In Partial Fulfillment Of the Requirements in

RLE: University of Santo Tomas Hospital

BREAST MASS RIGHT T/C FIBROCYSTIC CHANGE/FIBRO ADENOMA

Submitted to:
Elma Jazz E. Macrohon, RN, MAN

Submitted by:
Abrea, Armand
Cuya, John Arnold
Dacillo, Ariane May
Demohina, Mylene
Duran, Joel
Fidel, Emmanuel
Gandeza, Kim Kaela
Gatchalian, Danica
Rengel, Sheila Mea
Silang, Shirlie
Holy Trinity University
College of Health and Sciences-BS in Nursing
May 28, 2010

Chapter I
INTRODUCTION
Breast cancer is the most common cause of cancer in women and the
most common cause of death in women . While the majority of new breast
cancers are diagnosed as a result of an abnormality seen on a mammogram,
a lump, or change in consistency of the breast tissue can also be a warning
sign of the disease. Heightened awareness of breast cancer risk in the past
decades has led to an increase in the number of women undergoing
mammography for screening, leading to detection of cancers in earlier
stages and a resultant improvement in survival rates. Still, breast cancer is
the most common cause of death in women between 45-55 years of age.
Although breast cancer in women is a common form of cancer, male breast
cancer does occur and accounts for about 1% of all cancer deaths in men.
Research has yielded much information about the causes of breast cancers,
and it is now believed that genetic and/or hormonal factors are the primary
risk factors for breast cancer. Staging systems have been developed to allow
doctors to characterize the extent to which a particular cancer has spread
and to make decisions concerning treatment options. Breast cancer
treatment depends upon many factors, including the type of cancer and the
extent to which it has spread. Treatment options for breast cancer may
involve surgery (removal of the cancer alone or, in some cases,
mastectomy), radiation therapy, hormonal therapy, and/or chemotherapy.
With advances in screening, diagnosis, and treatment, the death rate
for breast cancer has declined. In fact, about 90% of women newly
diagnosed with breast cancer will survive for at least five years. Research is
ongoing to develop even more effective screening and treatment programs.
During our first week of exposure to USTH, we have identified a client who
has satisfied our interests about this condition. We chose her case so that we
can gain deeper and broader knowledge about the cause and effects of the
disease; develop skills based on the management options and treatment
modalities available; and the most importantly, to impart values to the client
which we have acquired as a nursing students.

Scope and delimitation

This study is delimited in terms of problem, source of data or
population, locale and time frame.
Problem:
This study focuses on Breast Cancer, together with the
manifestations, treatment modalities of the disease and possible nursing
care plans.
Source of Data/ Population:
The population being referred in this study is the patient, significant
others, and patients chart.
Locale:
The study was conducted on the Female Surgical Ward of University of
Santo Tomas Hospital.
Time Frame:
The study was performed on May 26-28, 2010 at 6:00am-12pm;
though the interventions were limited for just eight hours at the Female
Surgical Ward of USTH.

Statement of the Problem

CHAPTER II
Personal Data
Name: Mrs. Q
Age: 32 y/o
Birthday: November 25, 1973
Gender: Female
Nationality: Filipino
Civil status: Married
Address: cluster 24 ROTC Hunters Tatalon Quezon City
Religion: Roman Catholic
Date and Time of admission: May 24, 2010-11:51 am
Chief complaint: Breast mass right
Diagnosis: Breast mass right t/c fibrocystic change/fibro adenoma
Physician: Dr. Zip
Source of data: patients subjective and objective cues, SO and chart

Past Medical History

Client was last ill sometime on December 2009. She experienced persistent
cough associated with hemoptysis. Due to this condition, consulted at USTH
and was diagnosed (+) PTB. She had undergone 4 months of treatment.
Meds taken were HRZE (FIXCOM-4). Treatment is still going on which afforded
relief of her symptoms.

Present Medical History

December 2009, client experienced intermittent sharp stabbing pain on right
breast, specifically on the right and left upper quadrants with Pain Scale of
4/10. No meds taken since this only last for 1-2 minutes, adequate rest
served as remedy to relieve the pain felt.
February 2010, she noticed a painful immovable mass on the right outer
quadrant of the breast approximately 1-2 cm in diameter. She decided to
consult at USTH OPD. Physical examination of breast was done and was
advised to have ultrasound. Due to financial constraints, unable to comply
needed diagnostic procedures.
March 2010, client noticed gradual enlargement of breast and decided to
come back @ USTH for follow up check up and then advised removal of
mass, have ultrasound of right breast including the axillary part and biopsy.
Due to financial constraints, only ultrasound was completed and the result
revealed 3x3 cm mass on right upper outer quadrant of breast, firm, and
immovable. She was again advised to comply biopsy and removal of mass.
Hence, these prompted admission.
Nursing History
She was delivered normally and spontaneously in cephalic presentation
assisted by a midwife. Has complete immunization status. Childhood
illnesses are cough and colds, fever, headache usually treated at home with
paracetamol, calamansi juice and adequate rest which afforded her relief.
Heredo-familial diseases are diabetes and hypertension in paternal side and
with family history of leukemia.

SPECIFIC BASIC NEEDS

A. PERCEPTION AND EXPECTATION OF ILLNESS/ HOSPITALIZATION
Akala ko dati basta bukol lang sya na tumubo, nung nalaman ko na cancer
ang sakit ko hindi na ko mapalagay. Natatakot ako dahil pag cancer hindi mo
alam kung mabubuhay ka pa ng normal at matagal, as verbalized. She is
sometimes anxious about the treatment that is being done to her because it
was her first time to be brought to the hospital for admission. She still
believes and expects that hospitalization and operation will greatly make her
feel better and be back to her usual work/activities.
B. SPECIFIC BASIC NEEDS
B.1. Rest and comfort
Prior to hospitalization: Her usual sleeping pattern is 7-8 hours, usually from
9pm to 5 am. Even though she works for the whole day she always finds time
to take a nap for 1-2 hours usually at noon. She can do whatever she wants
comfortably and independently. She takes a bath everyday usually in the
morning before going to work. Form of leisure / recreation?
During hospitalization: According to her, she has an average sleeping
duration of 6-7 hours a day but with interruptions such as hospital routines
and environment. Minsan nakakatulog din ako ng maayos pero kalimitan
talaga paputol- putol lalo na pag may iinumin akong gamot tapos medyo
kumikirot yung sugat ko at mainit pa dito, as verbalized. Her daily hygiene
is provided by her SO.
Analysis: She is quite dependent to her SO now specially after her operation.
Her sleeping pattern is also disturbed because of hospital routines and
environment.
Nursing Diagnosis: Sleep pattern Disturbance r/t hospital routines and
environment
B.2. Safety needs

