Nursing Assignment: Case Analysis of Mrs Catherine Prakash

Question

Task: Case Study:
Mrs Catherine Prakash is a 34-year-old woman who presented to her General Practitioner (GP) for her yearly medical review. During her breast check the doctor found a palpable lump in her right breast. Catherine told her doctor that she noticed the lump about 6 months ago but was not worried as she was still breast feeding her 12-month-old baby and having “lumpy”breasts was normal for her. The GP ordered an urgent breast ultrasound. The ultrasound results show a small solid mass in her right breast. Catherine was referred to a breast surgeon for continued care. After further investigations by Dr. Middleton (breast surgeon) Catherine was diagnosed with Invasive Ductal breast carcinoma stage IIA. Catherine was scheduled for a Right Breast Partial Mastectomy and removal of several axillary lymph nodes the following week.

Catherine’s past history includes:
Medical: diagnosed with type 2 diabetes at 28 years old. Catherine weighs 91kg. Social: Catherine is married and has two children aged four years old and 12 months old. Catherine is a civil engineer working part-time with her local council.

Catherine was admitted to her local private hospital one day prior to her surgery so that the Clinical Nurse Consultant (CNC) who specialises in breast care can have a private consultation with her to discuss the surgery, postoperative expectations and ongoing care including the follow-up radiotherapy that will commenced in six weeks’ time. Catherine’s surgery went well. Post operatively on return to the ward Catherine’s vital signs are:

- BP 144/85mmHg, HR 89bpm, HR 16bpm, SpO2 96% on RA (room air) - BGL (Blood Glucose Level) 5.2mmol/L
- Current pain score 3/10

Catherine has insitu:
- aHaemovac drain with 10mL of bright red blood
- an intact dressing on her chest incision

Catherine has been ordered:
- I.V. Sodium Chloride 0,9% 1000mls 8 hourly
-Paracetamol 1 gram P.O. 6 hourly
-Morphine 2.5mg I.V. 6 hourly PRN
-Metoclopramide 10mg I.V. 8 hourly PRN

Consider the above case and prepare a nursing assignment addressing the following questions:
Question 1. Explain the pathogenesis of invasive ductal breast carcinoma.
Question 2. Explain how the administration of Morphine alters the conscious perception of pain.
Question 3. Explain the pathogenesis of Lymphoedema that may occur for women who have undergone axillary lymph node removal during breast cancer surgery.

Answer

Answer 1:Explain the pathogenesis of invasive ductal breast carcinoma.
It has been identified herein nursing assignment that approximately 90 percent of the case of breast carcinomas develops from the proliferation of tumors of the ductal epithelium, whereas the remaining tends to develop in the lobules. It has been examined that invasive breast carcinoma is a type of solid tumor that is visible grey-whitish with infiltrating irregular border to the adjacent adipose tissues of the suffering body. The uniformity of these cells is stable to solid which takes place due to calcifications reacting to the marked desmoplastic response.As the stages of invasive ductal breast carcinoma advance several changes within the color, texture, and structure of the affected area are observed which includes retraction of nipples due to infiltration of the tumor to the lactiferous duct, change in skin texture from normal to orange peel-like appearance. It occurs due to the development of lymphedema in the lymphatics by the tumor emboli. It also develops a state of fixation of the tumor to the skin which also changes the structure due to infiltration in the deep fascia or the pectoral muscles, and at the same time ulceration is identified when the skin gets infiltrated by the carcinoma cells. The pathophysiology of breast cancer or of invasive ductal breast carcinoma clearly defines the excessive proliferation of the carcinoma cells within the tissues inside the breast which further consists of genetic alteration in multiple numbers (Sun et al., 2017). Generally, it has been identified to take place at the genetic level due to having inherited carcinoma suspected genes or hormonal exposure.

Invasive ductal breast carcinoma thus has two natures of development which account for either hereditary or sporadic nature. Hereditary invasive ductal breast carcinoma arises in individual dye to having germline mutation of the gene called the tumor suppressor gene. It has been examined that the penetration of the hereditary breast malignancy gets influenced by environmental factors, while in case of the sporadic form of invasive ductal breast carcinoma, both genetic as well as environmental factor functions together to develop the state of cancer. Pathogenesis of invasive ductal breast carcinoma takes place when the damaged DNA doesn’t witness any repair mechanism to be actively working and the initiation of cell apoptosis takes place in order to remove or eliminate the damaged cells. At this point of apoptosis, the ATM gene identified the DNA damage and with the help of CHEK2 arrests the cell cycle of the damaged DNA within the breast tissue. The development of breast cancer thus takes place as soon as the ATM and CHEK2alongwith BRCA1 and BRCA2 lose their ability to repair the damaged DNA and thus allows the damaged DNA to survive and propagate to increase in number which takes the turn of carcinoma (Weidner et al., 2020). It has been also identified by several research studies that estrogens have a significant role in the development of breast cancer as during pregnancy, menstruation as well as puberty the cells sustain high turnover which tends to increases the chances of development of cancerous cells from normal cells due to conduction of apoptosis.

