Inpatient Management Of Breast Cancer And Amputation Essay.

Breast Cancer: Diagnosis and Clinical Manifestation

Question:

Discuss About The Inpatient Management Of Diabetic Disorders?

Breast cancer is one of the most significant chronic health conditions for women and the rate of women suffering with this particular chronic health condition has been rising alarming in the past decade. Although it belongs to the most common occurrence of cancer in the aging women, according to research studies, 80% of the cases, with early diagnosis and evidence based treatment plan, it can be easily managed or even cured. However, it completely depends on the ability of the healthcare professionals for the early diagnosis and adequate care planning and evidence based practice is one way of ensuring best practice in health care (DeSantis et al., 2014). This assignment will attempt to formulate an evidence based practice for a patient suffering from breast cancer encountered in my professional practice, although the credentials of the patient will not be disclosed to protect the confidentiality and privacy (Early Breast Cancer Trialists' Collaborative Group., 2015).

The case report presents a scenario where a 38 year old female, divorced with two children, had been admitted to the facility with a mass in the right breast. The patient experienced the presence of the 1*1 cm mass over the upper quadrant of her right breast. The patient assessment data explains that the patient has reported that the mass had been moving and non- tender to touch. Accounting to the assessment data the mass has gradually enlarged for a few months and had been nontender to touch all along, however since the past month the patient has noticed skin dimpling in the right breast coupled with tenderness in her right breast, which has prompted her to seek medical advice. The past history of the patient includes cardiac distress and excessive smoking and anxiety attacks, although she had been under any heavy medication dosage (Cortazar et al., 2014). The patient is not an alcoholic and her menstruation cycles had been consistent as well with no major trauma in the past. The family history indicates mortality in the bloodline of her mother due to right breast cancer and her signs and symptoms also indicate at breast malignancy. For further confirmation that patient had been advised to go through a few diagnostic tests like mammogram and biopsy. Diagnostic mammography will help in discovering subtle abnormalities in the suspected site before the biopsy is performed. The excision biopsy revealed a 3*2.5cm mass in the right breast of the patient indicating at the presence of invasive ductal carcinoma (Wolff et al., 2013).

Importance of Evidence-Based Practice in Nursing

Invasive ductal carcinoma is considered to be one of the most common type of braest cancers frequently seen in women. In this type the abnormal cell growth priginates inthe milk duct and it gradually breaks through the walls and invade the rest of the breast tissues. Although, the proliferating cells may stay localized or they may move around in the body spreading the cancer everywhere, a pursuit usually in the later stages of the carcinoma. The clinical manifestation of this particular carcinoma includes the formation of a lump or thickening in the breast tissues which may appear like a hard rounded mass of cells to touch. The manifestation escalates within a few months by changes in the shape and size of the breast affected and increasing tenderness to the tissue (Goldhirsch et al., 2013). The clinical manifestations continue with the secretion of a clear or blood stained exudates from the nipple and the presence of skin dimpling, presence of scaly tissues or inflammation is also common occurrence, although it had been absent in case of the patient under consideration in the case study. The patient has also had redness on different areas of the breast and the presence of subtle abnormality in the overall appearance of the affected breast with a marble like hardened area under the skin or her right breast (Goldhirsch et al., 2013).

Breast cancer might be one of the most common health concern among middle aged or older women, the curability depends on early diagnosis and proper and timely treatment. In case of the patient under consideration for this assignment, there had been a number of health issues that the patient had been suffering with during her stay in the health care facility. One of the most important health issues with the patient had been the acute pain and tenderness she had been suffering with which prompted her to get admitted to the facility. And post diagnosis of her IDC, another most significant health issue for her had been extreme anxiety and fear (Coates et al., 2015).