Prior to hospitalization: Their house is located at sub-urban area near in a

main highway. As verbalized, their home and environment is safe and
convenient for them. She can perform daily activities without assistance.
Client has no known visual and hearing impairments.
During hospitalization: She is sometimes dependent to her SO and health
team. Her bed is 1 m above the ground with side rails on both sides and also
pillows for support. Her SO stays with her at all times to take good care of
her, provides her needs, and doing all means to ensure her fast recovery.
GCS= 15/15 (E=4;V=5;M=6).
Analysis: There is no alterations with her safety needs.

B.3. Oxygenation
Prior to hospitalization: Their living place is adequately ventilated with trees
at the vicinity. Their house has 4 windows and facilities that can be used in
providing ventilation such as electric fans. She is exposed to second hand
smoking. No any unusualities reported.
During hospitalization: Ward has electric fans and windows. Not in
respiratory distress. Can breathe normally without the aid of oxygen therapy.
RR= 17-20 bpm.
Analysis: No alterations noted.
B.4. Fluids and Nutrition
Prior to hospitalization: Her diet is usually consist of fish, meat and
vegetables and 1 -2 cups of rice. She loves to eat fish and vegetables like
fried fish, sinigang with swam cabbage and horse radish. She rarely eats
meat, once or twice a week. She drinks 7-8 glasses (approximately 1680 to
1920ml) of water/ fluids a day. She had no allergies to any food. Does she
take coffee/ juices or any snacks in between meals?
During hospitalization: As verbalized, hindi naman nawawala ang gana ko
kumain, nauubos ko naman ang mga binibigay sakin;consumes 1 cup of
rice, 1 serving of fish or meat, and fruit; was placed on NPO from May 25
midnight to May 26 afternoon; on May 26 night, was placed on DAT.
Consumes 4-5 cups of water approximately 840-1080 ml a day.
Analysis: Because of her present condition and environment, her eating
pattern is affected such as quality and quantity though she is on DAT.

Nursing Diagnosis:
B.5. Elimination
Prior to hospitalization: patient has normal pattern of bowel movement. She
defecates for at least once a day (time varies) to a brown, soft formed stool
in moderate amount approximately180-200cc a day and voids approximately
4-5x a day into a yellowish urine approximately 30-50cc per void.
During hospitalization: Since admission on May 24, 2010, defecated twice to
a brown well-formed stool approximately 140 to 160 cc a day, voids
approximately 3-4x a day into a yellow urine approximately 30cc/void.
Analysis: There are alterations with regards to her elimination due to
decreased physical activity.
Nursing Diagnosis: Risk for constipation r/t decreased physical mobility
B.6. Sexuality
Generally feminine in the way she appears, speaks and dressed. She is
married for 11 years and has 3 children. Able to maintain intimacy with her
husband.
B.7. Allergies
No reported allergies to any food, drugs/medicine, and pollens.
B.8. Communication
Able to speak Bisaya, Tagalog and English dialect as her language and to
express her needs.
Physical Assessment
HEENT
Mental Status: Awake, alert, oriented to person, place and time;
with GCS of 15/15
Head:
Normocephalic; hair is worn long and evenly distributed along
scalp with black; approximately 8-9 inches in length; (-) lesion and scars
noted;able to rotate head up to 180 degree; free from lice, knits and
dandruff; scalp is soft to touch; hair is smooth and shiny; no tenderness;
able to feel touch on his scalp (CN V Trigeminal intact)
Eyes: Eyebrows are 0.3 cm long and eyelids are intact, arched along bony
prominences above orbits; lashes present on upper and lower lids; (-)

swelling of lacrimal gland or duct; anicteric sclera noted; with pinkish

conjunctivae; with symmetrical pupils equally round and reactive to light
accommodation; with pupillary size of 2-3 mm on both eyes; medial
movement of both eyes, symmetric movement of eyelids observed, able to
follow moving objects (CN III Oculomotor intact); inferior movement of the
eyes (CN IV Trochlear intact); lateral movement of eyes (CN VI Abducens
intact)
Ears: Same color with the facial skin; top of pinna in line with the outer
canthus of the eye; moderate amount of cerumen on both ears; no
discharge; responsive to sound stimuli and able to count sound provided (CN
VIII Acoustic intact)
Nose:
Symmetrical; with patent nares, (-) nasal flaring noted; septum
at midline, straight and intact; slightly pointed; mucosa pale pink in color;
able to identify 2 different smell (CN I - Olfactory is intact)
Mouth/Throat: Lips are intact in reddish color; pinkish buccal mucosa
membrane; able to stick out tongue and (-) deviation noted (CN XII
Hypoglossal intact); with gag and swallowing reflexes, able to speak and
cough; able to chew (CN Trigeminal V intact); uvula intact at the midline of
nasopharyngeal cavity; with grade 0 of tonsil; regular equal carotid pulses;
trachea at the midline; (-) palpable non tender lymph nodes; thyroid and
parathyroid are not inflamed; (+) gag reflex (CN IX Glossopahryngeal
intact)
Chest and Lungs
Inspection:
With fair complexion; downward equal slope of ribcage noted,
anteroposterior diameter less than transverse diameter with approx. ratio of
1:2; dark brown areola noted on left breast with a diameter of approximately
4-5mm;; with symmetrical thoracic excursion during respiration;
diaphragmatic breathing noted, RR- 17-21 cpm with regular deep breathing
pattern; right and left shoulder are at the same height;
Right Breast: with post operative wound on right chest approximately 26 cm
in length secondary to removal of right breast and lymph nodes on right
axilla; with jackson pratt inserted @ right axilla area draining to
approximately 30 cc level into a bloody discharge
Left Breast: intact; everted nipple; areola is rounded with dark-brown color;
(-) dimpling of nipple noted; (-) orange peel skin observed; (-) lesion; no
discharge, visible mass and retraction seen
Palpation:
Posterior with equal tactile fremitus on both lung fields

