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TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus Brgy.

Ungot, Tarlac City

A Case Study on Breast Cancer

In Partial Fulfillment of the Requirements of the Subject Nursing Care Management 104

Presented to: Gienelle M. Sabado, R.N., M.A.N. (Clinical Instructor) Presented by: BSN IV - D Santos, Marivic C. Santos, Willa Milafrosa M. Sotelo, Jeffrey R. Suarez, Christine Karen A. Sumang, Jerico B. Date Submitted: October 11, 2010

Acknowledgment Our group would like to extend our deepest gratitude to the following: We would like to extend our heartfelt gratitude to our Clinical Instructor, Mrs. Gienelle M. Sabado, we would like to broaden our appreciation for your time and magnanimous knowledge to teach us nursing skills and develop attitude to each and every one of us to become better nurses someday. To the members: Marivic C. Santos, Willa Milafrosa M. Santos, Jeffrey R. Sotelo, Christine Karen A. Suarez, and Jerico B. Sumang, for their efforts, and cooperation in finishing this Case Study. To our Dear Parents, we are very grateful for always being there to support us. For giving us the sole opportunity to experience studying BSN and for their financial help. To our patient and his husband, thank you for imparting your knowledge and the essential information needed for our Case Study. And above all, we would like to express our earnest and sincerest homage and love to our Lord God, who constantly guides us in this course of our life. We thank him for his unconditional love for each and every one of us.

I. INTRODUCTION Breast cancer (malignant breast neoplasm) is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas. Prognosis and survival rate varies greatly depending on cancer type and staging. Some breast cancers are sensitive to hormones such as estrogen and/or progesterone which make it possible to treat them by blocking the effects of this hormone in the target tissues. These have better prognosis and require less aggressive treatment than hormone negative cancers.

Worldwide, breast cancer comprises 10.4% of all cancer incidences among women, making it the most common type of non-skin cancer in women and the fifth most common cause of cancer death. In 2010, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths). Breast cancer is about 100 times more common in women than in men, although males tend to have poorer outcomes due to delays in diagnosis.

The Department of Health says that breast cancer is now the most common cancer in the Philippines, accounting for 16 percent of the 50,000 cases of the dreaded disease in the country. Computerized models are available to predict survival. With best treatment and dependent on staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes surgery, drugs (hormonal therapy and chemotherapy), and radiation.

II. Objectives Nurse centered General: This study is aim to gain or broaden the knowledge and skills with regards to the disease condition Beast Cancer. Specific: To gain more knowledge about Breast Cancer, its epidemiology, contributing factors, pathophysiology, clinical manifestations, and the treatment required. To enhance the student skills by performing various nursing interventions to solve or alleviate the patients needs as implementations of the formulated plans of care. To promote the students wellness of social health by conducting a healthy social interaction with the patient. The nurse should be able to impart knowledge to the patient and significant others regarding the patients condition. To gain fulfillment during and after rendering care to the patient, thus uplifting their emotional health. Patient centered General: To be able to know his/her existing condition and to be able to participate well with procedures and things he/she needs to comply for the success of his/her disease treatment. Specific: To increase the clients knowledge about her disease, which is Breast Cancer, by means of giving health teachings in the contributing factors, disease course, manifestations and treatments involved. To address the patients needs and problems that accompany the disease by performing appropriate nursing interventions based on health care plans. To promote her emotional well-being by encouraging her to speak of whatever she feels about her disease condition. The client should be able to gain knowledge about her condition and the different ways on how to understand and accept her state of being. To gain cooperation with the health care provider in implementing the nursing intervention as well as compliance to medical management.

Reasons in choosing the Case Study We chose the case of breast cancer with Modified Radical Mastectomy because of the following reasons: a. Breast cancer is the most common cause of mortality and morbidity among women in the Philippines and all over the world; b. To know the Etiology, Pathophysiology, Clinical Manifestations of the Disease, Prognosis, and treatment for such disease and be able to know what nursing managements are appropriate. c. To amalgamate health promotion and health maintenance into the case of post surgical phase. d. Knowledge and understanding about breast cancer and its surgery can develop us to be better health care providers. Importance of the case study Our case study gives us a comprehensive stepwise in terms of skills and knowledge on applying the nursing process namely assessment, planning, implementation, evaluation, and including health teachings. In the context assessment, different skills are applied such as inspection, palpation, percussion and auscultation to fully obtain an accurate and objective finding. Nurse patient interaction (NPI) is also essential in determining the different problems of a patient which leads to giving a Nursing Diagnosis. The North American Nursing Diagnosis Association (NANDA) helped us in formulating this diagnosis. Planning gives us a goal and formulates certain objectives to alleviate problems seen in the patient. Using the SMART (Specific, Measurable, Attainable, Realistic, and Time Bounded) technique is crucial in attaining goals. Several Nursing Intervention are implemented and rationales behind are given to determine the purpose on how and why we do certain interventions. Lastly would be the evaluation in which it weighs or rates if the goal was attained partially attained or not met. Having an evaluation is a prerequisite to know if further nursing process is needed. A case study such as this allows us to develop critical thinking and use our nursing judgment among different problems and situations to fully develop our Nursing Skills.

