A Case Presentation to the Faculty of

Ateneo de Davao University

College of Nursing

Breast Cancer Stage IIB

In partial fulfillment of the requirements in Related Learning Experience

Presented by:

Lim, Stephanie

Madrazo, Benedict

Mangitngit, Jeferson

Margaja, Dominique

Nalzaro, Sheena

Presented to:

Ma'am Sarah Manalili, RN

Clinical Instructor

July 11, 2008

TABLE OF CONTENTS

I. Acknowledgement

II. Introduction

III. Objectives

IV. Patient’s Data

V. Family Background

VI. Developmental Data

VII. Definition of Complete Diagnosis

VIII. Physical Assessment

IX. Anatomy and Physiology

X. Etiology and Symptomatology

XI. Pathophysiology

XII. Doctor’s Order

XIII. Diagnostic Exam

XIV. Drug Study

XV. Surgical Procedure

XVI. Nursing Theories

XVII. Nursing Care Plan

XVIII. Discharge Plan

XIX. Recommendation

XX. References

ACKNOWLEDGEMENT

We, the students from group 3 of section 3E, wish to extend our

gratitude to all of the following, for the corresponding reasons:

To the ever-powerful and ever-loving God, who watches over us in every

step of the way, may He bless all student nurses striving to make the world a

better place, one intervention at a time;

To the Ateneo de Davao University, College of Nursing, for without its

existence, this case presentation wouldn’t even exist and thus cannot teach us

very crucial lessons in the practice of Nursing;

To the Davao Medical School Foundation Hospital’s medical staff, who

really showed the group how it is to work round the clock just to keep patients

safe and healthy, may they serve as inspirations for more and more student

nurses who come to practice a very humbling profession in their hospital;

To all our previous Clinical Instructors, who voluntarily impart their

knowledge for us to be able to work our best as Student Nurses, may they all

find it in their hearts to keep going and keep teaching the eager young minds

of tomorrow;

To our parents and family members, who unrelentingly give their

support for each of us to pursue our Nursing careers, may they remain in our

hearts throughout our profession;

To our class, 3E, for the unending companionship throughout the school

years, may we live to see each other grow into the Nurses that we ought to be;

To each of the group members, Blance, Stephanie, Benedict, Jeferson

and Sheena, who have dedicated and sacrificed a huge amount of time and

effort in making this Case Presentation, may this experience serve as a booster

for every skill in nursing and as a basis to measure how much better every one

of us should do next time;

To everyone mentioned above, thank you very much. You have all

contributed to the making of this Case Presentation. We hope that in any way

possible, we have contributed something to your lives as well.

INTRODUCTION

Cancer is a major health problem worldwide and the morbidity and

mortality from cancer give rise to much suffering. The risk of developing cancer in

an individual's lifetime is about 33%, and the risk of dying of cancer is 25%.

Cancer is not only a disease of the elderly although for many cancers the

incidence increases with age. Breast cancer in the US and Western Europe is the

commonest female cancer, and accounts for the most cancer deaths in women.

Eighteen percent of women who develop breast cancer will be under 50 years of

age and with an average of 50% mortality this will produce a significant number of

deaths in a population of wives and mothers who are making major contributions

to the nurture of future generations and the economy. Loss of life in this age group

has very serious consequences both for society in general and for the individual

families involved. There are now major health programs throughout the world

involved in research and development into prevention, early detection, and new

treatments with the aim of reducing the morbidity and mortality from breast

cancer. It is of some considerable interest that the East in general has amongst

the lowest rates of breast cancer in the world. This is assumed to be a

combination of environmental and genetic factors and their interaction

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.

A national population-based breast-screening program was commenced 6

years ago on the evidence from randomized trials, which demonstrate a reduction

in breast cancer mortality from screening. This remains an area of considerable

medical debate, which centers on the question of cost-effectiveness. In the not too

distant future it should be possible to better define women who are at increased

risk of breast cancer, to discover the reasons for their increase in risk, and then to

target both specific preventive and early detection strategies at this "at risk"

population.

In Asia, the Republic of the Philippines has the highest reported

incidence rate of breast cancer. From 43.2 in 2003-2005, 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

most Eastern 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 Objectives:

The group aims to present facts about breast cancer, details of how this

may affect any woman, and ways to prevent, avoid, treat, and recover from

breast anomalies.

Specific Objectives:

Cognitive:

To be able to critically understand the pathology of breast cancer and its

deviation from the normal physiologic functioning of the body

Psychomotor:

To be able to present a scientific-based, comprehensive and significant

case study with the aid of proper and complete data gathering

Affective:

To be able to give importance and attention to the concerns and needs

of our patient and our patient’s family members through therapeutic

communication

To successfully come up with the written output of this case study and

be able to attain the general objectives, the group aims to:

Gather information and pertinent data from the patient’s chart and the

significant others by interviewing them

Trace the family health history and family background of the patient

Identify effects or expectations of the illness to the patient herself and

her family

Trace the health history of the patient, including the history of past ill-

nesses and history of present illness

Utilize and apply developmental concepts to the patient’s own develop-

ment

Define the complete diagnosis of the patient

Perform and discuss a complete, thorough and comprehensive physical

assessment by using inspection, percussion, palpation and auscultation

cephalocaudally

Research and discuss about related anatomy and physiology of the

breast, the rest of the reproductive system, and the lymphatic system.

Research and discuss the etiology and symptomatology of the patient’s

condition

Trace the pathophysiology of the patient’s diagnosis which would also

include the precipitating and predisposing factors of the patients condition

Discuss the doctor’s order, the specific date of the order and individual

rationales for each doctor’s order

Interpret the diagnostic exams included in the patient’s chart which

would include the date the lab was ordered, the name of the diagnostic exam,

rationales for each exam, the normal values, the result of the patient’s diag-

nostic exam, clinical significance of the result and the appropriate nursing re-

sponsibilities to be carried out for each diagnostic exam

Research on drug studies on the drugs given to the patient which would

include the generic name of the drug, its brand name(s), therapeutic and phar-

macological classification, dosage and frequency, the mechanism of action of

the drug, indications, contraindications, side effects, adverse reactions, and

Nursing responsibilities for each drug.

Formulate appropriate nursing care plans through the utilization of the

various nursing theories related to the case of the patient

Provide health teachings and recommendations for the patient and sig-

nificant others

Formulate a discharge plan using M.E.T.H.O.D.

Cite the sources utilized by the group through an outlined bibliography

FAMILY HEALTH HISTORY

All information regarding the family’s health history comes from Patient

X. According to her, no one in the past two generations has had a breast

cancer. All the sicknesses she recalls are from her father’s side; one aunt has

diabetes and one uncle has kidney failure. Among her siblings, the second and

the third eldest sons have hypertension.

Effects/Expectations of illness to self/family.

According to Patient X, her family has this kind of practice in the onset of

an illness: Self medicate… Then go to a quack-doctor (albularyo) for

massaging with palm-oil… If still sick, then go to the hospital.

Going to a quack-doctor helps indeed, says Patient X.