Anterior uniform temperature on the anterior thorax noted; skin intact; (-)
palpable mass on all quadrants of the breasts including the axilla; (-)
tenderness on left breast upon palpation
Percussion:
Resonant sound heard on anterior lung fields only upon percussion at
intercostals spaces
Auscultation:
Wheezing sound heard on both lung fields
Heart sounds: S1-S2 sounds heard over 5th midclavicular intercostals spaces;
cardiac rate of 72 bpm
Abdomen
I With fair complexion; convex abdomen noted; (+) symmetric movement
during respiration; visible abdominal pulsation
A With active hypoactive bowel sounds @ 20-30 seconds interval per
minute of the peri-umbilical region
P Dullness heard upon percussion of the RUQ and LUQ
P Soft to touch, non-tender, rounded abdominal contour
Genito-Urinary
Unable to perform thorough physical assessment
Skin-Extremities/Musculoskeletal
Fair complexion on her upper and lower area; complete digits of both upper
and lower extremities; pale nail beds noted with capillary refill of 1-2 seconds
of all extremities; clubbing of finger nails; (+3-easy to palpate) radial and
brachial pulses of both upper extremities; (+3-easy to palpate) popliteal and
dorsalis pedis pulse of the right lower extremity, and dorsalis pedis pulse of
the left leg; with apical pulse of 72bpm, radial pulse of 71bpm and dorsalis
pedis of 70bpm (with pulse deficit of 1-2bpm); with BP ranging from
80/60mmhg to 100/60mmhg (with pulse pressure of 20-40mmhg); with
muscle grade of 4/5 on both upper and lower extremities; cold clammy skin
to touch; heplock is inserted at left basilic vein; no edema formation seen;
(+) triceps, biceps, knee jerk and ankle jerk reflexes; (+) pain right upper
extremity upon moving.

General Condition
Conscious and coherent with GCS of 15; with post-operative wound on her
right chest approximately 26 cm long secondary to surgical removal of right
breast and lymph nodes in axilla; dry mouth noted; irritability observed; with

poor eye contact; frequent questioning; staring with blank mood and affect;
for recovery.

STAGE
Infancy
(0-18
months)

DEVELOPMENTAL TASKS
PSYCHOSOCIAL THEORY BY ERIK ERIKSON
DEVTAL
BOOK PROFILE
ACTUAL PROFILE
TASK
Trust vs.
An individual can
At age 0-18 months,
Mistrust
differentiate self
she was close in
from the
bonding with her
environment and
mother most due to
begin to develop
her dependence. Her

self-concept and
relationship with
the caring person.

Toddler
(18
months
3 years
old)

Preschooler
(3-6
years
old)

School
age (6-12
years
old)

Adolesce
nts (1218 years
old)

basic needs are

immediately
attended by her
mother.
Autonomy
An individual
During toddlerhood,
vs. Shame
learns to control
she was toilet& Doubt
bowel and begin to
trained. She began
develop his/her
to learn language
identity. Also, it is
skills. She has also
a stage on which
begun to develop
he develops motor
independence by
skills and learns to
learning to feed
talk.
herself and dress her
own.
Initiative
An individual
She was informed
vs. Guilt
begins to relate
that she was fond of
with another or
learning new things
play with the same through experiences
age children. He
and exploring. She
also begins to
was not restricted for
fantasize about the
seeking new
future and ask
learning. She was
why.
allowed to play with
the other children of
the same age.
Industry
A person starts to
At this stage, certain
vs.
have mastery of
responsibilities were
Inferiority
skills and work.
already expected of
Intellectual growth
her (i.e. simple
sets in.
household
chores).Her parents
gives her recognition
for every
accomplishment she
had done .He was
also able to gain
more friends in
school and
participate in school
activities
Identity
An individual
She became more
vs. Shame
learns to have
bonded to her
& Doubt
sense of self.
friends rather than
with her family at
this stage but her
bond with her family

Young
Adult
(19-28
years
old)

Intimacy
vs.
Isolation

Learn to establish
relationship with
partner. Gratifying
social relationship.

Middle
Adult
(28-41
years
old)

Generativ
ity vs.
Stagnatio
n

Generativity is
reflected in the
individual
establishment
building the next
generation. A
negative revolution
is self-absorption
and result in sense
of stagnation.

was still felt. She

started to seek self
identity through
going out with
friends.
At this stage, she
began to build a
family of her own.
She met her
husband and they
were married. They
have three children.
At this age, she
helps in the finances
of her family. She
and her husband
provides their basic
needs such as food,
shelter, clothing and
education. She is the
one who does the
budgeting of their
finances.

Chapter III
LABORATORY EXAMS & DAGNOSTIC PROCEDURE
Complete Blood Count (CBC)
Rationale: RBCs, HGB, and HCT are important to the oxygen-carrying
capacity of the blood; WBCs are indicators of immune function
Date ordered: May 24, 2010
DIAGNOSTIC
PROCEDURE
S

RESULT

NORMAL
VALUES

INTERPRETATION

RATIONALE

Hemoglobin
(Hgb)

124g/L

120170g/L

Within normal
range which
indicates
sufficient oxygen
supply in the
body though
capillary refill is
normal.

To determine the
amount of Hgb in
the blood and is a
good indicator of
the bloods ability
to carry O2
throughout the
body.

Hematocrit
(Hct)

0.37

0.37-0.54

MCV

91

MCH

33.9

Within normal
To measure the
range which
space (volume) of
indicates
plasma occupied
sufficient volume
by the RBC.
of RBC contained
in a given plasma

87+-5 u^3 Result is within

The MCV
the normal range,
describes
which indicates individual red cell
that there is
size. It is the ratio
neither anemia of the volume of
nor any liver
packed cells to
diseases or folate the red cell count.
or vitamin B12
deficiencies.
29

Above normal

MCH measures

+-2 pg

MCHC

33.9

Platelet

204 x 10
g/L

34+-2 g/dL

range.

the weight of
hemoglobin in an
average red cell.
It is related to
MCV, because the
weight of a red
blood cell
increases when its
amount of
hemoglobin, and
therefore its size,
increases.

