2010

BREAST CANCER
Group 3

Abbas, Sittie Omaimah

Avila, Paul

Gadugdug, Rizalyn

Gentallan, Sheena Claire

Herrera, Cynthia

Mangombaya, Jelanie

Masbod, Ratanah

Mulok, Anna Farinah

Pacot, Leonard Mitchel

Pendang, Ma. Lorelyn

Reyes, Marie Hazel

paul-gwapo
[Type the company name]
1/1/2010
Saripada, Nor-jhalea

Table of Contents
I. Case Presentation Objectives 3
II. Introduction 4
III. Definition of Terms 9
IV. Vital Information 11
V. Assessment
a. Nursing History 12
b. Genogram 14
c Gordon’s Assessment of Functional Health Patterns 15
d.. Physical Assessment and Review of System 18
e. Diagnostic Test 21
VI. Normal Anatomy & Physiology 21
VII. Risk Factors and Pathophysiology (CONCEPT MAP) 30

VIII. Nursing Management

a. Nursing Care Plans 31

b. Health Education Plan 45

c. Discharge Plan 48
IV. Medical Management/Surgical Management 53-69

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 X. Prognosis 70
XI. Bibliography 72

Objectives:
This Case Sharing is fuelled by these objectives:

To the Students/ Classmates:

Within 1hour and 30 minutes of Case Presentation, students will be able to:

 Learn the underlying causes of the Breast cancer.

 Trace the pathophysiology of Breast cancer.
 Know the manifestations of patient having breast cancer.
 Identify at least 2 nursing diagnosis out from the assessment data gathered.
 Enumerate nursing interventions appropriate for the diagnosis.

To the Reporters/Presenters:

Within 1 hour to 1hour and 30 minutes of Case Presentation, reporters will be able to:

 Execute an organize introduction of the case.

 Systematically present the data pertinent to the case being gathered.
 Convey significant concepts and skills as far as nursing profession is conserved.
 Manifest confidence, coherence, logic and effective audience management.
 Emphasize nursing managements necessitated by the diseases presented

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 Introduction
In most people's minds there is no scarier diagnosis than that of cancer. Cancer is often thought of as an untreatable, unbearably
painful disease with no cure, but may be this point of view about cancer is exaggerated and over-generalized. Cancer is undoubtedly a serious
and potentially life-threatening illness and being diagnosed with cancer may leave a patient the feeling of helplessness, but there are some
who fight against it and succeeded.

Cancer is a disease that begins in the cells of the body. In normal situations, the cells grow and divide as the body needs them- no
more, no less. This orderly process is disturbed when new cells form that the body don’t need and old cells don't die when they should. These
extra cells lump together to form a growth or tumor.

Cancer has many forms and each specific type of cancer is different and consequently has a different set of associated risk factors and
has a unique set of symptoms associated with it. We will introduce to you some of the types of cancer classified by body system:

• Blood Cancer: The cells in the bone marrow that give rise to red blood cells, white blood cells, and platelets can sometimes become
cancerous. These cancers are leukemia or lymphoma.
• Bone Cancer: Bone cancer is a relatively rare type of cancer that can affect both children and adults, but primarily affects children and
teens.
• Brain Cancer: Brain tumors can be malignant (cancerous) or benign (non-cancerous). They affect both children and adults. Malignant
brain tumors don't often spread beyond the brain. However, other types of cancer have the ability to spread to the brain.
• Digestive/Gastrointestinal Cancers : This is a broad category of cancer that affects everything from the esophagus to the anus. Each
type is specific and has its own symptoms, causes, and treatments.
• Endocrine Cancers: The endocrine system is an instrumental part of the body that is responsible for glandular and hormonal activity.
Thyroid cancer is the most common of the endocrine cancer types and generally, the least fatal.
• Eye Cancer: Like other organs in the human body, the eyes are vulnerable to cancer as well. Eye cancer can affect both children and
adults.
• Genitourinary Cancers: These types of cancer affect the male genitalia and urinary tract.
• Gynecologic Cancers: This group of cancer types affect the organs of the female reproductive system. Specialized oncologists called
gynecologic oncologists are recommended for treating gynecologic cancer.

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 • Head and Neck Cancer: Most head and neck cancers affect moist mucosal surfaces of the head and neck, like the mouth, throat, and
nose. Causes of head and neck cancer vary, but cigarette smoking plays a role. Current research suggests a strong HPV link in the
development of some head and neck cancer.
• Respiratory Cancers: Cigarette smoking is the primary cause for cancer affecting the respiratory system. Exposure to asbestos is also a
factor.
• Skin Cancers: Non-melanoma skin cancer is the most common type of cancer among men and women. Exposure to the UV rays of the
sun is the primary cause for non-melanoma skin cancer and also melanoma.
• Breast Cancer: Breast cancer is a common type of cancer that affects women and much less commonly, men.

In this case presentation we will focus more on the breast cancer. So what is really breast cancer? What are the important things we should
know about it?

Breast cancer can be defined as a cancerous growth that inhabits the tissues in the breast. In this type of cancer, the cells in the breast
region grow abnormally and in an uncontrolled way. Though breast cancer is mostly found in women, in rare cases it is also found in men.

Types of breast cancer:

INVASIVE CARCINOMA NON-INVASIVE CARCINOMA
• Invasive ductal carcinoma is found in 70% of breast • Ductal carcinoma starts in the tubes (ducts) that
cancers. It is palpated as a stony-hard lump. move milk from the breast to the nipple. Most
Frequently, there is metastasis to axillary lymph breast cancers are of this type.
nodes. • Lobular carcinoma starts in parts of the breast,
• Invasive lobular carcinoma is found in 5- 10% of called lobules that produce milk.
breast cancers. It usually presents as an area of ill-
defined thickening rather than a lump. Multicentricity
or involvement of the opposite breast may be found.
Frequently, there is metastasis to axillary lymph
nodes.
• Medullary carcinoma is found in 5- 7% of breast
cancers. Frequently, it reaches large size. However,
the prognosis is better than for many types of breast
cancers.
• Tubular carcinoma frequently occurs with other types
of breast cancers. Axillary metastasis are uncommon.
Prognosis is better than for infiltrating ductal
carcinoma.

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 • Mucinous (colloid) carcinoma is found in 3% of breast
cancers, frequently occurs with other types of breast
cancer. It is slow growing and can become quite
large.
• Inflammatory carcinoma is a rare type of breast
cancer with symptoms different from those of other
breast cancers. The localized tumor is tender and
painful, and the skin over is red and dusky. The
breast is abnormally firm and enlarged. Often, edema
and nipple retraction occur.

• Paget’s disease is a scaly lesion and burning and

itching around the nipple areola complex are frequent
symptoms. The neoplasm is ductal and may be in situ
alone or may have invasive cancer cells.

Differentiation of benign and malignant breast cancer:

Malignant breast masses: Benign breast masses:
o Consistency: hard o Consistency: firm or rubbery
o Painless (90%) o Often painful (consistent with benign breast conditions)
o Irregular margins o Regular or smooth margins
o Fixation to skin or chest wall o Mobile and not fixed
o Nipple retraction may be present o Skin dimpling unlikely
o Discharge: bloody, unilateral o No nipple retraction
o Skin dimpling may occur o Discharge: no blood and bilateral discharge. Green or
yellow colour.

Breast cancers can be classified by different schemata. Every aspect influences treatment response and prognosis. Description of a
breast cancer would optimally include multiple classification aspects, as well as other findings, such as signs found on physical exam.
Classification aspects include stage (TNM) and grading.

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TNM GRADING:
Primary tumor (T):
 TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ; intraductal carcinoma, lobular
carcinoma in situ, or
 T1: Tumor 2.0 cm or less in greatest dimension
 T1mic: Microinvasion 0.1 cm or less in greatest dimension
 T1a: Tumor more than 0.1 but not more than 0.5 cm in greatest dimension
 T1b: Tumor more than 0.5 cm but not more than 1.0 cm in greatest dimension
 T1c: Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension
 T2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension
 T3: Tumor more than 5.0 cm in greatest dimension
 T4: Tumor of any size with direct extension to (a) chest wall or (b) skin
 T4a: Extension to chest wall
 T4b: Edema or ulceration of the skin of the breast or satellite skin nodules confined to the same breast
 T4c: Both of the above (T4a and T4b)
 T4d: Inflammatory carcinoma*

Regional lymph nodes (N):

 NX: Regional lymph nodes cannot be assessed (e.g., previously removed)
 N0: No regional lymph node metastasis
 N1: Metastasis to movable ipsilateral axillary lymph node(s)
 N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
 N3: Metastasis to ipsilateral internal mammary lymph node(s)

Pathologic classification (pN):

 pNX: Regional lymph nodes cannot be assessed (not removed for pathologic study or previously removed)
 pN0: No regional lymph node metastasis
 pN1: Metastasis to movable ipsilateral axillary lymph node(s)
 pN1a: Only micrometastasis (none larger than 0.2 cm)

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  pN1b: Metastasis to lymph node(s), any larger than 0.2 cm
 pN1bi: Metastasis in 1 to 3 lymph nodes, any more than 0.2 cm and all less than 2.0 cm in greatest dimension.
 pN1bii: Metastasis to 4 or more lymph nodes, any more than 0.2 cm and all less than 2.0 cm in greatest dimension
 pN1biii: Extension of tumor beyond the capsule of a lymph node metastasis less than 2.0 cm in greatest dimension
 pN1biv: Metastasis to a lymph node 2.0 cm or more in greatest dimension
 pN2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
 pN3: Metastasis to ipsilateral internal mammary lymph node(s)

Distant metastasis (M):

 MX: Presence of distant metastasis cannot be assessed
 M0: No distant metastasis
 M1: Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes)

STAGING:
STAGE EVENT
Stage 0 Tis, N0, M0
Stage I T1,* N0, M0
*T1 includes T1mic
Stage IIA T0, N1, M0 T1,* N1,** M0 T2, N0, M0
*T1 includes T1mic **The prognosis of patients with pN1a disease is similar to that of
patients with pN0 disease.
Stage IIB T2, N1, M0 , T3, N0, M0

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 Stage IIIA T0, N2, M0 T1,* N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0
*T1 includes T1mic
Stage IIIB T4, Any N, M0 , Any T, N3, M0
Stage IV Any T, Any N, M1

INCEDENCE RATE:

Breast cancer is now the leading cancer site overtaking lung cancer for both sexes in the Philippines (i.e. 15% of all cancers). It is also
the number one cause of cancer morbidity and mortality among Filipino women accounting for almost 30% of all female malignancies.