Evidence based practice in the health care aims at arriving at best clinical decision regarding the health issues of the patients and address those issues with individual clinical expertise of the nursing professional and best external clinical advice or evidence available. In case of the patient under consideration the first issue that she had been experiencing had been pain for which the evidence based nursing intervention administered had been to administer non pharmacological pain management techniques like massage therapy, physical repositioning and relaxation therapy coupled with mild analgesics. For the extreme anxiety in the patient regarding the breast cancer and its possible outcome evidence based nursing intervention had been step by step patient education regarding the curability of IDC and relaxation techniques like meditation and music along with providing a safe and compassionate experience to the patient (Tutt et al., 2015).

Nursing Care Plan for Patient with Amputation

On a concluding note it can be stated that any chronic health condition, whether it is breast cancer or cardiovascular, nervous system or respiratory disorders, the recovery status of the patient depends completely on the perception of the patient regarding the medical condition and the proper treatment experience. Hence it is extremely importance for health care professionals to be compassionate and adhere to evidence based guidelines to ensure best treatment experience provided to such patients.

1.      NURSING CARE PLAN
MINIMIZE SENSORY PERCEPTIONS Paula may experience a phantom limb pain in her amputed leg after surgery.  She may experience unusual sensations, numbness, pain and muscle cramps. When she describes phantom pain, the nurse should acknowledge her feelings and help her to modify the perceptions (American Diabetes Association, 2016).	PROMOTE WOUND HEALING The nurse should handle the residual limb gently. She should use aseptic techniques while changing the dressing. This will prevent possible osteomyelitis and wound infections.
HELP THE PATIENT IN ACHIEVING MOBILITY The nurse should prevent development of knee joint or hip contracture in the patient. Flexion, abduction and external rotation of the lower extremities should be avoided. The residual limb should be placed in an elevated or extended position for a brief time period following advice from the surgeon, after amputation. The foot of the bed should be raised to extend the residual limb.	ENHANCE BODY IMAGE Amputation alters the body image of the patient. It is a reconstructive process. The nurse should establish a good rapport and trustworthy relationship with her patient. The patient will be then able to better communicate her problems. This will increase acceptance of the nurse for her patient who has undergone an amputation surgery. The nurse should encourage the patient to feel, look at and care for her residual limb The patient’s resources and strengths should be identified to facilitate proper rehabilitation. The nurse should assist the patient in regaining her previous confidence and independence. The patient should be accepted as a complete and normal person. This will make her readily resume self-care responsibilities. Her self-concept will improve and changes in body image will become accepted (Alavi et al., 2014)..

2.      DISCHARGE PLAN
Continue medication of Panadol and Ibuprofen. Immediately contact your healthcare provider if she feels the medicines are not helping.	Seek care from physicians immediately if there is severe pain in the residual limb or sudden chest pain occurs.
The skin around stitches can become red or swollen and may release pus from the wounds. The area should be cleaned and the doctor should be consulted.	The stitches can come apart and blood may soak through the bandage. Care should be taken to avoid stress on the limbs.
The foot should be elevated above heart level as often as the patient can. This will reduce pain and swelling.	A physiotherapist or occupational therapist should be contacted. Exercises will improve strength and movement of the limbs.
Regular monitoring of blood sugar levels should be done. Insulin doses should not be skipped. That will aggravate the condition.	A healthy sleeping pattern should be followed (Wukich et al., 2013)

3.      HEALTH TEACHING PLAN
The patient should be encouraged to actively participate in self-care. Family members should assist the patient in managing prosthetic devices if supplied, residual limb care and skin care.	The nurse should organize practice sessions that will enable the patient to understand the instructions needed to be followed after discharge.
The home environment should be assessed. An overnight or weekend visit may help in identifying the problems that will cause distress in the patient. The patient should be taught to follow the preventive healthcare measures written in her discharge plan.	The patient should be given proper information on the risk factors that can worsen her residual limb. She should be taught about the ill effects of high blood sugar level and the proper intervention strategies that need to be maintained for a holistic patient-centered care (Lowe et al., 2015).