Client’s Health History

In the past, she claims to be generally healthy. Her past sicknesses

includes fever and cough. In the present, she has had hypertension after

reaching the age of 50. In the year 2001, she had the onset of a breast mass

which was removed by going through a lumpectomy. This year, 2008, there

seemed to have been some residual neoplasm which then grew again and

became another breast mass. She then underwent MRM to remove her left

breast in order to have a cancer free life in the future.

Hypertension Diabetes Kidney Failure Breast Cancer Female Male

Paternal Grandfath

er

Maternal Grandmother

Maternal Grandfath

er

7 OFFSPRING4 OFFSPRING

3rd Offspring

5th Offspring

Mother84yo

Father92yo 6 OFFSPRING

1st Offspring

2nd Offspring

3rd Offspring

Patient X59yo

5th Offspring

6th Offspring

7th Offspring

8th Offspring

9th Offspring

11th Offspring

10th Offspring

removal of the breast

mass

(1st wife of Paternal

Grandfather)

Married

DEVELOPMENTAL DATA

Psychosocial Theory:

Erikson contended that ego development is lifelong. He viewed that life

development is a continuous struggle for an emotional – social equilibrium.

According to him, a person’s personality does not magically appear at a

specific time but rather spends a life time constructing, shaping and reshaping

his personality.

His theory of psychosocial development covers eight stages across the life

span. Physiological, social, emotional, and environmental factors all influence

the formation of personality. Erikson defined specific tasks that must be

accomplished for each stage of development. The primary task of each stage

has both positive and negative components or psychosocial crises and the

person undergoing the crises must balance both components to progress

developmentally. the person resolves the conflict of a specific stage and

attains emotional – social equilibrium when these tasks are successfully

accomplished.

The eight (8) crises according to Erik Erikson are:

a. Trust versus Mistrust (Infancy, birth to first year)

b. Autonomy versus Shame and Doubt (1 -3 years)

c. Initiative versus Guilt (Early childhood, 3 -5 years)

d. Industry versus Inferiority (Mid and late childhood, 5 – 12 years)

e. Identity versus Confusion (Adolescence or about 12 -18 years)

f. Intimacy versus Isolation (Early adulthood or 18 – 40 years)

g. Generativity versus Stagnation (Mid adulthood around 40 – 65 years)

h. Integrity versus Despair (Late adulthood or Old age)

Our client, Patient X, is 59 years old and fell under the middle adulthood

stage. Her task is to fulfill life’s goals that involve family, career, and society.

The crisis that she is undergoing will be generativity or stagnation.

Through the interview with the client, the watchers, and the visitors, it was

evident that Patient X has established a warm and loving relationship with

them. They talk freely, share conversation blithely and had an easy

relationship.

Not only does she show generosity and care to her immediate family, she

also helps her friends, colleagues, and siblings who are not as well-off as her

family. Her job as a teacher is something to offer financial help to them and

she does not wait for them to come to her. Whenever she feels that they are in

need, she would readily come to them and offer comfort and helping hands.

Indeed, Patient X has succeeded in achieving the abilities of being

thoughtful and caring to others. She has opened herself to her family, friends,

and society and created a mark that will outlive her. She did not wallow in self-

absorption and cast out people who will help her in achieving the task of her

stage.

Physiological Theory:

Robert Havighurst, the proponent of Physiological Theory of growth and

development, believed that learning is basic to life and that to understand

growth and development, one must comprehend learning and accept the

premise that people continue to learn throughout life.

He defines a developmental task as one that arises at a certain period in

our lives, the successful achievement of which leads to happiness and success

with later tasks; while unaccomplished goal leads to unhappiness, social

disapproval, and difficulty with later tasks. He identifies three (3) sources of

developmental tasks:

Tasks that arise from physical maturation. For example, learning to

walk, talk, and behave acceptably with the opposite sex during adolescence;

adjusting to menopause during middle age.

Tasks that have their source in the pressure of society. For example,

those that emerges from the maturing personality and takes the form of per-

sonal values and aspirations, such as learning the necessary skills for job suc-

cess.

Tasks that have their source in the pressures of the society. For exam-

ple, learning to read or learning the role of a responsible citizen.

Havighurst has also identified six major age periods: infancy and early

childhood (0 – 5 years, middle childhood (6 – 12 years), adolescence (13 – 18

years), early adulthood (19 – 20 years), middle adulthood (30 – 60 years), and

later maturity (61+).

Our client belongs to the middle age stage filled with seven tasks to

accomplish. As a good citizen of Davao City, she knows her responsibility to

keep the environment clean and create a happy home for her family. Although

they have employed someone to manage the household chores, Patient X still

gives a hand in performing daily chores.

Being a teacher for twenty nine years contributes so much to the family

income and greatly helps in paying the house bills. On weekends or any spare

time she has, she often reads books and magazines or watch movies with her

family just to enjoy the leisure time she has.

She has a very good relationship with her husband. It’s unavoidable that

sometimes they will have misunderstandings regarding some matters. In

dealing with this, she sometimes nags at him but keeps quiet when she feels

she has gotten through him. Silence will be maintained until such time that

each one has cooled down and then they would talk about the problem

objectively and find solution together.

Patient X is now fifty nine years old and knows that she is not getting any

younger. Aside from the physical changes that have occurred, like the

appearance of lines on her face, she is aware that she is presently facing her

breast problems and would pose some serious problems if not monitored all

throughout.

Despite having a family of her own, Ma’am Fe has not forgotten about her

parents. She visits them regularly at her elder sister’s home. They are in good

terms and will remain that way as she claimed.

As a responsible parent, she always looks forward for the bright future of

her children. Luckily, she has two professional children already and one

graduating college student.

At this age that she is now, she has accomplished her tasks and created a

happy life.

DIAGNOSIS WITH COMPLETE DEFINITION

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 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.

Stage II breast cancer means one of the following: cancer is no larger than 2

centimeters but has spread to the lymph nodes in the armpit (the axillary

lymph nodes); cancer is between 2 and 5 centimeters (from 1 to 2 inches) and

may have spread to the lymph nodes in the armpit; cancer is larger than 5

centimeters (larger than 2 inches) but has not spread to the lymph nodes in

the armpit. This is the stage that describes invasive breast cancer in which the

affected lymph nodes have not yet stuck to one another or to the surrounding

tissues, a sign that the cancer has not yet advanced to stage III.

Stage II is divided into stages IIA and IIB. In stage IIA, (1) no tumor is found

in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes

under the arm); or (2) the tumor is 2 centimeters or smaller and has spread to

the axillary lymph nodes; or (3) the tumor is larger than 2 centimeters but not

larger than 5 centimeters and has not spread to the axillary lymph nodes. In

stage IIB, the tumor is either (1) larger than 2 centimeters but not larger than 5

centimeters and has spread to the axillary lymph nodes; or (2) larger than 5

centimeters but has not spread to the axillary lymph nodes.

PHYSICAL ASSESSMENT

Date and Time: June 29, 2008; 12:00am

Name: Patient X

Age: 59

Sex: Female

Ward: 324 (3C)

Bed: 6

Civil Status: Maried

Religion: Roman Catholic

I. VITAL SIGNS

Temperature: 36.7˚C Cardiac Rate: 65

Blood Pressure: 120/80 Respiratory Rate: 18

Pulse Rate: 64

II. GENERAL SURVEY

Patient stands at 4 feet and 9 inches tall and weighs 59.2 kilograms.