It is estimated that there will be a total of 12, 262 new breast cancer cases in 2010 with 4,371 deaths. Latest data reveals that three out
of every 100 Filipinas are likely to develop breast cancer in their lifetime and that one out of every 100 are likely to die from the disease
before age 75 (Philippine Cancer Facts and Estimates 2010).

In Asia, the Philippines is among the countries with the highest age standardized incidence rate for breast cancer. Survival rate for
breast cancer in the Philippines is below 40% compared to the high survival rates of 80-98% already achieved in developed countries.

The presenters did not expect that out of the incidence rates mentioned above they would encounter one who have developed this type
of disease.

Definition of Terms
®Cancer - a class of diseases characterized by out-of-control cell growth.

®Breast Cancer - 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

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®HAMA – Home Against Medical Advise

®Cobalt 60 unit - a beta emitting radioactive isotope of cobalt-59 with a half-life of 5.27 years decaying to nickel-59, a stable isotope

®Linear Accelerator - is the device most commonly used for external beam radiation treatments for patients with cancer

®Metastasis - the process by which cancer spreads from the place at which it first arose as a primary tumor to distant locations in the body

®Carcinoma - is a medical term that refers to an invasive malignant tumor consisting of transformed epithelial cells

®Radical Mastectomy - a surgical procedure in which the breast, underlying chest muscle (including pectoralis major and pectoralis minor),
and lymph nodes of the axilla are removed as a treatment for breast cancer

®DNA (Deoxyribonucleic Acid) - a nucleic acid that contains the genetic instructions used in the development and functioning of all known
living organisms, with the exception of some viruses

®Proliferation - rapid growth or reproduction of new parts, cells, etc

®Tumor - name for a neoplasm or a solid lesion formed by an abnormal growth of cells (termed neoplastic) which looks like a swelling.[1]
Tumor is not synonymous with cancer

®Lymphatic System - made up of a network of conduits that carry a clear fluid called lymph

®Bilateral Pleural Effusion - buildup of fluids in both the right and the left lungs, as in the development of pleural mesothelioma

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®Exudate - any fluid that filters from the circulatory system into lesions or areas of inflammation. It can apply to plants as well as animals. Its
composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood

®Biopsy - medical removal of tissue from a living subject to determine the presence or extent of a disease

®Lymphadenopathy - a swelling, or enlargement, of the lymph nodes

®Peau ‘d Orange - a swollen pitted skin surface overlying carcinoma of the breast in which there is both stromal infiltration and lymphatic
obstruction with edema

®Chemotherapy - treatment of an ailment by chemicals especially by killing micro-organisms or cancerous cells

®Lymphedema - also known as lymphatic obstruction, is a condition of localized fluid retention and tissue swelling caused by a
compromised lymphatic system

®Carcinogen - a substance that is capable of causing cancer in humans or animals

Vital Information
Name: Mrs. Jeorge dry graping wound from sternum to mandibular area, with
slight

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Room Number: AB209 body weakness, conversant and responsive.
Age: 52 yrs. old
Gender: Female Day 2
Civil status: Married Sleeping, lying on bed in semi-fowler’s position, w/o
IVF, still with
Date of birth: May 24, 1958 02 attached increased into 5LPM, with edema all
over the body, with
Birthplace: Iligan City difficulty of swallowing, with whole body weakness,
with dry wound
Cultural Group: Iliganon on her neck, slightly conversant and responsive.
Primary Language: Bisaya, Tagalog
Religion: Catholic Day 3
Highest Educational Attainment: College Graduate awake, lying on bed in semi-fowler’s position, with
IVF of D5w
Occupation: Retired Accountant hooked @ L arm run for 60 gtts/min, 02 decreases @
2LPM, still
Usual Health Care Provider: UST hospital, MSH on edema, with seepage noted and bruise reported
@ L knee,
Reason for health contact: cough and body malaise cyanosis on the sole of her feet noted, still dry
graping wound on
Date of confinement: December 5, 2010 her neck with presence of blood, generalized body
weakness, non-
Source of history: 50% patient & SO, 50% patient's chart conversant.
Attending Physician: Dr. Richito Sarmiento

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Impression/Final Diagnosis: Breast Cancer stage 4
Description of Patient:
Day 1
Sitting on bed , right knee extended on chair, with patent IVF of D5W @ 60 gtts/min
@ L arm, attached 02 @ 4 LPM via nasal cannula, with edema all over the body with
Nursing History

A. Chief Complaints

Patient came in due to productive cough, body weakness and difficulty of breathing.

B. History of Present Illness

Year 1998 PTA, Mrs. Jeorge first noticed a lump in her left breast during her breast-self examination (BSE) but she can not remember
how big or small the lump is. Then she asked her husband to feel it, but uncertain to what it really is, they just ignored it. Eventually, she felt
pain on her left breast as the time goes by. We tried to ask the PQRST of the pain during that time, but unfortunately she can not recall.

After 4 yrs, Mrs. Jeorge went for a check-up at University of Santo Tomas Hospital because she was already in doubt that something is
wrong with her but can not figure what it is. It was discovered in her checkup that a cyst is present in her left breast. She was advised to go
through a surgery to remove the mass on her left breast which she agreed upon. However, weeks after the removal of the mass she went
back to the hospital for follow-up check-up. Mrs. Jeorge was advised to undergo biopsy by Dr. Ulalia in which they found out that she had
Stage 2 Breast Cancer. Then again, she had to undergo surgery but this time it is already mastectomy or the removal of her left breast to
prevent metastasis or further development of the carcinoma. Dr. Ulalia did not prescribe her any maintenance medication after the
mastectomy. Months later, she had her chemotherapy for one month at the same hospital. She experienced loss of hair (alopecia) as a side
effect of the treatment.

Several months later on the same year, she went to St. Luke’s to have her right breast evaluated to see if it has been affected. Hence,
she had her second biopsy at the same hospital. Unfortunately, it was found out that her cancer had already metastasized on her right breast.
Under the supervision of her attending physician, Dr. Ulalia, she was suggested to go through a different kind of radiation therapy called linear
accelerator and cobalt 60 unit. It is a procedure wherein a laser with high levels of radiation will be shot to the targeted area, in this case, on
the patient’s right breast. After the therapy, she had an open conversation with her attending physician. It was discussed that she had only 5
years left to live, thus, her physician gave her freedom to do whatever she wants knowing that she had already an idea regarding her term in

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life. With regards to that, her physician did not prescribe any maintenance medication after the surgery and did not restrict her with any food.
After that she did seek any medical advised.

According to Mrs. Jeorge S/O, from the time after her surgery up to March 2010 she was hyperactive. In the later part of the month of
April 2010, her edema began to occur first on her right leg. Early July 2010 they went to Timoga together with her relatives to have swimming,
days after the said event the edema progress to her right arm and breast. Then as the time goes by it further affected the right side of her
face.

Month of September they noticed the redness in her neck up to her chest but they ignored it because they thought it was just a simple
rash because it was not itchy. Then weeks later it began to bulge “Murag kanang burot nga nalabtikan ug mantika” as verbalized by the S/O.
Mrs. Jeorge’s sister-in-law advice her to try some herbal treatment in which they will use coconut vinegar (tuba) together with alovera to treat
her neck and chest’s condition but unfortunate it did work out as expected. But even though it did work so well, she continued the routine of
the said herbal treatment. But the bulge already burst and it became a lesion/open wound. Several days later she experience tightening of her
neck resulting to her difficulty in swallowing. Because she already had this open wound, we (presenters) perceived that the open wound was
infected resulting further spread of the size and exudates production. Mrs. Jeorge began to experience pain on her open wound with a pains
scale of 8 out of 10 as claimed. When the pain was already severe, in which she can not take it anymore, she prompted to seek medical
intervention for pain management in Mindanao Sanitarium and Hospital on November 30, 2010 at 9:08 am under the supervision of Dr.
Delorino.

