Mrs. Annie Flett, 68 y.o. was diagnosed with breast cancer

Case study: Mrs. Flett, the experience of cancer

Mrs. Annie Flett, 68 y.o. was diagnosed with breast cancer originally 8 years ago. She underwent a total

mastectomy on the L side, chemotherapy, radiation therapy, and endocrine therapy. She was deemed cancer-free at her 5-year follow-up. Two months ago there has been a recurrence of cancer this time with metastasis to the bone. She was diagnosed because of severe back pain that was eventually found to be a compression fracture of the spine secondary to bone mets. She received a course of urgent radiotherapy for the compression fracture and once this was completed, she started on chemotherapy 2 weeks ago as an outpatient. She has been staying in Winnipeg for her treatments along with her sister and husband in a room arranged through Cancer CareManitoba.

HxPI: Two days ago, she presented to the emergency room with a fever and is admitted with “febrile neutropenia”. She was also experiencing stomatitis, nausea, vomiting and diarrhea. The diarrhea has since resolved and the emesis has reduced but nausea persists. The pain in her mouth makes it difficult to eat or drink. Her back pain from the compression fracture has decreased a great deal but with this illness, the increased time in bed has aggravated it somewhat.

Social: Mrs. Flett is married has 4 adult children and seven grandchildren with her current husband. She and her husband live in St. Theresa Point First Nation Community. Their children live in various areas of the province. She also has a son from a previous relationship but they are estranged. Her husband has several chronic illnesses and Mrs. Flett was the one who generally coordinated his care before her cancer returned. She also provided daycare for 2 of her grandchildren most days. Her sister Mary accompanied Mr. and Mrs. Flett to Winnipeg from St. Theresa Point. She is helping out Mr. Flett with his medications and getting to the hospital due to mobility issues and a diabetic foot ulcer. Her one daughter, Laura and two teenaged granddaughters are in visiting today.

On admission: VS 98/55, 98 reg, 20 shallow, 97% on room air, 38 tympanic

A&O x3, fatigued, pale,

Open areas to oral mucosa, lips scabbed.

Poor skin turgor, +2 chronic lymphedema to L arm

From Kardex:

PICC to R upper arm

No BP or venipuncture to L arm

IV D5 ½NS @ 125ml/hr

I&O

Standard diet

Repeat blood cultures if temperature >38

Medications during this admission

metoclopramide 5 mg po/IV a.c. TID Ceftazidine 2 gm IV TID

ondansetron 8 mg IV BID allopurinol 300 mg po OD

dexamethasone 4 mg po BID hydromorphone contin 4 mg po BID

G-CSF (Neupogen) 300 ?g subcut. OD until ANC 1.0 Pamidronate 90 mg IV every friday

PRNs
hydromorphone 1-2 mg po/IV q 4h

prn dimenhydrinate 25-50 mg po/IV q 6h prn

acetaminophen 325-650 mg po q 4h prn

HEMATOLOGY	Normal Range	Admission value	Current value
WBC	4.5 – 11.0x10E9/L	1.0	1.0
ANC	1.5-8 x10E9/L	0.2	0.2
Platelets	140 – 450 fL	20	20
RBC	4.4 – 5.9 x10E12/L	3.6	4.71
RBC INDICIES
MCV	80-98 fL	85.3	84.7
MCH	26-34 pg	28.2	28
Hgb	140 – 180 g/L	86	80
Hct	0.4-0.52 1/L	0.318	0.299
General Chemistry
Anion gap	8 – 16 mmol/L	6	8
TCO2	22-30 mmol/L	30	25
Sodium	135-147 mmol/L	150	138
Potassium	3.5 – 5.0 mEq/L	3.0	3.5
Creatnine	44 – 106mmol/ L	56	50
BUN	2.8 – 7.1 mmol/L	4.6	5.2
Protein (total)	60-80 g/L	46	Not avail
Albumin	33-45 g/L	20	18
Calcium	2.1-2.6 mmol/L	2.8	2.6
Phosphate	0.81-1.45 mmol/L	0.95	0.98

Guiding questions

1. What may be contributing to Mrs Flett’s fatigue? Try to think of a variety of contributors.

For each one, list interventions that could help reduce the experience of fatigue. (List at least 3 factors and 2 interventions for each one)

2. What types of disabilities do you see Mrs. Flett experiencing? What things can off-set these

disabilities to maintain her independence? (List 2 disabilities and 2 actions to offset each)

3. What can be done to assist Mrs. Flett with pain control? Think of the different types of pain

and both pharmaceutical and non-pharmaceutical interventions. (list 3 pharmacological and 3 non-pharmocological actions)

4. Of the general potential complications which are most pertinent for Mrs.

Flett? How can the nurse minimize/reduce the risks? (List 2 potential complications and 3 actions to minimize risk)

5. Given Mrs. Flett has experienced cancer before, how might this influence this experience? How would you go about finding out about her personal experience so that her treatment plan is being sensitive to her experiences?

6. What is unique about Mrs. Flett’s family situation? How might this affect her experience?

Scenarios

7. You take Mrs. Flett’ temperature via her axilla because of her mouth sores and there are no tympanic thermometers where you work. The temperature is 37.5. What would you do?

8. Mrs. Flett is requesting breakthrough hydromorphone for her pain (located in her back and mouth) before the 4 hour prn period is up. How do you deal with this?

9. You come on shift a week later at 2330. Mrs. Flett still has the IV but is now NS at 125 ml/hr which has been running for past 2 days. The IPNs indicate she is now stable and likely to be discharged tomorrow or the next day. You enter her room, she is awake and her daughter lets you know her “hat” in the bathroom needs to be emptied. You notice the urine is pale, clear and there is 800 ml. What is your next move?

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