She is awake, conscious, coherent and oriented. 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 Physical Assessment.

III. SKIN

General skin color is from tan to brown and is grossly smooth. Her skin

has good skin turgor and is warm to touch. Her skin is mostly dry with no signs

of any lesions or breakage of skin integrity.

IV. HEAD

Her head is normocephalic with symmetrical facial features. Fontanels

are closed, and hair is long, black and thick with a few strands of white hair.

Her scalp is clean and shows no signs of lesions.

V. EYES

Her eyelids are symmetrical in shape and she has anicteric sclera.

Opaque lenses and equally sized pupils are observed when exposed to light.

Pupils react briskly to light and accommodation. She is farsighted and has

intact peripheral vision.

VI. EARS

She has symmetrical ears without any reports of pain or tenderness

upon palpation. There are no discharges observed upon inspection of the

external canal. Her gross hearing is symmetrical.

VII. NOSE

Her nasolabial fold and septum are along the vertical midline of her face.

Her nasal mucosa is pinkish in color. There are no discharges noted upon

inspection of nostrils. Both nostrils are patent with symmetrical gross smelling.

No pain or tenderness is reported upon palpation of sinuses.

VIII. MOUTH

Her lips are colored pink to dark pink. Her mucosa is colored pink and is

well lubricated with saliva. The tongue is along the vertical midline of her face

and she has missing teeth which are replaced by false teeth. Her speech is

intact.

IX. PHARYNX

The uvula is along the vertical midline of her face and the mucosa is

observed to be pinkish. Tonsils are not inflamed.

X. NECK

The trachea is along the vertical midline of her face and there are no

observations of inflamed cervical lymph nodes. The thyroid gland is not

enlarged.

XI. CHEST AND LUNGS

Her breathing pattern is regular and she has symmetrical chest

expansion. No crackles are heard upon auscultation of both lung fields. She

has a surgical incision with dressing, dry and intact, located at upper outer

quadrant of left breast.

XII. HEART

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

upon auscultation.

XIII. BREAST AND AXILLAE

Patient did not allow male student nurse to assess her breasts

thoroughly but was open to answer questions verbally.

Patient’s breasts are equal in size and shape with nipples colored dark

brown. No tenderness is reported by the patient.

XIV. ABDOMEN

The patient has a symmetrically-shaped abdomen with a globular

configuration. Bowel sounds are normoactive. There were no reports of pain

or tenderness upon palpation of abdomen. The patient had a JP drain;

draining well with minimal bloody output.

XV. GENITO-URINARY

The patient did not allow male student nurse to assess her genitals but was open to

answer questions verbally.

The patient is able to urinate without any reports of pain or burning

sensations. The patient claims to have pinkish colored labia.

XVI. BACK AND EXTREMITIES

Peripheral pulses are present and symmetrical when palpated. Nail

beds are pinkish and have good capillary refill. Range of Motion is impaired

specifically for the left upper extremity. Muscle tone on both sides on each

extremity is equally strong. The spine is along the vertical midline of the back.

Patient reports that she feels pain in her upper right back when she checks

papers in school for an extended period of time.

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.

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 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,

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.

i. 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 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.

i. 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.

ETIOLOGY

Risk factors are the things that raise your chance of getting a disease.

There are various risk factors that may contribute to the development of breast

cancer. Some have a stronger link to breast cancer than others. The following

are some of the most significant risk factors for developing breast cancer.

Etiologic Factors Actual Rationale

Precipitating Factors

History of abnormal

breast biopsies

(breast mass)

Present: This was the

chief complaint of the

client upon

submitting for check-

up.

There was residual

neoplasm left from the

first occurrence of a

breast mass in 2001.

These masses are the

visible results of the

neoplasia process.

They are composed of

actively growing tissue

in which growth-

controlling mechanisms

are permanently

impaired, permitting

progressive growth.

Predisposing Factors

Age

(greater than 50 yrs.

Old)

Present: The patient

is already 59 years

old

Increasing age is also

associated with an

increasing risk of

breast cancer; the risk

is greatest after 50

years of age.

Gender (mostly

women)

Present: The patient

is female.

Women are more

prone to breast cancer

because of the

excessive exposure to

sex hormones.

Late menopause (age

>55 y)

Present: The patient

had her menopausal

period during 56

years of age.

Breast cancer is clearly

related to the sex

hormones. In some

types of breast

cancers, the presence

of the female sex

hormone estrogen

causes the cancer cells

to grow and divide

rapidly. During

puberty, estrogen

levels dramatically

increase. During

menopause, estrogen

levels decrease. The

longer the time the

breasts are exposed to

estrogen, the higher

the risk of developing

breast cancer.

Therefore, breast

cancer risk may be

higher in women who

started menstruating

before age 12 or in

women who went

through menopause

after age 55.

SYMPTOMATOLOGY

Knowing the Signs and Symptoms of a disease or a sickness can really help in

early detection. When it comes to breast cancer, a technique for early detection has been

encouraged to women for a very long time already. The “Breast Self Exam” has

increased the rate of early detection of breast cancer. This is important because early

detection means early and treatments would have lesser consequences, and late detection

would require greater consequences.

Basic Actual Rationale

A lump or

thickening in an

area of the breast 

Present: This is why the

patient went to the

hospital.

The lump is caused by

the neoplasm that

formed in the area of the

breast.

A change in the

size or shape of a

breast   

Present: Upon

assessment, Patient X

shared that she noticed

that her breasts are

irregular in shape.

A breast can become

smaller if a cancer is

pulling the skin in and

shortening the ducts.

Dimpling of the

skin   

Absent Dimpling, known as peau

d'orange, may indicate

the presence of a tumor

that is blocking the

lymph system and

causing fluid

accumulation under the

skin.

A change in the

shape of the

nipple,

particularly if it

turns in, sinks into

the breast or

becomes irregular

in shape   

Absent The growth in the breast

pulls the nipple inward.

A blood-stained

discharge from

the nipple   

Absent The neoplasm affects

one or more breast

ducts.

A rash on a nipple

or surrounding

area   

Absent An inflammatory

response to cancer

A swelling or lump

in the armpit

Absent The lump was found in

the upper outer

quadrant of the left

breast.

Precipitating factors:History

of abnormal breast biopsies

Predisposing factorsAge

GenderLate Menopausal

Neoplasm formation in

the breast

Primary tumor begins in the breast

Tumor becomes invasive

PATHOPHYSIOLOGY

Travel (metastasize) to other organ

systems in the body

Progressed beyond breast to regional

lymph nodes

ItBecomes systemic

Primary cancer spreads

if treated:surgeryradiotherapychemotherapyInterstitial laser thermotherapy

Removal of Breast Tissure

CANCER CELL

DESTROYED

Breast cancer spreads to

major organs

Compromise the functions of the major

organs

If not treated:

DEATH

DOCTOR’S ORDERS Date Ordered

Doctor's OrderRationale

Remarks

6/29/2008 >please admit patient under my service To establish a

designated doctor

to which all

pertinent

information

regarding the

patient will be

referred to.

DONE

  >TPR q shift To monitor the Vital

Signs of the

patient.

