Mrs. Galloway, age 64, had a left-sided mastectomy and is now receiving follow-up chemotherapy for recurrent breast cancer with axillary node involvement at the outpatient oncology center. She reports intermittent pain and soreness on her left side and under her left arm. She has a central venous access device (CVAD) (double-lumen Hickman catheter) inserted in the right side of her chest. Recent laboratory work shows a low white blood cell count of 1,800/mm3 and a low platelet count of 39,000/mm3. She also bleeds and bruises very easily. You have to obtain vital signs and draw a complete blood count (CBC). The dressing on her CVAD must be changed.
Prescribed Interventions
- Vital signs on arrival
- CBC on arrival
- Acetaminophen 650 mg po q6h prn pain
- Change central line dressing q week
Developing Clinical Reasoning and Clinical Judgment
- What special precautions should you take while obtaining Mrs. Galloway's vital signs?
- Identify your interventions when changing Mrs. Galloway's central line dressing and the rationale for these interventions.
- Explain why some sites would be contraindicated when taking Mrs. Galloway's temperature.
- Describe the special precautions you would take when drawing blood from Mrs. Galloway. Identify the site where you would draw the blood.
Suggested Responses for Integrated Nursing Care
- To individualize care, always assess your patient's condition and special needs. When a patient undergoes a mastectomy, they will often have lymph nodes removed from the affected side. Taking a blood pressure reading in the affected arm could interfere with circulation and harm the extremity (see Chapter 2). In Mrs. Galloway's case, her affected side is on the left, so take her blood pressure on the right side.
- Mrs. Galloway has a low platelet count, which places her at risk for bleeding. In addition, her low white blood cell count places her at risk for infection and other complications. Therefore, taking a rectal temperature would be contraindicated for Mrs. Galloway. It would also be contraindicated to take a left-sided axillary temperature on Mrs. Galloway because she is still having some discomfort due to her recent mastectomy (see Chapter 2).
- Given Mrs. Galloway's risk for bleeding, would a peripheral venipuncture be the best choice to obtain the prescribed CBC? Due to the risk for prolonged bleeding, her central line may provide the best access for a blood specimen (Chapter 18). Determine whether her health care provider has restricted her central line for chemotherapy. If her central line is dedicated to chemotherapy only, obtain a blood specimen via venipuncture (Chapter 18). If you needed to do a venipuncture, using Mrs. Galloway's left side would be contraindicated due to the mastectomy. You will need to apply pressure to the site for a longer period of time because of her increased risk for bleeding.
- When changing Mrs. Galloway's central line dressing, use sterile technique due to her increased risk for infection (Chapter 1). Maintain sterile technique when changing the CVAD dressing and wear a mask (see Chapter 16). Ensure that the CVAD is patent prior to use. Check the CVAD for patency and blood return per facility policy (Chapter 16). To prevent bleeding and bruising at the central line site, do not move or pull on the catheter as you are manipulating the central line dressing.