Cancer – Patient 1

Patient Data

Client was brought to the emergency department (ED) by her husband due to reports of severe fatigue. The husband reports that client has been sleeping all the time for the past few weeks and has been difficult to arouse at times. Client has a history of stage 4 breast cancer. Client has been receiving chemotherapy treatments through a central venous access device (CVAD) for the past few months. Client admits to having a poor appetite and drinking less fluids, but she denies nausea and vomiting. Client is alert and oriented but appears extremely drowsy. Client complains of dizziness when standing and walking.

Patient Data

• History and Physical
• Laboratory Results
• Flow Sheet

Vital Signs at the ED – temperature 98.6°F (37°C), heart rate 108 beats per minute, respiratory rate 18 breaths per minute, blood pressure 90/60 mm Hg, and pulse oximetry reading 96%

Rationale:

Potential Conditions:

Anemia is a common side effect of chemotherapy-induced bone marrow suppression. Neutropenia is characterized by a decrease in white blood cells (WBC), which increases the client’s susceptibility to infection. The client is most likely dehydrated and not experiencing fluid retention as a result of decreased fluid intake. Erythema is a skin reaction caused by radiation therapy

Actions to Take:

The client’s red blood cells (RBC), hemoglobin (Hgb), and hematocrit (Hct) will all decrease. These result in a lack of oxygen being transported throughout the body, resulting in extreme fatigue. A transfusion of packed red blood cells (PRBCs) would be used to treat anemia. Epoetin alfa is an erythropoiesis-stimulating agent used to treat chemotherapy-induced anemia. Petrolatum gauze would be applied to erythematous skin areas. Alopecia, a common side effect of cancer treatment, may be reduced by scalp cooling during chemotherapy. The client should be encouraged to drink fluids and eat high-calorie, nutritious foods.

Parameters to Monitor:

Epoetin alfa is an erythropoiesis-stimulating agent used to treat chemotherapy-induced anemia. After administering this medication, the LPN should monitor blood pressure for hypertension and blood flow obstruction, such as thrombosis. An electroencephalogram (EEG) is a test that measures the electrical activity of the brain. This is not usually done following cancer or anemia treatments. Serum glucose levels would be monitored in diabetic clients or as a side effect of a specific medication. This is not usually done following anemia treatments. If the client has liver failure rather than anemia, the abdominal girth is measured.

9m 54s

Clinical Judgment Skill(s):
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, Evaluate Outcomes

4 / 5 points

Cancer – Patient 2

Patient Data

0800

A 64-year-old Black man with suspected prostate cancer. Client has a history of smoking and hypertension. His father developed prostate cancer at the age of 55, and his brother who is 52 years old currently has prostate cancer. Digital rectal examination (DRE) last year revealed a prostate that was hard with indurated areas. Current prostate-specific antigen (PSA) is 8 ng/mL. Client reports frequent constipation and a history of gastroesophageal reflux disease (GERD).

Presents for transrectal imaging studies after referral from primary care. Reports difficulty urinating, specifically starting to urinate, and occasional hematuria. Pain with intercourse is also reported. Client denies pain but is anxious regarding the possible diagnosis and the scheduled invasive testing.

Weight 3 months prior: 210 lb. (95.2 kg)

Current weight: 198 lb. (89.8 kg)

Height: 5 feet, 11 inches

Vital Signs – heart rate 92 beats per minute, respiratory rate 20 breaths per minute, blood pressure 188/90 mm Hg, and oxygen saturation 95% on room air

0800

PSA: 8 ng/mL (<2.5 ng/mL)

0800

Vital Signs – heart rate 92 beats per minute, respiratory rate 20 breaths per minute, blood pressure 188/90 mm Hg, and oxygen saturation 95% on room air

Rationale:

Aging is the most important risk factor for prostate cancer. The client’s age, as well as his race, is a risk factor, as Black men are more likely to be affected than other racial groups. Having a first-degree relative diagnosed with prostate cancer increases the risk. This client has two first-degree relatives who are affected. The client’s prostate-specific antigen (PSA) level is high, which could indicate prostate cancer. The presence of a hard and indurated prostate on a digital rectal examination (DRE) is also suggestive of a malignancy. Signs and symptoms of prostate cancer include difficulty starting the flow of urine, hematuria, and pain during intercourse or ejaculation. The client’s weight loss could also be an indication of cancer.

A heart rate of 92 beats per minute and an oxygen saturation of 95% are both normal and do not indicate prostate cancer risk. Anxiety about a possible diagnosis and further testing is a normal reaction in a client suspected of having prostate cancer.

3m 41s

Clinical Judgment Skill(s):
Recognize Cues

4 / 5 points

Cancer – Patient 2

0800

Client came to the outpatient imaging center for a follow-up on suspected prostate cancer. Client is visibly anxious and requests to the be sedated for the procedure. Gown and changing instructions are provided. Teaching about the procedure was completed. Client reports that he is taking the prescribed antibiotic and that he hasn’t eaten anything this morning.

Rationale:

Prostate cancer is a tumor of the prostate gland that is frequently detected through a PSA screening. Although an elevated PSA level may indicate prostate cancer, a follow-up biopsy is advised. Unexpected weight loss is an assessment finding that is consistent with the diagnosis of prostate cancer. Difficulty urinating and pain during intercourse are symptoms associated with prostate cancer.

