lOMoAR cPSD| 6070128
Breast Cancer/Complications of Chemotherapy
SKINNY Reasoning
Jan Leisner, 50 years old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
• Fluid and Electrolyte Balance
• Cellular Regulation
• Immunity
• Stress
• Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
□ Management of Care 17-23%
□ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
□ Basic Care and Comfort 6-12%
© 2018 Keith Rischer/www.KeithRN.com
, lOMoAR cPSD| 6070128
□ Pharmacological and Parenteral Therapies 12-18%
□ Reduction of Risk Potential 9-15%
□ Physiological Adaptation 11-17%
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jan Leisner is a 50-year-old Caucasian woman who has been healthy with no previous medical history. One year ago, she
noted a small palpable lump in her right breast about the size of an almond. Because she has been healthy, she assumed it
was nothing and ignored it. Over the last month she has noted that this lump has been increasing in size. Her mammogram
confirmed a 5 cm mass. An ultrasound biopsy confirmed the presence of cancer cells in the tumor as well as in three of
her lymph nodes most proximal to the tumor. An MRI scan that followed revealed a 1 cm tumor on her lumbar spine. She
is not a surgical candidate at this time, so an implanted venous access device (VAD) will be placed later this afternoon so
that chemotherapy can be started as soon as possible. You are the nurse responsible for her care on the oncology unit of a
community hospital.
Personal/Social History:
Jan has four children under the age of 17. She has no personal or family history of breast cancer. She has never smoked
and lives with her husband in a suburban community. She works part-time as a substitute teacher. Jan is a devout Christian
who has a strong faith and trust in God. She also believes in the power of prayer and believes that God can heal her. She
chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
One year ago she noted a small palpable lump Any lump in the breast area has the potential to be cancerous and
in her right breast about the size of an almond. needs to be followed up. The majority of breast masses are benign,
10% are cancerous…Irregular fixed masses are suspicious for
malignancy [Epocrates, 2015].
Over the last month she has noted that this lump A rapidly growing lump is a clinical RED FLAG, a cause for
has been increasing in size. Her mammogram concern, and must not be ignored! Though denial is a common
confirmed a 5 cm mass. coping mechanism, in this context it could be deadly!
This biopsy confirmed the presence of cancer Cancer that has progressed to lymph nodes is a clinical RED FLAG
that increases the likelihood of metastasis. Finding cancer cells in the
cells in the tumor as well as in three of her
lymph nodes is stage III because of their close proximity to the
lymph nodes most proximal to the tumor. primary tumor.
The MRI scan revealed a 1 cm tumor on her Metastasis from the primary site to a distant location meets the
lumbar spine. criteria for stage IV. This is the worst possible staging and makes this
a terminal diagnosis.
RELEVANT Data from Social History: Clinical Significance:
Jan has 4 children under the age of 17. She is a mother with children whom she wants to see grow up. This
complicates this scenario for both Jan and the nurse. The stakes are
high, but the nurse can make a difference by choosing to ENGAGE in
her experience and make the “art” of nursing a priority to support
her holistically.
With any serious illness, but especially a terminal illness such as
Jan is a Christian who has a strong faith and cancer, to provide true holistic care, the nurse must be willing to
© 2018 Keith Rischer/www.KeithRN.com
, lOMoAR cPSD| 6070128
trust in God who also believes in the power of gently “go there” when appropriate and establish a trust relationship.
prayer and believes that God can heal her. I have found that any one of the following spiritual assessment
questions can guide the nurse to support this patient’s spiritual needs:
□ “What is your source of strength, peace, and hope in this
illness?
• “Are you connected with a faith community?”
• “How has this illness affected your faith?”
• “What can I do to support your faith?”
She chose to have a mammogram before her A lack of insurance also complicates this scenario! Social services
husband’s insurance plan expired because he must be consulted to see what state/federal health programs for which
just lost his job. she may be eligible.
Five Weeks Later…
Jan is promptly started on chemotherapy of Cytoxan and Adriamycin every three weeks for the next three months. Two
weeks after her first chemotherapy treatment she experiences persistent nausea and vomiting, and has been unable to keep
anything down the past 24 hours. She has fatigue so severe she has been unable to move off the couch for the past three
days, and has experienced night sweats with a fever last night. After contacting her oncologist, he arranges to have Jan
admitted directly to the med/surg floor where you will be the nurse responsible for her care.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.5 F/38.6 C (oral) Provoking/Palliative: Eating/nothing
P: 110 (regular) Quality: Sharp, ache
R: 20 Region/Radiation: Mouth/tongue
BP: 96/40 Severity: 5/10
O2 sat: 98% room air Timing: Persistent the past 3 days
Orthostatic BP’s:
Position: HR: BP:
Lying 110 96/40
Standing 136 82/42
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 101.5 F/38.6 C (oral) Fever in the context of likely neutropenia after chemotherapy has been
started is a clinical RED FLAG! Further lab tests are needed to identify the
source. The nurse will need to situate this knowledge to identify and
anticipate current care priorities.
P: 110 (regular) WHY is her heart rate elevated?
