Ateneo de Davao University

College of Nursing

A Case Presentation

On

Breast Cancer

In Partial Fulfillment of the Requirements in Related Learning Experience

Submitted to:

Ms. Kristina Concepcion, RN

Clinical Instructor

Submitted By:

Jonna Lisa M. Lagdameo

BSN- 4E

Date Submitted:

January 27, 2010

Acknowledgement

This case study has provided me new knowledge and ideas to understand the

condition that most women have and suffer.

With the following people, this case study has been successfully completed and

was made possible:

First, my co-worker, Jesus Christ for guiding me through and enlightening my

path by giving me enough patience and persistence to do this case study with optimism

and confidence.

Second, I would like to thank my family, for making me take up nursing and get

through this individual case presentation, for having served as my reason to strive harder

to be a successful person and for making my life complete and my journey worth beyond

a lifetime.

Third, I would like to extend my gratitude to my clinical instructors for guiding

me and correcting all my mistakes which served as lessons and for being a part of the

challenges of my basic foundation in this world of health care.

Fourth, I am grateful to the hundreds of authors of my references for about 3 years

of making a case study, whose works served as my substance and inspiration from which

I derived my answers and rationales.

Lastly, to the DMSF staff for guiding me in copying and carrying out the Doctor’s

Orders and for teaching us to become a good nurse that practice ideal nursing skills and

to my group mates from group 3 of sections F and E, you made my life happy on my

entire nursing life.

DAGHANG SALAMAT!

Introduction

“Women agonize... over cancer; we take as a personal threat the lump in every

friend's breast. “ ~Martha Weinman Lear, Heartsounds

All women are at risk, approximately 70% of breast cancers occur in women with

none of the known risk factors. Only about 5% of breast cancers are inherited, about 80%

of women diagnosed with breast cancer will be the first to be victims in their families. It

is the leading killer of women ages 35 to 54 worldwide, more than a million women

develop breast cancer without knowing it and almost 500,000 die from it every year. One

out of 4 who are diagnosed with breast cancer die within the first 5 years. No less than

40% die within 10 years. The incidence of breast cancer has been rising for the past 30

years, and the supposed authorities and experts that should know, do not know why.

The grim fact” for every 2 new cancer cases diagnosed annually, one will die

within the year”.

In the UK 30,000 new cases of breast cancer are diagnosed each year making this the

commonest malignancy in women and causing nearly 15,000 deaths per year. Randomized

studies of prevention strategies particularly with the anti-oestrogens Tamoxifen and more

recently raloxifene, and retinoids have either been completed or are on-going. The final

analysis is awaited but it is likely that effective preventive measures will be available in the

not too distant future.

In Asia, the Philippines has the highest reported incidence rate of breast cancer.

From 43.2 in 1993-1995, the age- standardized incidence rate (ASR) is now 47.7 per

100,000 females, and this figure exceeds the rate reported for several Western countries,

including Spain, Italy and moset European countries.

Many breast cancers are diagnosed among 35 to 50-year-old Filipino women. In

terms of breast cancer detection, a local study revealed that the use of breast self-

examination (BSE) and aspiration biopsy/open biopsy are the most cost-effective

strategies in the Philippine setting, incurring savings for the government by almost 3

million Philippine Pesos or US $60,000 (1989 value) per year per 100,000 women.

Mammography is neither readily available nor affordable especially in the rural areas.

Cancer site 1980–82 1983–87 1988–92 1993–95

  BS M F BS M F BS M F BS M F

Lung 25.8 42.3 11.5 31 46.7 14.9 40 64.7 18.8 40 64.7 18.8

Breast   0.7 40.5   0.7 44.4   0.8 43.2   0.8 43.2

Liver 13.4 20.4 7.3 14.7 20.4 8 16.8 25.6 9 16.8 25.6 9

Cervix uteri 20.5 – 20.5 22.5 – 22.5 26.4 – 26.4 26.4 – 26.4

Stomach 9.6 11.9 7.6 9.6 11.4 7.7 9.6 12.1 7.6 9.6 12.1 7.6

Colon 6.5 7.3 5.7 8 8 7.7 10.7 11.8 9.8 10.7 11.8 9.8

Oral cavity 5.9 5.4 6.3 6.9 6.4 7.3 8.6 8.5 8.3 8.6 8.5 8.3

Prostate 12.5 12.5 – 14.6 14.6 – 19.3 19.3 – 19.3 19.3 –

Rectum 5.5 6.5 2.8 6.6 7.4 5.6 7 8.1 6.2 7 8.1 6.2

Leukemia 5.2 5.7 2.9 5.7 5.6 5.5 6.6 7.2 6.2 6.6 7.2 6.2

Nasopharynx 2.5 6 1.6 5.2 6.7 3.1 6.2 8.6 4 6.2 8.6 4

Larynx 1.4 4.3 0.4 2.8 4.4 1.1 3.4 6.2 1 3.4 6.2 1

Ovary 8 – 8 9.2 – 9.2 10.8 – 10.8 10.8 – 10.8

Thyroid 2.7 1.3 6.6 5.6 2.7 8 6.6 3.1 9.8 6.6 3.1 9.8

Corpus uteri 6.1 – 6.1 5.8 – 5.8 5.2 – 5.2 5.2 – 5.2

Non-Hodgkin’s lymphoma 2 2.1 1.6 3.3 3.8 2.6 4.6 5.8 3.6 4.6 5.8 3.6

Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4)

Objectives

General:

The researcher formulated a general objective to guide her throughout the case

study:

This study aims to present facts about breast cancer, details of how this may affect

every woman in the society and to protect them from further advancement of breast

cancer. And also for the researcher to explore, investigate, analyze and present a

comprehensive case study regarding the case of Patient Star.

Specific:

a) To establish a good rapport and therapeutic relationship with the patient to gather

much information about her personal data and her present condition through

interview

b) To gather pertinent data found in the patient’s medical chart

c) To conduct a thorough physical assessment as a part of the baseline data gathering

d) To study the anatomy and physiology of the affected system of the patient’s

current condition

e) To trace the pathophysiology of the disease process

f) To determine and interpret the medical management employed, including

laboratory and diagnostic procedures

g) To identify and study the drugs prescribed to the patient which affects her present

condition

h) To formulate nursing care plans and health teachings that are appropriate for the

patient’s problem

i) To formulate prognosis based on the gathered information

j) Enumerate the discharge planning using the M.E.T.H.O.D. system.

k) List down all the references used in the study

Patient’s Data

Personal Data

Code Name: Patient Star

Age/ Sex: 58/ Female

Address: Blk. 4 Lot 12 Stella Maris Village, Garcia Heights, Davao City

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Birth date: March 13, 1951

Birth place: Dagupan, Pangasinan

Occupation: Housewife

Clinical Data

Hospital Number: 01-80-**

Room / Bed Number: 424-2

Date of admission: December 14, 2009

Time of admission: 11:00 am

Chief Complaint: Left Breast Wound

Admitting Physician: Meliza Carla T. Agoilo, M.D

Attending Physician: Ferdinand Malubay, M.D

Vital signs upon admission:

. T P R BP

37.4◦ 128bpm 27cpm 120/70mmHg

Family Background and Health History

Patient Star, 58 years old, she lived in a simple lifestyle at Dagupan, Pangasinan. Her

paternal side was pure Ilocano, her father has 5 siblings wherein hypertension was manifested by

the three of them. Her father has Bronhcial Asthma and was already deceased. Meanwhile, her

mother side hailed from Malasiqui, Pangasinan. Her grandmother died from Diabetes which was

also caused the death of her one aunt. Hypertension was also manifested by her uncles, her

mother’s siblings. Star transferred here in Davao because of her job which was part of her Rural

Training as a nurse. Patient Star has five four siblings, one of her sister has hypertension and

died from it, while her other sister was diagnosed with colon cancer.

At present, star and her family lived at Garcia Heights his husband continued to work at

his uncle’s business. They have two children, her daughter who is already 26 years old finished

International Technology at John Paul College and is already working at Victoria Plaza Mall

while his son, 24 years of age is a personal driver of a known family in the city.

Lifestyle, Diet and Activities of Daily Living (ADL)

Patient Star wakes up early at about 4:30 am to cook breakfast for her family and clean

their house and backyard. Her daughter also testified that her mother is really hardworking, she

added that her mother feels weak if she does not work or do anything and just sit and rest the

entire day. Star shared that when she was still not feeling the pain on her breast she really wants

to do everything on their house just to make it clean and beautiful, she also makes it sure that her

family is in good condition and health. She cooks food for her family everyday and sees to it that

these foods are healthy and well- balanced. She admits that before, she really eats rice and foods

rich in carbohydrates without limit but now, she learned from it already and minimizes her intake

of those restricted foods. They sleep at around 10pm in the evening.

She is not active on her subdivision’s activities because she easily gets tired on it. Their

family is not that active on parish activities but they go to church if they have time, it is not their

routine to have a mass every Sunday.

9

Patient Star is a smoker, she consumes four sticks of cigarette everyday but she does not

drink any alcoholic beverages frequently, just occasionally. Her husband does not earn that much

of money and it brought them financial problem since they had their family life.

Client’s Past Health History

Patient Star does not have any allergic reaction towards foods, drugs and environment.

Patient stated that she had measles, mumps and chicken pox when she was young.

On year 2006, she experienced minimal amount of bleeding on her left nipple for 3 days

and after a week, she felt pain on it. She went for check-up at Davao Doctors Hospital and was

diagnosed with Mastitis and the doctor advised her to take Augmentin and to stop all her vices

mainly her smoking issue. After being diagnosed she seek help to the so called albolaryos and

quack doctors. She took Alive capsule and Green power which are herbal supplements.

She is a known Diabetic since 2006 and takes Metformin 500mg BID as her maintenance

drug.

She takes Mefenamic Acid whenever she experience headache and Paracetamol for her

fever.

Client’s Present Illness

One year prior to admission, Patient Star noted again a blood on her left nipple consulted

the physician that she had on 2006 and was given unrecalled drugs. Three months prior to

admission, patient noted crusting on the affected area, a consultation was done by the physician

and advised her for surgery but the patient failed to comply due to financial constraints, she

opted to use guava leaves and amoxicillin capsule powder instead.

Due to the pain that she felt on December 10 up to the 14 th of 2009 she was advised to be

admitted at Davao Medical School Foundation Hospital.

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Effects and Expectations of Illness to Self and Family

Patient Star understands the fact that she must be in the hospital for her to be at ease

while fighting her disease. She was just anxious and worried because of the financial aspect that

needs to be sufficient enough for her treatment. She optimistically shared that illness is just a part

of our body to respond and act against the virus and cells that spreads inside our system~ may it

be that deadly or not. She knows that her immune system is at risk during this time of her life

that is why she needs to eat nutritious foods and lessen her intake of those restricted foods that

may compromise her health.

Patient Star and her family were open about the risks of having cancer. Even though God

has given her these diseases she remained alive and kicking just like other normal persons.

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Developmental Data

Development is an increase in the complexity of function and skill progression. It is the

capacity and the skill of a person to adapt to the environment and it implies a progressive and

continuous process of change leading to a state of organized and specialized functional capacity.

Development is the behavioural aspect of growth, such as a person’s ability to walk, talk, and

run. It proceeds from simple to complex or from single acts to integrated acts. Any interpretation

of this process by a disease or a disorder is called developmental delay. These changes can be

measured quantitatively but more distinctly measured in qualitative changes.

Theory Stages Justification

Erik Erikson’s

Psychosocial Theory

Erik H. Erikson believes

that people continue to

develop throughout life. He

envisions life as a sequence

of levels of achievement.

The resolution of each task

can be complete, partial, or

unsuccessful. He believes

that the greater the tasks

achieved the healthier will

the personality of the person

be; failure to achieve a task

affects the person’s ability

to achieve the next task.

Erikson’s eight stages

Our patient belongs to

the stage of Generativity

versus stagnation (25 years

to 65) because she is already

58 years old. Generativity is

when an individual is

creative, productive and

shows concern for others.

While stagnation is when an

individual is to self-indulge,

self-concern and shows lack

of interests and

commitments.

Our patient is in the stage

of Generativity because she

is creative and productive.

Our patient does not only

think about herself but she is

also a very good mother and

wife. She does her job as a

mother and wife by taking

good care of her family. She

provides for the needs of her

family and also takes good

care of their health and

welfare. She makes sure that

she gives her family the love

and care they needed.

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reflect both positive and

negative aspects of the

critical life periods. The

resolution of the conflicts at

each stage enables the

person to function

effectively in the society.

Developmental tasks can be

viewed as a series of crises,

and successful resolution of

these crises is supportive to

the person’s ego

Robert Havighurst’s

Developmental Task

Theory

Robert Havighurst

believed that learning is

basic to life and that people

continue to learn throughout

life. He described growth

and development as

occurring in six different

stages which is associated

with different tasks. A

developmental task arises in

a certain period of an

individual’s life and leads to

Our patient is 58 years

old and belongs to the

Middle Age (40 – 65 years

old) and the following are

the task that the person must

achieve during this stage.