Mrs Paula Jones, 68 year old lady was admitted to the hospital ward for a left below knee amputation. She was diagnosed with Diabetes Type 1 and was dependent on insulin. Along with that she was suffering with unhealed chronic leg ulcers on the left part of her shin for eleven months. She was also reported with poor eyesight and peripheral neuropathy in both the eyes due to glaucoma and cataracts. She did not even adhere to her diabetic diet with irregular checkups of her blood sugar levels.

The clinical manifestations of diabetes include polyuria, polyphagia and polydipsia followed by blurred vision, nausea that results into hyperglycemia (Surya et al., 2014). The feeling of fatique and weakness is usually caused by wasting of muscles due to insulin deficiency and weight loss with increased appetite, a catabolic state followed by reduced glycogen. Some of the long term affects of diabetes are damage in the heart’s large blood vessels followed by brain and legs. It can also damage the small blood vessels affecting the eyes, nerves, feet and kidney. The skin, teeth and the immune system are the other body parts that are affected (Forbes & Cooper, 2013).

A medical team, ward pharmacist, ward Nurse, Diabetes Inpatient specialist nurse (DISN) and foot care teams are the list of workers who are involved in the discharge planning of the diabetic foot amputation patient. The medical team should perform postoperative monitoring to minimise infection risk after discharge along with special referral to rehabilitation unit. Ward pharmacist should prescribe proper medicines. The ward nurse should provide proper guidelines to educate her. A dietician under the DISN should provide assessments on nutrition to manage body weight in diabetes.  And the foot care team should provide coordinated care service of glycemic control and proper management of the amputated foot (Hillson, 2015).

The strategic goals to manage the diabetic patient with foot amputation are done by performing the wound closure by removing foreign and infected materials. As diabetes is believed to be a multi organ disease, all the comorbodities that can influence the healing of the wound should be managed by the medical team. The primary reason behind the foot amputation in diabetes is reduced blood sugar control which should be monitored by measuring HbA1C level test. Offloading technique to modulate the pressures helps in managing the ulcers. Advanced dressing with proper education on managing the diabetes should also be implemented in recovery process of Paula (Yazdanpanah, Nasiri  & Adarvishi, 2015).

Discharge Plan for Patient with Amputation

The physical impact of diabetic foot amputation in Paula’s case is reduced mobility, deficits in her ADL that will adversely affect her life quality. It will exert negative impact on her psychosocial and social life with reduced activities with increased tension in the patient and her family and carers. The psychology impacts involves depression, anxiety disorders followed my adjustment disorders (Crews et al., 2016).

The available resources and support services that should be made available to Paula upon her discharge from the rehabilitation centre to home were a proper counselling as she was not accepting the pain of being amputed. The social workers of the hospital should assist her for proper orthotics, assistive devices and physiotherapy at home to recover in an effective way (Acker et al., 2014).

The case study represents a patient named Shane Gillespie, and 80 year old male suffering with exacerbation of chronic obstructive pulmonary disorders along with abrasions to his left shin and elbow along with a cut to the forehead due to sustaining a fall.  The chronic health problems associated with the patient include exacerbations of COPD, risk of fall, living on his own, extreme shortness of breath and anxiety. The patient has been an smoker for 46 years of his life, and has stopped smoking 20 years ago all that he had a past medical history of chronic asthma since very childhood and epilepsy, which indicates significant risk factors for the chronic obstructive pulmonary disorders he has been suffering with (Ford et al., 2015).

The clinical manifestation of chronic obstructive pulmonary disorder includes extreme shortness of breath with the patient has been experiencing, although the shortness of breath increases especially during physical activity that may be strenuous for the patient. Along with that, wheezing and extreme tightness of the chest muscles is also associated with manifestation of COPD. Chronic recurrent coughing coupled with production and accumulation of excessive sputum is also considered to be a significant clinical manifestation of COPD. The long term effects of a severe chronic obstructive pulmonary disorders on the body system of the patient may include increased susceptibility to frequent lung infections such as pneumonia and increased risk of osteoporosis in the patient that are taking oral corticosteroids for COPD (Ford et al., 2015).