DONE

  >DAT To signify that the

patient has no

restrictions

regarding intake of

solid or liquid foods

DONE

  >attach labs

For information DONE

regarding the

patient to be

documented,

recorded and

organized for

convenient viewing.

  >please inform me [when] admitted For the doctor to

know where to find

the patient during

her rounds.

DONE

  >scheduled for FS biopsy of (L) breast mass possible MRM

To determine

whether an MRM is

needed to be done.

DONE

  

>refer to Dr. Villarosa for aneth  To indicate that Dr.

Villarosa is involved

in a procedure

DONE

>profurex 1.5 for IVTT ANST 30 min prior to OR For prophylaxis;

prevention of

infection.

 

  >no IV line/IV med on (L) upper extremity To prevent the

condition from

getting worse

DONE

10pm >scheduled for OR tomorrow 6/30/08 @ 1pm DONE12mn >NPO after 7am To prevent any

complications

during the

operation

scheduled for the

next day

DONE

  >start IVF of D5LR 1L @ 120cc/˚ where on NPO To supplement the

nutrition of the

patient while NPO

DONE

  Post - op order   DONE6/30/2008 >20 PACU x 2hrs then to room. To monitor and

take care of the

patient after an

operation

DONE

4pm >DAT when fully awake. To notify the

caretakers that the

patient can eat any

tolerated food when

fully awake

DONE

  >V/S q 15 min. x 2 hrs. then hourly x 6 hrs then q 2˚ To monitor the vital

signs of the patient

closely and for the

immediate

intervention to be

taken in case any

unusualities are

revealed

DONE

  >cont. D5LR 1L @ 120cc/˚ To hydrate the patient

DONE

  >cont. profurex 750mg q 80 IV x 1 more dose   DONE  >ketorolac 30g q 6˚ IVTT x 4 doses given at 4pm OR   ADMINISTERED  >tramadol 50g q 6˚ IVTT x 2 doses then PRN   ADMINISTERED  >metoclofromide 10g q 80 IV PRN for vomitting   ADMINISTERED

  >O2 at 4L/min   DONE  ketoprofen 100g 1 tab BID start 12 noon tom   ADMINISTERED  >O2 at 4L/min   DONE  >mod-high back rest To promote the

breathing of the

patient DONE

  >refer For the doctor to

know the condition

of the patient

DONE

  >cefuroxime (profurex) 500mg 1 tab BID   DONE10:30pm >IVFTF: D5LR 1L @ 100cc/hr For the continuation

of the IVF of the

patient

DONE

7/1/2008 >DAT To notify care

takers that the

patient can eat any

tolerated food

DONE

1:35pm >D/C IVF To signify that the DONE

IVF infusion is

discontinued

  >please instruct patients how to drain JP For the promotion

of the patient's self

care

DONE

5:30pm >celcoxib 400mg 1 cap now then OD   ADMINISTERED

Diagnostic ExamDate

OrderedTest Normal Value Patient's Result Clinical

SignificanceNursing

Responsibility6/30/200

8Histopathology --- gross: a tan pink piece of

tissue that measures 1.2cmfrozen section infiltrating ductal carcinoma poorly differentiated

-Explain meaning of result

5/9/2008 Ultrasound Sonomammography clear Sonomammography delineates a hypoechoic solid mass at 12 o'clock position (L) measuring up to 11.7 mm.

Suspicious solid mass, left.

-Explain meaning of result

      Chemical Test    5/9/2008 Urinalysis Color pale yellow

to ambercolor: light yellow normal Pretest Care

  Transparency clear to protein: (-) normal Explain

slightly hazy

purpose and procedure and need to follow appropriate urine collection procedures.

-List patient drugs that can affect test outcome on laboratory slip or computer screen.

Intratest Care:

-Provide Privacy during urine collection.

-Testing procedure usually done by the nurse or laboratory personnel

  Glucose negative sugar: (-) normal  Albumin negative appearance: slightly hazy normal  Reaction   reaction: 6.0    Specific

Gravity1.010 - 1.035

specific gravity: 1.015 normal

  Pus Cells 0-3/hpf    Red Blood

Cells0-2/hpf Microscopic Test  

      cells:        squamous cells: moderate        pus cells: 2-3 normal      RBC: 0-1 /hpf normal      Renal Cell: 2-4 /hpf normal                                                                      

5/14/200 Blood Chemistry glucose 70- 101mg/dl normal Pretest Care:

8 105mg/dl-Explain purpose and procedure no fasting is required.

-Explain the relation of test to potential serious transfusion reactions.

-Recognize need for follow-up testing in prenatal screening of Rh-antibody if titer is negative (repeat 30-36 weeks of pregnancy)

-List drugs patient is taking on lab slip or computer screen

  blood urea nitrogen

10-50mg/dl 33.3mg/dl normal

  creatinine ♀ 0.60-1.10mg/dl

0.95mg/dl normal

  blood uric acid ♀

2.6-6.0mg/dl

5.1mg/dl normal

         hemoglobin 110-150g/L 139g/L normal

  hematocrit 0.38-0.47g/L

0.42g/L normal

  WBC 5-10x10/L 6.5 normal  differential

count   

  seg. neut. 0.50-0.70 0.65 normal 

lymphocytes0.35 0.35 normal

  platelet count 150-400x10/L

350.0x10/L normal

                                                        

Posttest Care:

-Monitor venipuncture sites for signs of bleeding or infection – apply pressure dressing to site.

-In addition to blood specimen, saliva, semen, and cervical mucus specimens may be tested to identify blood groupings (paternity tissues)

                                                                                        

5/16/2008

Radiography Section Lung fields are clear. The heart is not enlarged. Both hemidiaphragms and costophrenic sulci are intact

Lung fields are clear. The heart is not enlarged. Both hemidiaphragms and costophrenic sulci are intact

implication: normal chest findings

Explain meaning of result

Generic Name Cefuroxime sodium

Brand NameProfurex

Classification Anti- Infectives Drug; Cephalosporins

Dosage & Frequency Adults: 750mg to 1.5g cefuroxime sodium I.V. or I.M. q 8 hrs. for 5 to 10 days.

Mechanism of Action Second - generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

Indications Serious lower respiratory tract infection, UTI, skin or skin-structure infections, bone or joint infection, septicemia, meningitis, and gonorrhea.

Perioperative prevention Uncomplicatd gonorrhea

Contraindications Contraindicated in patients hypersensitive to drug or other cephalosporins.

Use cautiously in patients hypersensitive to penicillin because of possibility of

cross-sensitivity with other beta-lactam antibiotics.

Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.

Side Effects

diarrhea stomach pain upset stomach vomiting

Adverse Reaction unusual bleeding or bruising difficulty breathing itching rash hives sore mouth or throat

Nursing Responsibility Tell patient to take all of the

drug as prescribed, even after he feels better.

If suspension is being used, tell patient to shake container well before measuring dose.

Tell patient to notify doctor if rash or signs and symptoms of superinfection occur.

Inform patient receiving drug I.V. to alert nurse if discomfort occurs at I.V. insertion site.

Tell patient to notify doctor if loose stools or diarrhea occur.