Developmental task

1. Achieving adult

civic and social

responsibility.

2. Establishing and

maintaining an

economic standard

√

Patient Star has not

achieved the first

developmental task because

she didn’t join in any

organizations in her

community.

Our patient has achieved

the second task because she

strives so hard to support

her family’s needs

emotionally and

physiologically by preparing

foods and providing

comfortable home to sleep

and rest.

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unhappiness and success if

is achieved and leads to

unhappiness if tasks is

failed. Through this theory it

can help provide a

framework in evaluating a

person’s accomplishment.

of living.

3. Assisting teenage

children to become

responsible and

happy adults.

√

4. Developing adult

leisure – time

activities.

√

5. Relating oneself

to one’s spouse as a

person.

√

6. Accepting and

adjusting to the

physiologic change

of middle age.

√

7. Adjusting to

aging parents.

√

Our patient had achieved

the third task because she

has 2 children and she was

the one who assisted them

while growing up. In the

present, some of her

children have their own

family and all of them are

already successful in life.

Our patient has achieved

the fourth task because

Whenever our patient is not

busy she would really rest

and spend time watching

television. Also when she is

not doing anything, she

would spend quality time

with her husband.

Our patient has achieved

the fifth task because our

patient does not only think

of herself but also for the

needs of her husband.

Whenever her husband is

having some problems she

will really give her full

support and try to console

and understand him.

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Our patient has achieved

the sixth task because she is

already quite adjusted to the

changes she is having

because she is aware that as

she grows old, many

changes would really

happen to her physically and

psychologically because she

knows that is life’s reality.

Our patient already

adjusted herself to her

husband’s father who is

already very old and many

things change. As her father

grew older and older, he

became to irritating,

annoying and kept on

nagging. Still, she possesses

her value of being patient

with him and tries to adjust

to it.

Moral Developmental

Theory by Lawrence

Kohlberg

Our patient belongs to

the Post conventional

(Social Contract Legalistic

Orientation) in which this

Our patient belongs to this

stage because she does not

base her decisions and

behaviors on the social roles

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This theory addresses

moral development in

children and adults. This

theory focuses on the

reasons an individual makes

a decision. According to

Kohlberg, this theory

progresses through three

levels and six stages, which

do not always linked to a

certain developmental stage

due to the fact that some

people progresses in a

higher level compared to

others.

person lives autonomously

and defines moral values

and principles that are

distinct from personal

identification with group

values. A person lives

according to principles that

are universally agreed on

and that the person consider

appropriate for life.

(universal focus)

but she believes a higher

moral principle such as

equality, justice or due

process.

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Definiton of Complete Diagnosis

Breast cancers are malignant tumors that typically begin in the ductal-lobular epithelial

cells of the breast and spread via the lymphatic system to the axillary lymph nodes. The tumor

may then metastasize to distant regions of the body, including lungs, liver, bone, and brain. The

finding of breast cancer in the axillary lymph nodes is an indicator of the tumor’s ability for

potential distant spread and is not merely contagious growth into adjacent region of the breast.

Most primary breast cancers are adenocarcinomas located in the upper outer quadrant of the

breast.

Bibliography:

Black, J. et. al. (2002).MEDICAL-SURGICAL NURSING: Clinical Management for Positive

Outcomes. Vol. 1. Philadelphia, USA: W.B. Saunders Company. pages 1011 – 1040.

Breast cancer is a cancer that starts in the cells of the breast in men and

women. Worldwide, breast cancer is the second most common type of cancer after

lung cancer (10.4% of all cancer incidence, both sexes counted) and the fifth most

common cause of cancer death. Worldwide, breast cancer is by far the most common

cancer amongst women, with an incidence rate more than twice that of colorectal

cancer and cervical cancer and about three times that of lung cancer. However breast

cancer mortality worldwide is just 25% greater than that of lung cancer in women. In

2005, breast cancer caused 502,000 deaths worldwide (7% of cancer deaths; almost

1% of all deaths). The number of cases worldwide has significantly increased since

the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world.

Malignant tumors within the breast are called “breast cancer”. Theoretically,

any of the types of tissue in the breast can form a cancer, cancer cells are most likely

to develop from either the ducts or the glands. These tumors may be referred to as

“invasive ductal carcinoma” (cancer cells developing from ducts), or “invasive lobular

carcinoma” (cancer cells developing from lobes). Sometimes, precancerous cells may

17

be found within breast tissue, and are referred to as ductal carcinoma in-situ (DCIS)

or lobular carcinoma in-situ (LCIS). DCIS and LCIS are diseases in which cancerous

cells are present within breast tissue, but are not able to spread or invade other

tissues. DCIS represents about 20% of all breast cancers. Because DCIS cells may

become capable of invading breast tissue, treatment for DCIS is usually

recommended. In contrast, treatment is usually not needed for LCIS.

Bibliography:

The internet: http://health.yahoo.com/breastcancer-overview/breast-cancer-

topic-overview/healthwise--tv3617.html

Stage III breast cancer is divided into two categories, which are the stage IIIA and the

stage IIIB. In stage IIIA, the breast cancer will now be larger than 5 centimeters in diameter and

will already have spread to the lymph nodes located under the arm. The survival rate for stage

IIIA breast cancer is from 56% to 67% depending on how the patient responded with the

treatments.

Stage IIIB breast cancer is when the cancer has spread to the other tissues near the breast.

In this stage, the survival rate will be from 49% to 54% depending on how the patient responded

to the treatments and medications. Always remember that the key to surviving breast cancer is

through early detection. By going through breast cancer diagnoses at least once or twice a year,

you will be able to detect the cancer early on if you have it and increase your chances in getting

rid of it.

Bibliography:

The internet: http://www.breastcanceranswers.net/articles/What-should-you-know-about-

stage-3-breast-cancer.html

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PHYSICAL ASSESSMENT

Date of Assessment: December 15, 2009

Time of Assessment: 6:00pm

I. VITAL SIGNS

Temperature Pulse Rate Respiratory

Rate

Blood

Pressure

37.3ºc 92 bpm 21 cpm 120/80

mmHg

Clinical Measurement:

Height Weight

4 ft.9” 44kg.

II. GENERAL SURVEY

. She is awake, conscious, coherent and oriented. Responsive when asked and well-

conversant during interview. Her emotions were visible and vary in every situation. She does

not show any signs of respiratory distress. She is a well developed mesomorph and looks

according to age. She is very calm during the assessment, wearing white shirt and pajama.

19

III. SKIN

Skin was senile, fair in color, warm to touch, slightly moist and smooth. Returns quickly

to its original shape after being pinched. No evidence of bruising or edema on upper and lower

extremities. Nails were well- trimmed. Hair was fairly distributed all over the body.

IV. HEAD

Face and skull were symmetrical, with fair distribution of hair in the head. Hair was

black, curly with shades of dark brown and white hairs were noticed and it was also short and

dry. Scalp was flesh in color without any signs of dandruff and lice manifestation. No tenderness

and swelling were observed. Skull’s contour and size was normal. Involuntary movements and

spasmodic contractions were absent. Has an oblong- shaped face without skin pigmentations.

Forehead was furrowed with wrinkles.

V. EYES

Both eyebrows had an equal quantity of hair with no flakes and scars noted. Eyelids were

symmetrical. The lacrimal duct openings were evident at the nasal side of the upper and lower

lids. No presence of edema or hematoma. Has short eyelashes on both eyes. Blinking reflex was

present. Sclerae were anicteric, clear and white in color. Iris were dark brown in color. Pupils

briskly constrict with light and when looking at near objects; dilate when looking at far objects.

Palpebral conjuctiva were pinkish. Periorbital sections were not edematous or sunken. No

secretions observed on her eyes.

Patient verbalized that she is not using any corrective glasses or any supportive devices

on her eyes.

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VI. EARS

Ears were symmetrical. No lesions, masses and swelling observed in both pinna. External

canals were clear with perhaps minimal cerumen. Inflammation and impacted cerumen were

absent.

Sense of hearing was normal. Whispered voice tones were heard.

VII. NOSE

Nose was symmetrical, having the same color with her face. No unusualities noted like

discharges, lesions and abnormal growth in the nasal cavity. Air moves freely through the nares

as she breathes. Nasal septum was intact and in the midline.

Sense of smell is good and she was able to distinguish different kind of scents.

VIII. MOUTH

Lips were pinkish and dry but not cracked. A red birthmark of about 1.5cm in length was

found below her lower lips. Pinkish gums were observed. Bleeding, ulceration and lacerations

were absent in the mouth. Hard and soft palates were normal with no defects or inflammation.

Tonsils were pinkish and not inflamed. A grayish discoloration was noted on the tip of her

tongue. Left molar tooth was missing. Halitosis was noted. Patient was able to masticate and

swallow.

IX. NECK

No signs of swelling, masses and lacerations noticed in the anterior and posterior of the

neck upon inspection and palpation. Range of motion was normal which includes right and left

lateral, right and left rotation, flexion, extension and hyperextension and able to move freely

21

without discomfort. A birthmark which was brown in color, 8cm in length and 4cm in width was

noted.

X. BREAST

Nipple on the right breast was dark brown in color. No discharges, scars or lesions seen.

No lumps palpated. Left breast was covered with a bandage and properly dressed. It was intact

and not soaked. No rashes or infection in the axillae noted.

A foul smell was noticeable coming from her breast wound.

XI. CHEST AND LUNGS

Thorax was symmetrical, it moved easily without impairment upon respiration. There

were neither bulges nor retraction of the intercostal spaces. The breathing pattern was regular.

No presence of dyspnea, cough or hiccup noted. Spinal deformities and chest tubes or drainage

were absent. Breath sounds were clear upon auscultation.

XII. HEART

Her pericardial area is flat. Her heart sounds are distinct and regular upon auscultation.

XIII. ABDOMEN

The general contour of the abdomen was soft and flabby. No foul odor or discharges

observed in the umbilical area. Has a normal bowel sound of 12 per minute with a gurgling

sound.

XIV. GENITO-URINARY

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No catheter attached. Patient verbalized that she urinates about 12 times daily without

any discomfort after the day of her admission. Her urine is yellow in color.

Patient added that she is already meopaused.

XV. UPPER EXTREMITIES

Peripheral pulses are present and symmetrical when palpated. Shoulder and arms were

symmetrical. Swelling and deformities were absent. No nodules and abnormal growth in the

elbows. Forearms can be flexed, supinated, pronated and extended with no pain. No missing,

deformities and tremors in the hands and fingers. Both palms were not calloused, without palmar

pallor. Has a capillary refill of less than 2 seconds. The range of motion in the upper extremities

was good.

XVI. LOWER EXTREMITIES

Absence of pain tenderness and has a good range of motion in the hips and joints. A scar

of 6 cm was found at the right lower leg due to an accident when she was still 14 years old. No

deformities, edema, rashes and amputation in both legs and knees. No missing toes in both feet.

Slightly calloused soles. Nails in the toes were not trimmed. Has a good range of motion in the

lower extremities.

23

ANATOMY AND PHYSIOLOGY

Reproductive System

The breasts, or mammary tissues, are located between the third and the seventh ribs of the

anterior chest wall and are supported by the pectoral muscles and superficial fascia. They are

specialized glandular structures that have an abundant shared nervous, vascular, and lymphatic

supply. The contiguous nature of breast tissue is important in health and illness. Men and women

alike are born with rudimentary breast tissue, with the ducts lines with epithelium. In women, the

pituitary released of FSH, LH, and prolactin at puberty stimulates the ovary to produce and

released estrogen. This estrogen stimulates the growth and development of ductile system. With

the onset of ovulatory cycles, progesterone release stimulates the growth and development of

ductile and alveolar secretory epithelium.

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Structure

Structurally, the breasts consist of fat, fibrous connective tissue, and glandular tissue. The

superficial fibrous connective tissue is attached to the skin, a fact that is important in the visual

observation of skin movement over the breast during breast self-examination. The breast mass is

supported by the fascia of the pectoralis major and minor muscles and by the fibrous connective

tissue of the breast. Fibrous tissue ligaments, called Cooper's ligaments, extend from the outer

boundaries of the breast to the nipple area in radial manner.

These ligaments support the breast and form septa that divide the breast into 15 to 25

lobes. Each lobe consists of grape like clusters, alveoli or glands, which are interconnected by

ducts. The alveoli are lined with secretory cells capable of producing milk or fluid. The route of

descent of milk and other breast secretions is from alveoli to duct, to intra lobar duct, to

lactiferous duct and reservoir, to nipple. Breast milk is produced secondary to complex hormonal

changes associated with pregnancy. Fluid is produced and reabsorbed during the menstrual cycle.

The breasts respond to the cyclic changes in the menstrual cycle with fullness and discomfort.

The nipple is made up of epithelial, glandular, erectile, and nervous tissue. Areolar tissue

surrounds the nipple and is recognized as the darker, smooth skin between the nipple and the

breast. The small bumps or projections on the areolar surface known as Montgomery's tubercles

are sebaceous glands that keep the nipple area soft and elastic. At puberty and during pregnancy,

increased levels of estrogen and progesterone cause the areola and nipple to become darker and

more prominent and at the same time cause the Montgomery's glands to become more active.