During her admission in MSH, Dr. Delorino prescribed the following medication to manage her pain: Tramadol 50mg IV every 8 hrs;
Cefuroxime (kefox) 750mg IVTT every 8 hrs and TDL 50mg IVTT every 8 hrs. During her hospital stay she already had generalized edema and
productive cough (cough occurred 2 months PTA). On her 3rd December 3, 2010 hospital day her pain was already managed but edema and
productive is still present, due to financial problem Mrs. Jeorge decided to HAMA (home against medical advice) at 4 pm. She was prescribed
by Dr. Delorino of her home medication; TDL 50mg i capsule every 6 hours and Dolan 500g/ml 5ml every 6 hours both for fever; Loviscol syrup
50ml TID 8-1-6 for cough; Bactroban cream- apply to neck lesion 2 times a day 8-6 and Ensure milk 1 glass a day 8am.

She was apparently well, until early morning PTA for the 2 nd time on December 5, 2010 when Mrs. Jeorge complained of body
weakness and cough which prompted admission at 3:49 am under Dr. Sarmiento.

C. History of Past Illness

Mrs. Jeorge had no known allergies to any foods, medications, substances or environmental factors. Due to progressing age she can no
longer remember what diseases/illness attack her during her childhood days as well as if her mother ever brought her to the barangay health
center for immunization. She did not undergo any surgery and hospitalization that she knows of aside from what is stated in her present
health history. She also doesn’t have any diseases/chronic illness such as HPN, DM aside from breast cancer. She did not experience any
injury or accident but recently, during our (presenters) 3 rd week of duty as what her x-ray revealed she had a fractured 2 nd rib in the right side

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and according to Dr. Sarmiento it was because of the lymphatic spread/metastasize of the cancer cells and the wound that she have at
present is also due to the lymphatic spread secondary to breast cancer. She did not seek any consultation that is not related to her present
condition. She doesn’t have any obstetric records because she had never been pregnant in her whole life ever because her husband is unable
to produce enough sperm for reproduction. She did not have any maintenance medication or vitamins, pills taken aside from those that were
prescribed to her by Dr. Delorino & Dr. Sarmiento.

Genogram
PATERNAL
MATERNAL

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 52 yrs old

Legend:

-male -hypertension

-female -cancer (Breast: stage 4 and Ovary)

-patient -deceased - heart attack

Gordon’s Assessment of Functional Health Patterns

Health Perception/ Health Management Pattern

Hospitalized Client
Presently, the patient is admitted to Mindanao Sanitarium and Hospital because of complains of body weakness, productive cough, and
difficulty of breathing. The client fully understands the purpose of the treatment but she perceives her health to be unstable. She elaborated
this word by saying that she can die because of her condition any moment now.
Year 2002, she was admitted to University of Santo Thomas for the surgery of her left breast. And months later, she went to the same
hospital for advice to take chemotherapy. And several months later at the same year, she went to Saint Luke’s for radiotherapy called Linear
Accelerator and Cobalt 60 unit for the control and prevention of the spread of cancer cells to the body.
And on November 30, 2010, she was admitted in Mindanao Sanitarium and Hospital because of pain on lesion of neck under the
supervision of Doctor Sarmiento.

Nutrition/Metabolic Pattern
Previously, before she was diagnosed with Breast Cancer, the client’s diet was mainly of rice, vegetables, and meats like beef, pork,
chicken and fish. Has a good appetite and had no problems or discomfort in eating and swallowing. She doesn’t drink alcoholic beverages, but
seldom drinks soft drinks.

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 When she was diagnosed with Breast Cancer, when she had a discussion on her physician, she was not restricted to any foods that she
wants to eat. She stated that she loves to eat fried peanuts and mayonnaise. She eats peanuts a lot every time she sales them. She stated
that when people buy peanuts the ratio of she eats is 1:3.
Recently, during her hospitalization the client is on Diet as Tolerated. She claimed that she has a good appetite but have difficulty in
swallowing and cannot tolerate the food that was served to her because of Lymphedema. As a substitute for her regular diet, she takes liquid
diet such as Ensure milk and corn soup.

Elimination Pattern
Bowel:
Before, the client normally defecates two times a day without experiencing discomforts, usually morning and afternoon.
When she was hospitalized, she defecates once in small amount and brownish in color before our duty as claimed by the client. During
our shift, she did not defecate at all.
Bladder:
Before, client normally voids 6-8 times a day without experiencing any pain and discomforts. Urine is yellowish in color.
When she was hospitalized, client voids in her diaper for 3-4 times a day without pain and discomfort.

Exercise and Activity Pattern

In the morning, clients activities of daily living include preparing foods to be serve in the cafeteria. In the afternoon after lunch she likes
to watch television program as her leisure activity and listening to radio music. She is considered obese and no regular exercise.
Client’s daily activities in the hospital are deep breathing exercise, sits in the bed with assistance. The clients stated that she
experience difficulty in eating, pain in right arm and left leg due to lympedema.

Sleep/Rest Pattern
Before the admission, client wakes up 6 in the morning and sleeps 10 in the evening. Client takes her nap about 15-20minutes in the
afternoon. In the evening, she puts herself to sleep by watching primetime television program. She feels rested when sleeping and she thinks
that her energy is enough for her activities. She has no complaints of nightmares or insomnia during sleep.
When she was admitted, client complained difficultly in sleeping and sleeps for short period of time (3-4 hours) due to pain and difficulty
of breathing. She doesn’t feel rested and comfortable.

Cognitive/Perceptual Pattern
The client has good eye sight and has no problems in seeing. She does not wear glasses or contact lenses. She has no other problems
that concern her sensory perception.

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 When she was admitted, client complains of having trouble seeing in her right eye because of edema present in her face.

Self-Perception Pattern
Client is a friendly person; she loves to socialize with her friends and neighborhood. She considered herself as a holistic human being as
long as she’s complete, healthy, and her husband is always there for her. She wants to have a good health and live her life to the fullest.
When she was hospitalized, she doesn’t consider herself as a holistic person. She thinks she can’t function well than before due to her
present condition.

Role-Relationship Pattern
Patient can speak and understand English, tagalong, and visayan language. She can clearly express herself. She had no children but
she as an adopted niece. The patient is very active and usually socialized with her neighbors.
When she was admitted, she is very dependent on his husband. Her husband and siblings supports her medical treatment.

Sexuality-Reproductive Pattern
Before, they try to engage sexual activity. But for some reasons, they were not given children because of the fact that Mrs. Jeorge’s
husband can not reproduce or lack of sperm for reproduction.
Now, the patient do not perform sexual activity due to progressing age.

Coping Stress Management Pattern

Before, when she gets angry she prefers to just eat. When it comes to problems, she let herself think for awhile to find solutions.
When client was diagnosed with breast cancer in 2002, it causes a great change to her life. But despite of her diagnosis, she continued
her life as it is and have a positive outlook on her condition. She remains very active and sociable.
The recent hospitalization on November 29, 2010 was a traumatic experience for the client because there have been many changes
occurred that made it difficult for her to adjust.

Values and Belief Pattern

Patient is a Roman Catholic. According to the client, she goes to the mass every Sunday and listens for the words of wisdom of the
priest. She also stated that asking guidance to God through prayer can help her in her problems.
When she was diagnosis with breast cancer, she tightly strengthens her belief to God and continues to go to church despite on her
condition.

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 When she was admitted recently on November 29, 2010, she seldom goes to church but requested to be prayed by the chaplain of the
hospital.

Assessment: PEROS
Day 1 Day 2 DAY 3 PROBLEM
IDENTIFIED
Objective Subjective Objective Subjective Objective Subjective

General • Body weakness • Anxiety • Snarl smile “nihuyos na • Generalized • Pain on her • Risk injury
Appearance • Difficulty • P- • Reduced gamay akong body weakness right foot • Improper
sustaining a sitting edema at left hupong” as • Productive • uncomfortab hygiene
posture arm verbalized by cough le • Acute pain
• No alterations of • With IVF the patient. • Irritable
level of hooked at left • Non-
consciousness arm conversant
• Edema all over the • O2 sat

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 body with a grade increased to 5
4 LPM
• Dry, gaping wound
from sternum to
the submandibular
area
• Productive Cough:
whitish
• Without IVF
• O2 inhalation at 4
LPM
Head/Hair/Fac • Edema at t he right • “burot daan • Snarl smile • “Sakit-sakit • No head ache • “wala na • Body image
e face akong nawong” • Slight head ako ulo” as sakit” as disturbed
• Facial assymmetry as verbalizes ache verbalized verbalized • Acute pain
by the by the
by the patient.
patient. patient.
Eyes/Ears/Nos • Right eye is • Right eye is • No changes • No verbal • No changes • No verbal • risk for injury
e and Sinuses affected by edema unable to see cues cues
• No discharge noted clearly
• no symptoms on • Hearing is
ears good, no ear
• with O2 inhalation aches and loss
attached of hearing
Mouth and • drooling • Has difficulty in • Secretions • “maglisod • No changes • No changes • difficulty of
Pharynx • dysphagia swallowing and noted with jud ko ug swallowing
chewing brownish tulon” as • impaired
sputum verbalized communicati
• Difficulty in by the on
speaking patient. • risk for
aspiration
Neck • Dry, gaping wound • Itchiness • Dry and • “katol man • Dry and • “Kot-kot • Impaired
from sternum to around the gaping wound gud” gaping wound man gud skin
the submandibular wounded neck patient with presence niya” as integrity
area verbalized. of blood verbalized