III.NURSING PROCESS 1. Personal Data A. Demographic Data Name: Sex: Age: Civil Status: Birth date: Place of Birth: Chief Complaint: Nationality: Role in the Family: Religion: Mrs. V Female 66 years old Widow January 4, 1944 Gerona, Tarlac Breast Mass Filipino Mother Roman Catholic

Admitting Diagnosis: Breast Mass, Right, t/c Malignancy

Health Care Financing: Philhealth Usual Source of Medical Care: RHU/Gov. Hospital

B. Environmental Status Mrs. Vs house is made up of cement and wood. It composes of two bedrooms, a small kitchen, living room and a comfort room. Their source of water is coming from NAWASA. Their house is located along the Highway and their neighbouring company is the Jaysons Pancit Bihon wherein they usually inhaled the smoke coming from it.

C. Lifestyle

According to Mrs. V, before she had this condition, she is socially active; she used to attend fiestas in their Gerona, Tarlac. Still she can sweep their yard, cook their foods and wash. She sits for quite sometimes to mingle with her co-barrio people about whats new and to relax for the day. Since almost all their neighbours are family and relatives she maintain a good relationship to them. According to the patient, she occasionally drinks alcoholic beverages. She is not an illegal drug user neither a smoker.

D. History of Past Illness

Mrs. V said that she worked as cook for almost 20 years. 9 years to a Chinese family and 11 years to the workers of a Buying Palay Station.So aside from the hot workplace, she used to lift heavy kitchen wares containing foods. But at the age of 45 years old, she stopped cooking and just baby sit on her grandchildren.

She did not remember anything that contributes to the mass on her breast. She said that she never bumped on any things, fall down, or any object that may hurt the site. Mrs. V has 6 children with her husband (deceased due to Asthma 15 years ago), who are 2 boys and 4 girls. She said she had a Normal Spontaneous Delivery to all of them at home. All breastfed, but she confessed that it may be one of the contributing factor that time because while she was asleep, she carry and breastfeed each baby and they accidentally kicked her breast.

At year 2007, she noticed that a thumb - like mass located below the right armpit. With minimal pain she felt. She did not tell to anybody about it for almost 3 years because she did not want her children to be bothered. But as days passing by for this 3 years, this 2010, the lump or mass becomes bigger and its shape according to her is like her closed fist comparing as ball. So she begins to worry and tell to her children about it. They decided to consult at Tarlac Provincial hospital last November 2009 and the doctor said that its a Breast Cyst and as soon as possible she must be operated. But the family refused to have the operation since the expenses for the operation was expensive and they decided to delay it then save for the amount needed.

E. History of Present Illness

After the diagnosis, in order to cope and keep from worrying, they seek advices from albularyos and drunk different boiled leaves of plants like Aroma, Bugnay , Tanglad and many more herbal medicines for 4 months. But the situation seems become worst. 1 month prior to admission ,she noticed that the lumps color becomes like a purple star apple with lesion beside the armpit and has blood secretions thus as days goes by, the breast skin becomes thinner and looks like a cellophane and transparent, and it seems like to burst. They rushed to TPH to have it check up last September 17, 2010, admitted and scheduled for operation last September 23, 2010 for a Breast mass to consider Malignancy.

IV. FAMILY HISTORY OF HEALTH AND ILLNESS

Paternal Side OA OA

Maternal Side OA OA

HTN

UC

6 6

AST

HTN

UC

BCA

UC

LEGEND: LIVING MALE PATIENT AST Asthma Hypertension LIVING FEMALE BCA Breast Cancer OA Old Age DECEASED MALE DECEASED FEMALE HTN UC Unknown Cause

IV.

13 Areas of Assessment

September 18, 2010

A. Social Status According to Mrs. V, as a mother she cannot deny whatever her children request on her. So at her age, she can manage on house hold chores aside from baby sit on her grandchildren. Her sons and daughters with their spouses and grandchildren are very supportive to her. She can sweep their yard, cook their foods and wash. When her grandchild fall into sleep, she said she watched afternoon variety shows on T.V. She is also active to church activities. If they run out of budget and kitchen needs, there is a little store nearby their house and here is where they usually buy what are lacking for households. She sits for quite sometimes to mingle with her co-barrio people about whats new and to relax for the day. Since almost all their neighbours are their family and relatives, she maintains a good relationship to them. And her children help together when there are problems arises, especially concerning to health on each every member. Norms: The patient and his family have respect to other people, believing that

relationships with other people are based on mutual trust (Westershoff) and putting their faith in action and standing up for their beliefs (Kohlberg), (Med.& Surg. Nursing Lemone and Burk 2004) Analysis: The patient developed interpersonal relationship within the family and their

neighbors with a certain degree of satisfaction. She developed a good coping ability as evidenced by being hopeful to regain her normal functioning or health condition. Preferences and interest exposed of her age were rather normal. Her activities were mostly dynamic in nature. B. Mental status/Neurological Status Facial expression Her expressions were appropriate according to the content of her dialogue and showed a smile during the entire interview.

Consciousness

She was well oriented with the time and date, although she wasnt able to

recall some of her past memories. Communication She has a good eye contact during the interview. She was conversant, and she could understand and speak Ilocano as well as Tagalog language. Attention She was attentive during the interview and had a good communication

process. She was cooperative and answers the question appropriately. Memory age. Norms: The patient should appear relaxed with appropriate amount concern of spontaneous, coherent speech; and assessment, Mary The patient wasnt able to remember some of her past memories due to her

the assessment; should be clean and well groomed; expressions should be appropriate to the content of the conversations; should be able to produce Elen zator Estes). Analysis: The patient was oriented and conscious. She was cooperative during the interview should respond to questions properly. (Health assessment and physical

and was confident in expressing herself. The patient was also unable to recall some past events that happened in her life due to her age. C. Emotional Status Mrs. V stated that despite all the problems in life, it should not affect her stability in life. She tried to cover up before about her condition in order to make her sons and daughter not to worry about her, but later, she confesses it. Since she has the fear too of what she expects to happen in the future. She tried to manage her condition alone for almost 3 years.