The erectile tissue of the nipple is responsive to psychological and tactile stimuli, which

25

contributes to the sexual function of the breast. There are many individual variations in breast

size and shape. The shape and texture vary with hormonal, genetic, nutritional, and endocrine

factors and with muscle tone, age, and pregnancy. A well-developed set of pectoralis muscles

supports the breast mass higher on the chest wall. Poor posture, significant weight loss, and lack

of support may cause the breast to droop.

The Lymphatic System

The lymphatic system consists of organs, ducts, and nodes. It transports a watery clear

fluid called lymph. This fluid distributes immune cells and other factors throughout the body. It

also interacts with the blood circulatory system to drain fluid from cells and tissues. The

lymphatic system contains immune cells called lymphocytes, which protect the body against

antigens (viruses, bacteria, etc.) that invade the body.

Functions:

a.) to collect and return interstitial fluid, including plasma protein to the blood,

26

and thus help maintain fluid balance

b.) to defend the body against disease by producing lymphocytes

c.) to absorb lipids from the intestine and transport them to the blood.

Lymph organs include the bone marrow, lymph nodes, spleen, and thymus. Precursor

cells in the bone marrow produce lymphocytes. B-lymphocytes (B-cells) mature in the bone

marrow. T-lymphocytes (T-cells) mature in the thymus gland. Besides providing a home for

lymphocytes (B-cells and T-cells), the  ducts of the lymphatic system provide transportation for

proteins, fats, and other substances in a medium called lymph.

Lymph nodes:

Structure:

Human lymph nodes are bean-shaped and range in size from a few millimeters to about

1-2 cm in their normal state and there are about 500-700 lymph nodes spread throughout the

body. Lymph nodes are body organs (not glands) spread throughout your body.

The lymph node is surrounded by a fibrous capsule, and inside the lymph node the

fibrous capsule extends to form trabeculae. The substance of the lymph node is divided into the

outer cortex and the inner medulla surrounded by the former all around except for at the hilum,

where the medulla comes in direct contact with the surface. Thin reticular fibers, fibroblasts and

27

elastin fibers form a supporting meshwork called reticulum inside the node, within which the

white blood cells (WBCs), most prominently, lymphocytes are tightly packed as follicles in the

cortex. Elsewhere, there are only occasional WBCs.

The number and composition of follicles can change especially when challenged by an

antigen, when they develop a germinal center. A lymph sinus is a region within the lymph that is

less densely packed with WBCs and offers less resistance to the flow of lymph. It is lined by

highly branched reticular cells and macrophages. Thus, subcapsular sinus is a region immediately

deep to the capsule, and contains very sparse lymphocytes. It is continuous with similar sinuses

flanking the trabeculae. Multiple afferent lymph vessels that branch and network extensively

within the capsule, bring lymph into the lymph node. This lymph enters the subcapsular sinus.

The innermost lining of the afferent lymph vessels is continuous with the cells lining the lymph

sinuses. The lymph gets slowly filtered through the substance of the lymph node and ultimately

reaches the medulla. In its course it encounters the lymphocytes and may lead to their activation

as a part of adaptive immune response. The concave side of the lymph node is called the hilum.

The efferent attaches to the hilum by a relatively dense reticulum present there, and carries the

lymph out of the lymph node.

Function

Nodes act as filters, with an internal honeycomb of reticular connective tissue filled with

lymphocytes that collect and destroy bacteria and viruses. When the body is fighting an

infection, they begin producing large numbers of lymphocytes which causes them to swell.

Lymphatic fluid in the tissues, before it has gone into a lymph node, is called interstitial fluid.

28

Etiology and Symptomatology

BREAST CANCER

PREDISPOSING FACTORS

FACTORS RATIONALE PRESENT

/

ABSENT

JUSTIFICATION

SEX Simply being a woman is the

main risk factor for developing

breast cancer. Although women

have many more breast cells

than men, the main reason they

develop more breast cancer is

because their breast cells are

constantly exposed to the

growth-promoting effects of the

female hormones estrogen and

progesterone. Men can develop

breast cancer, but this disease is

about 100 times more common

among women than men.

www.cancer.org

This is present, since

our patient is a

FEMALE.

AGE Breast cancer can affect women

of any age. The disease is more

common in post-menopausal

women, but 25 percent of

This is present since

our patient is 58

years old and is

already menopaused.

29

women with breast cancer are

younger than 50.

www.cancer.med.umich.edu

Your risk of developing breast

cancer increases as you get

older. About 1 out of 8 invasive

breast cancers are found in

women younger than 45, while

about 2 out of 3 invasive breast

cancers are found in women

age 55 or older

www.cancer.org

According to experts

post- menopausal

women are more

predisposed to have

breast cancer.

GENETIC RISK

FACTORS

About 5% to 10% of breast

cancer cases are thought to be

hereditary, resulting directly

from gene changes (called

mutations) inherited from a

parent.

BRCA1 and BRCA2: The

most common inherited

mutations are those of the

BRCA1 and BRCA2 genes. In

normal cells, these genes help

to prevent cancer by making

proteins that help keep the cells

from growing abnormally. If

you have inherited a mutated

copy of either gene from a

parent, you are at increased risk

for breast cancer.

Women with an inherited

X

There is no test that

would support that

the patient has

genetic mutation that

would make here

predispose to breast

cancer. Patient also

stated that she does

not have any

relatives or even

family member with

breast cancer.

30

BRCA1 or BRCA2 mutation

have up to an 80% chance of

developing breast cancer during

their lifetime, and when they do

it is often at a younger age than

in women who are not born

with one of these gene

mutations. Women with these

inherited mutations also have

an increased risk for developing

ovarian cancer.

www.cancer.org

RACE White women are slightly more

likely to develop breast cancer

than are African-American

women. African-American

women are more likely to die of

this cancer. At least part of this

seems to be because African-

American women tend to have

more aggressive tumors,

although why this is the case is

not known. Asian women has

the least number of breast

cancer cases compared to that

of the Americans, Europeans

www.cancer.org

X

This is absent since

our patient is of

Asian race.

EARLY MENARCHE,

LATE MENOPAUSAL

AGE

Women who have had more

menstrual cycles because they

started menstruating at an early

The patient reported

that her menarche

was at 11 years old.

31

age (before age 12) and/or went

through menopause at a later

age (after age 55) have a

slightly higher risk of breast

cancer. This may be related to a

higher lifetime exposure to the

hormones estrogen and

progesterone.

-www.cancer.org

-Hawks and Black , Medical-

Surgical Nursing, 7th Edition,

2005

NULLIPARITY

AND

NON-BREASTFEEDING

WOMEN

Women who have had no

children or who had their first

child after age 30 have a

slightly higher breast cancer

risk. Having many pregnancies

and becoming pregnant at an

early age reduces breast cancer

risk. Pregnancy reduces a

woman's total number of

lifetime menstrual cycles,

which may be the reason for

this effect.

Some studies suggest that

breast-feeding may slightly

lower breast cancer risk,

especially if breast-feeding is

continued for 1½ to 2 years.

The explanation for this

possible effect may be that

This is absent in my

patient because she

has undergone

pregnancy for her 2

children and has

experienced

breastfeeding.

32

breast-feeding reduces a

woman's total number of

lifetime menstrual cycles

(similar to starting menstrual

periods at a later age or going

through early menopause).

33

BREAST CANCER PRECIPITATING FACTORS

FACTORS RATIONALE PRESENT/

ABSENT

JUSTIFICATION

HIGH FAT DIET Most studies have found that breast

cancer is less common in countries where

the typical diet is low in total fat, low in

polyunsaturated fat, and low in saturated

fat.

High-fat diets can lead to being

overweight or obese, which is a breast

cancer risk factor.

X

This is absent since

patient eats a wide

variety of food.

OBESITY Being overweight or obese has been

found to increase breast cancer risk,

especially for women after menopause.

Before menopause your ovaries produce

most of your estrogen, and fat tissue

produces a small amount of estrogen.

After menopause (when the ovaries stop

making estrogen), most of a woman's

estrogen comes from fat tissue. Having

more fat tissue after menopause can

increase your estrogen levels and thereby

increase your likelihood of developing

breast cancer.

The connection between weight and

breast cancer risk is complex, however.

For example, the risk appears to be

increased for women who gained weight

as an adult but may not be increased

among those who have been overweight

since childhood. Also, excess fat in the

X

This is absent since

our patient’s BMI

is 18.9, which is

interpreted as a

healthy weight

since BMI less

than 18.5 are

classified as

underweight and

more than 22.9 are

overweight.

34

waist area may affect risk more than the

same amount of fat in the hips and

thighs. Researchers believe that fat cells

in various parts of the body have subtle

differences that may explain this.

-www.cancer.org

-Hawks and Black , Medical-Surgical

Nursing, 7th Edition, 2005

LONG TERM

ESTROGEN

THERAPY

Post-menopausal hormone therapy

(PHT), also known as hormone

replacement therapy (HRT), has been

used for many years to help relieve

symptoms of menopause and to help

prevent osteoporosis (thinning of the

bones).

-www.cancer.org

-Hawks and Black , Medical-Surgical

Nursing, 7th Edition, 2005

X

This is absent since

Patient Star is not

having this

therapy.

ALCOHOL Alcohol use are associated with increased

levels of circulating estrogen, and this is

thought to be the primary means through

which they confer an increased risk of

breast cancer, since estrogen can fuel

breast cancer growth

-Fred Hutchinson Cancer Research

Center

www.sciencedaily.com

X

This is absent since

patient Star does

not consume nor

drink regularly.

LACK OF

PHYSICAL

MOBILITY

Physical activity may prevent tumor

development by lowering hormone

levels, particularly in premenopausal

women; lowering levels of insulin and

X

This is absent since

Patient Star does

all the house

chores.

35

insulin-like growth factor I (IGF-I),

improving the immune response; and

assisting with weight maintenance to

avoid a high body mass and excess body

fat

-McTiernan A, editor. Cancer Prevention

and Management Through Exercise and

Weight Control. Boca Raton: Taylor &

Francis Group, LLC, 2006.

CIGARETTE

SMOKING

Carcinogens found in tobacco smoke

pass through the alveolar membrane and

into the blood stream, by means of which

they may be transported to the breast via

plasma lipoproteins. That potential breast

carcinogens in tobacco smoke can be

taken up and metabolized in humans is

suggested by studies showing that

urinary excretion levels of such

compounds vary among individuals

according to their smoking habits. Due to

the fact that they are lipophilic, tobacco-

related carcinogens can be stored in

breast adipose tissue and then

metabolized and activated by human

mammary epithelial cells. Experimental

studies have indicated that tobacco

smoke contains potential human breast

carcinogens [including PAHs, aromatic

amines, and N-nitrosamines, and the

higher prevalence of smoking-specific

DNA adducts and p53 gene mutations

This is present

because Patient

Star is a smoker

that consumes four

sticks of cigarette

per day.

36

found in the breast tissue of smokers

compared with that in nonsmokers

supports the biological plausibility of a

positive association between cigarette

smoking and breast cancer risk.

-Cigarette Smoking and the Risk of

Breast Cancer in Women

Paul D. Terry and

Thomas E. Rohan,

http://cebp.aacrjournals.org

RADIATION

THERAPY

Women who, as children or young

adults, had radiation therapy to the chest

area as treatment for another cancer

(such as Hodgkin disease or non-

Hodgkin lymphoma) are at significantly

increased risk for breast cancer. This

varies with the patient's age when they

had radiation. If chemotherapy was also

given, the risk may be lowered if the

chemotherapy stopped ovarian hormone

production. The risk of developing breast

cancer appears to be highest if the

radiation was given during adolescence,

when the breasts were still developing.

www.cancer.org

X

This is absent since

patient is not on a

radiation therapy.

RECENT

CONTRACEPTIVE

USE

Studies have found that women using

oral contraceptives (birth control pills)

have a slightly greater risk of breast

cancer than women who have never used

them, but this risk seems to decline once

their use is stopped. Women who stopped

X This is absent since

patient is not using

any contraceptive

as reported.

37

using oral contraceptives more than 10

years ago do not appear to have any

increased breast cancer risk. When

thinking about using oral contraceptives.

-www.cancer.org

ANTIPERSPIRANT

USE

Many experts have suggested that

chemicals in underarm antiperspirants

are absorbed through the skin, interfere

with lymph circulation, cause toxins to

build up in the breast, and eventually

lead to breast cancer.

One small study has found trace levels of

parabens (used as preservatives in

antiperspirants and other products),

which have weak estrogen-like

properties, in a small sample of breast

cancer tumors.

-www.cancer.org

This is present

since patient

reported use of

antiperspirant since

adolescent age.