20 | P a g e
 • Redness by the S.O

Respiratory • RR = within normal • No pain during • Difficulty of • “Maglisod • No changes • No verbal • Ineffective
range of 18-20 respiration breathing ko ug cues breathing
bpm ginhawa
kung mag
sige kog
storya”
patient
verbalized
Back • No deformities • “wala ra man • No changes • No verbal • No changes • No verbal
koy laing cues cues
gibati” as
verbalized by
the patient.
Breast and • With masses or • Sometimes • Flattened of • “ning gahi • No changes • No verbal • Impaired
Axilla tenderness complains pain & the right na sya cues skin
• The cancer has tenderness breast tanan” integrity
spread to other • Dark in color patient • Risk for
parts of the body verbalized. infection
(metastasize) • Acute pain

Cardiovascula • (-) murmur • No chest pain • No changes • No verbal • Increased • No verbal • Decreased
r/ Peripheral • BP = within normal • No heart cues Blood Pressure cues cardiac
range of 120/90- murmurs = BP 140/90 output
130/90 mmHg reported
• Good peripheral
pulses
• PR = within normal
range of 79-93
bpm
• No palpitation upon
auscultation
Lymphatic • With • (+) • No changes • No verbal • No changes • No verbal • Acute pain

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 lymphadenopathie lymphadenopat cues cues
s hy
GIT • Decreased bowel • “dili ko kalibang” • (-) vomiting • (-) nausea • No changes • No verbal • Decreased
movement as verbalized by cues G.I motility
the patient.

GUT/Reprodu • Oliguric 300ml/24 • Urinated • No changes • No verbal • No changes • No verbal • Altered

ctive hours once in a day cues cues urinary
• (-) dysuria elimination
• (-) anuria pattern
• (-) hematuria

Musculoskelet • Fatigue • No muscle and • Restlessness • “wala jud • No changes • No verbal • Risk for
al • Generalized body joint pains • Was unable to sya cues injury
weakness reported sleep makatulog” • Acute pain
• Fractured at as • Altered
second right rib verbalized sleeping
by the S.O pattern

Integumentar • Presence of edema • Itchiness of • Sole of feet • “kana man • With bruise • “natumba • Impaired
y • Peau d’orange skin wounded neck cyanotic tong dati noted on left man gud na skin
edema at right arm and chest area • With seepage na nga knee sya pag ihi integrity
• Skin cold to touch noted fluid” nya” as • Poor skin
patient verbalized turgor
verbalized. by the S.O
Neurologic • Oriented to person • “usahay • No changes • No verbal • No changes • • Acute
and place and time magsakit akong cues pain
• Able to perceive hupong” as
pain verbalized by
the patient.

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 Diagnostic Test
Diagnostic Test Date Result Normal Interpretation Significance Nursing consideration
Values
RBC 12/6/10 7.56 4.6x10 12/L Increase - A high RBC count may - Explain to the pt that the RBC count
indicate absolute or relative evaluates the number of blood cells and
polycethemia. detects possible blood disorders
- Explain to the pt that he may feel
slight discomfort from the needs
procedure and the tourniquet.
- ensure that subdermal bleeding has
stopped before removing pressure

Hematocrit 12/6/10 0. 0.37- Increas - High HCT indicates -Explain to the pt that the HCT test
50 0.47 e polycythemia or hemo detects anemia and other abnormal
concentration caused by blood condition.
blood loss and dehydration. - Explain to the pt that he may feel
slight discomfort from the tourniquet
and the needle puncture.

Hemoglobin -Low hemoglobin level may -Tell the pt that the test requires a
12/6/10
108. 0 110-180 Decrease indicate anemia, recent blood sample explain will perform the
g/L hemorrhage, or fluid venipuncture and when.
retention, causing -Apply direct pressure to the
hemodilution. venipuncture site until bleeding stops.
- If large hematoma develops at the
venipuncture site, monitor pulse distal
to the site.

WBC - Explain to the pt that the WBC test

12/6/10 12.6 Increas - An increase such as detect an infection or inflammation.
5-10X10 e abcess, meningitis, - notify the laboratory and physician of
g/L appendicitis, or tonsillitis, or drugs in the pt. is taking that may affect
may result from leukaemia test results, it may be necessary to
and tissue necrosis caused restrict them.

23 | P a g e
 by burns, myocardial - instruct the pt that he may resume his
infarction, or gangrene. usual diet, activity and medications
stopped before removing pressure.

LYMPHOCYTES 12/6/10 - Explain to the pt that this test requires

0.16 blood sample.
Decrease - Decrease counts in occur -apply direct pressure to venipuncture
0.25-0.35 in conditions such as site until bleeding strops.
acquired immunodeficiency
syndrome, a plastic anemia,
and bone marrow
MONOCYTES suppression. - Explain to the pt that this test requires
12/6/10 0 a blood sample.
Decrease -Apply direct pressure to the
0.03-0.07 venipuncture site until bleeding stops.

EOSINOPHILS - Explain to the pt that this test requires

12/6/10 0 a blood sample.
Decrease -Apply direct pressure to the
0.01-9.03 venipuncture site until bleeding stops.
- Decrease count may
indicate alcohol intoxication
and excessive production of
BASOPHILS 12/6/10 adrenocorteroids. - Tell the pt that she need not to restrict
0 food or drink.
Decrease - inform the pt that she may fell slight
0.01 discomfort from the tourniquet and
needle puncture.
- A rapid decrease in - Explain the procedure to the patient.
basophils is linked to an -Apply pressure to the venipuncture.
anaphlylactic reaction.

24 | P a g e
 Normal Anatomy and Physiology
Mammary Gland
The mammary glands are present inn both sexes, but they normally function only in females. Since the biological role of the mammary
glands is to produce milk to nourish a newborn baby, they are actually important only when reproduction has already been accomplished.
Stimulation by female sex hormones, especially estrogens, causes the female mammary glands to increase in size at puberty.

Breast schematic diagram (adult female human

cross section)

Legend:

1. Chest wall
2. Pectoralis muscles
3. Lobules
4. Nipple
5. Areola
6. Duct
7. Fatty tissue
8. Skin

Mammary glands/breast
• Are modified sweat glands that are actually part of the skin.
• is contained within a rounded skin-covered breast anterior to the pectoralis muscles of the thorax

25 | P a g e
 • consists 15 to 25 lobes which radiates around the nipple internally
• develop in the response to the secretions from the hypothalamus, pituitary gland, and ovaries
• an organ of sexual arousal in the mature adult
• located between the second and sixth ribs, between the edge of the sternum ant the midaxillary line.
• supported by the Cooper’s suspensory ligaments that are attached to underlying muscles
• have abundant blood supply and lymph flow (drains from an extensive network toward the axilla

Lobes
• consist of smaller chambers called lobules, which contain clusters of alveolar glands that produce milk when the woman is lactating
(producing milk)

Lactiferous ducts
• where the alveolar glands of each lobule pass the milk
• open to the outside at the nipple

Stroma
• interlobular tissue, also referred to as connective tissue, contains capillaries and other specialized cells.

Ductal System
The milk is collected by distal lactiferous ducts or acini which merge into minor and then major lactiferous ducts. In most instances,
these empty into the major duct or sinus which ends in the nipple. The ductal system has a ductal epithelium surrounded by a myo-
epithelium. This ductal epithelium is responsible for the propulsion of milk through the ductal system as it has contractile capabilities. This
ductal system is sealed and surrounded by an uninterrupted basement membrane.

26 | P a g e
Areola
• a pigmented area slightly below the center of each breast
• colored from pink to dark brown and has several sebaceous glands

Montgomery’s glands
• are small, round sebaceous glands that appear as elevations on the areola
• thought to secrete a fatty substance that protects the nipple during breastfeeding

The arterial blood supply to the breasts is derived from the internal thoracic artery (formerly called the internal mammary artery),
lateral thoracic artery, thoracoacromial artery, and posterior intercostal arteries. The venous drainage of the breast is mainly to the axillary
vein, but there is some drainage to the internal thoracic vein and the intercostal veins. Both sexes have a large concentration of blood vessels
and nerves in their nipples. The nipples of both women and men can become erect in response to sexual stimuli, and also to cold.
The breast is innervated by the anterior and lateral cutaneous branches of the fourth through sixth intercostal nerves. The nipple is
supplied by the T4 dermatome.

Breast development
The development of a girl's breasts during puberty is triggered by sex hormones, chiefly estrogen. This hormone has been
demonstrated to cause the development of woman-like, enlarged breasts in men, a condition called gynecomastia, and is sometimes used
deliberately for this effect in male-to-female sex change hormone replacement therapy.
In most cases, the breasts fold down over the chest wall during Tanner stage development. It is typical for a woman’s breasts to be
unequal in size particularly while the breasts are developing. Statistically it is slightly more common for the left breast to be the larger. In rare
cases, the breasts may be significantly different in size, or one breast may fail to develop entirely.

27 | P a g e
 A large number of medical conditions are known to cause abnormal development of the breasts during puberty. Virginal breast
hypertrophy is a condition which involves excessive growth of the breasts and in some cases the continued growth beyond the usual
pubescent age. Breast hypoplasia is a condition where one or both breasts fail to develop.