A pulse rate of 92 beats per minute is normal and unrelated to prostate cancer. A blood pressure reading of 188/90 mm Hg is not a common assessment finding in men with prostate cancer. Constipation could be caused by the client’s diet rather than prostate cancer.

56s

Clinical Judgment Skill(s):
Analyze Cues

7 / 7 points

Cancer – Patient 2

0800

Client came to the outpatient imaging center for a follow-up on suspected prostate cancer. Client is visibly anxious and requests to the be sedated for the procedure. Gown and changing instructions are provided. Teaching about the procedure was completed. Client reports that he is taking the prescribed antibiotic and that he hasn’t eaten anything this morning.

0830

Consent for the procedure and possible prostate biopsy on the chart. Teaching regarding the procedure provided at this time. Client appears anxious but did interact while discussing the procedure. Client spouse is at the bedside.

0800

PSA: 8 ng/mL (<2.5 ng/mL

0800

Vital Signs – heart rate 92 beats per minute, respiratory rate 20 breaths per minute, blood pressure 188/90 mm Hg, and oxygen saturation 95% on room air

Obtain consent for transrectal ultrasound with possible prostate biopsy.

Rationale:

Because of the prostate biopsy, the client is at the highest risk of infection. Although prophylactic antibiotics reduce the overall risk, the biopsy will pierce the rectal wall, posing an infection risk. Because of the client’s history of hematuria, anemia is not a concern. Rectal prolapse is unrelated to the transrectal biopsy or the possibility of prostate cancer in this client, and it is not a risk. Hemorrhoids may or may not be present, but they are unrelated to the transrectal biopsy or potential prostate cancer; there is no link to any of the client findings presented. A sexually transmitted infection can cause hematuria, but based on the assessment data, this is not the highest risk for this client.

42s

Clinical Judgment Skill(s):
Prioritize Hypotheses

1 / 1 points

Cancer – Patient 2

0830

Consent for the procedure and possible prostate biopsy on the chart. Teaching regarding the procedure provided at this time. Client appears anxious but did interact while discussing the procedure. Client’s spouse is at the bedside.

0800

PSA: 8 ng/mL (<2.5 ng/mL)

0800

Vital Signs – heart rate 92 beats per minute, respiratory rate 20 breaths per minute, blood pressure 188/90 mm Hg, and oxygen saturation 95% on room air

Obtain consent for transrectal ultrasound with possible prostate biopsy.

done

That’s right!

Rationale:

Informing the client that lidocaine is applied to the ultrasound probe prior to rectal insertion. The LPN will check for lidocaine allergies and explain how a lidocaine jelly is used to ease insertion into the rectum and reduce discomfort. Informing the client that hematuria is common after a prostate biopsy. Although rectal bleeding is possible, hematuria is far more common following the procedure. Placing the client on his side with his knees bent allows for rectal access and the insertion of the ultrasound probe. It is accurate teaching content to inform that PSA levels can be caused by conditions other than cancer. The PSA level alone is insufficient for diagnosing prostate cancer, and the current procedure is required for an accurate diagnosis. It is accurate teaching to explain that infection is a risk with the biopsy. Antibiotics taken prior to the procedure help to reduce the risk.

Informing the client that he will be asleep for the duration of the procedure is one action that the LPN will not anticipate in the plan of care at this time. This is incorrect. Some providers will administer a mild sedative prior to the procedure, but the client will not be anesthetized or fully asleep. It is accurate teaching to advise that a biopsy can be performed immediately if warranted. However, telling the client that there is no pain is not accurate. If a biopsy is necessary, many providers will inject lidocaine into the prostate to make the procedure more comfortable for the client. It’s not entirely accurate to say that prostate cancer grows slowly and rarely spreads. Although it is a slow-growing cancer, it can and does spread to other parts of the body.

1m 15s

Clinical Judgment Skill(s):
Generate Solutions

5 / 5 points

Cancer – Patient 2

Initial visit

Transrectal ultrasound: Finding consistent with malignancy. Biopsy performed. Stage 2 prostate cancer confirmed.

Rationale:

Low-dose brachytherapy is internal radiation therapy. Low-dose radiation seeds are implanted directly into the prostate tumor to treat prostate cancer. This is usually done under anesthesia, with a transrectal ultrasound guiding the placement of the seeds. After this treatment, the client will pose no risk to others. The radiation dose is low, and tissue penetration is minimal. As a result, the client is not radioactive and poses no risk to others. The client was diagnosed with stage 2 prostate cancer, which means that the cancer has not spread to the seminal vesicles or other organs.

Rationale:

Assessment findings indicating that interventions are effective include a lower PSA level, voiding with consistent urine stream, and a reduction in anxiety associated with the new cancer diagnosis. Reports of fatigue and erectile dysfunction are most likely related to low-dose brachytherapy and indicate an ineffective outcome, as the goal is for the client to be free of side effects. The client is still hypertensive and suffers from reflux. Both have no bearing on the outcomes of prostate cancer treatment.

54s

Clinical Judgment Skill(s):
Evaluate Outcomes