CASE STUDY & NURSING CARE PLAN 1

A Patient with Melanoma

Mr. Catalino "Lino" Bartolome is a 35-year-old man who has scheduled an

appointment with a dermatologist to have a black spot on his right ear assessed. Mr.
Bartolome states, “My wife noticed a black circular area on my ear about two weeks ago
and she suggested I get it looked at since she did not remember the spot being there before.
I know that too much time in the sun is not very good for your skin. I’m a furniture designer
and in to outdoor sports so I am out in the sun a lot, and I admit that I do not always
remember to apply sunscreen.” There is a dark area on Mr. Bartolome’s right ear
approximately 0.4 cm by 0.4 cm round in size. The color of the surrounding skin is normal.
Mr. Bartolome says that he noticed the spot about four months earlier but did not think
much of it. “I figured it was a mole. Since it did not hurt, I really didn’t give it much
thought.”

1. Explain the ABCD criteria for assessing a skin lesion.

2. The pathology report from the punch biopsy states, “deep penetrating nevi with
atypical features worrisome for melanoma.” The dermatologist suggests that Mr.
Bartolome have a sentinel lymph node mapping and biopsy procedure. How might the
nurse explain what this procedure is, why it is done, and potential common and serious
adverse effects/complications?
3. Mrs. Bartolome says, “How did this happen? My husband has dark hair and olive skin. I
thought only fair-skinned redheads got skin cancer.” Is there any truth to Mrs.
Bartolome’s assumption? List five risk factors the nurse should include in an
explanation of what puts individuals at greater risk for skin cancer.
4. The results of the sentinel lymph node mapping and biopsy reveal that the most
proximal lymph node near Mr. Bartolome’s parotid gland is positive with a 0.1 mm
micrometastasis. Given that the punch biopsy was suspicious for melanoma and that
there is a positive sentinel lymph node, the dermatologist prescribes a CT scan of the
head, chest, neck, abdomen, thorax, and pelvis, a MRI of the brain, and a PET scan of the
body to determine the extent of Mr. Bartolome’s melanoma. Mr. Bartolome asks, “What
gland is it near?” and then states, “I know what a CT scan and MRI are but what is a PET
scan?” What function does the parotid gland serve? Explain a PET scan to Mr.
Bartolome.
5. What does it mean to explain cancer according to its “stage” using the TNM system?
Melanoma may be staged according to a “clinical stage” and a “pathological stage.”
Briefly discuss the difference.
6. It has been six weeks since his initial visit to the dermatologist and Mr. and Mrs.
Bartolome are meeting with the dermatologist today to get results of the diagnostic
tests. They learn that Mr. Bartolome has been diagnosed with “Stage IIIA T1a, N1a, M0”
malignant melanoma. What does this stage mean?
7. Mr. Bartolome asks the dermatologist, “What is my prognosis?” What is Mr. Bartolome’s
five-year survival rate?
8. Identify five nursing diagnoses the nurse should consider for Mr. Bartolome when he
learns of his diagnosis of melanoma. List the diagnoses in order of priority.
9. Formulate a nursing care plan for the priority nursing problem.
10. Discuss what the nurse can do to reduce the fear and anxiety that Mr. Bartolome may
feel upon learning that he has melanoma.
 CASE STUDY & NURSING CARE PLAN 2
A Patient with Breast Cancer

Mrs. Jade Flores-Bartolome is a 32-year-old woman who noticed a lump in her left
breast during her monthly breast self-exam two weeks ago. She made an appointment with
her gynecologist who documents “a fixed round lump with irregular borders palpated in
the upper outer quadrant of left breast at 2:00. Left axillary edema noted. There is
symmetry of the breasts with no puckering or nipple discharge. The client denies pain.”
Mrs. Bartolome began having her menstrual period at 10 years of age. She has two children,
both of whom she breastfed for approximately twelve months. Mrs. Bartolome’s oldest
sister died of breast cancer. Mrs. Bartolome has a diagnostic mammogram and a fine-
needle aspiration biopsy. It is determined that she has stage II breast cancer. Mrs.
Bartolome will have a lumpectomy with lymph node dissection (partial mastectomy). A
Jackson-Pratt (JP) drain will be in place postoperatively. Following surgery, tamoxifen is
prescribed.

1. Discuss the best time of the month to perform breast self-examination (BSE).
2. What factors placed Mrs. Bartolome at greater risk for the development of breast
cancer?
3. Discuss the priority nursing intervention prior to Mrs. Bartolome’s biopsy and
immediately following the procedure.
4. Mrs. Bartolome is discharged from the postanesthesia care unit (PACU) following her
lumpectomy and lymph node dissection. Now that she is in your care on the nursing
unit, discuss what you will assess.
5. Identify five postoperative nursing diagnoses to consider for Mrs. Bartolome. List the
diagnoses in order of priority.
6. Formulate a nursing care plan for the priority nursing problem.
7. Identify at least two other complications the nurse will include in the discharge
teaching.
8. Discuss why tamoxifen is prescribed as part of Mrs. Bartolome’s treatment plan.
9. Mrs. Bartolome asks about the adverse effects of tamoxifen. Create a list of the possible
common and potentially life-threatening adverse effects of this medication.
10. What instructions should you include regarding sexual activity?
 CASE STUDY & NURSING CARE PLAN 3
A Patient with Metastatic Lung Cancer

Ace Corpuz, aged 72, has been receiving medical care for chronic obstructive
pulmonary disease, chronic bronchitis, status postmyocardial infarction, and type I
diabetes mellitus for over 15 years. He reports that he lost his wife from lung cancer 5
years ago and still “misses her terribly.” He describes his bad habits as smoking two packs
of cigarettes a day for 52 years (104 packs/year), one to two six-packs of beer a week, one
“Tanduay Lapad” a night, and “a lot of sugar-free junk food, like french fries.” He assures
the nurse that he quit smoking 2 years ago, when he could no longer walk a block without
considerable shortness of breath, and just quit drinking alcohol a few weeks ago at his
physician’s insistence. About a year ago, he had a basal-cell carcinoma removed from his
right ear. Six months ago, cancerous tumors were discovered in his bladder, and he
underwent two 6-week chemotherapy courses of bladder instillations of BCG. His latest
report indicates that the tumors have grown back and no further chemotherapy would be
useful. The urologist had considered surgery but believed that Mr. Corpuz’s other medical
problems would compromise his chances of survival. Mr. Corpuz decides to let the disease
run its course and to be managed at home through hospice care. Because he lives alone in a
modest home, he asks his daughter, and her family to move in with him to provide care and
support during his final months. The daughter accepts, saying she is glad to be able to
spend this time with her father; she has been informed of the physical and emotional stress
this will entail.

1. What factors may be responsible for Mr. Corpuz’s diagnosis?

2. What factors may contribute to his negative attitude toward the chemotherapy?
3. Mr. Corpuz had severe back pain. What were the possible pathophysiologic reasons for
his pain?
4. Why do you think the urologist did not considered surgery as treatment in the case of
Mr. Corpuz’s?
5. Based on the assessment data presented, what are the priority nursing diagnoses?
6. Formulate a nursing care plan for the priority nursing problem.
7. His daughter is visiting and wants to know how the cancer metastasized to his lung.
What should the nurse teach her about metastasis?
8. During her visit, Mr. Corpuz’s daughter questions how likely she is to get cancer. What
should the nurse explain to her about risk factors and screening tests?
9. What are the priority teaching measures that should be included in the teaching plan
for Mr. Corpuz and his family to manage his condition?
10. What interventions can you give to support the psychological need of Mr. Corpuz and
his family?