38

SYMPTOMATOLOGY

BREAST CANCER

FACTORS RATIONALE PRESENT/

ABSENT

JUSTIFICATION

Thickening/Lump in or

near the underarm area

A woman's breasts can feel

lumpier just before her

menstrual period. At this time

of the month, she experiences

a surge in female hormones—

estrogen, progesterone and

prolactin. These hormones

stimulate fibrous breast tissue

to grow and retain fluid.

Breast cancer first announces

itself in the form of a lump.

http://www.mothernature.com/

This is present since

patient noted

thickening or lump

in an area of her

breast.

Asymmetry Prior to each menstrual period,

the surge in estrogen and

progesterone stimulates fluid

retention and growth in breast

tissue.

http://www.mothernature.com

This is present since

patient reported very

noticeable

asymmetry of her

breast due to

swelling and

tenderness.

Bleeding and Discharge

from the nipples

Excess fluids seeps out into

the duct which causes

discharge from the nipples.

http://www.mothernature.com

This is present since

patient reported that

she had discharges or

bleeding during the

course of her illness.

39

Skin Dimpling/Orange

peeling or

Pitting of the breast

A dimpling of the breast skin

or nipple could be from the

loss of elasticity in the

supporting ligaments as you

age. But dimpling may also be

a sign that a tumor buried in

the tissues is pulling on the

skin or nipples. In the case of

a tumor, dimpling might show

up long before a lump

becomes large enough to feel.

http://www.mothernature.com

This is present since

patient reported that

there skin dimpling

or pitting of the

breast noted during

the duration of her

illness. Added by the

patient, there is also

crusting around the

pitting area.

Warmth

Redness

Swelling

Warmth, redness and swelling

are due to the inflammation

process. It is due to the

invasion and obstruction of the

dermal lymphatics by the

tumor

Medical-Surgical Nursing

Black and Hawks, 2004

This is present since

patient noted

warmth, redness,

swelling of her left

breast

40

Narrative Pathophysiology

The etiology of breast cancer and even on any type of cancer is still unknown.

Predisposing factors that are present on the case of my patient are the following, sex, age, early

menarche and her late pregnancy, while her precipitating factor is her usage of antiperspirant for

a long period of time, since she was on adolescent stage. Under the predisposing factors, these

leads to an over expressed estrogen receptor and an increase in the estrogen level with thses it is

now expose to estrogen when it is increased, also its metabolism goes up or it also increases,

which leads to an increase in cell proliferation. On the otherhand, under the precipitating factor,

there is now an absorption of chemicals particularly that of Parabens chemical which is a weak

estrogen-like substance that enters in our breast tissues and that toxins also interferes the

circulation in our lymphatic system. Toxins being impacted and stored on our breast, builds up.

When these two factors meet, Initiations phase then starts. Wherein carcinogens bind to cell’s

DNA resulting into an alteration of functions. Genotoxic waste in estrogen metabolism takes

place and there is already an error in cellular duplication. Resulting into a damaged genes of

Tumor Suppressor Cells and modifies functioning of the proto-oncogenes. When there is already

a damage and interruption on the cell proliferation, the repair and elimination process that

supposed to be is going to happen in a certain cell, is now inhibited. Oncogenes now, make it

possible for cell transformations as dividing excessively and uncontrollably/ until it proceeds to

the next phase which is the Promotion phase where a continuous duplication of mutated DNA

happens. A single cell begins to divide abnormally and a formation of new tissue or tumor

follows. Which is now the STAGE 1 of cancer, wherein if not treated, Malignant Conversion

happens, an accumulation of cancer cells in the breast, center of tumor necrotizes and begins to

chip of malignant cells to seek new blood supply and cells eventually break out of the tumor and

invades the surrounding nodes and blood vessels. Before proceeding into the next stage the

cancer cells spreads in two ways, it is either the Lymphatic or Hematologic. When Stage 2

occurs, cells penetrate the lymphatic vessles by invasion process and cells lodge in the lymph

nodes and grow. Surrounding lymph nodes and vessles around the breast become obstructed and

are a malignant one. Cancer cells continue to stream in lymph fluid and may undergo metastasis

41

destroying epithelial wall until there is already an impairment in the lymph flow and

accumulation of fluid in the chest cavity until new sites of tumor develop. In Stage 3 before it is

going to be diagnosed in that stage, diagnostic exams are being conducted first, like excisional

biopsy, blood test, mammogram and chest x-ray. Once a patient has symptoms suggestive of a

breast cancer or an abnormal screening mammogram, she will usually be referred for a

diagnostic mammogram. A diagnostic mammogram is another set of x-rays with additional

angles and close-up views. Often, and ultrasound will be performed during the same session. An

ultrasound uses high-frequency sound waves to outline the suspicious areas of the breast. It is

painless and can often distinguish between benign and malignant lesions.

Depending on the results of the mammograms and/or ultrasounds, your doctors may

recommend that you get a biopsy. A biopsy is the only way to know for sure if you have cancer,

because it allows your doctors to get cells that can be examined under a microscope. There are

different types of biopsies; they differ on how much tissue is removed. Some biopsies use a very

fine needle, while others use thicker needles or even require a small surgical procedure to

remove more tissue. Your team of doctors will decide which type of biopsy you need depending

on your particular breast mass.

Once the tissue is removed, a doctor known as a pathologist will review the specimen.

The pathologist can tell if is the cells are cancerous or not, If the tumor does represent cancer, the

pathologist will characterize it by what type of tissue it arose from, how abnormal it looks

(known as the grade), whether or not it is invading surrounding tissues, and whether or not the

entire lump was removed during surgery. The pathologist will also test the cancer cells for the

presence of estrogen and progesterone receptors as well as a receptor known as HER-2/neu. The

presence of estrogen and progesterone receptors is important because cancers that have those

receptors can be treated with hormonal therapies. HER-2/neu expression may also help predict

outcome. There are also some therapies directed specifically at tumors dependent on the presence

of HER-2/nue. On STAGE 3B if its not treated, the patient will have poor prognosis which

means that the cancer cells that are able to sutvive the environment and pressure still continue to

venous blood flow and metastize which leads to STAGE 4wherein an impairment in liver and

lungs functioning happen that results to organ failure and arrest that may lead to death.

42

43

PATHOPHYSIOLOGY

44

PREDISPOSING FACTOR-SEX-AGE

-EARLY MENARCHE-NULLIPARITY and NON-BREAST

PRECIPITATING FACTOR-LONG TERM

ANTIPERSPIRANT USE

Increased estrogen level

Increased estrogen

Over expressed estrogen receptor

Absorption of chemicals in antiperspirant through the

INCREASED ESTROGEN METABOLSIM

Initiation:Carcinogens bind to cell’s DNA

results to alteration of functions.

Toxins interfere with lymph circulations

Toxins build up in the breast

Parabens, weak estrogen-like chemicals

in antiperspirant enters breast tissues

Increased cell proliferation

45

Genotoxic waste in estrogen

metabolism

Spontaneous error of cell duplication

Modified functioning of proto-oncogenes.

Damage to the genes of Tumor Suppressor Cells

Repair or elimination of cells with damaged DNA is

inhibited.

Proto-oncogene becomes oncogene

due to genetic

Impaired program cell death

Oncogenes make it possible for cell transformations such as

dividing excessively and uncontrollably.

A single cell begins to divide abnormally

Formation of new tissue or tumor

Promotion: Continuous duplication of

mutated DNA

STAGE 1 Thickening/Lump in or near the underarm area

46

Center of Tumor Necrotizes and begins to chip of malignant cells to seek new blood supply.

Malignant Conversion:Accumulation of cancer cells in the breast

Cells break out of the tumor and Invades to surrounding lymph nodes and/or Blood

vessels.

If not treated

Blood vessels including arteries and veins carries cancer cells to organs: liver, lungs, and Blockage of Lymph

vessel draining the fluids from the breast

Inflammation of breast and swelling of

lymph nodes

Unblocked Lymph nodes drain towards the venous

blood flow.

STAGE 2LYMPHATIC SPREAD:

Dissemination of Cancer cells to the lymph channels in a process called

embolization.

Cells lodge in the lymph nodes and

grow.

Cells penetrate lymphatic vessels

by invasion process

HEMATOLOGIC SPREAD:Dissemination of Cancer

cells through blood vessels.

Surrounding lymph nodes and vessels around the breast become obstructed by malignant tumor

Cancer move to extracellular matrix by secreting enzymes

Endothelium cracks open then causes surrounding tissue to be damaged

Entry to blood vessels

47

Cancer cells continue to stream in the lymph fluid

May undergo invasive metastasis destroying epithelial

wall.Impaired Lymph flow and erosion of tumor accumulates fluid in the chest

cavity.

Cancer cells spread into the membrane linings

Irritation and build up of fluid on adjacent tissues

Increase in capillary permeability

DIAGNOSTIC EXAMS

Excisional Biopsy:

-a section of tissue is removed under general or local anesthesia and sent for mammographic and histological

Blood test:-A test done to check for a specific tumor marker, CA 15-3 for breast cancer.

Chest x-ray:- Chest films acquired in the lateral decubitus position (with the patient lying on his side) are more sensitive, and can pick up as little as 50 ml of fluid. At least 300 ml of fluid must be present before upright chest films can pick up signs of pleural effusion. A chest with >500ml of fluid is positive for pleural effusion.

Mammogram:-A mammogram is a low-dose x-ray of the breast tissue. Mammograms can detect changes in the breast tissue before they develop into a lump large enough to be

New sites of tumor STAGE 3

48

Breast Cancer Stage IIIB T4N2M0

Medical Treatment:Pharmacologic Intervention-

1. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence.

2. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery.

3. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.

Surgical Treatment:Modified Radical Mastectomy with Split Thickness Skin Graft-

-is an en bloc removal of the breast, axillary lymph nodes, and overlying skin, with the muscles left intact

Bilateral Chest Tube Thoracostomy--it is done to drain excess fluid from the

pleural space.

Nursing Interventions:1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. 2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain

or loss, fatigue, stomatitis, anxiety, and depression. 3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological

support to the patient throughout the diagnostic and treatment process. 4. Involve the patient in planning and treatment. 5. Describe surgical procedures to alleviate fear. 6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. 7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. 8. Administer I.V. fluids and hyperalimentation as indicated. 9. Help patient identify and use support persons or family or community. 10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems. 11. Teach all women the recommended cancer-screening procedure

If treated:

49

If not treated:

Poor Prognosis

Prolonged or delayed development of metastasis

Metastasis:New tumors metastasize in the

liver, lungs and lymph.

Cancer cells that are able to survive the environment and pressure still

continue to venous blood flow

Impaired functioning of the liver and lungs.

Failure of the liver and lungs. lymphedema

STAGE 4

Organ Failure

Fair Prognosis

Cardiac Arrest

DEATH

DOCTOR’S ORDER

Date Ordered Doctor’s Order Rationale Remarks

December 14,200911:00 am

Wt: 44kgBP: 120/70PR: 128bpmRR: 27 cpmT: 37.3 ◦cHgt: 219mg/dl

Please admit under the service of Dr. Malubay (PC)

Diabetic Diet

Monitor VSq4 and record please

Hospital admission is

advised for observation

and managementer of the

client.

Diabetic Diet is being

given to patients with

history of Diabetes and

high blood glucose level.

Patient Star’s Hgt value

which is 219mg/dl

revealed that she needs to

control the glucose intake

in her body.

To obtain baseline data

and check for

unusualities or deviations

from normal.

DONE

DONE

DONE

50

Labs: > CBC,PC

> Bld. Typing > CXR- PA view > ECG > HGT now > UA > S. Na, K+

Start venoclysis

with PNSS 1L at

120cc/ ◦ # 1

To evaluate the

composition and

concentration of the

cellular components of

blood which measures

the following:

the number of

red blood cells

(RBCs)

the number of

white blood

cells (WBCs)

the total

amount of

hemoglobin in

the blood

the fraction of

the blood

composed of

red blood cells

(hematocrit)

the mean

corpuscular

volume (MCV)

— the size of

the red blood

cells

DONE

DONE

51

Meds:

>Metformin

500g tab 1 tab

BID P. O

(Maintenance)

>Ketorolac 30g

IVTT q 6◦; Give

1st dose now

> Cefuroxime

750g IVTT q 8◦

ANST

For dressing with

Daikins solution

Monitor I&O q shift

Dr. Malubay

informed of this

admission ( seen

To supply water and

electrolytes (e.g.,

calcium, potassium,

sodium, chloride), either

with or without calories

(dextrose), to the body.

>Metformin is used to

minimize glucose level.

It is the patient’s

maintenance drug for her

Diabetes.

>Ketorolac is given for

short term management

of pain in her left breast.

Also used to prevent

fever and inflammation.

>Cefuroxime is used to

treat skin and soft tissue

infections. Patient Star is

having a wound at her

left breast due to breast

CA.

> Daikins solution is

used for dressing, to

prevent germ growth on

wounds.

> To maintain fluid and

electrolyte balance.

DONE

DONE

DONE

DONE

DONE

DONE

52

Signed:

Meliza Carla T.

