A patient with metastatic breast cancer has been experiencing increased fatigue and shortness of breath. Recent diagnostic imaging revealed multiple pulmonary nodules and a suspicious liver lesion, with laboratory results showing elevated liver enzymes and mild anemia. The oncology team has decided to initiate a new systemic therapy and involve palliative care. As the nurse caring for this patient, which of the following interventions should be prioritized to address the patient's immediate symptoms and improve her quality of life?

D) Coordinate with palliative care to manage the patient's symptoms.

A) Administer supplemental oxygen to alleviate shortness of breath.

B) Provide nutritional supplements to address mild anemia.

C) Educate the patient about the new systemic therapy regimen.

D) Coordinate with palliative care to manage the patient's symptoms.

A patient with metastatic breast cancer has been experiencing increased fatigue and shortness of breath. Recent diagnostic tests indicate multiple pulmonary nodules and a suspicious liver lesion. Laboratory results show mild anemia and elevated liver enzymes. Which nursing intervention is most appropriate to address the patient's fatigue?

B) Schedule frequent rest periods between activities to conserve energy.

A) Encourage the patient to participate in daily physical exercise to increase energy levels.

B) Schedule frequent rest periods between activities to conserve energy.

C) Administer supplemental oxygen to improve oxygenation and reduce fatigue.

D) Provide a high-calorie diet to support metabolic needs.

A patient undergoing systemic therapy for metastatic disease presents with new symptoms of abdominal pain, jaundice, and elevated liver enzymes. An ultrasound reveals bile duct dilation. What is the priority nursing intervention to address the patient's current condition?

B) Prepare the patient for possible biliary drainage procedure.

A) Administer prescribed antiemetic medication to manage nausea.

B) Prepare the patient for possible biliary drainage procedure.

C) Educate the patient about maintaining a low-fat diet to support liver function.

D) Monitor the patient's blood pressure and administer antihypertensives if needed.

A patient undergoing systemic therapy for metastatic cancer presents with persistent abdominal pain, jaundice, and elevated liver enzymes. An abdominal ultrasound indicates bile duct dilation. Which nursing intervention should be prioritized to address the patient's current condition?

B) Prepare the patient for an interventional radiology procedure for biliary drainage.

A) Administer the prescribed antiemetic medication to manage nausea.

B) Prepare the patient for an interventional radiology procedure for biliary drainage.

C) Educate the patient about dietary modifications to support liver function.

D) Monitor the patient's fluid intake and output to prevent dehydration.

A patient who recently underwent a percutaneous biliary drainage procedure is experiencing a low-grade fever and tachycardia. Which nursing intervention is the priority at this time?

B) Monitor the patient's vital signs and notify the healthcare provider of any significant changes.

A) Administer antipyretic medication to reduce the fever.

B) Monitor the patient's vital signs and notify the healthcare provider of any significant changes.

C) Encourage fluid intake to prevent dehydration.

D) Educate the patient about signs and symptoms of infection.

A patient who recently underwent a percutaneous biliary drainage procedure is now experiencing a low-grade fever, increased heart rate, and leukocytosis. What is the most appropriate initial nursing intervention to address the potential complication of infection in this patient?

C) Notify the healthcare provider immediately to discuss antibiotic therapy.

A) Administer antipyretics to manage the fever.

B) Increase fluid intake to help reduce the fever.

C) Notify the healthcare provider immediately to discuss antibiotic therapy.

D) Monitor vital signs every 4 hours and document changes.

A patient with a history of liver dysfunction and recent biliary drainage procedure is exhibiting signs of increased confusion and lethargy. The laboratory results show elevated ammonia levels and positive blood cultures for Escherichia coli. Which nursing intervention is most critical at this time to address the patient's condition?

A) Administer lactulose to reduce ammonia levels and monitor for bowel movements.

B) Increase fluid intake to support renal clearance of toxins.

C) Provide a high-protein diet to support energy needs.

D) Encourage ambulation to prevent deep vein thrombosis.

A patient is diagnosed with hepatic encephalopathy and cholangitis secondary to a biliary drainage procedure. The interdisciplinary team has initiated lactulose therapy to manage elevated ammonia levels. Which nursing assessment finding would indicate that the treatment is effective?

B) Improved orientation and mental status

A) Decreased serum bilirubin levels

B) Improved orientation and mental status

C) Reduced heart rate and fever

D) Negative blood cultures for Escherichia coli

A patient with hepatic encephalopathy is showing signs of mild jaundice and elevated bilirubin levels, suggesting potential biliary obstruction. Which nursing intervention is most appropriate to prioritize in this situation?