Lymphatic System
Lymphatic system is a specialized component of the circulatory system; made up of lymph, lymphatic vessels, lymph nodes, tonsils,
thymus and spleen.

Functions:
• maintain fluid balance in the internal environment
• involved in immunity
• lymph vessels act as drains to collect excess tissue
fluid and return it to the venous blood just before it
returns to the heart
• transport tissue fluid, proteins, fats and other
substances to the general circulation
• lacteals absorb fats and other nutrients from the
small intesine

Lymph – a clear, watery appearing fluid found in the

lymphatic vessels; closely resembles blood plasma in
composition but has lower percentage of protein; isotonic.

28 | P a g e
Structure of the lymphatic vessels:
• similar to veins except lymphatic vessels have thinner walls, more valves, and contain lymph nodes
• lymphatic capillary wall is formed by as single layer of thin, flat endothelial cells
• as the diameter of lymphatic vessels increase from capillary size, the walls become thicker
Cell Cycle
It is the series of changes a cell goes through from time to time it is formed until it reproduces
itself.
It is the sequence of regular and repetitive physical and chemical processes taking place
within the cell.
The cell cycle consists of four distinct phases:

1. G1 phase – RNA and protein synthesis occur.

2. S phase – DNA synthesis occurs.
3. G2 phase – premitotic phase; DNA synthesis is complete, mitotic spindle forms.
4. Mitosis – cell division occurs.

M phase is itself composed of two tightly coupled processes: mitosis, in which the cell's chromosomes are divided between the two
daughter cells, and cytokinesis, in which the cell's cytoplasm divides forming distinct cells.
Mitosis: an indirect cell division; the cell has to pass through several stages, namely Prophase, Metaphase, Anaphase, and Telophase,
before the cell could finally divide into 2 daughter cells.
Stages of Mitosis:
The genetic code of the cell is contained in the double helix DNA molecule which in combination with nucleoproteins form the
chromosome. Two important events occur in the interphase cell prior to cell division.
First, the DNA molecule is copied or replicated for distribution of its information to each daughter cell.

29 | P a g e
 Second, the centriole is also duplicated for subsequent spindle formation.

I. Prophase
• the nuclear membrane starts to break down
• the nucleolus membrane distentegrates and disappears
• the centrosome (centriole) splits and each centriole repels each other, thus, migrate
towards the opposite poles, at the same time forming a “centrodesmus” between
them from which the continuos spindle fibers originate. Some radiate outward.
Forming distinctive lines, the astral rays
• cdhromosomes start to condense, shorten and thicken
• each chromosomes is composed of two highly coiled filaments called chromatids
which retain a closed side by side relationship. The centromere or kinetochore serves
to hold the two chromatids together and eventually become the attachment site of
the microtubules of the spindle fibers
• this phase believed to last for 30 to 60 minutes
II. Metaphase
• through metakines, the chromosomes moved toward and become positioned at the
equatorial plane.
• this lasts for 2-6 mins

30 | P a g e
 III. Anaphase
• the centromere or kinethocor splits and active repulsion between sister centromeres
occur, thus chromosome are dragged and migrate towards the opposite poles.
• this last for 3-16 minutes.
Mechanisms responsible for the movement of the chromosome:
A. the energy transmitted by the kinethocore of the chromosome pushes the chromosome
towards the opposite poles
B. the elongation of the interchromosomal fibers pushes the chromosomes towards the
opposite poles
Telophase
This is the reverse of the prophase
• chromosomes have reached the opposite poles.
• the nuclear membrane is reoriented and reformed.
• the nucleolus and centrosome are reformed
• chromosomes start to elongate, extend and lengthened until the threadlike or
filamentous appearance is assumed, hence the term chromosomal filament.
• a constriction or cleavage furrow starts from the outer middle portion of the cell and,
through progressive constriction along a girdling cleavage furrow, continous towards
the outer until it finally divides the cell into 2 daughther cells.
• this last for 30- 60 mins

Cytokinesis
The process by which the cytoplasm divides and one cell becomes two individual cells.
Due to the activity of a contracile ring made of microfilaments, a cleavage furrow appears
over the midline of the spindle, and it eventually squeezes or pinches the original
cytoplasmic mass into two parts. Thus, at the end of cell division, two daughter cells exist.
Each is smaller and has less cytoplasm than the mother cell, but it is genetically identical to
it. The daughter cells grow and carry out normal cell activities until it is their turn to divide.

31 | P a g e
 Concept Map

32 | P a g e
 Nursing Care Plan
PROBLEM: Difficulty of Breathing
NURSING DIAGNOSIS:Impaired gas exchange r/t accumulation of fluid in the pleural space secondary to lymphatic abnormalities tertiary to breast cancer
TAXONOMY: Activity-Exercise Pattern
CAUSE ANALYSIS: Fluid buildup between the chest wall and the lung causing a pleural effusion, which in turn causes shortness of breath, chest aching,
discomfort and heaviness. Fluid builds up because cancer cells are irritating the pleura. The pleura are the two sheets of tissue that cover the lungs. The
irritated tissues make extra fluid and the fluid collects between them. There may also be cancer cells in the pleural space that stop the extra fluid draining
away. The lungs inflate as we breathe in. This fluid buildup gets in their way and stops them from inflating fully.( http://www.cancerhelp.org.uk/about-
cancer/what-is-cancer/grow/where-a-cancer-spreads#lungs)

CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“maglisod ko ug After 3 hours of immediate
ginhawa day” as nursing intervention the
verbalized by the patient patient will be able to
minimize difficulty of
breathing and will be able to
breathe accordingly.
OBJECTIVE:
• with oxygen
inhalation of 5
LTO:
LPM
• Irritable
After 8 hours of nursing
• Dyspnea intervention the patient will be
• Grimace face able to demonstrate improve
ventilation and oxygenation of
• RR: 13bpm
tissues by ABGs within client’s
acceptable range and absence
of symptoms of respiratory
distress.
1. Monitor/assess respiratory
rate, depth and ease
2. Position client in semi/high-
fowler’s position, with an
upright posture at 45 degrees
if possible.
3. If the client is acutely
dyspneic, have the client lean
forward over a bedside table.
4. Help/demonstrate the client
how to deep breathe and
perform controlled coughing.
o Manifestations of respiratory After 3 hours of immediate
distress are dependent nursing intervention the patient
on/indicative of the degree was able to minimize difficulty of
of lung involvement and breathing and was be able to
underlying general health
breathe accordingly.
status.
o 45 degree upright position
increased oxygenation and
ventilation.
LTO:
o Leaning forward can help
decrease dyspnea, possibly
After 8 hours of nursing
because gastric pressure
allows better contraction of intervention the patient
demonstrate improved ventilation
the diaphragm.
and oxygenation of tissues by
o helps in improving ABGs within client’s acceptable
ventilation. range and absence of symptoms
of respiratory distress.

33 | P a g e
 5. Maintain bedrest. Encourage
use relaxation techniques and
diversional activities.
COLLABORATIVE:
6. Administer oxygen therapy by
appropriate means
-nasal cannula @ Lpm
7. Prepare for/transfer to critical
care setting if indicated
REFERENCE: Nursing Care Plans by Doenges and et al 7th edition.
PROBLEM: Productive cough
34 | P a g e
o Prevents overexhaustion
and reduces oxygen
consumption/demands to
facilitate resolution of
infection.
o The purpose of oxygen
therapy is to maintain PaO2
above 60mmHg
o Intubation and mechanical
ventilation may be required
in the event of severe
respiratory insufficiency.
NURSING DIAGNOSIS: Ineffective airway clearance r/t increased sputum production; edema formation secondary to lymphatic spread tertiary to BCA
TAXONOMY: Activity-Exercise pattern
CAUSE ANALYSIS: The lungs are the most common organ for cancers to spread to. This is because the blood from most parts of the body flows back to the
heart and then to the lungs before it goes to any other organ. Cancer cells that have found their way into the bloodstream can get stuck in the tiny
capillaries of the lungs causing a cough that doesn’t go away.( http://www.cancerhelp.org.uk/about-cancer/what-is-cancer/grow/where-a-cancer-
spreads#lungs)

35 | P a g e
 CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“mag sige man

REFERENCE: sya ugCare
Nursing PlansAfter8 hours of
by Doenges andimmediate 1. Assess rate/depth of
et al 7th edition. o Tachypnea, shallow After8 hours of immediate
ubo, nga nay brown na nursing intervention the respirations and chest respirations, and nursing intervention the patient
color sa iyang plema” as patient will be able to movement. Monitor for signs asymmetric chest was able to identify/demonstrate
of respiratory failure (e.g, movement are frequently
verbalized by the S.O identify/demonstrate behaviors to achieve airway
cyanosis and severe present because of
behaviors to achieve airway tachypnea) clearance.
discomfort of moving chest
clearance. 2. Elevate head of bed, change wall and/or fluid in lung.
position frequently o Keeping the head
OBJECTIVE:
elevated lowers
diaphragm, promoting
• Cough withwhitish
chest expansion, aeration
sputum LTO:
of lung segments, and
• Has a respiration LTO: mobilization and
After 3 days of nursing
rate at 24. expectoration of secretions
After 3 days of nursing 3. Suction as indicated (e.g., intervention the patient was able
• Hoarseness of to keep the airway clear.
intervention the patint will be frequent or sustained cough, o Stimulates cough or to display patent airway with
breathe
able to display patent airway adventitious breath sounds, mechanically clear airway breathe sounds clearing; absence
• Oxygen inhalation
with breath sounds clearing; desaturation related to airway in client who is unable to of dyspnea, cyanosis.
at 5 ml/ min secretion.
absence of dyspnea, cyanosis. do so because of
4. Assist client with frequent ineffective cough or
deep-breathing exercises. decreased level of
Demonstrate/help client to consciousness.
perform activity; e.g., splinting o Deep breathing
chest and effective coughing facilitates maximum
while in upright position. expansion of the
5. Maintain bedrest. Encourage lung/smaller airways.
use relaxation techniques and Coughing is a natural self-
diversional activities. cleaning mechanism,
assisting the cilia to
maintain patent airways.
o Prevents
COLLABORATIVE: overexhaustion and
reduces oxygen
6. Provide supplemental fluid; consumption/demands to
humidified oxygen and room facilitate resolution of
humidification. infection