Norms:

A persons emotional status depends much on is ability to cope up with the

happenings in his life. He may or may not be emotionally stable of unfortunate incidents happened. (Nursing CEU.com: The process of human development) Analysis: The client has a positive outlook in life and can handle her emotions well.

D. Sensory Perception Sense of Sight Visual acuity Visual acuity has no alterations. Symmetry Patients eyes are symmetrical and round in shape. Both scleras are whitish in color but the conjunctivas are pinkish in

Color of Sclera color. Norms:

The patient should have a visual acuity of 20/20; the eyes must

be symmetrical during the six cardinal gazes; sclera should be white with some small blood vessels. (Health Assessment and physical assessment, Mary Elen Zator Estes). Analysis: The patients visual aciuty was normal. Her eyes were symmetrical in shape, the

sclera is whitish in color, and he has pale conjunctiva. Sense of Taste Color Hydration The tongue is pinkish in color. It is moist and rough with a clear secretions or saliva.

Taste

She verbalized the sweet taste when she ate her food, indicating

she could determine the taste the food served to her. Norms: A person has no problem about his sense of taste if he can identify the

sweet, sour, salty, and bitter taste of foods he eats. (Estes, Third edition, Copyright 2006) Analysis: Revealed normal condition of the sense of taste based from the standards.

Sense of Smell External inspection Nose is in the midline of the face, symmetrical, without lesions or pain. Patency There was no obstruction upon breathing. The student nurse asked her to

smell the objects we held near her nose through blindfold. The patient responded and verbalized what she smelled and stated that she smelled alcohol and perfume. Norms: Nose must be symmetrical and along the midline of the face. Each nostril must be

patent. (Health assessment and Physical Assessment, Mary Elen Zator Estes) Analysis: Revealed normal findings upon assessment based on standards. There were no

deviations observed. Tactile Sensitivity Pain tolerance The student nurse pointed the sharp and dull edges of the ballpen

to the pt.s skin and asked her to tell the sensation. The patient responded and verbalized what she felt and stated that she felt sharp and dull object touched her skin. Temperature She could feel the humid temperature in the hospital.

Norms:

The skin contains receptors for pain, touch, pressure and temperature.

Sensory signals that help determine precise locations on the skin are transmitted along rapid sensory pathways, and less distinct signals such as pressure or poorly localized touch are sent via slower or sensory pathways. (Health Assessment and Physical Examination, Mary Ellen Zator Estes 5th Edition) Analysis: The patients sensory transmission functions are within the normal as

manifested by the data presented. Auditory Acuity Watch tick test Symmetry level of his eyes. Whisper test She could hear the sound of the watch 1inch away from her. Ears were symmetrical with each other and were aligned on the There was no pain complained felt upon inspection. The patient was able to hear whispered words from 1-2 inches

away and repeated the words accordingly. Norms: The patient should be able to hear whispered words to 2 inch away. The pt.

should not complain of pain upon palpation. (Health assessment and physical assessment, Mary Elen Zator Estes) Analysis: Upon assessment, there were no lesions or inflammation found.

E. Motor Stability Mrs. V is able to ambulate with assistance on the first and second day but on the third day she does it alone. She moves slowly with minimal movements.

Norms:

Normal motor stability includes the ability to perform the different steps in doing

range of motion. It should be firm with smooth and coordinated movements (Estes, Third edition, Copyright 2006) Analysis: The clients walking gait was not normal on the 1st and 2nd day after operation.

F. Body Temperature Date September 27, 2010 September 28, 2010 Time 10:00 am 07:00 am 10:00 am 02:00 pm September 29, 2010 07:00 am 10:00 am 02:00 pm Norms: Temperature 37.5 C 37.2 C 36.3 C 36.9 C 36.8 C 37.0 C 36.8 C

36.5 C to 37.5 C is the normal body temperature (Kozier, Seventh edition,

Copyright 2004) Analysis: The body temperature of the patient was within normal range.

G. Respiratory Status Date September 27, 2010 September 28, 2010 Time 10:00 am 07:00 am 10:00 am 02:00 pm September 29, 2010 07:00 am 10:00 am 02:00 pm Respiratory Rate 19 cpm 20 cpm 17 cpm 16 cpm 20 cpm 18 cpm 20 cpm

Norms:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of

pattern, normal respiration must be regular and even in rhythm. The normal depth of respirations must be effortless. (Health Assessment and Physical Examination 3rd Edition Mary Ellen Zator Estes). Analysis: The patient has normal respiration during the assessment.

H. Circulatory Status

Date September 27, 2010 September 28, 2010

Time 10:00 am 07:00 am 10:00 am 02:00 pm

Blood Pressure 110/80 mmHg 120/70 mmHg 120/90 mmHg 110/70 mmHg 100/70 mmHg 120/90 mmHg 110/90 mmHg

Pulse Rate 84 bpm 89 bpm 92 bpm 90 bpm 98 bpm 94 bpm 96 bpm

September 29, 2010

07:00 am 10:00 am 02:00 pm

Norms:

The average heart rate of an adult is 80 100 bpm, and the average blood

pressure of an adult is 120/80mmHg. (Kozier, Seventh edition, Copyright 2004). Analysis: With regards to Mrs. Vs circulatory status, it shows that her pulse rate and blood

pressure is in the normal range. I. Nutritional Status In the recall of previous diet taken by the patient, the clients diet is under control of glucose and carbohydrate diet. Her diet according to the physicians order is on high fiber. She eats 3 meals per day with some snacks during the afternoon or siesta time. Her fluid intake was less than 3 bottles of water (1.5L each) amounting to approximately 4.5L.