COPD is considered to be one of the most frequent respiratory disorders, and there are various contributing risk factors that can cause this particular disease. Among all the risk factors, smoking is considered to be the most significant one, as the patient has been the chain- smoker for 46 years of his life, smoking 25 cigarettes a day, the adverse effects on his lung passages and respiratory airways due to excessive consumption of nicotine and smoke fumes, is possibly the most applicable cause for the COPD in the patient under consideration. Along with that, his previous medical history of chronic asthma since childhood can be another significant risk factor for this disease (Criner et al., 2015).

Teaching Plan for Patient with Amputation

Multidisciplinary Healthcare is the most vital concept of modern treatment and care patterns, and COPD being a chronic respiratory disorder, the patient under consideration will also receive the care of a specialized and specific multidisciplinary healthcare team. The specialized multidisciplinary team for Shane will include a hospitalist physician who will be the clinical decision maker for the patient outlining the diagnosis and treatment pattern, pulmonologist who will take specialized care of the lungs and respiratory system of the patient, respiratory therapist who will win the patient in Nebulizer treatments and invasive and noninvasive ventilator support therapies, pharmacist responsible for cash transactions for the patient including different kinds of therapies, nursing professionals including registered nurses, enrolled nurses, and physician assistants, responsible for the entire caring for the patient. And lastly social workers and care manager is responsible for address in a psycho-social and support issues of the patient (Magnussen et al., 2014).

There are different physical and psychosocial aspects associated with the care that the patients receive in the health care facility. The physical aspects of care will include ensuring that the patient remains safe and comfortable all throughout his stay in the facility, as the patient in this case scenario had sustained a few injuries due to falling as well, the physical aspect of a sound optimal care for him will also include wound and pain management for his injuries and a complete fall risk assessment for the patient (Magnussen et al., 2014). Considering the psychosocial aspects of care, as the patient is lonely and responsible for his own well being, social support must be provided to him along with counseling and social inclusion activities like group therapies to help him overcome his medical complexities with adequate social support (Belchamber et al., 2015).

Conclusion:

As the patient is extremely elderly at the age of 80 and is living alone, the support services and resources that he will be applicable for include respite care, addictive home care, transport assistance, information services, group and individual counseling therapies, social inclusion activities, and dementia support programs if applicable (Postma & Rabe, 2015).

As the patient is unconscious, is not breathing and there is no portable Pulse for the patient it can be considered that the patient is undergoing a heart attack. The emergency procedures and protocols to be followed in such a situation comprises of immediate administration of CPR to the patient, followed by administration of oral nitroglycerin preferably under the tongue of the patient, after breeding of the patient returns moved immediately to the emergency department and consulting a cardiac specialist as soon as possible (Callaway et al., 2015).

The emergency trolley on crash guard is a set of case laws on self with attached wheels utilize in the hospital for transportation of emergency medication and equipment for life support protocols at site at the purpose of potentially saving someone's life. An emergency trolley generally contains defibrillators, suction devices, BVMs, advanced cardiac life support drugs such as epinephrine, atropine, amiodarone, sodium bicarbonate, dopamine, vasopressin, first line drugs for cardiac treatment such as naloxone, nitroglycerin, drugs for Rapid sequence intubation, peripheral and Central venous access drugs, pediatric equipment, etc.  Out of these, equipments that could be used in this situation include advanced cardiac life support drugs, nitroglycerin,  suction devices to clear his airway and defibrillators (Soar et al., 2015).

The emergency response team within Hospital scenario includes of members like patient decontamination expert, who will  prevent any contamination happening to the patient, the emergency department executive, for rapid response, radiation safety officer, who will review and edit all radiological emergency plans, security officer taking into consideration complete security of the patient, spill team member, environmental service officer, what are the responsibility of controlling and management of the entire scenario, and clinical expert lead the immediate treatment plan for the patient (Soar et al., 2015).

The medications used in case of a cardiac arrest are generally, cardiac life support drugs such as epinephrine, and vasodialators like nitroglycerin.