Answer2:Explain how the administration of Morphine alters the conscious perception of pain.
Morphine is known to possess analgesic properties which tend to block visual as well as affective factors related to pain. Morphine analgesia is known to be facilitated by the areas identified as supraspinal brain locations. The drug is known to suppress the changes developed within the flow of information due to pain, which generally flows in a direction of lateral from the medial pathway and to the thalamus from the hippocampus in the human body. The process thus tends to electrically inactive the nerve cells that function in sensing pain and thus inhibits the firing of multiple impulses. Morphine also functions by silencing the nerves that are present in the spine and serves the role of carrying signals related to pain which thus tends to dull or fade away the pain. It is also known to suppress the pain in different pain processing locations which are located in the brain as well as nerve pathways that function in controlling heart rate, breathing as well as blood pressures (Peng et al., 2017). It is thus recommended to avoid an overdose of morphine within a patient such as Mrs. Catherine Prakash as she has been identified to have the condition of high blood reassure and abnormal heart rate indicating a rapidly beating heart.

Answer3:Explain the pathogenesis of Lymphoedema that may occur for women who have undergone axillary lymph node removal during breast cancer surgery.
As the case study of Mrs. Catherine Prakash highlights the fact that she has undergone removal of several axillary lymph nodes as well as Right Breast Partial Mastectomy, it is identified that she might possess the risk of lymphedema. It is so because it has been found that approximately 1 in every 6 patients with treatment for a solid tumor or breast cancer surgery sustains the risk of development of lymphedema in the premises of the United States. The prevalence rate of Lymphedema has been increasing with the increase in the effective delivery of oncologic therapies in order to improve the survival of patients with carcinoma (Azhar et al., 2020). Current studies and researches have been supportive of the fact that the condition results in fibro adipose deposition, inflammation, dysfunctional lymphatic pumping as well as lymphangiogenesis. While the surgical procedure is carried out for the removal of carcinogenic cells, the lymph node present nearby the site of cancer is also eliminated. The condition thus disrupts and inhibits the normal flow of lymph within the regions thus developing major swelling within the area, this condition is known as lymphedema. It has the nature of affecting multiple regions such as the head, neck, arms, belly, legs as well as genitals (Grada & Phillips, 2017). Generally, during the treatment of breast cancers, the lymph nodes present under the arm called the axillary lymph node gets treated with the help of radiation. It serves in the draining process of lymphatic vessels from the breast, upper arm, chest, neck as well as underarm regions of the patient.

Lymphedema is thus explained as a localized form of swelling within the tissues with occurs due to excessive retention of the lymphatic fluid within the lymph node or the axillary lymph nodes and also caused by impaired drainage of lymphatic fluids. Lymphedema is thus focusing on its way of occurrence classified into two categories which include primary or secondary. Primary lymphedema is found to be caused by major development of the lymphatic vascular anomalies while Secondary lymphedema is examined to be developed due to the resulting underlying systemic disease, surgery, or trauma faced by the tissue (Dayan et al., 2018). As Mrs. Catherine Prakash underwent removal of a lymph node as well as right Breast Partial Mastectomy, she developed a greater risk of lymphedema for the rest of her remaining life. The pathogenies of the lymphedema thus explain the reason behind the development of risk of the condition in the case of Mrs. Catherine Prakash. As the lymph from the affected and surgical removed region will no longer be able to function and transfer normally which will thus form major selling leading to the development of lymphedema. Though the development of the condition can be right after surgical or radiation procedures, months or even years, thus the patient remains with the risk of the lifetime.

References:
Azhar, S. H., Lim, H. Y., Tan, B. K., & Angeli, V. (2020). The unresolved pathophysiology of lymphedema. Frontiers in physiology, 11, 137.

Dayan, J. H., Ly, C. L., Kataru, R. P., & Mehrara, B. J. (2018). Lymphedema: pathogenesis and novel therapies. Annual review of medicine, 69, 263-276.

Grada, A. A., & Phillips, T. J. (2017). Lymphedema: pathophysiology and clinical manifestations. Journal of the American Academy of Dermatology, 77(6), 1009-1020.

Peng, C., Li, C., Qu, J., & Wu, D. (2017). Gabapentin can decrease acute pain and morphine consumption in spinal surgery patients: a meta-analysis of randomized controlled trials. Medicine, 96(15).

Sun, Y. S., Zhao, Z., Yang, Z. N., Xu, F., Lu, H. J., Zhu, Z. Y., ... & Zhu, H. P. (2017). Risk factors and preventions of breast cancer. International journal of biological sciences, 13(11), 1387.

Weidner, A. E., Liggin, M. E., Zuniga, B. I., Tezak, A. L., Wiesner, G. L., & Pal, T. (2020). Breast cancer screening implications of risk modeling among female relatives of ATM and CHEK2 carriers. Cancer, 126(8), 1651-1655.