BMI Computation: Given: weight = 45 kg Height = 5 ft (4 inches) BMI = weight in kg / height in (m) 2 = 45 / (1.6256)2 BMI = 17.01

Norms:

Normal eating pattern is on the minimum of 3 5 times per day, depending

upon metabolic need and demands. Fluid is on the average of 8-10 glasses (2-3 liters) per day. (Physical Assessment and Health Examination 4th Edition, Carolyn Jarvis) BMI is a measurement that indicates body composition. The degree of overweight or obesity as well as the degree of underweight can be determined by making use of BMI.(Estes, Third edition, Copyright 2006) Standard Body Mass Index for Adults (Estes, Third edition, Copyright 2006)

Underweight = <18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater

Analysis:

Based on the standards, her nutritional status was beyond the normal range and

she was underweight.

J. Elimination Status

She usually voids 3 4 times per day depending on the amount of fluid he ingests, and his urine colour was yellow. She also stated that she usually defecates once a day; and described her stool is brown in colour, and solid - formed. Norms: Normal bowel movement is usually 1 2 times per day. It should be solid -

formed and brown in colour. Normal urine output of an adult is usually 1200-1500mL per day, and voids 3 4 times a day. (Kozier Seventh edition, Copyright 2004) Analysis: assessment. K. Rest and Sleep Mrs. V stated that she only sleeps at 9:00 PM and wakes up at 4:00 AM. at home. She usually sleeps 6-7 hours at night but during her hospital, confinement she has a disturbed sleeping pattern due to her post - op condition with pain and minimal movement. So she takes nap during the afternoon. Norms: A normal sleep hour of an adult per day is 6-8 hours without disturbance.(Kozier, The patients elimination status is normal. No alterations found during

Seventh edition, Copyright 2004) Analysis: The patient has inadequate rest and sleep.

L. Reproductive Status The patient had her menarche at the age of 14. Her cycle usually lasts for 5 days. She experienced headaches and pain on the pelvic area during her cycle. She became sexually active at the age of 19. She had menopaused at the age of 45.

Norms:

Menarche, which is the first menstruation occur at an average age of

onset between 9 to 17 years old. (Maternal and Child Health Nursing 4th Edition by Pilliterri) Analysis: The patient has normal reproductive status.

M. State of Skin Appendages

Mrs. V has a normal complexion. She had undergone a capillary refill test resulting 3 seconds capillary refill. Her extremities was warmth. Her hair was black with some white hairs. She had an incision site at the Right breast with dry wound dressing. Norms: Skin varies from light to brown from ruddy pink to light pink. Generally, the skin

has uniform color except in areas exposed to the sun, in areas of lighter pigmentation in palms, nail beds, and lips. The hair should be evenly distributed, thick, shiny and free from infestation. Capillary refill must be within 2 3 seconds and should return immediately. (Kozier, Seventh edition, Copyright 2004) Analysis: Revealed abnormal findings based on the standards given due to her operation at

her right breast

V. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Normal Values (units used in the hospital)

Result/s

Analysis and interpretation of Results Normal

WBC 4.5-11X10 /L

WBC

10.6 G/L

LYM

0.23-0.35%

LYM 4.5 42.1 %L

Increased

MID

0.01.8

MID 0.7 6.3%M

Normal

Hematology Report

September 17, 2010

Complete blood count (CBC) is a GRAN 5.5 51.6%G determination of the GRAN 2.0 7.8 number of red and white blood cells per cubic millimeter of RBC 3.98 T/L RBC 4.206.30X10 blood. A CBC is one of /L the most routinely performed test in a HGB 120-180 g/L HGB 119 g/L clinical laboratory and one of the most valuable screening and HCT 0.370HCT 0.368L/L diagnostic techniques. 0.5%/L It also helps the health professional to check the patients condition, such as anemia, MCH 29.9pg infection and some MCH 26.0-32.0/g symptoms like fatigue. And weakness the MCHC 323 g/L patients have. MCHC 310-360 g/L

Normal

Decreased

Decreased

Decreased

Normal

Normal

PLT

140-940

PLT

264 g/L

Normal

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure. 2. Explain the importance of the procedures to be done to the pt.

Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Result/s

Analysis and interpretation of Results

Chest Pulmonary Radiography

September 17, 2010

Chest Pulmonary The ribs are intact. The heart Radiography is a projection is not enlarged. No radiograph of the chest used pneumothorax or pleural to diagnose conditions effusion is demonstrated. The affecting the chest, its lung fields are essentially contents, and nearby normal. The diaphragm is structures. Chest normal. radiographs are among the most common films taken, being diagnostic of many Impression: The lung fields conditions. are essentially clear.

Normal.

NURSING RESPONSIBILITIES: Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure. 2. Explain the importance of the procedures to be done to the pt. Diagnostic/ Laboratory procedures Date Ordered and Date Resulted Indication/s or purposes Normal Values (units used in the hospital) Result/s Analysis and interpretation of Results

Color: clear or amber Urinalysis September 17, 2010 For detection of any bacteria in the urine, glucose, albumin, blood, protein presence of infection. Appearance: straw Reaction: alkaline Specific gravity 1.010-1.030 Albumin: (-) Glucose: (-)

Amber Turbid Alkaline

Normal Not normal Normal

1.010 Negative Negative

Normal Normal Normal

NURSING RESPONSIBILITIES: Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure. 2. Explain the importance of the procedures to be done to the pt.

Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Normal Values (units used in the hospital)

Result/s

Analysis and interpretation of Results

Blood chemistry

September 18, 2010

For the determination of the chemical constituents of blood by assay in a clinical laboratory as part of a diagnostic protocol.

FBS 3.9 6.1 mmol/L

5.34

Normal

BUN 2.9 8.3 mmol/L

4.78

Normal

Crea 53 106 mmol/L

70.72

Normal

NURSING RESPONSIBILITIES: Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure. 2. Explain the importance of the procedures to be done to the pt/

Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Result/s

Analysis and interpretation of Results

Incisional Biopsy

September 23, 2010

Incisional biopsy often yield better diagnosis for Gross: The specimen deep pannicular skin consists of two dark diseases and more brown, irregular and soft subcutanous tissue can tissue measuring 1.0x1.be obtained. Advantage x0.3 cm in aggregate of the incisional biopsy dimension. is that hemostasis can be Micro: Microscopic done more easily due to sections reveal malignant better visualization. glands floating in pools of mucin. Also noted are scattered neoplastic cells in a desmplastic stroma.

MUCINOUS CARCINOMA

Not normal

NURSING RESPONSIBILITIES: Before, during and after diagnostic and laboratory test/s done: 1. 2. Inform the pt. and the family about the procedure. Explain the importance of the procedures to be done to the pt.

VI. ANATOMY AND PHYSIOLOGY

The breasts are composed of fatty tissue that contains the glands responsible for milk production in late pregnancy and after childbirth. Within each breast, there are about 15 to 25 lobes formed by groups of lobules, the milk glands. Each lobule is composed of grape-like clusters of acini (also called alveoli), the hollow sacs that make and hold breast milk. The lobules are arranged around ducts that funnel milk to the nipples. About 15 to 20 ducts come together near the areola (dark, circular area around the nipple) to form ampullae - cavities that store the milk before it reaches the nipple surface. Montgomery's glands are small oil glands that are located around each areola. They release a lubricant that protects the nipples during nursing.

Breast Size and Shape

The breasts are not always exactly the same size or shape. They are incompletely developed at birth and - in men - remain small and undeveloped unless subjected to abnormal hormonal stimulation. In general, breast formation is complete within a year or two after the start of menstruation; however, the acini keep growing, and fibrous and fatty tissues are continually added during adolescence. Pregnancy and nursing cause further increases in breast size. As a woman ages, the fatty tissue of the breasts may become more prominent than the glandular tissue, and the breasts may feel softer. The breasts gradually atrophy (shrink) after menopause.

Breast Position

The breasts cover a large part of the chest wall. In front, the breast tissue may extend from the clavicle (collarbone) to the middle of the sternum (breastbone). On the side, breast tissue may continue into the axilla (armpit) and reach as far as the latissimus dorsi (muscle extending from the lower back to the humerus bone of the upper arm). In fact, the anatomic relationship between the breasts and the underlying muscle is a very important consideration in surgical therapy. The breasts overlay vital chest wall muscles such as the pectoralis major (the 'pecs'), the pectoralis minor (thin, triangular muscle beneath the pecs), and the intercostals (muscles between the ribs). The breasts also may cover some of the serratus magnus (also called the serratus anterior; a slender muscle that is attached to the ribs/ rib muscles

and connects with the shoulder blade) and the rectus abdominis (long, flat muscle that stretches up the torso from the pubic bone to the ribs).

Lymphatic System

Lymph is a clear, tan fluid that contains lymphocytes (white blood cells that fight disease). Lymph is drained from the breast tissues by a rich supply of vessels. Such lymphatic vessels connect with a network of lymph nodes that are located around the breasts' edges or in nearby tissues of the armpits and collarbone. Lymph nodes play a central role in the spread of breast cancer. The axillary (underarm) lymph nodes are particularly important, as they are among the first places that cancer is likely to be found if it metastasizes (spreads) from the breast. This lymph node cluster is often referred to as the 'tail,' or level I nodes. Level II nodes are located underneath the pectoralis minor muscle, and level III nodes are found near the center of the collarbone.

VII.

PATHOPHYSIOLOGY

Predisposing factor: Sex Age Family History of Breast Cancer Early Menarche Race (African American, Asian) Non breastfeeding woman

Precipitating Factor: High fat diet Obesity Lack of physical Mobility Alcohol use Lifestyle Anti perspirant use

Increased estrogen metabolism Increased cell prolifertion

Absorpttion of chemicals through perspirant use

Toxins interfere in the lymph nodes Toxins build up in the breast

Carcingens bind to DNA results to alteration in function

Genotoxic waste in estrogen Damage to the genes of Tumor Supressor Cells

Spontaneous error of cells Continuous duplication of mutated DNA

Repair or elimination of cells with damaged DNA is inhibited

A single cell begins to divide abnormally

Thickening of a lump near the abdomen

Formation of new affected tissue

STAGE 1

If not treated:

Malignant conversion: accumulation of cells in the center of Tumor necrotized and begins to chip of malignant cells to seek new blood

Cells break out of the tumor and invades to surrounding lumph nodes

Lymphatic spread: dissemination of cancer cells to the lymph channels in the process Cells penetrates to lymph vessels by invasion and lodges in the lymph nodes

STAGE 2

Hematologic spread: cancer move to the extracellular matrix by secreting enzymes Entry to blood vessels

Surrounding vessels and lymph nodes becomes obstructed

Blood vessels including arteries and veins carries cancer cells to other organs

Unlocked lymph nodes drains towards the venous blood flow

Blockage of lymph vessels draining fluids

Inflammation of the breasts and lymph nodes

Cancer cells continues to stream in the lymph fluids

Cancer cells spread into membraane lining


Irritation and build up of fluids on adjacent tissues

May undergo invasive metastasis destroying epithelial tissues

Impaired lymph fow and erosion of tumors accumulates in the chest

New sites of tumor Cancer cells that are able to survive the environment and presuure will continues

STAGE 3

Metastasis

STAGE 4

If untreated:

DEATH

VIII.