Epinephrine: use: reversing the effects of cardiac arrest

action: increases arterial blood pressure and causes coronary perfusion

dose: 1mg

side effect: incorrect pulse, headache, nausea, sweating, paleness, vomiting (Callaway et al., 2015).

Nitroglycerine: use: coronary artery dilator

action: settling coronary vasospasm

dose: 40 U IV/IO

side effects: uneven heart rate, blurred vision, nausea, vomiting, sore throat (Callaway et al., 2015)

References:

Acker, K., Léger, P., Hartemann, A., Chawla, A., & Siddiqui, M. K. (2014). Burden of diabetic foot disorders, guidelines for management and disparities in implementation in Europe: a systematic literature review. Diabetes/metabolism research and reviews, 30(8), 635-645.

Alavi, A., Sibbald, R. G., Mayer, D., Goodman, L., Botros, M., Armstrong, D. G., ... & Kirsner, R. S. (2014). Diabetic foot ulcers: Part I. Pathophysiology and prevention. Journal of the American Academy of Dermatology, 70(1), 1-e1.

American Diabetes Association. (2016). Standards of medical care in diabetes—2016 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 34(1), 3.

Belchamber, K., Singh, R., Wedzicha, J., Barnes, P., & Donnelly, L. (2015). Elevated mitochondrial reactive oxygen species in COPD macrophages at exacerbation.

Callaway, C. W., Donnino, M. W., Fink, E. L., Geocadin, R. G., Golan, E., Kern, K. B., ... & Zimmerman, J. L. (2015). Part 8: Post–Cardiac Arrest Care. Circulation, 132(18 suppl 2), S465-S482.

Chiauzzi, E., Rodarte, C., & DasMahapatra, P. (2015). Patient-centered activity monitoring in the self-management of chronic health conditions. BMC medicine, 13(1), 77.

Coates, A. S., Winer, E. P., Goldhirsch, A., Gelber, R. D., Gnant, M., Piccart-Gebhart, M., ... & Baselga, J. (2015). Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015. Annals of oncology, 26(8), 1533-1546.

Cortazar, P., Zhang, L., Untch, M., Mehta, K., Costantino, J. P., Wolmark, N., ... & Swain, S. M. (2014). Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. The Lancet, 384(9938), 164-172.

Crews, R. T., Schneider, K. L., Yalla, S. V., Reeves, N. D., & Vileikyte, L. (2016). Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review. Diabetes/metabolism research and reviews, 32(8), 791-804.

Criner, G. J., Voelker, H., Albert, R. K., Bailey, W. C., Casaburi, R., Cooper, J. A. D., ... & Marchetti, N. (2015). Cardiac Events And Relationship To Rates Of Acute Exacerbation In COPD. In B23. WHEN I GET HOME: CONFRONTING THE CHALLENGES OF COPD EXACERBATION (pp. A6368-A6368). American Thoracic Society.

DeSantis, C., Ma, J., Bryan, L., & Jemal, A. (2014). Breast cancer statistics, 2013. CA: a cancer journal for clinicians, 64(1), 52-62.

Early Breast Cancer Trialists' Collaborative Group. (2015). Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials. The Lancet, 386(10001), 1341-1352.

Fisher, L., & Dickinson, W. P. (2014). Psychology and primary care: New collaborations for providing effective care for adults with chronic health conditions. American Psychologist, 69(4), 355.

Forbes, J. M., & Cooper, M. E. (2013). Mechanisms of diabetic complications. Physiological reviews, 93(1), 137-188.

Ford, E. S., Murphy, L. B., Khavjou, O., Giles, W. H., Holt, J. B., & Croft, J. B. (2015). Total and state-specific medical and absenteeism costs of COPD among adults aged≥ 18 years in the United States for 2010 and projections through 2020. Chest Journal, 147(1), 31-45.

Goldhirsch, A., Winer, E. P., Coates, A. S., Gelber, R. D., Piccart-Gebhart, M., Thürlimann, B., ... & Bergh, J. (2013). Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Annals of oncology, 24(9), 2206-2223.

