Working on the Oncology ward, and wanting to provide high-quality, holistic care to your patients

This case looks at the experiences and needs of Dianne, a woman experiencing breast cancer. Below is some background to Dianne and her diagnosis

Dianne’s story

Dianne Jenkins is a fifty-one (51) year-old pre-menopausal lady who is married to her husband, Daryl. They have two (2) adult daughters who are married with small children of their own.

Diagnosis

Dianne finally got around to going to BreastScreen©  for a routine screening mammogram. This test is available free of charge to women aged over forty (40) in Victoria.

A call back from BreastScreen© was a complete surprise for Dianne, especially as she was asked to return BreastScreen© for further tests including: 

o    Repeat mammogram,

o    Breast and axilla ultrasound; and

o    stereotactic left breast biopsy

 

Results                                                                                                                 

 

Dianne received the results of the further investigations one week later, and the news was not what she had hoped for. 

o    There were no abnormalities detected (NAD) in the right breast;

o    Breast cancer was confirmed in the left breast. The biopsy results detected a grade 3 invasive ductal carcinoma that was estrogen-receptor positive, progesterone-receptor positive, an HER-2-receptor positive

o    The breast and axilla ultrasound detected an approximately 6cm-sized mass in the left breast, and nil axilla lymphadenopathy.  

o    No family history of breast or ovarian cancer. 

Referral

o    Dianne was referred to a breast surgeon and a plastic surgeon, and had a number of appointments back and forth with them. 

o    Dianne is an oncology nurse, with a lot of experience caring for women in just her situation. 

o    Dianne explained that “For me, the discussion about the pathology and management of my breast cancer needed to be extensive. I actually spoke with three breast surgeons about my options – I had to be sure!“. 

 

Treatment plans

o    Dianne discussed the results with the surgeons and explored all the options available before any decisions were agreed upon. 

o    In line with best practice, Dianne was referred to a breast care nurse for information and social support.

o    The agreed upon surgial approach was a left skin-sparing mastectomy with breast and nipple reconstruction and left sentinel node biopsy.

o    An immediate (not delayed) left-sided DIEP FLAP with nipple reconstruction was the autologous breast reconstruction option chosen.

Timing

o    There were 3 weeks from diagnosis to surgery.

o    This allowed Dianne and her family some pre-operative grieving time. 

o    Dianne said that this was “VERY IMPORTANT! I only found the right head space the day before surgery“. 

Surgery day  

The day arrives for Dianne’s surgery.

Dianne gets up. She begins fasting (water only) Tuesday 0630

 

Dianne arrives at the hospital and is admitted. Tuesday 0900

 

Dianne is taken to the nuclear medicine suite. She is injected with radioactive tracer under her nipple and told to massage the breast for 30 minutes (“unpleasant – VERY!“) .She then spends the next 1.5 hours in the nuclear medicine scanner. Tuesday 0915.

Dianne finally leaves the nuclear medicine suite. Tuesday 1130

 

Dianne is seen by the breast surgeon, breast care nurse, and the plastic surgeon. Photos are taken of her whole body. Texta lines are drawn over her breasts and abdomen to indicate cutting and shaping lines. Tuesday 1200

The anaesthetic team visit Dianne. She is given venous thromoembolism (VTE) prophylaxis and Thrombo embolytic deterrent (TED) compression stockings. Tuesday 1230

 

 

 

Dianne is taken to the anaesthetic room. EEG (electroencephalogram) electrodes are applied to her head to measure depth of sleep. Anaesthesia is needed to keep Dianne just below the pain recognition threshold, due to the expected duration of the surgery (10 hours). Tuesday 1300

IV and Arterial lines are inserted. Anaesthetic agents commenced Dianne is taken into theatre, an in-dwelling catheter (IDC) is inserted, and surgery begins. Tuesday 1300

The surgery is concluded. Dianne is taken to the post anaesthesia care unit (PACU) to recover. Tuesday 2230