NURSING CARE PLANS Expected Outcome

Assessment S> Masakit ang sugat ko PS: 7/10 O> Grimace noted Guarding behavior noted Restlessness Diaphoretic

Planning Within 30 minutes of rendering appropriate nursing interventions, the clients pain scale will decrease from 7/10 to 3/10.

Intervention

Rationale

Dress the wound.

Provide comfort like back rubbing.

After 30 minutes of rendering To prevent appropriate nursing occurrence of interventions, the infection. clients pain scale To increase will decrease from relaxation of the 7/10 to 3/10. pt. Pursed-lip breathing and deep breathing was effective in decreasing pain Cognitive behavioral strategies can restore sense of self control, personal efficacy and active participation for her own care.

Assist in deep breathing and pursedlip breathing

Nursing Diagnosis: Acute pain r/t surgical procedure (Modified radical mastectomy) Scientific Explanation: An unpleasant sensation caused by noxious stimulation of the sensory nerve ending. It is a

Support the clients use of nonpharmacological methods to help control pain such as distraction, imagery and relaxation

subjective feeling and an individual response to the cause. Pain is subjective in which the pt. inhibits a feeling of distress. Stimulating or trauma to certain nerve endings as a result of surgery causes pain.

Reinforce the importance of pain medication to keep pain under control

Teaching client to stay on top of their pain and prevent it from getting out of control will improve the ability to accomplish the goals of recovery. To relieve pain

Administer pain medications such as morphine sulfate and analgesics as prescribed

Assessment S>O O> Disrupted skin surface Complaint of pain on incision site Restlessness noted Swelling and redness noted at the site Excessive perspiration noted

Planning Within 1 to 2 hours of proper nursing intervention, the patient will be able to participate in prevention and treatment program.

Intervention Periodically premeasured wound and observe for any complications such infection. Keep area clean and dry, carefully dress wound , and support incision Use appropriate padding device if indicated

Rationale To monitor progress of wound healing

Expected Outcome After 1 to 2 hours of proper nursing intervention, the patient will be able to participate in prevention and treatment program.

To reduce pressure enhance circulation to compromised tissue To provide positive nitrogen balance and aid in healing and maintain good health To achieve wellness and prevent further complications

Nursing Diagnosis: Impaired Skin r/t surgical procedure (Modified radical mastectomy) Scientific Explanation: The condition defines as a state in which bodys natural skin has been damaged either naturally or surgically.

Instruct and encourage strict compliance of medication regime

ASSESSMENT

PLANNING

IMPLEMENTATION

RATIONALE

EXPECTED OUTCOME

S> Nahihirapan akong > Within 3 of matulog ng maayos kasi rendering appropriate maingay dito nursing intervention, the pt. will able to sleep and feel O> frequent yawning comfortable. noted. >sleepy in appearance. >weak in appearance. >restless >irritable

Render sponge bath to provide better circulation. Change clothing. loosens

To maintain > After 3 of rendering freshness. appropriate nsg. Intervention, the pt. is able to sleep To provide and feel comfort comfortable.

Provide ventilation.

proper

To maintain a cool environment suitable for sleeping.

Nursing Diagnosis: Disturbed sleep pattern r/t physical discomfort

Render back rubs.

To promote and give relaxation techniques.

Scientific Explanation: Arrange linens. bedside

To provide comfortable and clean environment.

Time limited disruption of sleep (natural, periodic, suspension of consciousness) amount and quality.

Assessment S>O O> Complaint of pain on incision site Restlessness noted Malaise Swelling and redness noted at the site

Planning Within 4 hours of rendering proper nursing interventions, the patient will relieve from signs and symptoms of infection

Intervention

Rationale

Expected Outcome After 4 hours of rendering proper nursing intervention, the patient will relieve from signs and symptoms of infection as evidenced by temperature decreases from 37.8 C to 37.

Stress the importance of proper hand washing technique Maintain adequate hydration , increase fluid intake Instruct SO in techniques to prevent skin integrity and prevent spread of infection Encourage intake of vitamin C rich foods , CHON and protein Encourage patient observe proper hygiene

To reduce the risk of contributory factors To prevent dehydration and maintain hydration status To have more information SO needs

Nursing Diagnosis: Risk for infection r/t inadequate primary defense 2 surgical procedure (Modified radical mastectomy) Scientific Explanation: An infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting

To promote faster wound healing and increase resistance to infection To decrease the risk of acquiring infection Peripheral circulation may be impaired

Provide skin care gently massage bony area. Keep the skin

organism seeks to utilize the host's resources to multiply (usually at the expense of the host).

dry , linens dry and wrinkle free

placing patient at risk for skin irritation To reduce risk of spread of infection

Administer antibiotics as prescribed

IX. Medical Management/Treatment Date ordered / Date performed / Date changed / Date discontinued

Medical Management / Treatment

General Description

Indication/s or Purpose/s

Clients reaction to treatment

1. D5LR 1L

Date ordered: Sep. 19, 2010

2. D5LR 1L

Date ordered: Sep. 20, 2010

3. D5NM 30gtts

Date ordered: Sep. 21, 2010

A hypertonic solution with greater concentration of solutes than plasma and can draw fluids out of the cells and interstitial spaces into the vascular system.