Agoilo, MD

December 14, 2009

12: 30pm

PR)

Refer to Dr. Torno

for co mgt.

Refer to Dr.

Lamanosa for Pain

mgt.

Refer accordingly

MROD, Thank you

for this referral,will

inform Dr. Torno

Suggest to shift

antibiotic and

sulperazone 1gm q

8◦ ANST

Monitor CBG q 6◦

(5-11-5-11)

Give Humulin R,

8 units SQ now then

8 Units q 6 pm for

CBG ≥ 180mg/ dl

Include S. Crea

> To let other physicians

know if the physician is

already informed about

the patient.

>To let Dr. Torno know

about the patient’s

admission and condition.

> To manage the pain felt

by the patient on her left

breast.

>Nurse noted the ordered

referral of Dr. Agoilo

> To treat and prevent

infection and

inflammation on the

patient’s wound at left

breast.

> To monitor the patients

blood glucose level and

other blood components.

>To control

hyperglycemia. Patient is

DONE

DONE

DONE

DONE

DONE

DONE

DONE

53

Signed:

Dr. Torno

December 14, 2009

3:00 pm

Signed:

Dr. Torno

December 14, 2009

8:41 pm

Hold Cefuroxime

IV

Ciprofloxacin

500g 1tab BID 1st dose

ASAP

Clindamycin 300g

1cap q 6◦ after meal

Start Humalog

mix 20 units SQ at

breakfast, 12 units SQ

at dinner

Please secure 2

units PRBC of

patient’s Bld.

Type properly

a known diabetic.

>To know if the patient

has kidney problem.

>Before administering

Cefuroxime, physician

must know first the result

of the patient’s creatinine

value to evaluate any

renal insufficiency.

> To treat the patient’s

skin and soft tissue

infection on her breast

wound which may cause

fever and further

inflammation.

>To treat and prevent

infection on the patient’s

wound.

>To control

hyperglycemia. Patient is

a known diabetic since

2006.

>To normalize

DONE

DONE

DONE

DONE

DONE

54

Signed:

Dr. Malubay

December 15, 2009

12: 30am

crossmatched

Please transfer

once bld is

available, repeat

Hct 6 hours post

BT of 2 units

For Toilet

Mastectomy with

skin grafting

pending schedule

Please inform Dr.

Torno of plan

Refer accordingly

Please discontinue

Ketorolac for S.

Creatinine in Am,

please inform me

of result

Nalbuphine 5g

IVTT q 8◦ x 4

dose then shift to

Tramadol 100g ½

hemoglobin level, for

good blood circulation

and to maintain amount

of blood supply at

equilibrium.

>To normalize

hemoglobin level, for

good blood circulation

and to maintain amount

of blood supply at

equilibrium.

>Toilet Mastectomy is

done for mobile ulcerated

fungating tumours with

or without distant

metastases.

>To let the physician

know the procedure to be

done on her patient

>Ketorolac may interrupt

the blood levels and

readings of the S.

Creatinine result

>To treat the patient’s

pain.

DONE

DONE

DONE

DONE

DONE

55

Signed:

Dr. Lamanosa

December 15, 2009

1:00 am

Signed:

Dr. Agoilo

December 15, 2009

7:20 am

tab BID ( pls

inform if pt.

develops

persistent N&V)

Refer for

problems

Etericoxib 120g

P.O OD

IVFTF: PNSS 1L

@ 120cc/ ◦

Ff. up availability

of blood

Refer creatinine

result please to

ROD

> To let the physician

know the patient’s

problem and to provide

relief on it.

>To relieve acute pain

being felt by the patient.

> To provide patient

with adequate amount of

fluid and electrolytes.

>To start the treatment

rehgimen in order to

normalize hemoglobin

level, for good blood

circulation and to

maintain amount of

blood supply at

equilibrium.

>To know evaluate the

patient’s condition in her

treatment and therapeutic

DONE

DONE

DONE

DONE

DONE

56

Signed:

Dr. Agoilo

December 15, 2009

9:00 am

Signed:

Dr. Agoilo

December 15, 2009

10:00 am

Signed:Dr. Torno

December 15, 200911:00 am

For dressing with

Daikins solution

c/o ROD/ surgical

clerk in-charge

IVFTF: PNSS 1L

#3 @ 120cc/ ◦

Continue meds

Schedule for

Toilet mastectomy

TF 1st case

(lapcholecystecto-

my)

Dr. Lamanosa for

anesthesia

regimen.

> Daikins solution is

used for dressing, to

prevent germ growth on

wounds.

> To provide patient

with adequate amount of

fluid and electrolytes.

> To provide the patient

medications that will

relieve the pain that she

felt and to avoid further

inflammation and

infection.

> Toilet Mastectomy is

done for mobile ulcerated

fungating tumours with

or without distant

metastases.

>For anesthesia

administration of the

patient during the

DONE

DONE

DONE

DONE

DONE

57

Signed:

Dr. Malubay

December 15, 2009

11:50 am

Signed:Dr. Narisma

December 15, 2009

4:30 pm

Signed:Dr. Torno

Seen AC &

consult, start BT

once available

Inform OR

Refer, accordingly

Please give 1amp

Plasil now, then q

6◦ PRN for

vomiting

Hold Cipro and

Clinda p.o

Shift to Cipro

200g IV q 12; no

skin test

Hold Metformin

surgical procedure to be

done.

> To start the therapeutic

regimen and for the

patient’s body to be

ready for the procedure.

> To let the OR staff

know about the

procedure and for it to be

scheduled.

>To have a smooth

process on the

physician’s part.

>To prevent the patient

from vomiting.

> Ciprofloxacin IV drug

is used for patients who

are immunosuppressed

and with infection.

> Patient’s glucose level

is already decreased into

normal level, holding the

medicine avoids the

DONE

DONE

DONE

DONE

DONE

DONE

58

December 15, 2009

8:00 am

Signed:

Dr. Narisma

December 15, 2009

9:30am

Continue meds

Schedule for

Toilet mastectomy

tom TF 1st case

IVFTF: PNSS 1L

to run @ 120cc/ ◦

x 2 cycle #4, 5

Refer accordingly

PRE- OP Orders:

NPO post

midnight

V/S before OR

General / oral

hygiene PTOR

patient to be

hypoglycemic.

> To provide the patient

medications that will

relieve the pain that she

felt and to avoid further

inflammation and

infection.

> Toilet Mastectomy is

done for mobile ulcerated

fungating tumours with

or without distant

metastases.

> To provide patient

with adequate amount of

fluid and electrolytes.

> To prevent any

complications during the

operation scheduled for

the next day

>To have a baseline data

before operation and to

know any unusualities

that may not allow the

patient to be operated.

>To prepare the patient

DONE

DONE

DONE

DONE

59

Signed:

Dr. Lamanosa

December 16, 2009

IVF: D5NSS 1L

@ 120cc/ ◦

Meds:

1. Diazepam 5g 1tab

at 6 am with sips of

water

2. Ranitidine 15g

1tab at 6am with sips

of H20

Secure 1 unit of

bld and crossmatch

Pls let pt. void

prior to giving

meds

Refer for problem

May resume diet,

reschedule OR

for operation.

>To provide patient with

adequate amount of

liquid and electrolytes in

the body.

>To sedate the patient

while performing the

procedure.

> Ranitidine is useful in

promoting healing of

stomach and duodenal

ulcers, and in reducing

ulcer pain.

>To normalize

hemoglobin level, for

good blood circulation

and to maintain amount

of blood supply at

equilibrium.

>To prepare and avoid

the patient from

excreting waste during

surgery.

> To let the physician

know any problems prior

to operation.

> Resuming the patient’s DONE

60

10:30 am

Signed:Dr. Malubay

December 16, 2009

12:20 pm

Signed:Dr. Malubay

December 16, 2009

5:30 pm

Signed:Dr. Malubay

tomorrow @

7:30am

For

compliance of

antibiotics

Please schedule

tomorrow @

7:30pm

NPO post midnight

Inform OR and Dr.

Lamanosa

IVFTF: D5NSS 1L

@ 120cc/ ◦

diet allows the patient to

ingest food again for

body’s supplement. NPO

diet for her is only for

OR preparation.

> To prevent infection

and inflammation on the

affected area or her

wound on breast.

> To let the OR staff and

residents know about the

procedure to be done on

the patient.

> To prevent aspiration

and for the patient to

avoid excreting waste

during the procedure.

> To let the OR staff and

residents know about the

procedure to be done on

the patient and let Dr.

Lamanosa know the

changes that happened.

> To provide the patient

adequate liquid and

electrolyte intake and

supplement.

DONE

DONE

DONE

DONE

DONE

61

Diagnostic Exams

Blood Chemistry (12-14-09)

Date Exam Normal Value

Rationale Result of

patient

N/H/L Clinical Significance

Dec. 14, 2009

Creatinine 44.0- 80.0 umol/L

Measure the level of the waste product creatinine in your blood and urine. This test tells how well your kidneys are working.

109umol/L

H There is an indication of kidney problem.

Blood Chemistry (12-15-09)

Date Exam Normal Value

Rationale Result of patient

N/H/L Clinical Significance

Dec. 15, 2009

Creatinine 53 - 115 umol/L

Measure the level of the waste product creatinine in your blood and urine. This test tells how well your kidneys are working.

109umol/L

H There is an indication of kidney problem

Potassium 3.5- 5.3 mmol/ L

This test measures the amount of potassium in the blood. Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.

4.07 mmol/ L

N There is a normal regulation on how the heart beats.

Sodium 135-148 mmol/ L

The sodium levels are measured to detect

136.06mmol/

N There is a normal sodium level in the blood.

62

whether there is a right balance of sodium and liquid in the blood to carry out those functions.

L

Hematology

Date Exam Normal Value

Rationale Result of patient

N/H/L

Clinical Significance

Dec. 14,2009

Hemoglobin M: 140- 170 g/dl

F: 120- 150g/dl

This is the amount used to measure the amount of hemoglobin per liter of blood. It is measured to evaluate blood loss, anemia, and response to therapy.

99 L A decreased result below the normal range may indicate anemia.

Hematocrit M: 0.40- 0.60

F: 0.38- 0.40

This test is used to measure the proportion of whole blood volume occupied by erythrocytes. It is useful in the evaluation of blood loss, anemia, polycythemia, and dehydration.

0.30 L There is an indication of anemia and dehydration.

RBC Count 4.06- 6.0 x10^12/L

Used to evaluate any type of decrease or increase in the number of red blood cells as measured per liter of blood.

3.06x10^12/L

L Indicates anemia.

WBC Count 5.0-10.0 x10^9/L

Used to determine the presence of an infection or leukemia.

17.1x10^9/L

N There is an indication of infections or leukemia.

63

It is also used to help monitor the body’s response to various treatments and to monitor bone marrow function.

Neutrophils 45 – 65% This test measures the amount of neutrophils in blood. Neutrophils are a type of white blood cell (WBC). This test is used to evaluate and manage immune, blood, and cancer disorders, including suspected neutropenia..

65% H There is indication of immune, blood, and cancer disorders, including neutropenia.

Lymphocytes (P)

20 – 35% This test is done to determine the lymphocyte blood count.

10% L There are low secretion antibodies which are involved in the immune system response and regulation.

Monocytes 2 – 10% This test is done to help diagnose an illness such as infection or inflammatory disease.

6% N Monocytes remove debris or foreign particles from the circulation. They also participate in immune response.

Eosinophils 1 – 4% This test counts the number of eosinophil in blood. It is used to evaluate and manage allergic conditions, blood and infectious diseases, as well as certain infections.

4% N No indication of allergic conditions, blood and infectious diseases, as well as infections.

Basophils 0 – 1% This test measures 0 N

No indication of

64

the amount of basophils in blood. This test is used to help evaluate and manage treatments including certain allergic disorders, blood disorders, neoplastic disorders, and infections caused by parasites

allergic disorders, neoplastic disorders, and infections caused by parasite.

Blood Typing

Date Result

December 14, 2009 “A” Rh Positive

X- Ray Report (12-15-09)

Chest PA: Heart is within normal limits in size. There are infiltrates in the right lower

lobe. Rest of the lung fields are clear. Lateral CP sinuses are sharp.

Impression: Infiltrates may be inflammatory or neoplastic in origin. Please correlate

clinically.

65

Drug Study

GENERIC NAME Ranitidine hydrochloride

BRAND NAME Ranitidine

CLASSIFICATION Histamine2 (H2) antagonist

ORDERED DOSAGE 50 mg q 8 hours / q 4 hors IVTT

MODE OF ACTION

Competitively inhibits the action of histamine at the H2 receptors

of the parietal cells of the stomach, inhibiting basal gastric acid

secretion and gastric acid secretion that is stimulated by food,

insulin, histamine, cholinergic agonists, gastrin and pentagastrin.