Generic Name Cefuroxime

Brand Name Ceftin

Classification Anti – Infective drugs; Cephalosporins

Dosage & FrequencyAdults : 250 or 500 mg P.O. b.i.d for 10 days

Mechanism of Action Second – generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

Indications Uncomplicated skin and skin structure infection.

Contraindications * Contraindicated in patients hypersensitivity to drug or other cephalosporins.* Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics.* Use cautiously in breast-feeding women and in patients with history of colitis or renal insufficiency.

Side Effectsnauseavomitinganorexia

Adverse Reaction CV: phlebitisGI: diarrheaHematologic: thrombocytopeniaSkin: maculopapular, and erythematous rashesOther: anaphylaxis

Nursing Responsibilities Tell patient to take drug as prescribed, even after he feels better.

Instruct patient to take oral form with food.

If patient has difficulty swallowing tablets, show him how to dissolve or crush tablets but warn him that the bitter taste is hard to mask, even with food.

Instruct patient to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection.

Generic Name Celecoxib

Brand Name Celebrex

Classification Nonsteroidal anti-inflammatory drugs

Dosage & Frequency Adults: 400 mg P.O. b.i.d. with food, for up to 6 monthsElderly patients: Start at lowest dosage.

Mechanism of Action Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2 (COX-2), to produce anti-inflammatory, analgesic, and antipyretic effects.

Indications Adjunctive treatment for

familial adenomatous polyposis to reduce the number of adenomatous colorectal polyps.

Acute pain and primary dysmenorrheal.

Contraindications Contraindicated in patients

hypersensitive to drug, sulfonamides, aspirin, or

other NSAID’s. Contraindicated in those with

severe hepatic impairment and in the treatment of perioperative pain after coronary artery bypass graft surgery.

Avoid use in the third trimester of pregnancy.

Use cautiously in patients with history of ulcers or GI bleeding, advanced renal disease, dehydration, anemia, symptomatic liver disease, hypertension, edema, heart failure, or asthma and in poor CYP2C9 metabolizers.

Use cautiously in elderly or debilitated patients.

Side Effects dizziness or drowsiness Constipation diarrhea dizziness headache heartburn nausea sore throat stomach upset stuffy nose

Adverse ReactionCV: hypertensionEENT: Pharyngitis GI: dyspepsia

Nursing Responsibilities Tell patient to report history

of allergic reactions to sulfonamides, aspirin, or other NSAIDs before therapy.

Instruct patient to promptly report signs of GI bleeding such as blood in vomit, urine, or stool; or black, tarry

stools. Tell woman to notify

prescriber if she becomes pregnant or is planning to become pregnant during drug therapy.

Instruct patient to take drug with food if stomach upset occurs.

Tell patient that drug may harm the liver. Advise patient to stop therapy and notify prescriber immediately if he experiences signs and symptoms of liver toxicity including nausea, fatigue, lethargy, itching, yellowing of skin or eyes, right upper quadrant tenderness, and flulike syndrome.

Inform patient that it may take several days before he feels consistent pain relief.

Advise patient that using OTC NSAIDs with celecoxib may increase the risk of GI toxicity.

Generic Name Ketorolac Tromethamine

Brand Name Toradol

Classification Central nervous system drugs; Nonsteroidal anti-inflammatory drugs

Dosage & Frequency

I.M.: 60 mg as a single dose or 30 mg every 6 hours (maximum daily dose: 120 mg)

I.V.: 30 mg as a single dose or 30 mg every 6 hours (maximum daily dose: 120 mg)

Mechanism of Action May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.

Indications > Short-term management of moderately severe, acute pain for single-dose treatment, multiple dose treatment, and when switching from parenteral to oral administration.

Contraindications Contraindicated in patients

hypersensitive to drug and in

those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and those at risk for renal impairment from volume depletion or at risk of bleeding.

Contraindicated in children younger than age 2 and in patients with history of peptic ulcer disease or GI bleeding, past allergic reactions to aspirin or other NSAIDs, and during labor and delivery or breast-feeding.

Contraindicated as prophylactic analgesic before major surgery or intraoperatively when hemostasis is critical; and in patients currently receiving aspirin, an NSAID, or probenecid.

Use cautiously in patients who are elderly or have hepatic or renal impairment or cardiac decompensation.

Side Effects Dizziness, drowsiness, sedationEdema, hypertensionDiarrhea, vomitingrash

Adverse Reaction CNS: headacheCV: arrythmias GI: dyspepsia, GI pain, nauseaHematologic: decreased platelet adhesionSkin: diaphoresis, pruritis

Nursing Responsibility Warn patient receiving drug

I.M. that pain may occur at injection site.

Teach patient signs and

symptoms of GI bleeding, including blood in vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.

Tell patient not to take drug for more than 5 days in a row.

Generic Name Ketoprofen

Brand Name Apo-Keto, Apo-Keto-E, Novo-Keto-EC, Orudis, Orudis KT, Orudis SR, Oruvail

Classification Nonsteroidal anti-inflammatory drugs

Dosage & Frequency Adults: 25 to 50 mg P.O. q 6 to 8 hours, p.r.n. maximum dose is 300 mg daily.Or 12.5mg q 4 to 6 hours or 75 mg in 24 hours.

Mechanism of Action Unknown. Produces anti-inflammatory analgesic, and antipyretic effects, possibly by inhibiting prostaglandin synthesis.

Indications Mild to moderate pain,

dysmenorrheal Minor aches and pain or

fever.

Contraindications Contraindicated in patients

hypersensitive to drug and in those with history of aspirin-or NSAID-induced asthma,

urticaria, or other allergic reactions.

Avoid use during last trimester of pregnancy.

Drug isn’t recommended for children or breast-feeding women.

Use cautiously in patients with history of peptic ulcer disease, renal dysfunction, hypertension, heart failure, or fluid retention.

Side EffectsHeadache , dizziness , Peripheral edema Tinnitus, visual disturbancesAbdominal pain , diarrheaProlonged bleeding time dyspneaphotosensitivity reactions , rash

Adverse Reaction GI: dyspepsia GU: nephrotoxicity

Nursing Responsibility Tell client to take drug 30

minutes before or 2 hours after meals with a full glass of water. If adverse GI reactions occur, patient may take drug with milk or meals.

Tell client not to crush delayed-release or extended-release tablets.

Tell client that full therapeutic effect may be delayed for 2 to 4 weeks.

Teach client signs and symptoms of GI bleeding, including blood in vomit, urine, or stool.

Alert client that using with aspirin, alcohol, other NSAIDs, or corticosteroids may increase risk of adverse GI reactions.

Warn client to avoid hazardous activities that require mental alertness until CNS effects are known.

Because of possibility of sensitivity to the sun, advice clients to use a sunblock, wear protective clothing and avoid prolonged exposure to sunlight.

Instruct patient to report problems with vision or hearing immediately.

Tell client to protect drug from direct light and excessive heat and humidity.

Because NSAIDs impair synthesis of renal prostaglandins, they can decrease renal blood flow and lead to reversible renal impairment, especially in clients with renal or heart failure or liver dysfunction, in elderly clients and in those taking diuretics. Monitor these client closely

Generic Name Metoclopromide hydrochloride

Brand Name Apo-metoclop, Clopra, Maxeran, Maxolon, Octamide PFS, Pramin, Reglan

Classification Gastrointestinal tract drugs; Antiemetics

Dosage & Frequency Adults: 10 to 20 mg I.M. near end of surgical procedure; repeat q 4 to 6 hours, p.r.n.