To increase the volume of blood following severe loss of blood or plasma and is used for fluid and electrolyte replenishment and caloric supply.

There were no signs of inflammation or infiltration during the infusion.

4. D5LR 1L

Date ordered: Sep. 22, 2010

NURSING RESPONSIBILITIES: Before, during and after the treatment: 1. Explain the procedure to the patient. 2. Secure consent from patient before IV infusion. 3. Verify physicians order indicating the type of solution, amount to be administered, and rate of flow of the infusion. 4. Inspect IV site for signs of infiltration or inflammation. 5. Check IV flow rate and monitor fluid volume overload. 6. Monitor intake and output.

Drug Name

Date

Route of Administration

General Action

Indications

Nursing Responsibilities Before During After

Generic Name: Ketorolac

Ordered: 09/26/10

Intravenous, Oral

Brand Name: Toradol Dosage & Frequency

Classification: Non-Steroidal AntiInflammatory Drug

Possess antiinflammatory analgesic and antipyretic effects. They are largely related to inhibition of prostaglandin synthesis.

> Indicated for the relief of the s/s of RA and osteoarthritis > For relief of mild to moderate pain > For treatment of primary dysmenorrheal > For fever reduction

> Consider the rights in drug administration > Inform the patient about the medication > Administer with food and mild if GI upset occurs

> Administer as part of a regular analgesic schedule rather that on as needed basis > Check for any unusual bruising and/or bleeding

> Monitor patients intake and output to check for GI disturbance > Instructed patient to increase fiber intake such as pineapple > Record the medication given.

30 mg 2 cap P.O. T.I.D.

Type of Diet

Date Ordered, date Started, Date Changed

General Description

Specific Foods Taken

Clients Response and/or Reaction to the Diet

NPO

Date ordered: September 2010

Strictly, not allowed NONE to take any kind of 22, food or liquids by mouth.

The patient understood the procedure.

Full Liquid Diet

Date ordered: September 2010

Full liquid diet 1 cup noodle She was glad that allows only foods in soup or Broth finally she could 23, liquid form or those only, tea eat foods. which readily become liquid at body temperature.

Soft Diet

Date ordered: September 2010

A diet that allows Lugaw fruits and 24, vegetables with low-cellulose content as well as fish and meat with no or very little connective tissues.

She was glad that finally she could eat foods.

NURSING RESPONSIBILITIES: Before, during and after the administration of the diet: 1. 2. 3. 4. 5. 6. 7. Explain the procedure. Be sure that the patient flatus before giving the diet. Teach the family about the diet. Check the patients food. Observe tolerance for eating. Check the patients readiness for the next diet. Document the procedure.

Type of Exercise

Date Ordered, Date Started, Date Changed

General Description

Indication/s or Purpose/s

Clients response / reaction to the activity / exercise

Bed Rest

Date ordered: Sep. 23, 2010

Is a medical For fast treatment refers recovery of the to staying in patient. bed day and night as a treatment for an illness or medical condition.

Relaxed and comfortable.

Ambulation

Date ordered: Sep. 24, 2010

Ambulation is the recommended for a healthy lifestyle, and has numerous environmental benefits.

For progress She can and early walking recovery of the assistance. patient.

tolerate without

NURSING RESPONSIBILITIES:

1. Educate the patient about the importance of ambulation and bed rest, and the appropriate way of doing the exercise. 2. Assisted the patient in ambulation
X. SURGICAL MANAGEMENT

Name of procedure

Date performed

Brief Description

Indication/s or Purpose/s

Clients response to the operation

Modified Radical Mastectomy

Sep. 23, 2010

A surgical procedure that removes the breast, surrounding tissue, and nearby lymph nodes that are affected by cancer.

The purpose for modified radical mastectomy is the removal of breast cancer (abnormal cells in the breast that grow rapidly and replace normal healthy tissue). Modified radical mastectomy is the most widely used surgical procedure to treat operable breast cancer. This procedure leaves a chest muscle called the pectoralis major intact. Leaving this muscle in place will provide a soft tissue covering over the chest wall and a normalappearing junction of the shoulder with the anterior (front) chest wall. This sparing of the pectoralis major muscle will avoid a disfiguring hollow defect below the clavicle. Additionally, the purpose of modified radical mastectomy is to allow for the option of breast reconstruction, a procedure that is possible, if desired, due to intact muscles around the shoulder of the affected side. The modified radical mastectomy procedure involves removal of large

Client understood the risk and benefit of the operation. Thus accepting the postoperative outcome.

multiple tumor growths located underneath the nipple and cancer cells on the breast margins.

NURSING RESPONSIBILITY:

Before, during and after the surgical procedure:

1. Explain procedure to the patient.


2. Advise the patient to not eat or drink for several hours before the examination.

3. Provide patient privacy 4. Observe for patients response to the procedure 5. Assist patient to move from supine to sitting position 6. Follow up for the result of the procedure

XI. SOAPIE/R
SUBJECTI VE CUE/S

DATE

OBJECTIVES CUE/S

ASSESSMENT

PLANNING

INTERVENTION

EVALUATION

September 24, 2010

S> Masakit ang sugat ko PS: 7/10

O> Grimace noted Guarding behavior noted Restlessn ess Diaphore tic

Acute pain r/t surgical procedure (Modified radical mastectomy)

Within 30 minutes of rendering appropriate nursing interventions, the clients pain scale will decrease from 7/10 to 3/10.