7. Administer medications as
indicated:
Fluimicil: 600mg in one o Aid in mobilization of
tablet in 2 glass water secretions
36 | P a g e motor once a day

o Aids in reduction of
bronchospasm and
PROBLEM: Acute Pain
NURSING DIAGNOSIS: Altered Comfort: Chronic pain related to disease progression secondary to breast cancer
CAUSE ANALYSIS: General mechanisms that cause pain associated with breast cancer include pressure, obstruction, and invasion of a sensitive structure,
tissue destruction and inflammation. Tumor compression of nerve endings against a firm surface creates pain.(Pathophysiology by McCance and Huether
p.385, 386)
CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

37 | P a g e
SUBJECTIVE: STO: INDEPENDENT: STO:

• “ magsakit After 4 hours of immediate 1. Assess for pain descriptors o Thorough assessment After 4 hours of immediate
iyahang hupong nursing intervention the and cause, especially if will identify the appropriate nursing intervention the patient
sa iyang patient will be able to have continuous and severe, as well interventions to be given. was able to had gradual decrease
as nonverbal behavior
kalawasan” as gradual decrease of pain from of pain from 8/10 to 5/10.
(moaning, crying, and
verbalized by the 8/10 to 5/10. restlessness). o Pain is increased with
S.O 2. Provide environmental that stimuli
controls stimuli such as
• Reports of pain optimal lighting and temp.,
noise reduction, calm and
LTO:
OBJECTIVE: stress-free.
LTO:
3. Provide backrub, position o Non-pharmacological After 3 days of nursing
• Reports of pain change for comfort, relaxation measure to reduce pain.
After 3 days of nursing intervention the patient was able
• grimacing face techniques, music and deep
intervention the patient will be breathing exercises. to expressed feelings of comfort
• guarding able to express feeling of
o This reduces pain
and relief of pain as evidenced by
• pain @ upper associated with moist
comfort and relieve of pain as 4. Provide clean dry area and absence of facial grimace and
and lower desquamation and
evidenced by absence of facial provide bed cradle over prevents pressure on decrease of pain scale of 3/10.
extremities grimace and decrease of pain painful areas. exposed nerve endings of
• Limited ROM only
scale of 3/10. irradiated area.
R arm can move o To educate the family
5. Provide health teaching to the
about pain and discomfort
• P – pulling and patient/family concerning the
to expect.
burning pain cause of pain, duration based
on the disease and therapy
Q – sharp effectiveness.

R – radiates to the
upper and lower
extremities .

S – 8/10 COLLABORATIVE: o A wide range of

38 | P a g e
 T – unpredictable 6. Administer narcotic analagesic
as ordered by the physician:
e.g.,
o Tramadol IVTT 50 mg
every 6 hours
REFERENCE: Medical-Surgical Nursing Care Plans, 3rd Edition, by Jaffe
39 | P a g e
analgesics and associated
agents may be employed
around the clock to
manage pain.
-may be effective in
controlling pain associated
with inflammatory
process:e.g., metastatic
bone pain
PROBLEM: Difficulty in swallowing
NURSING DIAGNOSIS: Altered nutrition: less than body requirements r/t narrowing of food passageway, separation from the family secondary to
lymphadenopathy
CAUSE ANALYSIS: lymphatic systems are a very convenient route for metastasis to happen. Lymph ducts extend from all over our body which makes it an
easy passageway for cancer cells. Lymph nodes are spread all over your body and these nodes are where your lymph ducts drain and bring the virus or in
some cases cancer cells. There are concentrations of nodes in your throat, axilla(armpit), and inguinal area. This is why these areas are very palpable during
times of infection. The pain you have when you swallow while having a sore throat is also caused by the inflammed nodes in the throat.
( http://answers.yahoo.com/question/index?qid=20070915145143AAFw0pI)
CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“lisod jud itulon, sakit pa After 5 hours of immediate 1. Monitor daily food intake, o Identifies nutritional After 5 hours of immediate
jud” as verbalized by the nursing intervention the have client keep food diary as strengths/deficiencies. nursing intervention the patient
patient. patient will be able to indicated. o Makes mealtime more was able to participate in specific
participate in specific 2. Create pleasant dining enjoyable, which may interventions to stimulate
atmosphere. Encourage client enhance intake.
interventions to stimulate appetite/increase dietary intake.
to share meals with
appetite/increase dietary family/friends.
OBJECTIVE:
intake. o Good oral hygiene
• expressed 3. Provide good oral hygiene enhances appetite; the LTO:
difficulty and pain before and after meals. condition of the oral
in swallowing mucosa is critical to the After 3 days of nursing
LTO: ability to eat. The oral
through facial intervention the patient will be
expression mucosa must be moist,
After 3 days of nursing with adequate saliva able to verbalize “mas daghan
(grimacing)
intervention the patient will be production to facilitate and nakung makaon karon kaysa
• Drooling
able to verbalize “mas daghan aid in the digestion of food. kadtong naglabay nga adlaw.
• Secretions noted
4. Provide small frequent feeding
with whitish nakung makaon karon kaysa
kadtong naglabay nga adlaw.” of soft foods such as corn
sputum
soup. o Prevents early satiety
• Irritability to
5. Encourage client to eat high- and stimulate appetite.
swallow foods
calorie, nutrient –rich diet. E.g. o Metabolic tissue needs
cereals. Encourage us of are increased.
supplements. Supplements can play an
important role in
maintaining adequate

40 | P a g e

COLLABORATIVE:
6. Insert NGT or feeding tube for
enteric feedings, or central
line for total parenteral
nutrition (TPN) if indicated.
REFERENCE: Nursing Care Plans by Doenges and et al 7th edition.
PROBLEM: Swelling @ lower and upper extremities and R side of the face
41 | P a g e
caloric and protein intake.
o In the presence of
severe malnutrition or if
client has been NPO for 5
days and is unlikely to be
able to eat for another
week, tube feeding or TPN
may be necessary to meet
nutritional needs.
NURSING DIAGNOSIS: Impaired skin integrity r/t retraction of skin, peau d’orange and edema secondary to Lymphatic metastasis
CAUSE ANALYSIS: Edema is caused due to invasion and obstruction of dermal lymphatics by the tumor and swelling results from obstructed lymphatic
circulation. ( Medsurg by Smeltzer.)

CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“bug-at akong paminaw Within 1 ½ day of nursing 1. Monitor site of skin o Systemic inspection Within 1 ½ day of nursing
tungod sa akong intervention the patient will be impairment at least once a can identify impending intervention the patient was able
hupong” as verbalized by able to decrease grading day for color changes, problems early. to decreased grading edema from
redness, swelling, warmth,
the patient. edema from 4 to 3. 4 to 3.
pain, or other signs of
infection. Whether the client is
experiencing changes in
sensation or pain.
LTO: LTO:
o To prevent further
2. Do not position client on damage/complication to
Within 3 days of nursing Within 3 days of nursing care
site of skin impairment. the area.
care such as thorough health such as thorough health teachings
OBJECTIVE: teachings on safety on safety precautions the patient
3. Clean the skin in the o Pressure from tight or
precautions the patient will be treatment area with a mild irritating clothing will was able to maintain tissue
• Presence of edema able to maintain tissue non-perfumed soap and tepid integrity, improved body image
increase skin irritation and
• Peau d’orange skin integrity, improve body image water. Use a soft cloth & avoid the risk of skin breakdown and absence of complications.
edema at right arm and absence of complications. rubbing the skin, dry in the treatment areas.
• Skin cold to touch thoroughly. Lightweight cotton clothing
• Sole of feet cyanotic is best.
• With seepage noted
4. Soft massaging around o Massaging improve
• Grading Edema: 4 the site of skin impairment good circulation.
both lower and and over bony prominence.
upper extremities
except for the R arm. 5. Teach client to keep skin o Keeping the skin clean,
clean and dry at all times. dry and avoiding irritants
Teach the patient to avoid will promote skin integrity
scratching and exposing the and reduced the risks of
skin to pressure, sunlight, wet desquamation
rough clothing.

42 | P a g e
 COLLABORATIVE:

6. Apply lubricating lotions/

creams as indicated. Creams
that do not contain metals,
alcohol, fragrance/ and
additives are suggested
o Creams provide
lubrication to avoid skin
breakdown. Alcohols,
metals and strong fragrant
perfumes could cause
irritation and further
damage to the breast.