Mechanism of Action Stimulates motility of upper GI tract, increases lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone.

Indications > to prevent or reduce postoperative nausea and vomiting.

Contraindications

Contraindicated in patients hypersensitive to drug and in those with pheochromocytoma or seizure disorders.

Contraindicated in patients for whom stimulation of GI motility might be dangerous.

Use cautiously in patients with history of depression, Parkinson disease, or

hypertension.

Side Effects Decreased energy Diarrhea Dizziness Drowsiness Headache Nausea Restlessness Tiredness trouble sleeping

Adverse Reaction lassitude Insomnia Dyspnea Hypotension hepatotoxic

Nursing Responsibility Tell patient to avoid

activities that require alertness for 2 hours after doses.

Urge patient to report persistent or serious adverse reactions promptly.

Advise patient not to drink alcohol during therapy.

Generic Name Tramadol

Brand Name Ultram

ClassificationCentral Nervous System Drugs; Opioid analgesics

Dosage & Frequency Adult: Initially, 25mg P.O. in the morning. Adjust by 25 mg q 3 days to 100 mg/day. Thereafter, adjust by 50 mg q 3 days to reach 200 mg/day. Thereafter, give 50 to 100mg P.O. q 4 to 6 hours, p.r.n. maximum, 400 mg daily.

Mechanism of Action Unknown. A centrally acting synthetic analgesic compound not chemically related to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

Indications Moderate to moderately severe pain.

Contraindications Contraindicated in patients hypersensitive to drug or other opioids, in breastfeeding women, and in those with acute intoxication from alcohol, hypnotics, centrally acting

analgesics, opioids, or psychotropic drugs. Serious hypersensitivity reactions can occur, usually after the first dose. Patients with history of anaphylactic reaction to codeine and other opioids may be at increased risk.

Side Effects anxiety confusion vasodilation visual disturbances abdominal pain

Adverse Reaction

CNS: dizziness, headache, seizures

GI: constipation, nausea, vomiting

Respiratory: Respiratory depression

Nursing Responsibility Tell patient to take drug as prescribed and not to increase dose or dosage interval unless ordered by prescriber.

Caution ambulatory patient to be careful when rising and walking. Warn outpatient to avoid driving and other potentially hazardous activities that require mental alertness until drug’s CNS effects are known.

Advise patient to check with prescriber before taking OTC drugs because drug interactions can occur.

Warn patient not to stop the drug abruptly.

SURGICAL PROCEDURE

description rationale nursing responsibilities

Modified radical Mastectomy (MRM) -the procedure involves the removal of the entire breast tissue, including the nipple-aerola complex and a portion o f the axillary lymph node dissection (ALND).

MRM is performed to treat invasive breast cancer

Before surgery:MRM may be more threatening

to a woman's self image than any other type of surgery. Be sure to explore the client's feeling about it. Typically she will be afraid and anxious. Be a supportive, caring listener and help her express her concerns.

Explain that a drain or catheter and suction may be used to drain the incision and that the arm on her affected side will be elevated. She will have to sit up and turn in bed by pushing up with her unaffected arm. Tell her she will begin arm and shoulder exercises shortly after surgery.

Verify that the client has signed a consent form.

After surgery: When the client returns to

the unit, elevate her arm on

a pillow to enhance circulation and prevent edema.

As ordered, teach the client arm exercises to prevent muscle shortening and contracture of the shoulder and to promote lymph drainage.

To prevent lymphedema, make sure no blood pressure readings and injectionsare performed on the affected arm. Place a sign bearing this message at the head of the client’s bed.

Because MRM causes emotional distress, teach the client to conserve her energy and to recognize early signs of fatigue. Gently encourage her to look at the operative site by describing its appearance and allowing her to express her feelings.

Home care instructions: Advice client to use the

affected arm as much as

possible and to avoid keeping it in dependent position for a prolonged period.

The client should also protect the arm from injury to prevent trauma to the arm.

Instruct her to be alert for signs of fatigue and to rest frequently during the day for the first few weeks after discharge.

Reassure the client that she can wear the same type of clothing she wore before her surgery.

Description Rationale Nursing ResponsibilitiesFresh Frozen Biopsy involves removing a sample of breast tissue.

Fresh Frozen biopsy is used to determine whether it is cancerous or benign (non- cancerous).

Before Biopsy: Encourage the client to

verbalize her fears, concerns and questions.

Instruct the client to discontinue any agents that can increase the risk of bleeding, including products containing aspirin, nonsteroidal anti-

inflammatory drugs, vitamin E supplements, herbal substances ( such as gingko biloba and garlic supplements), and warfarin.

Instruct the client not to eat or drink for several hours after midnight the night before the procedure.

After Biopsy: Monitor the effects of

anesthesia and inspect the surgical dressing for any signs for bleeding.

Once the sedation has worn off, review the care of the biopsy site pain management and activity restrictions of the client.

Home Care Instructions: The dressing covering the

incision should remain in place approximately 7- 10 days.

Use of supportive bra following the surgery is encouraged to limit movement of the breast and reduce discomfort.

Encourage to avoid jarring or high- impact activities for 1 week to promote healing of

the biopsy site.

Nursing Theories

NEUMAN, BETTY

Betty Neuman’s Systems model presents levels of defenses wherein a

sickness may progress deeper into the individual’s core structure. The

stronger the defense that the individual has, lesser is the probability of that

person to get sick, and vice versa. It also presents how each layer of defense

brings about a level of prevention. According to this theory, there are three

levels of prevention namely: (1) Primary prevention, which reduces the

possibility of encounter with stressors and strengthens the flexible line of

defense; (2) Secondary prevention, which is responsible for early case-finding

and treatment of symptoms; and (3) Tertiary prevention, which focuses mainly

on readaptation, reeducation for the prevention of future occurrences, and

maintainance of stability.

atient X has gone through all of the levels of prevention and back. Her

first onset of a breast mass was over and done, which put her all the way from

Secondary prevention to Tertiary prevention. But a second onset a few years

later would put her back to the second level of prevention, and again back to

the third level of prevention. Knowing this, we must keep in mind that any

patient can go from one level of prevention to another and to another and to

another, yet again. This is mainly why Nurses exist. We are at the patient’s

bedside to offer whatever we can to ensure the welfare of each of our patients.

When it comes to Patient X, she was in the hospital and was then in the

Secondary prevention. As nurses, we were there to take care of our patient,

making sure that infection does not occur and prepare her for a very good

Tertiary prevention outside the hospital. After treating the symptoms of her

sickness, she can then readapt to maintain the stability of her health. If all

goes well during her Tertiary level of prevention, she will have a very healthy

and sickness-free life ahead of her.