INDICATION

Intractable duodenal ulcer; pathologic hypersecretory condition;

short term therapy for patients unable to tolerate oral forms,

duodenal and gastric ulcer, maintenance therapy for duodenal

ulcer, gastroesophagial reflux disease, erosive esophagitis, self

medication for occasional heart burn, acid indigestion, and sour

stomach

DRUG INTERACTION

Drug-drug: Antacids: may interfere with ranitidine absorption,

Diazepam: May decreased diazepam absorption, Gilipizide: May

increase hypoglycaemic effect, Procainamide: May decrease renal

clearance of procainamide, Warfarin: May interfere with warfarine

clearance

Drug-lifestyle: Smoking: may increase gastric acid secretions and

worsen disease

CONTRAINDICATION Contraindicated in patients hypersensitive to drugs and its

66

components; Porphyria

SIDE EFFECTSHeadache, malaise, dizziness, rash, constipation, nausea, vomiting,

abdominal pain

ADVERSE

REACTIONS

Tachycardia, bradycardia, hepatitis, impotence or decreased

libido, leucopenia, granulocytopenia, thrombocytopenia

NURSING

RESPONSIBILITIES

Assessment

History – allergy to ranitidine, impaired renal or hepatic

function

Physical – skin lesions; orientation, affect; pulse, baseline

ECG, live evaluation, abdominal examination, normal

output, CBC, renal function test

Intervention

Decrease doses in renal and liver failure

Provide concurrent antacid therapy to relieve pain.

Arrange for regular follow – up, including blood tests, to

evaluate effects.

Patient teaching

If you also are using antacid, take it exactly as prescribed,

being careful of the times of administration.

Have regular follow – up care to evaluate your response.

You may experience these side effects: constipation or

diarrhea (request aid from your health care provider),

nausea, vomiting, impotence or decreased libido, headache

Report sore throat, fever, unusual bruising or bleeding,

tarry stools, confusions, hallucinations, dizziness, severe

headache, muscle or joint pain.

BIBLIOGRAPHY

Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and

Wilkins, Wolters Kluwer Company

Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)

67

Generic Name Ketorolac

Brand Name Toradol

Classification NSAID, nonopioid analgesic

Dosage 30mg q 8hr IVTT

Mode of Action Inhibits prostaglandin synthesis, producing peripherally

mediated analgesia. Also has anti-pyretic and anti-

inflammatory properties

Indications Short-term management of pain

Ocular itching caused by seasonal allergic rhinitis

Postoperative inflammation following cataract surgery

Pain and burning or stinging following corneal refractive

surgery

Contraindications Hypersensitivity to the drug or other NSAIDS

Acute peptic ulcer disease, recent GI bleeding or

perforation, history of peptic ulcer or GI bleeding

Suspected or confirmed cerebrovascular bleeding,

hemorrhagic diathesis, or incomplete hemostasis and in

those with a high risk of bleeding

Intrathecal or epidural administration( due to alcohol

content of product)

Labor, delivery, or lactation

Perioperative pain from coronary artery bypass graft

surgery

Side Effects Drowsiness, dizziness, headache, nausea, vomiting,

epigastric pain, indigestion, flatulence, constipation,

68

insomnia, dry mouth, sweating

Adverse Effects Gastric or duodenal ulcers, renal failure, peripheral edema,

dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis,

anaphylaxis

Drug Interaction Concurrent use with aspirin may decrease effectiveness

With aspirin, other NSAIDS, potassium supplements,

corticosteroids, or alcohol, adverse GI effects is increased

Chronic use with acetaminophen may increase risk of

adverse renal reactions

May decrease effectiveness of diuretics or hypertensives

Increases risk of toxicity with methotrexate

Increases risk of bleeding with cefotetan, cefoperazone,

valproic acid, clopidogrel, and ticlopidine

Increases risk of adverse heamatologic reactions with

antineoplasctic or radiation therapy

May increase risk of nephrotoxicity from cyclosporine

Probenecid increases ketorolac blood levels and the risk of

adverse reactions

Nursing

Responsibilities

Assess pain ( type, location, & intensity) before and after

drug therapy.

Assess for rhinitis, asthma, urticaria. Patients who have

asthma, aspirin-induced allergy, and nasal polyps are at

increased risk of developing hypersensitivity reactions.

Instruct patient on how and when to ask for medication

Tell patient to take medication exactly as directed. Take

missed doses as soon as remembered if not almost time for

next dose. Do not double dose.

Advise patient to avoid driving or other activities requiring

alertness until response to the medication is known

because it may cause drowsiness or dizziness.

Caution patient to avoid the concurrent use of alcohol,

69

aspirin, NSAIDS, acetaminophen or other OTC

medications without consulting health care professional

Advise patient to consult health care professional if rash,

itching, visual disturbances, tinnitus, weight gain, edema,

black stools, persistent headache, influenza-like-syndrome

( chills, fever, muscle aches, pain) occurs/

BIBLIOGRAPHY

Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and

Wilkins, Wolters Kluwer Company

Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)

Handbook of Drugs for Nursing Practice .2nd Ed. Mosby Year

Book, St. Louis, Missouri, U.S.A.

Foley, M, RN, BSN, et.al. (2005) Mosby’s 2005 Drug Consult for

Nurses .1st Ed. Elsevier Mosby, St. Louis Missouri, U.S.A.

70

Generic Name Tramadol

Brand Name Ultram

Classification Analgesic ( centrally acting)

Dosage 50mg q 8hr IVTT

Mode of Action Binds to mu-opioid receptors and inhibits the reuptake of

serotonin and norepinephrine in the CNS

Indications Moderate to moderately severe pain

Contraindications Contraindicated with hypersensitivity or allergy to

tramadol or opioid.

Patients who are acutely intoxicated with alcohol,

sedatives/hypnotics, centrally acting analgesics, opioid

analgesics, or psychotropic agents.

Patients who are physically dependent on opioid

analgesics.

Not recommended for use during pregnancy or lactation

Side Effects Dizziness, headache, nausea, vomiting, constipation,

sweating, hypotension, dry mouth,

Adverse Effects Seizures, anaphylactoid reactions, hypertonia, physical/

sychological dependence, tolerance, anorexia

Drug Interaction Alcohol & general anesthetics: increases respiratory

depression

Carbamazepine: decreases tramadol effect r/t increased

metabolism

CNS depressants: additive CNS depression

Cyclobenzaprine: increases risk of seizures

Digoxin: increases risk of digoxin toxicity

71

MAO inhibitors/promethazine/trycyclic antidepressants:

increases risk of seizures

Naloxone: increases risk of seizures if naloxine used for

tramadol overdose

Quinidine: increases levels of tramadol

Nursing

Responsibilities

Assess pain (type, location, and intensity) before and after

administration of the medication.

Assess blood pressure and respiratory rate before and

periodically during administration.

Assess bowel function. Prevention of constipation should

be instituted with increased intake of fluids and bulk and

laxatives to minimize constipating effects.

Monitor patient for seizures. May occur within

recommended dose range.

Explain therapeutic value of medication before

administration to enhance the analgesic effect.

Instruct patient on how and when to ask for medication

Advise patient to avoid driving or other activities requiring

alertness until response to the medication is known

because it may cause drowsiness or dizziness.

Advise patient to change positions slowly to minimize

orthostatic hypotension.

Caution patient to avoid concurrent use of alcohol or other

CNS depressants with this medication.

Encourage patient to turn, cough, and breathe deeply for

every 2 hr to prevent atelectasis

BIBLIOGRAPHYLippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and

Wilkins, Wolters Kluwer Company

72

GENERIC NAME Etoricoxib

BRAND NAME Arcoxia

CLASSIFICATION COX-2 inhibitor

ORDERED DOSAGE 120mg cap 1 cap OD

MODE OF ACTION

COX-2 inhibitors reduce pain and inflammation by blocking

COX-2, an enzyme in the body which plays a role in joint

inflammation and pain.

INDICATION

acute and chronic treatment of the signs and symptoms of

osteoarthritis and rheumatoid arthritis

management of ankylosing spondylitis

relief of chronic musculoskeletal pain

relief of acute pain

to treat acute gouty arthritis

DRUG INTERACTION

CONTRAINDICATION allergy to Arcoxia or allergic reaction to aspirin or other

anti-inflammatory medicines

if the patient has had heart failure, a heart attack, bypass

surgery, chest pain (angina), narrow or blocked arteries of

the extremities (peripheral arterial disease), a stroke or

mini stroke (TIA or transient ischemic attack).

high blood pressure that is not well controlled on blood

pressure medication.

If the patient is having major surgery and has conditions

which increases the risk of coronary artery disease or

atherosclerosis such as high blood pressure, diabetes, high

cholesterol or smoking.

73

If the patient is having major surgery on his heart or

arteries.

SIDE EFFECTS

Nausea, vomiting, headache, dizziness, heartburn, indigestion,

uncomfortable feeling or pain in the stomach, diarrhea, swelling of

ankles, legs or feet, increased BP

ADVERSE

REACTIONS

Allergic reactions, including rash, itching and hives; altered taste;

wheezing; insomnia; anxiety; drowsiness; mouth ulcers; diarrhea;

confusions; hallucinations; decreased platelet count; severely

increased BP; atrial fibrillations; palpitations; stomach ulcers;

hepatotoxicity; renal toxicity

NURSING

RESPONSIBILITIES

BIBLIOGRAPHY http://www.drugs.com/arcoxia.html

GENERIC NAME Clindamycin

BRAND NAME Cleocin, Dalacin C

74

CLASSIFICATION Antibiotic

ORDERED DOSAGE 300mg 1cap q8 6am-2pm-10pm

MODE OF ACTIONInhibits bacterial protein synthesis by binding to 50S subunit of

ribosome.

INDICATION

Infections caused by sensitive staphylococci, streptococci,

pneumococci, Bacteroides, Fusobacterium, Clostridium

perfringens, and other sensitive aerobic and anaerobic

organisms

Endocarditis prophylaxisfor dental procedures in patients

allergic to penicillin

Acne vulgaris

Bacterial Vaginosis

Pneumocystis jiroveci (carinii) pneumonia

Toxoplasmosis (cerebral or ocula) in immunocompromised

patients

DRUG INTERACTION

Drug-Drug

Erythromycin: May block clindamycin site of action

Kaolin: May decrease absorption of oral clindamycin

Neuromuscular blockers: May potentiate neuromuscular blockade

CONTRAINDICATION

Contraindicated in patients hypersensitive to drug or

lincomycin

Use cautiously in patient seith renal or hepatic disease,

asthma, history of GI disease, of significant allergies

Use cautiously in neonates

SIDE EFFECTS/

ADVERSE REACTIONS

CV: thrombophlebitis

EENT: pharyngitis

GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,

diarrhea, dysphagia, esophagitis, flatulence, nausea,

pseudomembranous colitis, unpleasant or bitter taste, vomiting

GU: UTI, vaginal discharge

HEMATOLOGIC: eosinophilia, thrombocytopenia, transient

75

leucopenia

SKIN: maculopapular rash, urticaria

OTHER: anaphylaxis; erythema

NURSING

RESPONSIBILITIES

Inform patient of the possible side/adverse effects and drug

interactions

Instruct patient to notify physician/prescriber if

side/adverse effects and drug interactions is noted

Give with full glass of water to prevent dysphagia

Tell patient to follow proper medication regimen

Monitor vital signs for baseline data and patient

monitoring

BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and

Wilkins, Wolters Kluwer Company

GENERIC NAME Ciprofloxacin

BRAND NAME Cifroxin

CLASSIFICATIONQuinolones / Eye Anti-infectives & Antiseptics / Ear Anti-

infectives & Antiseptics

ORDERED DOSAGE PO Susceptible infections 250-750 mg twice daily. Acute

uncomplicated cystitis 100 mg twice daily for 3 days.

76

Gonorrhoea 250-500 mg as a single dose. Pseudomonal lung

infections in cystic fibrosis 20 mg/kg twice daily. Max: 750 mg

twice daily. Prophylaxis of meningococcal meningitis 500 mg as

a single dose. Surgical prophylaxis 750 mg as a single dose 60--

90 mins pre-op. Acute exacerbations of cystic fibrosis

Associated w/ P. aeruginosa infection: 20 mg/kg bid. Max: 750

mg bid. IV Susceptible infections 100-400 mg twice daily.

Pseudomonal lung infections in cystic fibrosis 400 mg twice

daily. Max: 400 mg 3 times/day. Ophth Superficial ophth

infections As 0.3% soln: Apply every 15 mins for 6 hr, followed

by every 30 mins for day 1, then hrly on day 2 and 4 hrly for days

3-14. Treatment duration: ≤21 days. Otic Otitis externa; Otitis

media As 0.2 or 0.3% soln: Instill 4 drops twice daily for 7 days.

MODE OF ACTION

Ciprofloxacin promotes breakage of double-stranded DNA in

susceptible organisms and inhibits DNA gyrase, which is essential

in reproduction of bacterial DNA.

INDICATION

Infections caused by sensitive staphylococci, streptococci,

pneumococci, Bacteroides, Fusobacterium, Clostridium

perfringens, and other sensitive aerobic and anaerobic

organisms

DRUG INTERACTION Decreased absorption with concurrent sucralfate, magnesium-

aluminum antacids, calcium, iron, zinc and multivitamins.