Within normal
MCHC measures
range which
the portion of
implies normal hemoglobin in an
count of Hgb in average cell. It is
an average cell.
the ratio of the
weight of
hemoglobin to the
volume of red
blood cells.

150-450x Within the normal

To determine
10 g/L
range indicating capability of the
effective blood body to maintain
coagulation.
endothelial
integrity, to
release a
substance that
begins the
coagulation
process. Along
with fibrin, they
form the network
for a clot to form,
necessary in
wound healing

Differential
count:
Lymphocyte
s

0.36

0.20-0.40

Within normal,
Resides at
indicating
lymphatic tissues,
effective ability to where they play
develop immune an important role
response.
in the immune

response. This is
to determine to
identify the bodys
ability to develop
immune response
against invading
pathogens.
Monocytes

0.01

0.00-0.07

Within normal
range indicating
sufficient ability
to engulf
pathogens.

To determine
number of WBC
capable of
engulfing
pathogens.

Eosinophils

0.04

0.00-0.05

Within normal
range, which
indicates no
presence of
parasitic
infection.

To determine any
parasitic infection.

Neutrophils

0.59

50-70%

within normal,
To determine
which indicates bodys capability
adequate second to fight against
line defense
invading infection
against infection.
through
phagocytosis.

X-ray of Chest
Date ordered: May 24, 2010
Impression: Consider cavitary Kochs infection common entirely rule out
concomitant pneumonia minimal volume loss, upper lobe
Rationale: To visualize underlying organs through indirect visualization.
ECG
Date ordered: May 24, 2010
Impression: Normal Sinus Rhythm
Rationale: To detect and monitor abnormalities in heart rate and rhythm.
ABO group/RH typing
Date ordered: May 25, 2010
Result: AB positive
Rationale: To determine the compatibility of the blood
Frozen section report
Date ordered: May 26, 2010

Impression: Invasive Ductal Carcinoma

Rationale: to confirm the malignancy of the mass
Sonography
Date ordered: May 01, 2010
Impression: Considered an inflammatory lesion in the breast but can
masked a more aggressive nodules; suggest closer follow up or tissue
correlation clinically warranted for better evaluation.
Bilateral axillary lymphadenopathies
Rationale: To better visualization of the breas
t through indirect visualization.

REVIEW OF ANATOMY & PHYSIOLOGY:

The breast generally refers to the front of the chest and medically specifically
to the mammary gland.(The word "mammary" comes from "mamma," the
Greek and Latin word for the breast, which derives from the cry "mama"
uttered by infants and young children, sometimes meaning "I want to feed at
the breast.") The breasts
Inside a woman's breast are 15 to 20 sections called lobes. Each lobe is
made of many smaller sections called lobules. Lobules have groups of tiny
glands that can make milk. After a baby is born, a woman's breast milk flows
from the lobules through thin tubes called ducts to the nipple. Fat and fibrous
tissue fill the spaces between the lobules and ducts.
The breasts also contain lymph vessels. These vessels are connected to
small, round masses of tissue called lymph nodes. Groups of lymph nodes
are near the breast in the underarm (axilla), above the collarbone, and in the
chest behind the breastbone.

The mammary gland

is a milk-producing structure that is composed largely of fat cells (cells
capable of storing fat). The fat deposits are laid down in the breast under the

influence of the female hormone estrogen. Just as the surge of estrogens at

adolescence encourages this process, androgens, such as testosterone,
discourage it.
Within the mammary gland there is a complex network of branching ducts
(tubes or channels). These ducts exit from sac-like structures called
lobules.The lobules in the breast are the glands that can produce milk in
females when they receive the appropriate hormonal stimulation. The breast
ducts transport milk from the lobules out to the nipple. The ducts exit from
the breast at the nipple.
Human breasts function somewhat differently than those of other primates.
In other primates, the breasts grow only when the female is producing milk
(lactating). When the non-human primate female has weaned her young, her
breasts flatten back down. In humans, the breasts develop at adolescence
usually well before any pregnancy has occurred and the breasts stay
enlarged throughout the remainder of life.
During pregnancy the breasts grow further. This growth is much more
uniform than that at adolescence. The breasts of women with small breasts
tend to grow about as much during pregnancy as those of women with large
breasts. The amount of milk-producing tissue is essentially the same. This is
the reason that when milk production begins, small-breasted women produce
as much milk as do large-breasted women.
The nipple becomes erect because of such stimuli as a cold environment,
breastfeeding, and sexual activity. The nipple of the post-partum female is
used by the infant to breastfeed.
The small darkened (pigmented) area around the nipple is called the areola.
(The word "areola" is the diminutive of the Latin "area" meaning a small
space.) In pregnancy the areola darkens further and spreads in size. The
areola contains small modified sweat glands (Montgomery's glands) that
secrete moisture that acts as a lubricant for breastfeeding.
The lobules and ducts in the breast are supported by surrounding fatty tissue
and the suspensory ligaments of the breast. There are no muscles in the
breast. The characteristic bounce of the breast comes from the elasticity of
the matrix of connective tissue fibers in the breast.
There are blood vessels and lymphatics in the breast. The lymphatics are thin
channels similar to blood vessels; they do not carry blood but collect and
carry tissue fluid which ultimately re-enters the blood stream. Breast tissue
fluid drains through the lymphatics into the lymph nodes located in the
underarm (axilla) and behind the breast bone

Pathophysiology

MEDICAL MANAGEMENT
IVF THERAPY
Date
Ordered
May 26,
2010

Name of
Solution

Type of
Solution

Indication

PLRS
500ml

Isotonic

Volume expanders with

osmolarity almost the
same as serum, thus they
stay inside the
intravascular
compartment.