Dianne is taken to the ward and settled into a private room. Dianne insists on seeing her husband and he is finally allowed in for 5 minutes. Flap observations commence (they continue every 30 mins for the next 3 days). Tuesday 2330

Plastic surgeon visits for Review. Wednesday 0100

 

Dianne is able to stand for 10 minutes at the bedside. Later in the day she takes a shower with 3 drainage tubes (2 in abdomen, 1 in breast), No dressing on breast flap, Combine and tapes across abdominal suture line, Tubigrip suit to get on and off IVs in each arm. Wednesday 1330

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After the surgery  

Intervention

Notes

Flap observations (breast)

Every 30 mins for 3 days

Antibiotics

IV, 4-6 hourly

Analgesia

·         IV morphine infusion (patient controlled analgesia; PCA) with NaCl background infusion

·         Assessing and documenting pain levels

·         Endone for breakthrough pain

·         Paracetamol slow release (SR)

Drain tubes x3

·         2 drain tubes in abdomen (one removed on day 6, second removed on day 10). 

·         1 drain tube in breast (removed on day 8)

IDC

·         Hourly urine measurement for 36 hours (removed day 3)

Dressings

·         No dressing on breast flap

·         Tapes and combine across abdominal suture line

Position

Z-type shape (semi-Fowler’s) with pillows under knees to keep pressure off abdomen

Other key information

Day 3: Dianne starts walking around the ward, increasing the number of circuits each day.

Day 6: Dianne gets the results of the surgery. (She learned that she had 6cms of invasive tumour detected. It had not metastasized to any axilla lymph nodes). 

Day 10: Dianne will be discharged in the afternoon.

Getting ready to go home

It’s day 10 and Dianne is about to be discharged. She’s carefully picking up her things and you are saying goodbye. You finish by telling Dianne:

“I know there’s a lot going on at the moment, and you probably want to just get home to your family, but you’ll probably think of lots of questions over the next few days and weeks, so here’s a factsheet I’ve put together based on previous questions from patients.

You’re past the first hurdle with the surgery, but you’ll still be seeing a lot of health professionals for the next few years. 

Hopefully this fact sheet will give you some information about all the support that is available, help when you’re experiencing strong emotions, and answer questions about what happens now.”

Professional Issues

  

Background

You are working on the Oncology ward, and wanting to provide high-quality, holistic care to your patients. 

In your respond, you should consider:

·          Psychosocial needs

·          Patient-centred care,

·         The effectiveness/effect of surgical, pharmacological and other interventions,

·         The role of nurses as part of inter-professional/multidisciplinary teams in the ongoing care of post-surgical oncology patients

 

Student response

Your student response needs to consist of three sections

 

Section 1: 

Dianne has just arrived on the ward on the day of the surgery. Identify some of the concerns Dianne might have [physical, psychological and other], and suggest how you might be able to help her to cope with those concerns during her stay in your ward. (300- 400 words)

Hints:  Would be better to identify say 2-4 key at each stage and concentrate on validating them. You may choose to consider key issues from a number of perspectives rather than limiting to one domain. For example- surgery and reconstruction may be considered as a physical issue; a psychological, emotional etc when you consider needs.

·          

 

Section 2:

It is now Day 2 (Dianne had surgery yesterday and is post-operative). What can you do, as a nurse, to meet her needs in a patient-centred way? (300 – 400 words)  

Hints: what is the nurse’s role in pain management? Assessment; management (administering prescribed meds; other pain management techniques-

 

Section 3:

It is Day 10. Dianne has been recovering well on the ward, and she is now ready for discharge. Knowing that she will have lots of questions over the next few days and weeks, you have put together a factsheet to give her, and her family, answers and tips. (Your factsheet should be ~300-400 words. You can include images and use different colours, dot points and fonts if desired). Use of layman’s terms (non-clinical phrasing) is expected, but you should reference or hyperlink to recognised sources (academic journals, government and non-governmental organisation websites, such as Cancer Council and Breastscreen). 

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