D) Prepare the patient for possible endoscopic or percutaneous biliary drainage procedures

A) Administer lactulose to reduce ammonia levels

B) Monitor vital signs and report any signs of hemodynamic instability

C) Educate the patient and family about the need for potential further interventions

D) Prepare the patient for possible endoscopic or percutaneous biliary drainage procedures

A patient with hepatic encephalopathy is showing signs of improvement; however, she has developed mild jaundice and an elevated bilirubin level. An ultrasound reveals dilation of the intrahepatic bile ducts. Which nursing intervention is most appropriate to address the current priority concern for this patient?

C) Prepare the patient for a possible endoscopic intervention.

A) Administer lactulose to decrease ammonia levels.

B) Monitor vital signs closely for signs of systemic infection.

C) Prepare the patient for a possible endoscopic intervention.

D) Initiate a low-protein diet to manage hepatic encephalopathy.

oncology - Nursing Case Study

Pathophysiology

• Primary mechanism: Uncontrolled cell proliferation - Cancer cells bypass normal regulatory mechanisms, leading to excessive growth and division due to genetic mutations in oncogenes and tumor suppressor genes.

• Secondary mechanism: Evasion of apoptosis - Cancer cells acquire the ability to evade programmed cell death, contributing to their survival and accumulation, often through mutations that affect apoptotic pathways.

• Key complication: Metastasis - Cancer cells invade surrounding tissues and spread to distant sites via blood or lymphatic systems, complicating treatment and worsening prognosis by establishing secondary tumors.

Patient Profile

Demographics:

45-year-old female, graphic designer

History:

• Key past medical history: Breast cancer stage II diagnosed 18 months ago, treated with lumpectomy and chemotherapy

• Current medications: Tamoxifen, Ondansetron as needed for nausea

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased fatigue and shortness of breath

• Key symptoms: Persistent cough, mild chest pain, unintentional weight loss over the past month

• Vital signs: Blood pressure 140/90 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, temperature 99.5°F (37.5°C), oxygen saturation 92% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, the oncology team decided to conduct further diagnostic tests to better understand the cause of the patient's increased fatigue and shortness of breath. A chest X-ray revealed multiple nodular opacities in both lungs, raising suspicion of metastatic spread. This finding prompted an urgent CT scan of the chest, which confirmed the presence of several small pulmonary nodules consistent with metastatic disease. Additionally, a PET scan was ordered to assess for further metastatic spread, revealing increased metabolic activity in the lungs and a suspicious lesion in the liver, suggesting possible hepatic involvement.

Laboratory tests were conducted to assess the patient's overall health status. The complete blood count showed mild anemia with a hemoglobin level of 10.5 g/dL, which could be contributing to her fatigue. Liver function tests revealed elevated liver enzymes, with alanine transaminase (ALT) at 75 U/L and aspartate transaminase (AST) at 85 U/L, indicating possible liver involvement. Tumor markers, including CA 15-3, were significantly elevated, supporting the suspicion of metastatic breast cancer progression.

The oncology team discussed these findings with the patient, explaining the implications of the metastatic disease and the need for a change in treatment strategy. Given the progression, the team recommended starting a new line of systemic therapy tailored to target the metastatic sites, with the goal of controlling the disease and improving her symptoms. This change in the treatment plan will require careful monitoring of her response and potential side effects, with regular follow-up appointments to reassess her condition and adjust the therapy as needed. The patient was also referred to a palliative care team to address her symptoms and improve her quality of life through supportive measures.

Section 2

Following the initiation of the new systemic therapy, the patient initially reported a mild improvement in her energy levels and a slight reduction in shortness of breath. However, during a routine follow-up appointment two weeks into the treatment, she presented with new symptoms including persistent abdominal pain and noticeable jaundice. Physical examination revealed scleral icterus and tenderness in the right upper quadrant of the abdomen. Vital signs showed a blood pressure of 110/70 mmHg, heart rate of 95 bpm, respiratory rate of 20 breaths per minute, and oxygen saturation of 94% on room air. These signs prompted further evaluation to assess potential complications.

A repeat set of liver function tests indicated further elevation in liver enzymes, with ALT rising to 110 U/L and AST to 120 U/L, alongside an increased bilirubin level of 3.5 mg/dL. These findings, combined with the patient's symptoms, suggested worsening hepatic involvement potentially due to the progression of metastatic lesions or a hepatotoxic reaction to the new medication. To differentiate between these possibilities, an urgent abdominal ultrasound was performed, which showed an increase in the size of the hepatic lesion with associated bile duct dilation, raising concern for biliary obstruction.