DIET THERAPY
Type of Diet
NPO
(Nothing
per Orem)

DAT (Diet as
tolerated)

Others

Date
Ordered
May 25,
2010

May 26,
2010

Rationale
This diet restricts the client from intake
of foods or fluids by mouth and to serve
as a preparation for upcoming surgical
procedure.
This diet would not restrict patient in
eating foods which he needs in order to
maintain body requirements such as
carbohydrates, proteins, vitamins and
minerals including fluid and
electrolytes. This is also to support his
immune system in fighting against
opportunistic microorganisms.

Type of
contraptions
Jackson Pratt

Date Ordered

Rationale

May 25, 2010

Heplock

May 26, 2010

It is use to remove
fluids that build up in
areas of body.
Unwanted fluid can
collect in areas of
infection, areas
where surgery has
been done.
This will serve as a
route for medication
administration.

Surgical procedure:
Total Mastectomy
Date performed: May 26, 2010
Rationale: to remove the mass and entire affected part to prevent
complications
MEDICATION THERAPY
Date ordered: May 25, 2010
Generic name: ranitidine hydrochloride
Brand name: Zantac
Pharmacologic class: Histamine 2-receptor antagonist
Therapeutic class: Antiulcer drug
Dosage:
Usual dose: 150 mg IV b.i.d
Actual dose: 150 mg IV STAT
Available forms:
Capsules (liquid-filled): 150 mg, 300 mg
Solution for injection: 25 mg/ml in 2, 6, and 40 ml vials
Syrup: 15 mg/ml
Tablets: 150 mg, 300 mg
Indications
To reduce risk of duodenal ulcers
Action
Reduces gastric acid secretion and increases gastric mucus and bicarbonate
production, creating protective coating on gastric mucosa and easing
discomfort from excess gastric acid.
Side effects:
CNS: headache, dizziness
GI: abdominal pain, nausea, vomiting, constipation, flatulence, abdominal
discomfort

Skin: rash.
Adverse reactions
Hepatic: Hepatitis
Hematologic: reversible granulocytopenia, thrombocytopenia
Interactions:
Drug-drug
Antacid: May decrease ranitidine absorption.
Drug-diagnostic test:
Creatinine: slight elevation
Contraindications
Contraindicated in patients hypersensitive to drug or its components.
Nursing considerations
Assess patients vital signs
Monitor CBC and liver function test
Monitor intake and output
Instruct patient to take drug oral drug with or without food.
Caution patient to avoid hazardous activities if he gets dizzy.
Advise patient to report abdominal pain and blood in stool or emesis.
Rationale:
This drug is given in order prevent possible ulceration.
Date ordered: May 25, 2010
Generic name: albuterol sulfate
Brand name: Combivent
Pharmacologic class: Symphatomimetic (beta2-adrenergic agonist)
Therapeutic class: Bronchodilator, antiasthmatic
Dosage:
Usual dose: 2.5 mg/neb. TID
Actual dose: 1 neb. STAT
Available forms
Capsules for inhalation: 200 mcg
Solution for inhalation: 0.083%, 0.5%, 0.63 mg/ml, 1.25 mg/3 ml
Syrup: 2 mg/5 ml
Tablets: 2 mg, 4 mg
Tablets (extended-release): 4 mg, 8 mg
Indications
To prevent or treat bronchospasm in patients with reversible obstructive
airway disease
Action
Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta2
receptors.
Side effects:
CNS: nervousness, dizziness, headache, weakness

CV: tachycardia, hypertension.

GI: nausea, vomiting
Musculoskeletal: muscle cramps.
Respiratory: cough, wheezing, dyspnea, bronchitis
Adverse reactions
Respiratory: bronchospasm
Others: hypersensitivity reactions
Interactions
Drug-drug
CNS stimulants: May increase CNS stimulation. Avoid using together.
Digoxin: May decrease digoxin level. Monitor digoxin level closely.
MAO inhibitors, tricyclic antidepressants: May increase adverse CV effects.
Monitor patient closely.
Propranolol, other beta blockers: May cause mutual antagonism. Monitor
patient carefully.
Drug-diagnostic test:
Potassium: may decrease level.
Contraindications
Contraindicated in patients hypersensitive to drug or its components.
Nursing considerations
Teach patient to perform oral inhalation correctly. Clear nasal passages
and throat.
Breathe out, expelling as much air from lungs as possible.
Instruct patient to notify prescriber immediately if prescribed dosage
fails to provide usual relief, because this may indicate seriously
worsening asthma.
Hold breath for several seconds, remove mouthpiece, and exhale
slowly.
Tell patient to remove canister and wash inhaler with warm, soapy
water at least once a week.
Rationale:
Combivent is a bronchodilator that relaxes muscles in the airways and
increases air flow to the lungs. The client was given to treat or prevent
bronchospasm with reversible obstructive airway disease.

Date ordered: May 25, 2010

Generic name: cefuroxime axetil
Brand name: Ceftin

Dosage:
Usual dose:
Actual dose: 75 mg IV
Available forms
Suspension: 125 mg/5 ml, 250 mg/5 ml
Tablets: 125 mg, 250 mg, 500 mg
Indications
Skin and skin-structure infections,; Perioperative prevention
Action
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting
osmotic instability; usually bactericidal.
Side effects
CNS: headache
GI: nausea, vomiting, abdominal pain
Skin: maculopapular and erythematous rashes, urticaria, pain, induration,
sterile abscesses, temperature elevation, tissue sloughing at I.M. injection
site.
Other: hypersensitivity reactions
Adverse reactions
CNS: seizures
Hematologic: anemia, hemorrhage
Interactions
Drug-drug
Aminoglycosides: May cause synergistic activity against some organisms;
may increase nephrotoxicity. Monitor patient's renal function closely.
Loop diuretics May increase risk of adverse renal reactions. Monitor renal
function test results closely.
Drug-food
Any food: May increase absorption. Give drug with food.
Drug-diagnostic test:
ALT, AST, alkaline phosphatase, bilirubin, and LDH levels: may increase
levels
Hemoglobin, hematocrit, neutrophil, platelet: may decrease level
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.
Nursing considerations
Before administration, ask patient if he is allergic to penicillins or
cephalosporins.

 Absorption of cefuroxime axetil is enhanced by food.