REFERENCE: Nursing Care Plan by Gulanick and et al.

PROBLEM: Body weakness

43 | P a g e
NURSING DIAGNOSIS: Activity intolerance r/t imbalance between oxygen supply and demand secondary to accumulation of fluid to pleural space tertiary to
breast cancer
CAUSE ANALYSIS: : cancer can alter the balance among capillary permeability , hydrostastic and colloidal osmotic pressure and lymphatic drainage in
several ways. Pleural implantation occurs by sending of the primary tumor unto the serosal surface of the visceral and parietal pleural implants lead to
increased capillary permeability through inflammation of the pleural surfaces with an increased net filtration of fluid into pleural space. Which can alter the
circulation of oxygen throughout the body. ( cancer symptom management 3rd edition vol.1 by Yarbro, Frogge, Goodman)
CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“luya kayo siya, dili After 8 hrs of nursing 1. Assess sleep patterns and o Multiple factors can After 8 hrs of nursing
kau siya makalihok” As intervention the patient will be note changes in thought aggravate fatigue, intervention the patient was able
verbalized by the S.O able to reduced body weakness process/behaviors. including sleep deprivation, to reduced body weakness from
from ROM of 2 to 3. emotional distress, side ROM of 2 to 3.
effects of medication, and
progression of disease
process.
2. Perform passive or active
OBJECTIVE: ROM exercises to all
LTO: extremities. o Exercises promote LTO:
• Fatigue increased venous return,
After 3 days of nursing prevent stiffness and After 3 days of nursing
• Generalized body maintain muscle strength
intervention the patient will be 3. Assisting/demonstrate intervention the patient was able
weakness (ROM) proper performance of ADLs, and endurance.
- Grade 2 able to be independent from to be independent from
position changes. Identify
• Restlessness dependent, not finishing a task safety issues; e.g. use of o Protect dependent, not finishing a task to
• Unable to sleep to finishing a task in ADL’s. assistive devices, keeping clients/caregiver from finishing a task in ADL’s.
• Dependent in way free of furniture. injury during activities.
transferring 4. Keep side rails up and bed
in low position.
• Limited ADL 5. Encourage nutritional o Promotes safety in the
intake/use of supplements as environment.
appropriate. o Necessary to meet
energy needs for activity.

COLLABORATIVE:

44 | P a g e
 6. Refer to physical therapy
or rehabilitation as indicated
7. Provide supplemental
oxygen as indicated and
monitor response.
REFERENCE: Nursing Care Plans by Doenges and et al 7th edition.
45 | P a g e
o Helps in bringing
muscle strength and
coordination of physical
movements.
o Increase oxygenation.
Evaluates effectiveness of
therapy.
PROBLEM: Anxiety
NURSING DIAGNOSIS: Anxiety r/t pain/damage in health status
CAUSE ANALYSIS: : Anxiety is a state of mental uneasiness, apprehension, or dread producing an increased level of arousal caused by an impending or
anticipated threat to self. It is common to patients who are so concern about the diagnosis, treatment plan and prognosis of their illness. Furthermore,
patients who have lost close relatives to breast cancer may have difficulty coping with the possible diagnosis of breast cancer because memories of loss and
death can emerge during their own crisis. (Fundamentals of Nursing 7th edition by Kozier et.al. p. 182-183 & MSN by Smeltzer and Bare p. 1469)

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 CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: STO: INDEPENDENT: STO:

“gusto na unta
REFERENCE: nia Care Plans
Nursing After
by 2Doenges
hrs of nursing
and et al 7th edition.1. Assess for level of o Anxiety ranges from After 2 hrs of nursing
mouli kay gasto nman intervention the patient will be anxiety, verbal expression mild to panic state with intervention the patient was able to
ka.au, mao ra jpun able to display appropriate such as feeling of verbal expressions display appropriate range of
apprehension, uncertainty, indicating degree and
maghulat na lang me range of feelings and lessened feelings and lessened fear.
tension and fear as well as responses to expect.
ani” fear. the reasons for it.
2. Provide open o Help client feel
As verbalized by the SO environment in which client accepted in present
feels safe to discuss feelings condition without feeling
OBJECTIVE: or to refrain from talking. judged and promotes sense LTO:
of dignity and control.
-irritable LTO: 3. Maintain frequent
-restlessness After 3 days of nursing
contact with client. Talk with o Provides assurance
-Poor eye contact After 3 days of nursing and touch client as intervention the patient was able to
that the client is not alone
-Facial tension intervention the patient will be appropriate. appear relaxed and report anxiety
or rejected; conveys
-Feeling of able to appear relaxed and is reduced to a manageable level.
respect for and acceptance
hopelessness/
report anxiety is reduced to a of the person, fostering
helplessness 4. Promote calm, quiet
manageable level. trust.
environment o Facilitates rest,
conserve energy, and may
enhance coping abilities.
5. Encourage client to share
thoughts and feelings. o Provides opportunity to
examine realistic fears and
misconceptions about
6. Encourage and foster diagnosis.
client interaction with
support system. o Reduces feelings of
isolation. If family support
systems are not available,
outside sources may be
needed immediately, e.g.,
COLLABORATIVE: local cancer support group.

7. Administer anti-anxiety
medication.
8. Refer additional resource
47 | P a g e for counseling/support as
needed.
o May be useful for brief
periods of time to help
client handle feelings of
anxiety related to
diagnosis/situation during
period of high stress.

o May be useful time to

time to assist client/SO in
PROBLEM: low self-esteem
NURSING DIAGNOSIS: Anticipatory Grieving r/t threat of death
CAUSE ANALYSIS: A strong & unpleasant emotion caused by the awareness or anticipation of pain/ danger. Patient fears on the diagnosis of cancer and its
treatment and its prognosis. (Nursing Care plans by Gulanick pg 23)
CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

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SUBJECTIVE: STO: INDEPENDENT: STO:

“gikapoy nako, hadlok After 8 hrs of nursing 1. Evaluate support o Helps with planning for After 8 hrs of nursing
pero maghulat na lang intervention the patient will be structures available to and care while hospitalized and intervention the patient was able to
ko wala man ko able to verbalize understanding used by client/SO after discharged. verbalize understanding of body
2. Discuss with client/SO o Aids in defining
mabuhat,” as of body changes, preparation of changes, preparation of self in
how the diagnosis and concerns to begin problem-
verbalized by the self in situation. treatment are affecting the situation.
solving process.
patient. client’s personal life/home
and work activities. o Although some client
3. Provide emotion support adapt/adjust to cancer
for client/SO during effects or side effects of
OBJECTIVE: diagnostic tests and therapy, many need
treatment phase additional support during
 Expressed this period.
concerns LTO: LTO:
regarding 4. Use touch during o Affirmation of
changes in life After 3 days of nursing interactions, if acceptable After 3 days of nursing
individuality and acceptance
events intervention the patient will be to client, and maintain eye intervention the patient was able to
is important in reducing
 Feelings of able to demonstrate adaptation contact. client’s feelings of insecurity demonstrate adaptation to
helplessness, to changes/event that have and self-doubt. changes/event that have occurred
hopelessness, occurred as evidenced by as evidenced by setting of realistic
inadequacy setting of realistic goals. 5. Acknowledge difficulties o Validates reality of goals.
 Increased client may be experiencing. client’s feelings and give
respirations, Give information that permission to take whatever
heart rate, and counseling is often measures are necessary to
respiratory rate necessary and important in cope with what is
 Increased the adaptation process. happening.
tension,
apprehension,
restlessness and
insomnia

COLLABORATIVE:

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 6. Refer client/SO to
supportive group program;
e.g., Reach to Recover

o Group support is usually

very beneficial for both
client and SO, providing
contact with other client
with cancer at various levels
7. Refer for professional of treatment and/or
counseling as indicated. recovery, validating
feelings, and assisting with
problem-solving.

o May be necessary to
regain and maintain a
positive psychosocial
structure if client/SO
support systems are
deteriorating.

REFERENCE: Nursing Care Plans by Doenges and et al 7th edition.

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 Health Education Plan
Objectives:

1.Within 3hours of effective health teaching, the pt. will be able to perform the specific health teaching.
2. Within 3 hours of effective health teaching, the pt. will be able to understand the specific health teaching by return demonstration.
3. Within 3 hours of effective health teaching, the pt. will ensure sustainability of performing the specific health teaching by verbalizing the
want to sustain the regimen.

Materials:

1. Ballpen

2. Papers

3. Laptop

General Health Teachings Specific Health Teachings

Diet –instruct patient to eat low fat, high fiber, high protein, low salt. high carbohydrates, ,

Medications -Encourage pt. To take her medications at regular bases.

-Teach the SO the time, route, dosage, adverse effect and special considerations of each
meds.

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 Hygiene
-Instruct the client to clean the dressing regularly.
-Instruct the client to always keep the dressing dry and intact.

Exercise
-instruct the patient to have simple exercise to promote good circulation like slight walking
if possible, slight exercise on her arms and feet.

Spiritual Care
- Advice never to forget God to ask for Jesus help and to believe in the healing power of the
Holy Spirit to promote peace of mind and relaxation, thus promoting comfort and healing
not just to the mind but also to avoid harm and promote a soothing and pleasant
atmosphere with everyone.