LEININGER, MADELEINE

n the 1940s Leininger (1991) recognized the importance of caring to

nursing. Statements of appreciation for nursing care made by patients alerted

her to caring values and led to her longstanding focus on care as the dominant

ethos of nursing. During the mid-1950s, she experienced what she describes

as cultural shock while she was working in a child guidance home in the

Midwestern United States. While working as a clinical nurse specialist with

disturbed children and their parents, she observed recurrent behavioral

differences among the children and concluded that these differences had a

cultural base. She identified a lack of knowledge of the children’s cultures as

the missing link in nursing to understand the variations in care of clients. This

experience led her to become the first professional nurse in the world to earn a

doctorate in anthropology, and led to the development of the new field of

transcultural nursing as a subfield of nursing.

atient X is Filipino. She is from the Philippines and Filipino culture runs

in her veins. She is from Davao City, and she teaches in a public school.

Knowing this, we knew that it was obvious how we should approach her:

Having a warm and happy voice will immediately catch the attention of the

patient and will have a presumption that the student nurse is friendly and

approachable. Speaking in Davao’s ‘Bisaya’ will establish more rapport

between the patient and the nurse as this will ensure the clear understanding

between the nurse and the patient and vice versa. Having enough knowledge

about the patient’s culture is definitely an advantage when it comes to

establishing rapport; especially that it is usually the first step to patient care.

HENDERSON, VIRGINIA

Virginia Henderson’s definition of Nursing was very unique and specific

that –if not all- most of what she wrote can still be applied today. It can even

be applied outside the hospital setting and still serve as a guide for healthier

living. According to the theory, a person is healthy if he/she can; (1) breathe

normally, (2) eat and drink adequately, (3) eliminate body wastes, (4) move

and maintain desirable postures, (5) sleep and rest, (6) select suitable clothes

– dress and undress, (7) maintain body temperature within normal range by

adjusting clothing and modifying the environment, (8) keep the body clean and

well groomed and protect the integument, (9) avoid dangers in the

environment and avoid injuring others, (10) communicate with others in

expressing emotions, needs, fears, or opinions, (11) worship according to one’s

faith, (12) work in such a way that there is a sense of accomplishment, (13)

play or participate in various forms of recreation, and (14) learn, discover, or

satisfy the curiosity that leads to normal development and health and use the

available health facilities.

All of these components of nursing care are essential for the patient to

live a healthy life. The components that are usually closely taken cared of by

nurses are numbers 1, 2, 3, 4, 5, 7, 8, and 10. If these components are not

taken cared of, the nurse may have failed to ensure the patient of a healthy

life. However, there are components that the patient his/herself can only

influence, which are 6, 9, 11, 12, 13 and 14. Therefore, a healthy life isn’t

provided by the nurse alone, the patient also has a very crucial role in

promoting good health. With Patient X, we were able to ensure all of the

components usually taken cared of by nurses, especially the 8th, keeping the

body clean and protecting the integument. Having a surgical procedure done

to a person’s body greatly increases the chance for pathogens to enter and

wreak havoc. But with a nurse at bedside, this is very unlikely.

NURSING CARE PLANS Name: Mrs. X Age: 59 yrs oldMedical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant Gender: FemaleChief Complaint: Breast mass Room and Bed no.: 324-6Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3CDate Admitted: June 29, 2008 Shift: 11-7Date Cues Need Nursing

DiagnosisObjective of Care

Nsg. Interventions

Evaluation

July 30, 200812:00am

Subjective: HEALTH-PERCEPTION-HEA

Risk for infection related to break in skin integrity as evidenced by surgical incision under dressing.

®At increased risk for being invaded by pathogenic organisms

Within 8 hrs span of nursing care, patient will be able to:

a. Recognizes signs and symptoms of infection

b. maintain normal Vital Signs

c. knows the basic principles of preventing infection

1. 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 recovery of a client

2.Stress proper hand washing techniques between nurse and

Goal Met:

Patient did not show signs and symptoms of infection; Patient did not get an infection

LTH-MANAGEMENT-PATTERN

patient

®kills or prevent the spread of microorganisms.

Name: Mrs. X Age: 59 yrs oldMedical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant Gender: FemaleChief Complaint: Breast mass Room and Bed no.: 324-6Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3CDate Admitted: June 29, 2008 Shift: 11-7Date Cues Need Nursing Diagnosis Objective of Care Nsg. Interventions Evaluation

July ,02 2008@ 12pm

Subjective

“Dili nalang nako ilihok kay basig magsakit.”

Objective:

>surgical incision under dressing; dry and intact>s/p MRM

ACTIVITY-EXERCISE-PATTE

Impaired physical mobility related to surgical incision on the affected side, loss of muscle tissue with radical mastectomy and potential lymphedema.

®Limitations independent , purposeful physical movement of the body or of one or more extremities.

Within 8 hrs span of nursing care, patient will be able to:a. Take safety precautions /measures and individual treatment regimen b. Verbalizes understanding of situation/risk factors.

1. Support affected body parts using pillows/foot support, air mattress, water bed, and so forth®to maintain position of function and reduce risk of pressure ulcers

2. Identify energy-conserving techniques for ADL's ®limits fatigue, maximizing participation.

3. Encourage participation in self-care,occupational/ diversional/recreational activities.®enhances of self-concept and sense of independence.

4. Note emotional/behavioral

July 02, 2008@6am

GOAL MET

Within the 8 hour shift, patient was able to:

>Take safety precautions to prevent injuring her affected.

RN

responses to problems of immobility.®feelings of frustration /powerlessness may impede attainment of goals.

5. Observe movement when client is unaware of observation® note any congruencies with reports activities

6. Encourage clients involvement in decision making as much as possible.®enhance commitment to plan, optimizing outcomes.

7.Encourage adequate intake of fluids and nutritious foods®promote well-being and maximizes energy production

8.Administer medication prior to activity as needed for pain relief® permit maximal effort/ involvement in activity

Name: Mrs. X Age: 59 yrs oldMedical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant Gender: FemaleChief Complaint: Breast mass Room and Bed no.: 324-6Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3CDate Admitted: June 29, 2008 Shift: 11-7

DATE

/ TIME

CUES NEED NURSING

DIAGNOSIS

GOAL

OF CARE

NURSING

INTERVENTION

EVALUATION

J

U

L

Y

01,

2008

@

12:00

AM.

Subjective:

“Unsa kaya

itsura sa akong

totoy karon?”

“Dili pa nako

kaya mutan-aw

kay wala koh o

kabalo kung

unsa akong

naingon.”

“Unsa kaya

ingnon sa mga

tao ani?”

Objective:

S

E

L

F

-

P

E

R

C

E

P

T

I

O

N

Disturbed body

image related to

impending changes

to breast or

disfiguring surgical

procedure and

psychosocial

concern about

sexual

attractiveness as

manifested by

actual change in

breast structure, and

negative feelings

about body by not

At the end of the

three-day span of

care, the client

will begin to

exhibit her

perception or

present her pre-

surgical or

baseline body

image, as

evidenced by:

a. verbalization

of positive

adaptation to her

surgery,

1. Establish trusting

relationship or rapport to

the patient.

® To gain trust.

2. Ascertain whether

support and counseling

were initiated when the

possibility of and/or

necessity of mastectomy

was first discussed.

® This provides

information about patient’s

level of knowledge and

anxiety about individual

situation.