Cefuroxime axetil tablets may be crushed, if absolutely necessary, for
patients who can't swallow tablets. Tablets may be dissolved in small
amounts of apple, orange, or grape juice or chocolate milk. However,
the drug has a bitter taste that is difficult to mask, even with food.
Instruct patient to notify prescriber about rash or evidence of
superinfection.
Advise patient receiving drug I.V. to report discomfort at I.V. insertion
site.
Tell patient to notify prescriber about loose stools or diarrhea.
Rationale:
This was given as prophylaxis for possible infection for upcoming
surgical procedure.

Date ordered: May 26, 2010

Generic name: ketorolac tromithamine
Brand name: Acular
Pharmacologic class: Nonsteroidal anti-inflammatory drug (NSAID)
Therapeutic class: Analgesics, antipyretic, anti-inflammatory
Dosage:
Usual dose: 30 mg IV q 6 hours
Actual dose: 30 mg IV q 6 hours
Available forms
Injection: 15 mg/ml in 1 ml preloaded syringes, 30 mg/ml in 1 and 2 ml
preloaded syringes
Tablets: 10 mg
Indications
Moderately severe pain
Action
Interferes with prostaglandin biosynthesis by inhibiting cylooxygenase
pathway of arachhidonic acid metabolism; also acts as potent inhibitor of
platelet aggregation.
Side effects:
CNS: drowsiness, dizziness, headache
GI: nausea, constipation, vomiting, epigastric pain, flatulence, stomatitis
Skin: diaphoresis, rash.

Adverse reactions
Hematologic: thrombocytopenia
Interactions
Drug-drug
Anticoagulants: prolonged prothrombin time
Corticosteroid, other NSAIDs: additive adverse GI effects
Diuretics: decreased diuretic effect
Drug-diagnostic test:
Bleeding time: prolonged for 24 to 48 hours after therapy.
Contraindications
Contraindicated in patients hypersensitive to drug, its components, aspirin,
or other NSAIDs; peptic ulcer disease; advanced renal impairment
Nursing considerations
Monitor for adverse reactions, especially prolonged bleeding time and
CNS reaction.
Monitor fluid intake and output
Advise patient to minimize GI upset by eating small, frequent serving
of healthy foods.
Instruct to avoid any hazardous activity until she knows how drug
affect concentration and alertness.
Tell patient to take drug as prescribed and not to increase dose or
dosage interval unless ordered by prescriber.
Warn patient not to stop the drug abruptly.
Rationale:
The patient was given with this drug to relive pain caused surgery.

Date ordered: May 26, 2010

Generic name: celecoxib
Brand name: Celebrex
Pharmacologic class: Nonsteroidal anti-inflammatory drug (NSAIDs
Therapeutic class: Antirheumatic
Dosage:
Usual dose:
Actual dose: 400 mg 1 cap OD
Available forms

Capsules: 100 mg, 200 mg

Indications
Rheumatoid arthritis
Action
Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2 (COX2), to produce anti-inflammatory, analgesic, and antipyretic effects.
Side effects:
CNS: dizziness, headache, insomnia.
EENT: rhinitis, sinusitis.
GI: abdominal pain, dyspepsia, flatulence, nausea.
Musculoskeletal: back pain.
Skin: rash.
Adverse reactions:
CNS: stroke
GI: GI bleeding
GU: renal failure
Hematologic: neutropenia, leukopenia, thrombocytopenia,
granulocytopenia
Interactions
Drug-drug
Aspirin: May increase risk of ulcers; low aspirin dosages can be used safely to
reduce the risk of CV events. Monitor patient for signs and symptoms of GI
bleeding.
Furosemide, thiazides: May reduce sodium excretion caused by diuretics,
leading to sodium retention. Monitor patient for swelling and increased blood
pressure.
Warfarin: May increase PT and bleeding complications. Monitor PT and INR,
and check for signs and symptoms of bleeding.
Drug-diagnostic test:
BUN, ALT, AST, and chloride: may increase levels
phosphate : may decrease level
Contraindications
Contraindicated in patients hypersensitive to drug, sulfonamides, aspirin, or
other NSAIDs; in those with severe hepatic impairment.
Nursing considerations
Alert: Patients may be allergic to drug if they are allergic to or have
had anaphylactic reactions to sulfonamides, aspirin, or other NSAIDs.
Patient with history of ulcers or GI bleeding is at higher risk for GI
bleeding while taking NSAIDs such as celecoxib. Other risk factors for
GI bleeding include treatment with corticosteroids or anticoagulants,

longer duration of NSAID treatment, smoking, alcoholism, older age,

and poor overall health.
Watch for signs and symptoms of overt and occult bleeding.
NSAIDs such as celecoxib can cause fluid retention; monitor patient
with hypertension, edema, or heart failure.
Drug may be hepatotoxic; watch for signs and symptoms of liver
toxicity.
Before starting drug therapy, rehydrate dehydrated patient.
Drug can be given without regard to meals, but food may decrease GI
upset.
Instruct patient to promptly report signs of GI bleeding such as blood in
vomit, urine, or stool; or black, tarry stools.
Advise patient to immediately report rash, unexplained weight gain, or
swelling.

Rationale: It was given to relieve pain.

Chapter V

Prioritization of Nursing Problems

1. Acute moderate intermittent pain

R/T surgical procedure (total mastectomy)
2. Sleep pattern disturbance r/t pain
3. Mild Anxiety r/t perception of condition
4. Impaired Skin Integrity r/t destruction of 1st to 3rd layers of skin
s/t post operative wound
5. Risk for Infection R/T destruction of first line defense
secondary to post total mastectomy

Assessment
S: Masakit na
parang tinutusok
ang sugat banda sa
kili-kili ko kapag
ginagalaw as
verbalized.

