colon cancer while managing the patient's symptoms. The oncologist recommends a change in chemotherapy regimen to include a combination of FOLFIRI (leucovorin, fluorouracil, and irinotecan) with bevacizumab, an angiogenesis inhibitor, to target the metastatic lesions in the liver. However, before starting the new regimen, the patient experiences a sudden increase in abdominal distension and tenderness, raising concerns about possible bowel obstruction or perforation, which are known complications in advanced colon cancer cases.

A follow-up abdominal X-ray and CT scan confirm the presence of a partial bowel obstruction, likely caused by tumor growth impinging on the intestinal lumen. This finding necessitates immediate intervention to prevent complete obstruction and potential perforation. The surgical team is consulted to discuss the possibility of a palliative surgical procedure to relieve the obstruction. In the meantime, the patient is placed on IV fluids and electrolyte replacement to manage dehydration and electrolyte imbalances secondary to reduced oral intake and vomiting. Nasogastric tube insertion is considered to decompress the stomach and relieve symptoms of nausea and vomiting.

The patient's clinical status is closely monitored, with a particular focus on her vital signs and laboratory values. Her blood pressure stabilizes slightly with IV fluid resuscitation, though her heart rate remains elevated at 110 bpm, reflecting ongoing physiological stress. Repeat laboratory tests show a slight decrease in white blood cell count but persistently elevated CRP levels, consistent with ongoing inflammation. The healthcare team continues to evaluate her response to these interventions, preparing for potential surgical intervention and adjusting her treatment plan as necessary to manage both her cancer and its complications. This stage in her care emphasizes the importance of timely clinical decisions and multidisciplinary collaboration to optimize her quality of life.

Section 3

As the healthcare team continues to manage the patient's partial bowel obstruction, they closely monitor her clinical status and response to the interventions. Overnight, her abdominal distension decreases slightly with the nasogastric tube decompression, and she reports a modest reduction in nausea. However, in the early morning hours, the nurse notes a change in the patient's vital signs: her heart rate has increased to 120 bpm, and her blood pressure has dropped to 90/60 mmHg, suggesting potential hemodynamic instability. Additionally, the patient appears more lethargic and less responsive, raising concerns about her overall condition.

A repeat laboratory panel shows a further drop in hemoglobin to 8.5 g/dL, alongside a rising lactate level of 3.2 mmol/L, indicating possible tissue hypoperfusion and the risk of developing lactic acidosis. The patient's elevated CRP remains unchanged, signaling persistent inflammation. Given these findings, the team suspects that the partial obstruction may be progressing towards a more complete obstruction or that another complication, such as a microperforation, may be developing.

In response to these changes, the healthcare team convenes an urgent multidisciplinary meeting to reassess the treatment plan. The surgical team advocates for immediate intervention to explore and relieve the bowel obstruction, while the oncology team emphasizes the importance of stabilizing the patient hemodynamically before proceeding. The decision is made to initiate blood transfusion to address the anemia and optimize perfusion, alongside continued IV fluid management to support her blood pressure. The plan is to stabilize the patient sufficiently to proceed with exploratory surgery, with the goal of preventing further deterioration and improving her chances of a positive outcome. This juncture in the patient's care highlights the critical need for timely and coordinated decision-making to manage complex cancer-related complications effectively.

Section 4

As the healthcare team implements the plan, the patient's response to interventions is closely monitored. The blood transfusion is initiated, and over the next few hours, incremental improvements are noted. Her hemoglobin level rises to 9.5 g/dL, and her heart rate stabilizes at 100 bpm, reflecting an improved hemodynamic status. Blood pressure also shows a positive trend, increasing to 105/70 mmHg, suggesting a better perfusion state. The IV fluids continue to support her circulatory volume, and her overall responsiveness improves marginally, as she begins to engage more with the nursing staff, albeit still fatigued.

While these changes indicate some stabilization, the team remains vigilant for further signs of complication, as the patient's abdominal examination reveals persistent tenderness and a slight rebound tenderness, raising the suspicion of ongoing intra-abdominal pathology. Her lactate level, however, remains elevated at 2.9 mmol/L, which keeps the concern for tissue hypoperfusion and possible ischemia at the forefront of clinical considerations. Given these mixed signals, the team decides to proceed with an urgent CT scan of the abdomen to further elucidate the cause of her symptoms and guide the next steps in management.

The CT results reveal significant distension of the bowel with a transition point suggestive of a high-grade obstruction. No overt signs of perforation are noted, but there is mild free fluid present, which could indicate serosal irritation or early inflammation. These findings confirm the need for surgical intervention to resolve the obstruction and prevent further complications. With this information, the surgical team prepares for an expedited exploratory laparotomy, aiming to relieve the obstruction and address any underlying issues, while the oncology team focuses on maintaining optimal perioperative care for this complex patient. This coordinated approach underscores the importance of dynamic clinical reasoning and adaptability in managing multifaceted cancer-related complications.

Section 5

As the surgical team proceeds with the exploratory laparotomy, they encounter a high-grade obstruction caused by an adhesive band from prior abdominal surgeries. Carefully releasing the adhesions, the team successfully decompresses the bowel, restoring intestinal continuity. Intraoperative findings also reveal areas of bowel with compromised perfusion, prompting a limited resection to prevent further ischemic damage. The procedure concludes without complications, and the patient is transferred to the recovery unit for close postoperative monitoring.

In the immediate postoperative period, the patient's vital signs reveal a stable hemodynamic profile. Her heart rate remains at 98 bpm and blood pressure stabilizes at 110/75 mmHg. Despite these encouraging signs, the patient reports increased abdominal pain, now localized and severe. On examination, the surgical incision appears intact, but there is noticeable abdominal distension, raising suspicions of postoperative ileus or potential anastomotic leak. Her white blood cell count has risen to 15,000/µL, and her lactate level is persistently elevated at 3.2 mmol/L, both suggesting an inflammatory response or ongoing tissue stress.

The healthcare team recognizes the importance of differentiating between common postoperative changes and early signs of complications. They initiate supportive measures, including nasogastric decompression and careful fluid management, while preparing for further diagnostic evaluation. A contrast-enhanced CT scan is ordered to assess for signs of anastomotic integrity or other complications. These steps highlight the ongoing need for vigilant monitoring and timely intervention, as the team continues to navigate the complexities of managing this patient's cancer and surgical recovery.