July 03, 2008

@ 7:00 AM

GOAL

PARTIALLY

MET:

After the three-

day span of care,

the client was able

to exhibit

perception or

present her pre-

surgical body

image as evidenced

- Modified

Radical

Mastectomy

(MRM) done on

left side of the

breast

- dressing placed

on left breast

- not looking at

the postoperative

site

/

S

E

L

F

-

C

O

N

C

E

P

T

P

A

T

T

E

R

N

looking at the

affected body part.

® 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

b. wearing of her

usual feminine

appearance or

attire after

surgery, and

c. looking at the

postoperative site.

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

that may require further

evaluation and more

by verbalization of

positive adaptation

to the surgery done

like looking

forward to the use

of temporary

prosthesis and

possible

reconstructive

surgery. The client

wore her favorite,

“sexy” clothes and

looks good about

her self. However,

she was not able to

look or take a

glimpse of the

postoperative site

since the dressing

was not yet

removed.

Evaluated by:

same way. Clients

who have surgically

lost a breast may

adapt in the same

way as they would

to any loss.

References:

Black, J. et. al.

(2001). MEDICAL-

SURGICAL

NURSING:

Clinical

Management for

Positive Outcomes.

6 th ed. USA: W.B.

Saunders Company.

Doenges, M. et. al.

(2002). NURSING

CARE PLANS:

Guidelines for

Individualizing

Patient’s Care. 6 th

ed. USA: F.A.

extensive therapy.

5. Provide opportunities for

patient to view and touch

the postoperative site,

using the moment to point

out positive signs of

healing, normal

appearance, and so forth.

Remind patient that it will

take time to adjust, both

physically and emotionally.

® Although integration of

the skin in the

postoperative site into body

image can take weeks or

even months, looking at the

site and hearing comments

(made in a normal, matter-

of-fact manner) can help

patient with this

acceptance.

6. Provide opportunity for

patient to deal with

mastectomy through

Stephanie Marie

Lim, St. N.

Benedict Madrazo,

St.N

Jeferson D.

Mangitngit, St.N

Dominique Dawn

Margaja, St.N

Sheena Ann A.

Nalzaro, St.N

Davis Co.

Gulanick, M. et. al.

(2003). NURSING

CARE PLAN:

Nursing Diagnosis

and Intervention, 5 th

ed. St. Louis

Missouri: Mosby

Publishing Co.

Linton, A. et. al.

(2000).

INTRODUCTORY

NURSING CARE

OF ADULTS, 2 nd

ed. USA: W.B.

Saunders Company.

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

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.

11. Provide temporary soft

prosthesis, if indicated.

® Prosthesis of nylon and

Dacron fluff may be worn

in bra until incision heals if

reconstructive surgery is

not performed at the time

of mastectomy. This may

promote social acceptance

and allow patient to feel

more comfortable about

body image at the time of

discharge.

DISCHARGE PLANNING

MEDICATION

Encourage the client to comply with all the prescribed medications.

Emphasize to the client and her family of the importance of taking the

medications at the prescribed schedule, dosage and frequency.

Educate the client about the purpose of the drugs.

Advice the significant others not to leave the client during medication to

secure that the client has taken the medicines.

Explain to the client the side effects and adverse effects of the drug she

takes by describing its manifestations. Client and significant others

should be aware so that prompt medical intervention can be given if in

case such reactions occur.

Rationale:

Client and significant others must know and understand the drug’s generic

and brand name, dosage, route, frequency, purpose and side effects for them

to be knowledgeable in administering the drug and to avoid any accidents

regarding drug administration. And for the significant others to know how

important they are in contributing to the healing process of the client.

EXERCISE

Encourage to ambulate and assume her normal activities as long as

there will be no problems.

Instruct client to have frequent arm exercise, the arm where the postop-

erative site is located.

Educate the client on proper body mechanics to enable her to relax, be

comfortable and prevent strains.

Instruct the client to balance activities with adequate rest periods.

Rationale:

Exercise is now also known to be major contributor to health and can

improve the body in three ways: through increased stamina; more efficient

heart, lungs, and circulatory system, improved muscle tone, through enhanced

strength; and more supple joints. It is also essential to prevent obesity and to

help control weight.

TREATMENT

Educate the client on the importance of drug and money compliance.

Discuss to the client the complication of the condition because knowl-

edge about the condition supports learning that will decrease anxiety.

Instruct the client to report or ask medical assistance when abnormali-

ties occur.

Educate the family on how to demonstrate a correct performance of the

treatment.

Rationale:

It is important for the client, including the family, to know the importance of

drug or treatment compliance in order to achieve an effective outcome and

facilitate continuous care.

HYGIENE

Instruct the client to do proper personal hygiene such as taking a bath

daily, brushing her teeth after eating and proper grooming.

Stress out to the client the importance of hand washing before and after

using the comfort room and eating to deter the spread of microorgan-

isms.

Encourage the client as well as the significant others to follow physi-

cian’s instructions regarding personal hygiene and self care.

Rationale:

It is essential to both the client and the significant others to have a hygiene

and healthy lifestyle in order to promote faster recovery and prevent causing

further injury and damage to the client.

OUT-PATIENT REFERRALS

Instruct the patient to comply with the scheduled follow up check up to

enable the physician to have continuous record on the client’s condition.

Advice the client to report any abnormalities observed to provide imme-

diate medical intervention.

Review signs and symptoms with the client. These symptoms may in-

clude pressure on the bladder with difficulty voiding or urinary fre-

quency and urgency, pressure on the rectum with constipation, lower

back and abdominal pain, as well as heavy bleeding.

Rationale:

Regular check-up or consultation with a physician provides continuous

update on the client’s condition. With the physician’s medical intervention and

the client’s cooperation, faster recovery can be obtained.

DIET

Instruct the client to follow physician’s order regarding proper food in-

take and tell her its importance.

Encourage the client to avoid fatty foods and increase intake of vegeta-

bles and fruits.

Advice client to increase oral fluid intake to facilitate proper circulation

of blood and to provide needed nutrients and electrolytes.

Rationale:

Having well balanced diet, prescribed foods, and proper fluid intake

facilitates in improving the health of the client.

SEXUALITY

Inform the client that there is a breadth and depth of sexual expression

possible and that she is a person of value.

Recognize the feelings of warmth, approval, and friendship, as well as

sharing and touching, are important.

Inform the patient of the availability of the following services: sex edu-

cation or counseling services (individual, couples and family); sex ther-

apy; group discussion; audiovisual materials and regarding materials.

Rationale:

Sexuality is part of a person’s self-concept and involves feelings of self-

worth, acceptance, sharing, affection and intimacy, as well as feelings of

femininity. It includes physical, psychological, emotional, and social elements

and is reflected in everything a person says and does. It also promotes to the

healing process of the client.

SPIRITUALITY

Encourage client to strengthen her faith with Almighty Father to provide

spiritual growth and promote healing.

Advice client never to forget God, to ask for Jesus’ help and to believe in

the healing power of the Holy Spirit to promote peace of mind and re-

laxation, thus promoting comfort and healing not just to the mind but

also to avoid harm and promote a soothing and pleasant atmosphere

with everyone.

Rationale:

It is important to take care of the spiritual aspect of the client because it is

one of the many factors that could promote healing to the physical aspect, the

body, but also to the client’s spirituality, the mind.