The oncology team, in collaboration with hepatology specialists, considered the implications of these new developments. The potential for biliary obstruction due to tumor growth necessitated an interdisciplinary approach to address the patient's worsening liver function and alleviate her symptoms. Interventional radiology was consulted for possible biliary drainage to relieve obstruction and improve the patient's condition. Meanwhile, discussions continued regarding the potential need to adjust her systemic therapy to minimize further liver damage while still addressing her metastatic disease. This situation required careful clinical reasoning to balance treatment efficacy with the management of emerging complications, emphasizing the need for ongoing monitoring and adaptive care strategies.

Section 3

Following the consultation with interventional radiology, the decision was made to proceed with a percutaneous biliary drainage procedure. The intervention was successful in relieving the obstruction, as evidenced by the immediate decrease in abdominal pain and a gradual improvement in jaundice. Over the next 48 hours, the patient's bilirubin levels decreased to 2.1 mg/dL, and her liver enzymes showed initial signs of stabilization, with ALT dropping to 85 U/L and AST to 95 U/L. These improvements suggested effective decompression of the biliary system and a positive response to the intervention.

However, during this period, the patient began to experience new complications. She developed a low-grade fever of 100.5°F, along with a mild increase in heart rate to 102 bpm. Blood cultures were obtained, given the risk of infection following an invasive procedure. Additionally, a complete blood count revealed leukocytosis with a white blood cell count of 15,000 cells/mm³, raising suspicion for a potential infection, possibly cholangitis or another procedure-related complication. The oncology and hepatology teams promptly initiated broad-spectrum antibiotics while awaiting culture results to address the possibility of infection effectively.

This new development required a reevaluation of the patient's care plan, emphasizing the need for vigilant monitoring of her clinical status and laboratory parameters. The interdisciplinary team discussed the importance of balancing aggressive management of any infectious process with the ongoing need to control the metastatic disease. Adjustments to her systemic therapy were considered, taking into account her hepatic function and the recent biliary intervention, to optimize her overall treatment outcomes while minimizing further complications.

Section 4

As the team continued to monitor the patient closely, her low-grade fever persisted, and her heart rate remained elevated. Over the following 24 hours, the patient began to exhibit signs of increased confusion and lethargy. A comprehensive neurological assessment was performed, revealing mild disorientation to time and place. Given these changes, the team considered the possibility of hepatic encephalopathy, a concern given her recent liver dysfunction and the ongoing risk of infection.

Laboratory tests were repeated to evaluate the potential causes of her altered mental status. Her ammonia levels were found to be elevated at 75 µmol/L, which supported the suspicion of hepatic encephalopathy. Meanwhile, the blood cultures returned positive for Escherichia coli, confirming a diagnosis of cholangitis secondary to the biliary drainage procedure. In response, the antibiotic regimen was adjusted to target the specific pathogen more effectively, and lactulose was initiated to address the elevated ammonia levels and support hepatic function.

These developments prompted the interdisciplinary team to revisit the patient's care plan. They emphasized the importance of maintaining a delicate balance between managing the infection and supporting her hepatic function to prevent further deterioration. Discussions were held to consider the timing and selection of systemic therapies for her metastatic disease, weighing the risks and benefits in the context of her current complications. The team remained vigilant, with frequent reassessments to monitor her response to these interventions, ensuring any adjustments to her treatment plan were made promptly to optimize her recovery trajectory.

Section 5

Over the next 48 hours, the patient's response to the interventions appeared cautiously optimistic. Her initial confusion and lethargy began to improve slightly, with her reorienting more accurately to time and place. However, her clinical picture remained complex. Despite the targeted antibiotic therapy, her low-grade fever persisted, and her white blood cell count remained elevated at 14,000/µL, indicating that the infection was still active albeit somewhat controlled. Her heart rate also stayed elevated, hovering around 110 beats per minute, raising concerns about potential cardiovascular stress due to a systemic inflammatory response.

The interdisciplinary team remained vigilant in their monitoring, recognizing that while the hepatic encephalopathy was showing signs of improvement, other complications could arise. On the third day of adjusted treatment, the patient started developing mild jaundice, with her bilirubin levels increasing to 3.5 mg/dL. This prompted an urgent reassessment of her hepatic function and the effectiveness of the biliary drainage. An ultrasound of the liver revealed dilation of the intrahepatic bile ducts, suggesting possible obstruction or incomplete drainage, which could potentially exacerbate her hepatic dysfunction and infection risk.

Given these findings, the team considered revising the drainage strategy, potentially exploring additional endoscopic or percutaneous interventions to ensure adequate bile flow. They also evaluated the need for further systemic therapies to manage her metastatic disease, mindful of the delicate balance required to avoid overwhelming her liver's capacity. The patient's family was updated on her condition, and discussions were initiated to reassess her goals of care, ensuring that her treatment plan remained aligned with her values and preferences. The team continued to prioritize her comfort and quality of life while navigating the complexities of her evolving clinical status.