Increased methotrexate and caffeine levels when taken

concurrently with ciprofloxacin. Probenecid reduces renal

clearance of ciprofloxacin. Potentiates oral anticoagulants and

glibenclamide. Concurrent use with corticosteroids may increase

tendon rupture. Concurrent use with ciclosporin may cause

transient increases in serum creatinine. CNS excitation may occur

77

with concurrent admin of quinolones and NSAIDs. Serum

concentrations of theophylline are markedly elevated when co-

administered with ciprofloxacin; monitor serum levels of

theophylline.

Potentially Fatal: Concurrent use with tizanidine can cause

marked elevation in serum levels of tizanidine; avoid concurrent

usage.

CONTRAINDICATION

Hypersensitivity. Not to be used concurrently with tizanidine.

Avoid exposure to strong sunlight or sun lamps during

treatment. Epilepsy, history of CNS disorders; severe renal or

hepatic dysfunction; G6PD deficiency; maintain adequate

hydration; myasthaenia gravis. Caution when used in patients

with QT prolongation or risk factors e.g. bradycardia, pre-

existing cardiac disease or uncorrected electrolyte

disturbances. Discontinue treatment if patients experience

tendon pain, inflammation or rupture. Avoid usage in

methicillin-resistant staphylococcus aureus (MRSA) infections

due to high level of resistance. May impair ability to drive or

operate machinery. Safety and efficacy have not been

established in pregnant and lactating women. Not to be used in

children <18 yr; except where benefit clearly exceeds risk.

SIDE EFFECTS/

ADVERSE REACTIONS

CV: thrombophlebitis

EENT: pharyngitis

GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,

diarrhea, dysphagia, esophagitis, flatulence, nausea,

pseudomembranous colitis, unpleasant or bitter taste, vomiting

GU: UTI, vaginal discharge

HEMATOLOGIC: eosinophilia, thrombocytopenia, transient

leucopenia

SKIN: maculopapular rash, urticaria

OTHER: anaphylaxis; erythema

78

NURSING

RESPONSIBILITIES

Inform patient of the possible side/adverse effects and drug

interactions

Instruct patient to notify physician/prescriber if

side/adverse effects and drug interactions is noted

Give with full glass of water to prevent dysphagia

Tell patient to follow proper medication regimen

Monitor vital signs for baseline data and patient

monitoring

Assess overall health status and alcohol usage before

administering acetaminophen. Patients who are

malnourished or chronically abuse alcohol are at higher

risk of developing hepatotoxicity with chronic use of usual

doses of this drug

Assess amount, frequency, and type of drugs taken in

patients self-medicating, especially with OTC drugs.

Prolonged use of acetaminophen increases the risk of

adverse renal effects.

Lab Test Considerations

• Evaluate hepatic, hematologic, and renal function

periodically during prolonged, high-dose therapy

BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and

Wilkins, Wolters Kluwer Company

79

Nursing Theories

Nursing theory is the term given to the body of knowledge that is used to support nursing

practice. In their professional education nurses will study a range of interconnected subjects

which can be applied to the practice setting. This knowledge may be derived from experiential

learning, from formal sources such as nursing research or from non-nursing sources.

Florence Nightingale’s Environmental Theory

Nightingale's core nursing theory has an environmental focus: She believed that the

environment is an alterable medium that can be used to improve the conditions of nature and

encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and

adequate waste management are just a some of the elements she believed could be monitored and

improved when necessary. She stated that nursing is an act of utilizing the patient’s environment

to assist him in his recovery. This involves the nurse's initiative to configure environmental

80

settings appropriate for the gradual restoration of the patient's health, and that external factors

associated with the patient's surroundings affect life or biologic and physiologic processes, and

his development.

This theory is applicable to our patient because the institution where she stayed was

following an ideal way of treating their patients. The ward where she stayed was clean with

proper ventilation, provision of light and with controlled noise. There was also an adequate

management wherein there were separate garbage bins for biodegradable, non-biodegradable and

infectious materials. These factors follows Nightingales assumptions that helps for a faster

recovery of the patient.

Faye Glen Abdellah’s Patient- Centered Approach

Faye Glenn Abdellah’s problem solving approach (twenty one nursing problems) was

created to direct the nurse. It helps the nurse have an organized approach in his or her care of the

patient. It does so by providing 21 nursing problems that serve as a guide for the patient to

pattern his or her plan of care after. It can be used for data collection, planning, and prioritizing

nursing interventions.

The client’s student nurse has the task of maintaining her health and improving her

wellbeing. Doing so entails an organized plan of care that we can get from Faye Abdella’s

theory. The nurse should gather necessary information about his condition before identifying a

therapeutic plan. The student nurse assessed her ability to maintain her proper nutrition,

elimination, fluid and electrolyte balance, the body’s response to disease, regulatory

mechanisms, and maintenance of sensory function. Last is remedial care such as identifying and

accepting feelings, maintenance of effective verbal and nonverbal communication. After

identifying the needs of the patient, nursing interventions were to be done to promote wellness of

our client. It is clear that these 21 nursing problems help organize the needs and the tasks that her

student nurse needed to accomplish.

81

DONE 1.. To promote good hygiene and physical comfort

DONE 2. To promote optimal activity, exercise, rest, and sleep

DONE 3. To promote safety through prevention of accidents, injury, or other

trauma and through the prevention of the spread of infection

DONE 4. To maintain good body mechanics and prevent and correct deformities

DONE 5. To facilitate the maintenance of a supply of oxygen to all body cells

DONE 6. To facilitate the maintenance of nutrition of all body cells

DONE 7. To facilitate the maintenance of elimination

DONE 8. To facilitate the maintenance of fluid and electrolyte balance

DONE 9. To recognize the physiologic responses of the body to disease

conditions

DONE 10. To facilitate the maintenance of regulatory mechanisms and functions

N/D 11. To facilitate the maintenance of sensory function

DONE 12. To identify and accept positive and negative expressions, feelings, and

reactions

DONE 13. To identify and accept the interrelatedness of emotions and illness

DONE 14. To facilitate the maintenance of effective verbal and nonverbal

communication

DONE 15. To promote the development of productive interpersonal relationships

DONE 16. To facilitate progress toward achievement of personal spiritual goals

DONE 17. To create and maintain a therapeutic environment

DONE 18. To facilitate awareness of self as an individual with varying physical,

emotional, and developmental needs

DONE 19. To accept the optimum possible goals in light of physical and

emotional limitations

N/ D 20. To use community resources as an aid in resolving problems arising

from illness

N/ D 21. To understand the role of social problems as influencing factors in the

cause of illness

82

Lydia Hall’s Theory

Lydia Hall’s theory is visually presented by three interlocking circles. Each circle

represents a particular aspect of nursing. The three circles represent the care, core and cure. The

major aspect of care is to achieve an interpersonal relationship with the health care provider that

will much more facilitate development. This aspect provides motherly care and comfort, provide

teaching-learning activities and support the daily biological function of the patient. The

closeness of the nurse and patient promotes the sharing and exploration of feelings with the

nurse. The core aspect emphasized the therapeutic use of self and usage of reflective technique.

The patient becomes more aware of the feeling being experienced as evidenced of making

conscious decision, understand and accept feeling. In Hall’s theory health is derived as a state of

self-awareness. The cure circle is based on pathological and therapeutic sciences like giving of

prescribed medications. These three aspects function independently but they are interrelated and

the circle’s size represents the progress in each aspect.

Hall’s theory is applicable in the case of our Client. The care aspect shows the

relationship between the patient and the health care provider who is, in her case, the student

nurse. The student nurse gives health teachings to the client like the prescribed diet, medications

and lifestyle for her condition. She is aware of her condition and listens to the student nurse’s

health teachings to avoid further complications and problems. Our client was able to verbalize

her willingness to be well with the student nurse. The student nurse should encourage support in

order to promote positive outlook of the client. The core aspect helped the patient reflect on her

situation today and in this manner the patient will learn to accept and understand her situation

and cope up with ways to promote her state of wellness. The client shows motivation on getting

well by taking her medications on time which is part of the cure aspect of Hall’s theory.

83

NURSING CARE PLAN NO. 1

DATE

CUES NEED

NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS

1

2

-

1

4

-

0

9

7

:

0

0

p

m

SUBJECTIVE:

“ Sakit kayo akong

samad sa breast,” as

verbalized by the

patient.

OBJECTIVE:

-painscale of 7 out of

10 as 8-10 severe pain,

5-7 moderate pain, 0-4

mild pain

-grimace face noted

-guarded behavior

noted

-uncomfortable

position

-with dry and intact

dressing at left breast

-VS

BP= 120/70mmHg

RR= 34cpm

PR= 80 bpm

S

A

F

E

T

Y

A

N

D

S

E

C

U

R

I

T

Y

N

E

E

D

ACUTE PAIN

related to

Wound at left

breast secondary

to Breast cancer

R.

Unpleasant

sensory and

emotional

experience arising

from actual or

potential tissue

damage can due

to a disease

process..

Within 2-4 hours

of my care, patient

will be able to:

-verbalized that

pain is relieved or

controlled

-verbalized that

pain scale of 7 out

of 10 will

decreased within

0-3 pain scale

a. Provide with calm and quiet

environment.

R. For adequate rest and sleep.

b. Provide comfort measures.

R. To provide nonpharmacological

pain management.

c. Administer analgesics/ pain reliever

as indicated to maximal dosage.

R. To alleviate pain.

d. Encourage adequate rest periods.

R. To prevent fatigue.

e. Instruct/ encourage use of relaxation

exercises.

R. Reduces skeletal muscle tension

which will reduce the intensity of the

pain.

f. Encourage diversional activities.

R. To redirect attention and control the

pain felt.

g. Encourage verbalization of feelings

about the pain.

84

T= 37.1 C R. Be able to know the degree of pain

felt.

h. Encourage deep breathing exercises.

R. To assist in muscle and generalized

relaxation.

NURSING CARE PLAN NO. 2

DATE

CUES NEED

NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS

1

2

-

1

4

-

0

9

7

:

0

0

p

m

SUBJECTIVE:

“Naga katol akong

samad, nagabaho pud

siya”, as verbalized by

the patient.

OBJECTIVE:

-disruption of skin

surface

-with dry, clean and

intact dressing at left

breast.

- foul odor was noted

coming from her left

breast

-Vital Signs:

S

A

F

E

T

Y

A

N

D

S

E

C

U

R

Impaired Skin

Integrity related

to left breast

wound secondary

to breast cancer.

R:

A dimpling of the

breast skin or

nipple could be

from the loss of

elasticity in the

supporting

ligaments as you

age. But dimpling

may also be a

Within my 3 days

span of care

patient will

maintain her

normal vital signs

and well being and

no further signs of

infection will be

seen or observed

on her.

1. Assess skin, note for color, turgor

and sensation.

R: establishes comparative baseline

providing opportunity for timing

intervention.

2. Demonstrate good skin hygiene

R: Maintaining clean dry skin provides

barrier to infection.

3. Instruct family to maintain clean dry

clothes preferably cotton fabric.

R: stiff or rough clothes causes skin

friction and increases risk of infection.

4. Emphasize the importance of proper

nutrition and fluid intake.

85

BP= 120/70mmHg

RR= 34cpm

PR= 80 bpm

T= 37.1 C

I

T

Y

N

E

E

D

sign that a tumor

buried in the

tissues is pulling

on the skin or

nipples. In the

case of a tumor,

dimpling might

show up long

before a lump

becomes large

enough to feel.

R: improve nutrition and hydration

will improve skin condition.

5. provide and apply wound dressing

R: wound dressing serves as barrier to

surrounding tissue.

6. encourage early ambulation

R: promotes circulation

7: assist client in understanding and

following medical regimen

R: enhances commitment to plans,

optimizing outcomes

8: encourage client to verbalize

feelings

R: to promote proper intervention to

the problem

NURSING CARE PLAN NO. 3

DATE

/ TIME

CUES NEED NURSING

DIAGNOSIS

GOAL

OF CARE

NURSING

INTERVENTION

Dec.

15,

2009

@

7:30pm

Subjective:

“Unsa kaya ang

mahimong itsura

sa akong totoy

paghuman sa

operasyon

noh?”, as

SELF-ESTEE

Disturbed body

image related to

impending surgical

procedure on her

left breast due to

Breast Cancer

At the end of my

shift, the client

will begin to

exhibit her

perception on her

baseline body

image after

1. Establish trusting

relationship or rapport to

the patient.

® To gain trust.

2. Ascertain whether

support and counseling

were initiated when the

86

verbalized by the

patient

Objective:

- Patient is

scheduled for

toilet

Mastectomy

tomorrow

morning

- dressing placed

on left breast

M

NEED

® Woman who

undergo surgery for

breast cancer

experience a sense

of loss – changes in

life routines, social

interactions, self-

concept, and body

image – and fear of

death. Recovery

during the

postoperative

period after

mastectomy

requires a great deal

of energy. A

client’s usual

coping strategies

may not be

effective. Not every

one perceives or

handles stress in the

same way. Clients

who have surgically

lost a breast may

adapt in the same

way as they would

to any loss.

surgery , as

evidenced by

verbalization of

positive

adaptation to her

impending

surgery,

possibility of and/or

necessity of mastectomy

was first discussed.