After 30 minutes of Provide comfort like rendering back rubbing appropriate nursing Assist in deep interventions, breathing and pursedthe clients lip breathing Support the clients use pain scale was decrease from of nonpharmacological 7/10 to 3/10. methods to help control pain such as distraction, imagery and relaxation Reinforce the importance of pain medication to keep pain under control Administer pain medications such as morphine sulfate and analgesics as prescribed Dress the wound.

DATE

SUBJECTI VE CUE/S

OBJECTIVES CUE/S

ASSESSMENT

PLANNING

INTERVENTION

EVALUATION

S>O September 24, 2010

O>

Disrupted Impaired Skin r/t surgical skin procedure surface Complain (Modified radical t of pain mastectomy) on incision site Restlessn ess noted Swelling and redness noted at the site Excessiv e perspirati on noted

Within 1 to 2 hours of proper nursing intervention, the patient will be able to participate in prevention and treatment program.

Periodically premeasured wound and observe for any complications such infection. Keep area clean and dry, carefully dress wound , and support incision Use appropriate padding device if indicated Instruct and encourage strict compliance of medication regime

After 1 to 2 hours of proper nursing intervention, the patient was be able to participate in prevention and treatment program.

DATE

SUBJECTI VE CUE/S

OBJECTIVES CUE/S

ASSESSMENT

PLANNING

INTERVENTION

EVALUATION

September 22, 2010

S> Nahihirap an akong matulog ng maayos kasi maingay dito

O> frequent Disturbed sleep pattern r/t yawning noted. physical >sleepy in discomfort appearance. >weak appearance. >restless >irritable in

> Within 3 of rendering appropriate nursing intervention, the pt. will able to sleep and feel comfortable.

Render sponge bath to After 3 of provide better rendering appropriate circulation. nsg. Change loosens Intervention, clothing. the pt. was able to sleep and Provide proper feel ventilation. comfortable. Render back rubs. Arrange bedside linens.

DATE

SUBJECT IVE OBJECTIVES CUE/S CUE/S

ASSESSMENT

PLANNING

INTERVENTION

EVALUATIO N

September 22, 2010

S>O

O> Complai nt of pain on incision site Restless ness noted Malaise Swelling and redness noted at the site

Risk for infection r/t inadequate primary defense 2 surgical procedure (Modified radical mastectomy)

Within 4 hours of rendering proper nursing interventions, the patient will relieve from signs and symptoms of infection.

Stress the importance of proper hand washing technique Maintain adequate hydration , increase fluid intake Instruct SO in techniques to prevent skin integrity and prevent spread of infection Encourage patient observe proper hygiene Provide skin care gently massage bony area. Keep the skin dry, linens dry and wrinkle free Administer antibiotics as prescribed

After 4 hours of rendering proper nursing intervention, the patient was relieved from signs and symptoms of infection.

DISCHARGE PLANNING i. General condition of the patient upon discharge. It was September 30, 2010 when the patient was discharge. She was able to do her ADL such us dressing and going to the bathroom without any assistance. The doctor ordered the patient for OPD fallow-up. And was also advice to have a complete bed rest and continue Diet as Tolerated with Low Salt, Low Fat Diet. ii. METHOD M- Take home medication instructed as follows: Cefuroxime 500mg 1 cap. P.O. once a day Ketorolac 10mg 1 cap three times a day

E Complete bed rest. T - Upon the day of discharge, she was advised to clean and change the dressing of the incision site daily. H Encouraged taking prescribed drugs for maintenance and early recovery. Instructed to report any adverse reaction of medicines immediately. Educated the patient to avoid activities or habits that can precipitate fatigue/ eating large meals, drinking coffee, smoking, exercising too extraneously. Explained the importance of balance diet. Encouraged brief rest period throughout the working day.

Advised patient who are anxious and nervous to consider counselling, to the relaxation techniques may also be used.

O- Follow-up check-up on October 07, 2010 at the Out-Patient Department of Tarlac Provincial Hospital. D- Diet as Tolerated

XIII. CONCLUSION The therapeutic management for this problem the patient is placed on bed rest either in the hospital or at home and administers medications as prescribed. All objectives were constructed for our patients benefit in able for the group to have prioritized nursing action. The group constructed and considered all the objectives that we gathered from our patient. For our objectives, the group had evaluated it as good and successful actions because the goals were achieved and all appropriate nursing interventions are rendered to our patient.

XIV. RECOMMENDATION The group recommended that after the operation, the patient should be aware for the problems that may occur in her incision site, especially for the risk of infection. The groups also recommend that the pt. must continue her medication as prescribed by the doctor that will help for her faster recovery. The pt. was advice to avoid her past lifestyle for the mean time, which may cause arising of problem in her situation. The cleaning of her incision site and changing the dressing daily was recommended to the patient. On her discharge, the pt. was

recommended to have a follow-up check up, to know if the treatment is effective, if there are changes during her recovery and to know if there is a progress and an improvement of the patients condition.

XV. BIBLIOGRAPHY

Fundamentals of Nursing, Daniels Fundamentals of Nursing: Process, Concepts and Practice, 7th Edition Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes Friedman and Smith, 1998 Nursing Diagnosis Handbook, 5th Edition 2006 by Ackley and Ludwig http://medical-dictionary.thefreedictionary.com/nutritional+status www.umm.edu/sleep/normal_sleep.html www.yahoo.com www.google.com www.scribd.com www.nursingcrib.com