Elevated HR could reflect increased metabolic needs driven by fever; she
likely has an infection. This has a RELATIONSHIP to fluid volume deficit
that will also cause tachycardia. Bring back pathology….CO=SVxHR and
© 2018 Keith Rischer/www.KeithRN.com
Breast Cancer/Complications of Chemotherapy
SKINNY Reasoning
Jan Leisner, 50 years old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
• Fluid and Electrolyte Balance
• Cellular Regulation
• Immunity
• Stress
• Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
□ Management of Care 17-23%
□ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
□ Basic Care and Comfort 6-12%
© 2018 Keith Rischer/www.KeithRN.com
, lOMoAR cPSD| 6070128
□ Pharmacological and Parenteral Therapies 12-18%
□ Reduction of Risk Potential 9-15%
□ Physiological Adaptation 11-17%
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jan Leisner is a 50-year-old Caucasian woman who has been healthy with no previous medical history. One year ago, she
noted a small palpable lump in her right breast about the size of an almond. Because she has been healthy, she assumed it
was nothing and ignored it. Over the last month she has noted that this lump has been increasing in size. Her mammogram
confirmed a 5 cm mass. An ultrasound biopsy confirmed the presence of cancer cells in the tumor as well as in three of
her lymph nodes most proximal to the tumor. An MRI scan that followed revealed a 1 cm tumor on her lumbar spine. She
is not a surgical candidate at this time, so an implanted venous access device (VAD) will be placed later this afternoon so
that chemotherapy can be started as soon as possible. You are the nurse responsible for her care on the oncology unit of a
community hospital.
Personal/Social History:
Jan has four children under the age of 17. She has no personal or family history of breast cancer. She has never smoked
and lives with her husband in a suburban community. She works part-time as a substitute teacher. Jan is a devout Christian
who has a strong faith and trust in God. She also believes in the power of prayer and believes that God can heal her. She
chose to have a mammogram just before her husband’s insurance plan expired because he just lost his job.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
One year ago she noted a small palpable lump Any lump in the breast area has the potential to be cancerous and
in her right breast about the size of an almond. needs to be followed up. The majority of breast masses are benign,
10% are cancerous…Irregular fixed masses are suspicious for
malignancy [Epocrates, 2015].
Over the last month she has noted that this lump A rapidly growing lump is a clinical RED FLAG, a cause for
has been increasing in size. Her mammogram concern, and must not be ignored! Though denial is a common
confirmed a 5 cm mass. coping mechanism, in this context it could be deadly!
This biopsy confirmed the presence of cancer Cancer that has progressed to lymph nodes is a clinical RED FLAG
that increases the likelihood of metastasis. Finding cancer cells in the
cells in the tumor as well as in three of her
lymph nodes is stage III because of their close proximity to the
lymph nodes most proximal to the tumor. primary tumor.
The MRI scan revealed a 1 cm tumor on her Metastasis from the primary site to a distant location meets the
lumbar spine. criteria for stage IV. This is the worst possible staging and makes this
a terminal diagnosis.
RELEVANT Data from Social History: Clinical Significance:
Jan has 4 children under the age of 17. She is a mother with children whom she wants to see grow up. This
complicates this scenario for both Jan and the nurse. The stakes are
high, but the nurse can make a difference by choosing to ENGAGE in
her experience and make the “art” of nursing a priority to support
her holistically.
With any serious illness, but especially a terminal illness such as
Jan is a Christian who has a strong faith and cancer, to provide true holistic care, the nurse must be willing to
© 2018 Keith Rischer/www.KeithRN.com
, lOMoAR cPSD| 6070128
trust in God who also believes in the power of gently “go there” when appropriate and establish a trust relationship.
prayer and believes that God can heal her. I have found that any one of the following spiritual assessment
questions can guide the nurse to support this patient’s spiritual needs:
□ “What is your source of strength, peace, and hope in this
illness?
• “Are you connected with a faith community?”
• “How has this illness affected your faith?”
• “What can I do to support your faith?”
She chose to have a mammogram before her A lack of insurance also complicates this scenario! Social services
husband’s insurance plan expired because he must be consulted to see what state/federal health programs for which
just lost his job. she may be eligible.
Five Weeks Later…
Jan is promptly started on chemotherapy of Cytoxan and Adriamycin every three weeks for the next three months. Two
weeks after her first chemotherapy treatment she experiences persistent nausea and vomiting, and has been unable to keep
anything down the past 24 hours. She has fatigue so severe she has been unable to move off the couch for the past three
days, and has experienced night sweats with a fever last night. After contacting her oncologist, he arranges to have Jan
admitted directly to the med/surg floor where you will be the nurse responsible for her care.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 101.5 F/38.6 C (oral) Provoking/Palliative: Eating/nothing
P: 110 (regular) Quality: Sharp, ache
R: 20 Region/Radiation: Mouth/tongue
BP: 96/40 Severity: 5/10
O2 sat: 98% room air Timing: Persistent the past 3 days
Orthostatic BP’s:
Position: HR: BP:
Lying 110 96/40
Standing 136 82/42
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 101.5 F/38.6 C (oral) Fever in the context of likely neutropenia after chemotherapy has been
started is a clinical RED FLAG! Further lab tests are needed to identify the
source. The nurse will need to situate this knowledge to identify and
anticipate current care priorities.
P: 110 (regular) WHY is her heart rate elevated?
Elevated HR could reflect increased metabolic needs driven by fever; she
likely has an infection. This has a RELATIONSHIP to fluid volume deficit
that will also cause tachycardia. Bring back pathology….CO=SVxHR and
© 2018 Keith Rischer/www.KeithRN.com