Henry, H. K., & Schor, E. L. (2015). Supporting self-management of chronic health problems. Pediatrics, 135(5), 789-792.

Hillson, R. (2015). Diabetes care: a practical manual. OUP Oxford.

Lawson, D. A., Bhakta, N. R., Kessenbrock, K., Prummel, K. D., Yu, Y., Takai, K., ... & Yaswen, P. (2015). Single-cell analysis reveals a stem-cell program in human metastatic breast cancer cells. Nature, 526(7571), 131.

Lorig, K., Ritter, P. L., Pifer, C., & Werner, P. (2014). Effectiveness of the chronic disease self-management program for persons with a serious mental illness: a translation study. Community mental health journal, 50(1), 96-103.

Lowe, J., Sibbald, R. G., Taha, N. Y., Lebovic, G., Martin, C., Bhoj, I., ... & Ostrow, B. (2015). The Guyana diabetes and foot care project: a complex quality improvement intervention to decrease diabetes-related major lower extremity amputations and improve diabetes care in a lower-middle-income country. PLoS medicine, 12(4), e1001814.

Magnussen, H., Disse, B., Rodriguez-Roisin, R., Kirsten, A., Watz, H., Tetzlaff, K., ... & Chanez, P. (2014). Withdrawal of inhaled glucocorticoids and exacerbations of COPD. New England Journal of Medicine, 371(14), 1285-1294.

Miodrag, N., Burke, M., Tanner?Smith, E., & Hodapp, R. M. (2015). Adverse health in parents of children with disabilities and chronic health conditions: a meta?analysis using the Parenting Stress Index's Health Sub?domain. Journal of Intellectual Disability Research, 59(3), 257-271.

Patterson, M. L., Moniruzzaman, A., & Somers, J. M. (2014). Setting the stage for chronic health problems: cumulative childhood adversity among homeless adults with mental illness in Vancouver, British Columbia. BMC public health, 14(1), 350.

Postma, D. S., & Rabe, K. F. (2015). The asthma–COPD overlap syndrome. New England Journal of Medicine, 373(13), 1241-1249.

Soar, J., Nolan, J. P., Böttiger, B. W., Perkins, G. D., Lott, C., Carli, P., ... & Sunde, K. (2015). European Resuscitation Council guidelines for resuscitation 2015. Resuscitation, 95, 100-147.

Surya, S., Salam, A. D., Tomy, D. V., Carla, B., Kumar, R. A., & Sunil, C. (2014). Diabetes mellitus and nursing plants-a review. Asian Pacific Journal of Tropical Disease, 4(5), 337-347.

Tutt, A., Ellis, P., Kilburn, L., Gilett, C., Pinder, S., Abraham, J., ... & Dowsett, M. (2015). Abstract S3-01: the TNT trial: a randomized phase III trial of carboplatin (C) compared with docetaxel (D) for patients with metastatic or recurrent locally advanced triple negative or BRCA1/2 breast cancer (CRUK/07/012).

van Boven, J. F., Román-Rodríguez, M., Palmer, J. F., Toledo, N., Cosío, B. G., & Soriano, J. B. (2015). LATE-BREAKING ABSTRACT: Prevalence of comorbidities in patients with asthma-COPD overlap syndrome (ACOS) in primary care. European Respiratory Journal, 46(suppl 59), OA4786.

Wolff, A. C., Hammond, M. E. H., Hicks, D. G., Dowsett, M., McShane, L. M., Allison, K. H., ... & Hanna, W. (2013). Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. Journal of clinical oncology, 31(31), 3997-4013.

Wukich, D. K., Armstrong, D. G., Attinger, C. E., Boulton, A. J., Burns, P. R., Frykberg, R. G., ... & Pinzur, M. S. (2013). Inpatient management of diabetic foot disorders: a clinical guide. Diabetes Care, 36(9), 2862-2871.

Yazdanpanah, L., Nasiri, M., & Adarvishi, S. (2015). Literature review on the management of diabetic foot ulcer. World journal of diabetes, 6(1), 37.