Statement of
Problem
Acute moderate
intermittent pain
R/T surgical
procedure (total
mastectomy)
Definition:

Pain Scale: 7/10

O:
-Slightly pale in
appearance
-grimaced face
noted
-guarding
behaviour noted
- with the incision
site @ right breast
approx. 26 cm
-With JP drain of
30cc
-Vital signs of:
BP-100/60
PR-78
RR-19
T-36.8

It is unpleasant
sensory and
emotional
experience arising
from actual or
potential tissue
damage or describe
in terms of such
damage.
Background
Theory: According
to Virginia
Henderson the
unique function of
the nurse to assist
the individual, sick
or well, in the
performance of
those activities
contributing to the

Planning

STG: at the end of

1 hour, will be able
to demonstrate
measures that will
decrease pain
sensation as
evidenced by a
decreased PS from
7/10 to at least
5/10.
LTG: at the end of
2 days, will be able
to continually
demonstrate
measures that will
lessen and manage
pain sensation.

Nursing
Intervention
Established trust
and rapport.
to gain trust and
rapport to effective
assessment and
intervention.
Accepted
description of pain.
Pain is a
subjective
experience and
cannot be felt by
others.
Encouraged
verbalization of
feelings about the
pain felt.
allows outlet of
for emotions and
may enhance
coping mechanism.
Provided comfort
measures such as
deep breathing
exercise.
These measures
reduce muscle
tension or spasm;

Outcome
medyo nawawala
na yung sakit sa
kili-kili ko,
Latest PS= 5/10;
semi fowlers in
position when last
seen.
STG: met
LTG: Partially met

health or its
recovery (or to a
peaceful death);
that he would
perform unaided if
he has the
necessary strength,
will or knowledge,
and to do this in
such a way as to
help him gain
independence as
rapidly as possible.

redistribute
pressure in the
body part and help
focus on non pain
related matters.
Encouraged to talk
with SO.
to divert
attention from pain.
Instructed
adequate rest
period.
rest may improve
pain tolerance and
reduce oxygen
consumption.
Dependent:
PRN medications
given by NOD
to relieve pain

Assessment

Nursing
Diagnosis

Planning

Interventions

Evaluation

Subjective cue:
none
Objective cues:
> with postoperative wound
on her right chest
approximately 26
cm long secondary
to surgical
removal of right
breast and lymph
nodes in axilla
> destruction of
skin integrity (1st
to 3rd layers of the
skin)
> Skin color is
slightly pinkish
around the post-op
wound area.
> use of steel
staples
>JP drainage of
approx. 30 cc level

Risk for
Infection R/T
destruction of
first line defense
secondary to
post total
mastectomy
Definition:
At increased risk
of being invaded
by pathogenic
microorganisms
Background
Knowledge:
According to
Florence
Nightingale,
Nursing is the act
of utilizing the
environment in
order to hasten
the patients
recovery.

STG:
At the end of 2
hrs nursing
intervention will
be able to,
demonstrate
assistive
measures to
prevent
infection
LTG:
At the end of 2
days nursing
intervention, will
be able to
continue to
demonstrate
measures to
prevent
infection
through the use
of assistive
measures and
show no further
inflammatory
signs.

Independent
1. Performed hygienic measures
such as bedside care
This promotes cleanliness and
lessens harboring of
microorganism from the clients
environment.
2. Demonstrated proper hand
washing technique and
instructed to perform this
frequently.
Hand washing procedure is a
first line defense to prevent
transfer of microorganism. To
prevent cross-infection.
3. Instructed client not to touch
with bare hands the postoperative site.
promotes cleanliness and
harboring of microorganisms.
4. Explained the importance of
proper changing of wound
dressing and maintained dry and
clean the affected site.
to prevent hindering of
microorganisms

STG:
SO ensured
clean bedside;
Jackson Pratt
drained by
NOD
Consumed 840
to 1, 080 of
fluids a day

5. Jackson Pratt kept intact and

advised SO to inform the NOD
when it is almost full.
to facilitate drainage and to
prevent ascending affection.
6. Instructed to increase OFI to
at least 1, 500 to 2, 5000 liters
per day as tolerated
for hydration and support
circulating volume
7. Instructed to give foods that
are rich in Vit. C oranges,
calamansi, and dalandan;
protein-rich foods such as meat,
fish, and egg white.
Vitamins C rich foods enhance
strong immune system making
the body rsistance. Protein rich
foods promote tissue and wound
healing through collagen
formation
Encouraged avoidance of
constrictive clothes
to promote circulation in the
affected part

Assessment

Subjective cue:
none
Objective cues:
> with postoperative wound
on her right chest
approximately 26
cm long secondary
to surgical removal
of right breast and
lymph nodes in
axilla
> destruction of
skin integrity (1st to
3rd layers of the
skin)
> Skin color is
slightly pinkish
around the post-op
wound area.

Nursing
Diagnosis

Planning

Impaired Skin
Integrity r/t
destruction of
1st to 3rd
layers of skin
s/t post
operative
wound

STG: at the end

of 30 minutes
nursing
intervention the
patient will be
able to verbalize
ways to maintain
skin integrity and
fast wound
healing.

Definition:
Destruction of
integumentary
system (skin
layres)

Background
Knowledge

Interventions

Post op intervention:
1. Elevate the post op site
with one pillow
R: to facilitate drainage
2. Proper wound
dressing ,change done
aseptically
R: to prevent further
complication

LTG: @ the end of

3 days nursing
interventions, will
be able to
demonstrate
ways for timely
wound healing
without any signs
of infection.

3. Encouraged early
ambulation/mobilization
R: promotes circulation
and reduces risks
associated eith immobility
4. Instructed patient to
increase intake of fluids

Evaluation

Amenable to
interventions
done AEB lagi
na akong
magpapabili ng
orange;
> seen eating
orange fruits.

> use of steel

staples
>JP inserted @
right in axilla part
drain approx. 30 cc
level

Lydia Hall,
Nursing centre
around three
components of
CARE, CORE,
and CURE. Care
represents
nurturance and
exclusive to
nursing. Core
involves
therapeutic use
self and
emphasizes the
use of
reflection. Cure
focuses on
nursing related
to the
physicians
orders.