® This provides

information about patient’s

level of knowledge and

anxiety about individual

situation.

3. Encourage patient to

verbalize feelings

regarding the procedure

done. Acknowledge

normality of feelings of

anger, depression, and grief

over loss. Discuss daily

“ups and downs” that can

occur.

® It helps patient realize

that feelings are not

unusual and that guilty

about them is not necessary

or helpful. Patient needs to

recognize feelings before

they can be dealt with

effectively.

4. Note behaviors of

withdrawal, increased

dependency, manipulation,

or noninvolvement in care.

® This suggests of

problems in adjustment

87

References:

Black, J. et. al.

(2001). MEDICAL-

SURGICAL

NURSING:

Clinical

Management for

Positive Outcomes.

6 th ed. USA: W.B.

Saunders Company.

that may require further

evaluation and more

extensive therapy.

6. Provide opportunity for

patient to deal with

mastectomy through

participation in self-care.

® Independence in self-

care helps improve self-

confidence and acceptance

of situation.

7. Encourage questions

about current situation and

future expectations.

Provide emotional support

when surgical dressings are

removed.

® Loss of breast causes

many reactions, including

feeling disfigured, fear of

viewing scar, and fear of

partner’s reaction to

change in body.

8. Plan or schedule care

activities with patient.

® Promotes sense of

control and give message

that patient can handle

situation, enhancing self-

concept.

9. Maintain positive

88

approach during care

activities, avoiding

expressions of disdain or

revulsion. Do not take

angry expressions of

patient personally.

® Assists patient to accept

body changes and feel all

right about self. Anger is

most often directed at the

situation and lack of

control individual has over

what has happened

(powerlessness), not with

the individual caregiver.

10. Identify role concerns

as woman, wife, mother,

career woman, and so

forth.

® This may reveal how

patient’s self-view has

been altered.

NURSING CARE PLAN NO. 4

Date Cues Need Nursing Diagnosis Objective of Nsg.

89

Care Interventions

December

16,

2009

Objective:

-wound at left

breast

-foul smell coming

from the wound

-clean and intact

dressing at left

breast

- foul smell

coming from her

wound was noted.

- Vital Signs:

BP= 120/70mmHg

RR= 24cpm

PR= 84 bpm

T= 37.3 C

S

A

F

E

T

Y

A

N

D

S

E

C

U

R

I

T

Y

N

E

E

D

Risk for infection related

to break in skin integrity

as evidenced by left breast

wound secondary to breast

cancer

® A woman who has

breast cancer with

draining wound is at risk

for infection.

Reference:

Lemone and Burke,

Medical Surgical Nursing,

Critical Thinking in Client

Care, 2004

Within 8 hrs span

of nursing care,

patient will be

able to maintain

an optimum level

of wellness and no

progress of

infection or spread

of wound.

1. Monitor vital

signs.

R: an increase in

temperature is the

first sign of

infection.

2. Administer

prophylactic

antibiotics as

ordered.

R: to reduce and

prevent bacterial

infection

3. Orient client for

signs and

symptoms of

sepsis (systemic

infection); fever,

chills, diaphoresis,

altered level of

consciousness,

positive blood

cultures.

®Health teachings

are essential for

the complete

90

recovery of a

client

4.Stress proper

hand washing

techniques

between nurse and

patient

®kills or prevent

the spread of

microorganisms.

5. Change

dressing as needed

or as indicated.

® to prevent

growth of bacteria

and infection

6.Eat nutritious

food and

encourage to take

vitamins

® to improve

immune system

7.Promote good

hygiene

® to promote

wellness

NURSING CARE PLAN NO. 5

DATE/

TIME

CUES N

E

NURSING DIAGNOSIS OBJECTIVE OF

CARE

NURSING

INTERVENTION

91

E

DWITH RATIONALE

Dec.

14,

2009

S/O:

-RR=34cpm

-shortness of

breath

-dyspneic

- use of

accessory

muscles while

breathing

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

I

S

E

P

A

T

T

E

R

N

Ineffective Breathing Pattern

related to disease process

secondary to Breast cancer

Rationale:

Cancer of the lung and breast

are the most common cancers

to cause breathlessness. The

former causes breathlessness

by invading and obstructing

airways in the lung. Breast

cancer on the other hand,

causes malignant pleural

effusions rather than

blocking an area in the lungs

Reference :

http://

www.virtualcancercentre.co

m/symptoms.asp?sid=15

After 8hours of

care, patient will be

able to establish

normal and

effective breathing

pattern as evidenced

by:

-RR of 16-20cpm

-be free from

cyanosis or other

symptoms of

hypoxia

Assessed respiratory

rate.

Provides a basis for

evaluating adequacy of

ventilation

Noted chest movement;

use of accessory

muscles during

respiration.

Use of accessory

muscles of respiration

may occur in response

to ineffective

ventilation.

Maintained patient on

moderate to high back

rest.

Positioning helps

maximize lung

expansion.

Encourage patient to

have adequate rest

periods between activity

To prevent fatigue

Checked for

obstructions:

accumulation of

secretions.

To maintain adequate

92

airway patency

DISCHARGE PLAN

Medications Exercise Treatment Health Teachings Out- Patient

Inform the patient of the importance of compliance of medication especially maintenance of medicines.

Inform the patient that she must take her medications at the right time prescribed by her doctor.

Since the patient is taking several medications, advise her to organize medications in a container so that it would be easier to access the medications on time.

Inform the patient not to skip medication, and if skipped, do not double the next dose.

Inform the patient that she can be ambulatory but avoid strenuous activities. Avoid lifting heavy things.

Encourage the patient to do stretching in the morning and at night as this would help in the circulation of the blood in the body.

If patient feels dizzy or weak, encourage to do range of motion exercise.

Encourage patient to do deep breathing

Inform the patient to take prescribed medications on time and with the right dosage.

If any signs and symptoms of recurrence of illness, immediately report to the doctor so that it can be intervened on.

Do not use any herbal medications to cure any sickness, immediately seek medical advice.

Avoid becoming too fatigue. Always make sure that she will be having

Encourage the patient to have adequate rest and sleep.

Advise the patient to have proper hygiene.

Encourage the patient to contact health care provider once symptoms are felt.

Relaxation technique can be done to help reduce blood pressure.

Lifestyle modification should be done because they are effective in preventing further illnesses.

Encourage the patient to have regular check-ups to monitor her health status.

Inform the patient not to self diagnose if there are cases where signs and symptoms are felt.

93

Encourage the patient to avoid taking OTC drugs unless consult has been done by the physician.

exercise. adequate rest.

Avoid stressful environment.

If dizzy, advise to sit or lie down immediately to avoid casualties.

94

Prognosis

CRITERIA GOOD FAIR POOR RATIONALE JUSTIFICATIONOnset of Illness As early as possible,

the patient should seek medical treatment when the signs and symptoms of a certain illness are manifesting. When medical attention is given early to the patient, the signs and symptoms will not lead to further complications. If the illness is diagnosed in the late stage, recovery would be slow and difficult.http://www.med.nyu.edu/patientcare/library/article.html?ChunkIID=165011

The patient seek medical help only on the event when there is already bleeding on her breast and it was still on the year 2006. She did not have any follow up check up, and now, it is already in stage 3B of the disease process.

Duration of Illness

With proper treatment by therapy and/or by medications, the client should adhere to what is being ordered by her physician during the duration of illness. Without these, the duration of illness will last longer which means the client will be at more risk of complications.http://www.healthteaching.com/pre.html

The patient only seeks and had a return check up to her physician only when her cancer progressed already.

Environment The environment affects an individual’s general health. Maintaining a good environment that is fit for the patient and aid’s in the recovery of the

The patient’s home environment is clean and comfortable to live in. The hospital is also clean and tidy which imposes

95

patient.http://www.environmentalhealth.ca/w90vision.html

proper and ideal place for their patient’s health.

Family Support Families and friends are considered to be significant others for they are the ones who provide a sick person strength, hope and encouragement. With their love and support, the patient would be able to show willingness in striving for optimum wellness.http://www.dailystrength.org/treatments/Friend_Family_Support

Patient Star has support from everyone in her family, her children visit her a lot and her current husband is very caring.

Willingness to take medications

The willingness to take medications is a good indicator that she will have a faster recovery because of the effectiveness of the drug. Ensuring that medications are taken on time, with the right dosage and route gives a big benefit to the patient.http://www.health.discovery.com/centers/articles/articles.html?chrome=c12

The patient verbalized that she really wants to get well and therefore complies with the medications and other interventions the doctor has ordered.

Precipitating Factors

The precipitating factors of the client are modifiable if proper health education is given as well as the eagerness of the client to cooperate. If these factors are modified,

I rate this as poor because the disease process is already in Stage 3B. she almost had all the precipitating factors that brought her the disease.

96

recurrence of the illness may be prevented and controlled.http://www.fcds.org/about/health/health_ed.as

Predisposing Factors

Predisposing factors are factors which cannot be changed. These factors may play crucial roles in placing a greater risk in acquiring the disease.http://www.rsirescue.com/excerpts/PredisposingFactors.htm

Although the patient is qualified for the predisposing factors for breast cancer, there are still other factors that were not manifested and even participated by Patient Star

TOTAL 3x3 2x1 1x3 14/7 = 2

LEGEND: 1 POOR= 1.0- 1.62 FAIR= 1.7-2.33 GOOD= 2.4-3.0

General Prognosis: FAIR

The patient’s prognosis is fair because patient in general is already in Stage 3B cancer

that is already in the advance stage of the disease. Although she cooperates well on the

therapeutic regimen being advised to her by the physician, family also supports her all

throughout the disease process and the patient is optimistic enough that she will gain her strength

again and be well after the surgery, still we cannot deny the fact that all the factors that brought

her the disease are present and are helping the spread of those cancer cells in her body.

97

Recommendation

To the Patient:

In order for Patient Star to achieve recovery, the researcher highly encouraged her to

maintain good nutrition by eating foods with roughage such as whole grains, raw fruits and

vegetables and try to eat less food high in salt and fats. Resumption of activities should also pace

gradually to avoid any problems, strenuous activities must be avoided and exercises or ADL’s

should be done as tolerated. Advised the importance of follow-up examinations and treatments

for these will promote faster recovery for the patient and possible complications that may arise

will be treated immediately.

To the Significant Others:

Patient Star’s family must understand the importance of early detection of the illnesses;

the researcher would like to encourage them to have routinary check ups to avoid any further

complications that may occur if not treated early. Consult a doctor if unusualities occur to the

patient so that proper medication may be prescribed to treat underlying condition. They must

extend their support, for assistance and guidance is a good way of helping the patient and

collaborate in plans to promote faster recovery. Lastly, is to always have a healthy way of living,

by doing so, the body is more ensured to be protected and armed against any diseases.

To my fellow Student Nurses:

98

In line with this case study and case presentation, we had undergone Leadership and

Training courses wherein we practiced it on our Head Nursing duties, I would like to emphasize

to practice teamwork and unity among our group. Let us be arole model in our patients. Lastly,

continue to have deep faith in our God Almighty.

Bibliography

Books: Handbook of diseases (thirds edtion) by Sarah Y. Yuan, MD, PhD Nurse’s Pocket Guide, diagnoses, prioritized interventions and rationales, by Marilynn E.

Doengers, Marry Frances Moorhouse 2008 Lippincott’s Nursing Drugs Guide by Amy Karch Fundamental of Nursing, standards and practice, third edition by Sue C. Delaune and

Patricia K. Lander Anatomy and physiology, fifth edition by Gary A. Thibodeau and Kevin T, Patton Fundamentals of Nursing, concepts, process and practice by Barbara Kozier, Glenora

ERB, Audrey Berman and Shirlee Snyder Pathophysiology made incredibly easy 4th edition. Pathophysiology Concepts of Altered Health States by Carol Mattson Porth Medical surgical Nursing, clinical management for positive Outcomes by Joyce M. black

and Jane Hokanson Hawks Springhouse Nurse’s Drug Guide 2008 MIMS 110th Edition 2006

Internet sources: http://www.smartskincare.com/reviews/product/

other_supplem_na_conzace_20040911.html http://www.rxlist.com/methergine-drug.htm http://www.umm.edu/altmed/drugs/methylergonovine-085300.htm http://www.drugs.com/pro/methergine.html http://www.answers.com/topic/scurvy http://www.rxlist.com/toradol-drug.htm www.mims.com http://www.patient.co.uk/showdoc/30002493/ www.wikipedia.com http://www.medscape.com/viewarticle/579312 http://emedicine.medscape.com/article/279116-overview http://brighamrad.harvard.edu/Cases/bwh/hcache/38/full.html http://www.personal.u-net.com/~njh/cgest.html http://www.merck.com/mmpe/sec18/ch254/ch254f.html

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