R: increase fluid to prevent

dehydration in and aid in
circulating blood volume
5. Encouraged to eat foods
rich in vitamin C such as
fruits such as orange and
calamansi
R: to increase and boost
immune system and for
fast wound healing
6. advised to have high
protein diet intake
R: for timely wound
healing and tissue repair
7. kept dressing clean and
dry
R: to prevent further
complication like infection
8. maintained Jackson
pratt on the site of
operative wound
R: to facilitate drainage

Assessment
Assessment
Subjective:

Nursing
Diagnosis
Nursing
Sleep
Diagnosis
pattern
disturbance
r/t pain

Planning

Planning
STG:
at the end
of 2hrs. nursing
Nahihirapan akong
intervention the
matulog sumasakit
patient will be
pa
Subjective
kasi tongcue:
sugat
able to
ko tapos minsan
Mild Anxiety
STG:
verbalized
at the end
Nung nalaman
nasasagi
pa ng
r/t perception ofunderstanding
8 hours
ko na ko
braso
cancer
kaya ang of Definition:
condition
nursing
of sleep
sakit ko hindi
nagigising
ako.na
interventions
disturbance
ko
mapalagay.
A disruption in will be able:
Natatakot
Objective:
ako
the
dahil pag cancer Definition:
individuals
1. Verbalize
hindi
mo alam
usual diurnal feelings
LTG: at about
the end
Received
kung mabubuhay
Vague
pattern
uneasy
of
her
of 2
condition
days
awake on
ka
pa
sleepofand
nursing
bed innang
sittingfeeling
normalposition; at discomfort
wakefulness
or
2.intervention
Identify
the
matagal,
that may be
support
patientsystem
will be
Post-op as dread
verbalized.
accompanied
temporary
or
by
effectively
able
to
wound on
chronic
achieved
right breast autonomic
response
(the
optimal amount
approximatel
source often
of sleep as
y 26 cm;
Objective
cues:
nonspecific
or
LTG:
evidenced
at the end
by
Restlessness
unknown to the ofrested
2 days
noted
dry
mouth
individual)
nursing
appearance
With frequent
interventions,
and
noted blinking of
will
improvement
be able to: in
irritability
eyes noted;
sleep pattern
observed
(+) dark
Background
1.
Appear
poor
eye
circles underKnowledge:
relaxed and
contact
eyes ;
report of feeling
teary
eyes
With frequent
anxiety
noted
yawning
frequent
Bp of 100/60
2. Demonstrate
questioning
hmmg
healthy ways to
staring
with
deal with and
blank mood and
express anxiety
affect
with
BP
ranging
from
80/60mmhg to
100/60mmhg

Nursing Interventions
Intervention
V/S
taken and recorded
R:for baseline data

Evaluation

Evaluation
STG:
The client
identify
individual
appropriate
Placed in comfortable
intervention to
semi-fowlers position
1. Established
therapeutic
Display
(+)sleep
and bed side care done promote
relationship
response
such as on the
R:to promote comfort
interventions
drinking 1
R: to facilitate
trust
made
glassAEB
of milk;
Instructed
toand
drink a
rapportglass of warm milk
salamat
BP of
pala sa
impormasyon
100/60hmmgna
before sleeping
2. V/S
taken
and
recorded
binahagi
nyo sa
R:milk contain tryptophan
akin,
LTG: The client
that helps to promote
R: tosleep
assess any changes in
reported
vital signs
>improvement
passive and
active
of
sleep
ROM
& rest
Discussed effective
3. Accepted client as is
exercise
pattern seen
appropriate bed time
doing and while
rituals such as reading
R: to promote belongingness on assessing
and listening to music
R: to enhance clients
4. Active listening and talking > participated in
ability to fall asleep
performing DBE
R: to establish therapeutic
Performed Sponge
relationship
> asleep when
bathing and oral care
last seen
and changed into light
5. Encouraged to
clothing
acknowledge and express
and verbalization of feelings
R: to facilitate fresh feeling
about her condition
and promote comfort and
relaxation
R: to further assess feeling of
anxious
Provided room air
ventilation
6. Provided accurate
information about the
R: to promote comfort
condition
Straighten
linens and
R: to aid
in self-awareness
puff pillows
7. Performed DBE
R: to provide comfort and
prevent body irritants

Assessment
S: Ano pa ba ang
pwedeng
makatulong sa akin
paglabas ko rito?
as verbalized.
O: Frequent
questioning
regarding
treatment
modalities.

Statement of
problem
Readiness for
enhanced
Therapeutic
Regimen
Management R/T
(to be developed)
Definition: A
pattern of
regulating and
integrating into
daily living a
program for
treatment of illness
and its sequelae
that is sufficient for
meeting healthrelated goals and
can be
strengthened.
Background
Theory:
Imogene Kings
Nursing as a
helping profession
that assist
individual and
groups to attain,
maintain and

Planning
STG: At the end of
1 hour will be able
to verbalized
understanding
about treatment
regimen.
LTG: At the end of
3 days will be able
to demonstrate
activities that will
aid in health
promotion.

Nursing
Intervention
See separate page
for intervention.

Expected
Outcome
To demonstrate
activities that could
promote health.

restore health.

DISCHARGE PLAN

INTERVENTIONS

Nursing Intervention
Medication:
Continue taking prescribed home
medication if any.

Rationale
To ensure that the patient will achieve the
desired effect of the medications.

Exercise
Encourage performing moderate
exercise such as walking and limited
ROM like flexion, extension &
hyperextension of arms, feet, wrist,
neck.
Perform breathing exercise.
Treatment
Change wound dressing regularly
Health Teaching
Encourage to perform self-care activities
daily such as bathing.
Practice proper Hand washing.

To promote good circulation and

relaxation; Promotes rapid recovery.
To promote oxygen supply thereby relaxes
muscle and relieves anxiety.

OPD
Advised to have follow-up check after
discharge
Diet
Eat foods rich in vitamin C such as citrus
fruits, proteins such as eggs and meat
products
Instruct the patient to follow special diet
as ordered.
Spiritual
Encouraged to pray and always seek
Gods help, always have faith that
everything has a purpose and it happens
according to Gods will

To prevent the growth of microorganisms

and possible complications.
To promote a sense of well being
bathing promotes good circulation of in the
body
To prevent transfer of microorganisms and
spread of infection.
To further evaluate clients health status
after discharge and to monitor progress.
To provide positive nitrogen balance to aid
in healing process and boosts resistance
against infection
To regain strength
To maintain appropriate sugar level
To strengthen faith that will help in healing
process.

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