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 Discharge Plan
Medications Dosage/Frequency Nursing Considerations
Co-Amoxiclav 1 tab once a day Instruct the patient to take the medication around the cock and to
finish the drug completely as directed.

Instruct female patients taking oral contraceptives to use an alternate or

additional non-hormonal method contraception during therapy with amoxicillin
and until next menstrual period.

Advise the patient to report signs of superinfection ( furry overgrowth

on the tongue, vagina itching or discharge, foul-smelling stools.and
allergy.
Burinex 1 tab once a day Give with food or milk to prevent GI upset.

Mark calendars or use reminders if intermittent therapy is best for treating

edema.

Give single dose early in day so increased urination will not disturb sleep.

Provide diet rich in potassium or supplemental potassium

Aldactone 1 tab once a day Take Aldactone exactly as it was prescribed for you. Do not take the medication in
Take each dose with a full glass of water.

To be sure this medication is not causing harmful effects, your blood will need to
be tested on a regular basis. It is important that you not miss any scheduled visits
to your doctor.

If you are being treated for high blood pressure, keep using this medication even

53 | P a g e
 if you feel fine. High blood pressure often has no symptoms.

Store this medication at room temperature away from heat, light, and moisture

Exercise
• Exercise as much as possible inorder to decrease risk for complications and do deep breathing inorder to have good circulation of the
oxygen.
• Do slight walking if possible.

Treatment/therapy
• Do yoga thing to improve symptoms and quality of life and reduce stress and may help live more comfortably.

Health Teachings
• Maintain a healthy weight
• Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days.
• Eat foods high in fiber,
• Inform the client that there is a breadth and depth of sexual expression possible and that she is a person of value.
• Recognize the feeling of warmth, approval, and friendship, as well as sharing and touching, are important.
• Inform the patient of the availability of the following services: sex education or counseling services (individual, couples and family); sex
therapy; group discussion; audiovisual materials and regarding materials.
• Instruct patient to do proper hygiene such as taking a bath daily, brushing her teeth after eating and proper grooming.
• Stress out to the client the importance of hand washing before and after eating and after using the comfort room to deter the spread of
microorganism.

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Hygiene
• Proper care of wound inorder to promote

OPD/Referral
• After treatment is completed, it is very important to go to all scheduled follow-up appointments. During these visits, your doctors will
ask questions about any symptoms and may do physical exams and order lab tests or imaging tests as needed to look for recurrences
or side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be
permanent. You should never hesitate to tell your doctor or other members of your cancer care team about any symptoms or side
effects that concern you.

Diet
Breast Cancer: Nutrition to Ease Symptoms
Nausea and vomiting are common after surgery. They are especially common if you've also had chemotherapy or radiation. Other
symptoms after surgery include a loss of appetite or desire to eat, and "wasting syndrome" called cachexia. This is a wasting away of
muscle, organ tissue, and other lean body mass. It's often accompanied by weight loss and weakness.
Here are some ways to ease symptoms of nausea after breast cancer treatment:
• Eat several smaller meals throughout the day instead of three big meals.
• Try protein shakes, yogurt, and liquid protein drinks when solid foods cause you to feel sick.
• Try simple soups, such as chicken with vegetables and broth, if nausea is an issue.
Breast Cancer: Nutrition to Aid Healing
Good nutrition is also associated with a better chance of recovery from cancer. After breast cancer surgery, your body needs more than its
usual supply of protein. It
needs it to repair cells, fight infection, and heal incisions. Right after surgery, boost your protein intake without worrying about calories. It will
aid your healing and help
you regain your strength. If you need to lose weight, you can focus on that after your post-op recovery.
Here are some ways to increase your protein intake:
• Add protein powder or dry milk to dishes to boost their protein level.
• Add grated cheese to vegetables, potatoes, rice, and salads to increase protein and calories.
• Add high-protein snacks such as almonds, peanuts, and cheese to your diet.

Breast Cancer: Nutrition to Help Prevent Recurrence

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Phytochemicals -- "phyto" means plant -- are chemicals found in plant foods. Some phytochemicals have been studied for their potential anti-
cancer benefits and their ability to prevent recurrence.
• Soy. Soybeans contain phytoestrogens. These are weak estrogen-like compounds. Soybeans (also called edamame), tofu, soy milk, and
miso soup all contain these phytoestrogens. Some researchers think they can help protect against the kind of breast cancer that
depends on estrogen for its growth. Experts agree that more research is needed to fully understand the role phytoestrogens might play
in preventing breast cancer recurrence. In the meantime, ask your doctor whether eating a moderate amount of soy foods -- one to
three servings a day -- is advised for you. It's possible it may interfere with hormone therapy or some other treatment. There is a link
between estrogen levels and breast cancer growth. But how various hormone therapies, surgery, phytoestrogens from foods, and
recurrence of cancer are all related is, as yet, far from understood.
• Antioxidants. Many vegetables, fruits, nuts, and other foods contain antioxidants. Examples of specific foods with antioxidants include
broccoli, liver, and mangos. Antioxidants protect your cells from damage from "free radicals." These are atoms or groups of atoms
thought to trigger cancer growth. Dietitians advise eating a balanced diet with a variety of fresh foods to provide antioxidants. That's
better than taking high "megadoses" of vitamin C, vitamin E, or other antioxidants.
• Beta-carotene. Beta-carotene gives carrots, apricots, yams, and other orange-colored vegetables and fruits their color. Results of
studies examining the relationship between breast cancer and beta-carotene are inconsistent. But there are some studies that suggest
that a diet high in beta-carotene-rich foods may reduce the risk of death from breast cancer.
• Lycopene. Lycopene is what puts the red in tomatoes and the pink in pink grapefruit. It might also help prevent recurrence of breast
cancer in some women. Studies haven't shown a consistent benefit, though.

Breast Cancer: A Lifelong Anti-cancer Diet

Research sponsored by the National Cancer Institute suggests that a low-fat diet reduces the risk of recurrence of breast cancer. This may
be especially true forpostmenopausal women. Here are some guidelines you can use for planning an anti-cancer diet. You might also want
to consider consulting with a registered dietitian. The dietitian can give you more personalized advice on the best diet and nutrition plan
for your condition.
• Choose low-fat protein, such as roasted chicken and baked fish, rather than steak, duck, sausages, or other high-fat meats.
• Try to eat five servings of a wide variety of vegetables and fruits each day.
• Avoid or eliminate processed meats linked to cancer. This includes meats such as bacon, bologna, hot dogs, ham, and smoked meats.
• Choose whole-grain products like whole-wheat bread and brown rice, rather than white bread and white rice.
• Cut back or eliminate alcohol. Limit yourself to one to two drinks a day at most.

Spiritual Care
• Encourage client to strengthen her faith with Almighty Father to provide spiritual growth and promote healing.

56 | P a g e
 • Advice never to forget God to ask for Jesus help and to believe in the healing power of the Holy Spirit to promote peace of mind and
relaxation, thus promoting comfort and healing not just to the mind but also to avoid harm and promote a soothing and pleasant
atmosphere with everyone.

Medical Management

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Generic CLassific Indication Mechanism of Adverse reaction/ Drug Interaction Route/ Nursing Considerations
name ation Action side effect frequenc
y/ dosage
Paracetamol Anti- • Relief of • Decreases • CNS: • Amphetamines,tricycl IVTT • Assess patient’sfever or
pyretic mild-to- fever weakness, ic antidepressant, 300mg as pain:type of
moderate by fatigue, procainamide: needed
pain,location,intensity,duration
pain inhibiting nervousness, decrease excretion and
• Temporar the sedation, enhanced or ,
y effects of drowsiness, prolonged effect of temperature
reduction pyrogens on dizziness, these drugs leading to •
of the depression, toxicity • Assess allergic reactions: rash,
fever hypothalam tremor, urticaria; if theseoccur, drug
ic headache, mayhave to be discontinued
heat seizures •
regulating • • Assesss :rapid, weak pulse
centers and • Dermatologic: dyspnea: cold, clammy
by pruritus, extremities report immediately
a to prescriber.
hypothalam urticaria, rash
ic •
action • GI: Anorexia,
leading nausea,
to sweating vomiting,
and constipation,
vasodilation
hepatic
• Relieves insufficiency
pain by •
inhibiting • GU:
prostagland Hematuria,
ins glycosuria,
synthesis at urinary
the frequency,
CNS but renal
does colic,
not have crystaluria
anti-
inflammato
ry
action
58 | P a g e
because
of its
minimal
effect on
 Surgical Management
Mastectomy

For a long time, a procedure called a radical mastectomy was the only treatment available to women with breast cancer. No matter what
stage of breast cancer you had, mastectomy was your only option. Catching a cancer early didn't give you the benefit of having a less radical,
more cosmetically acceptable treatment option. Things have changed a great deal since then. Mastectomy no longer has to be as extensive,
scarring, or disfiguring. After 25 years of follow-up, research has shown that more extensive surgery is not necessarily better. Mastectomy can
actually be different operations for different people, in different situations.

1. In a "simple" or "total" mastectomy, the surgeon removes the entire breast but does not take out any axillary lymph nodes (nodes in
the underarm area, also called the axilla). No muscles are removed from beneath your breast. Occasionally, lymph nodes may be removed
because they are actually located within the breast tissue taken during surgery. A total mastectomy is appropriate for women with ductal
carcinoma in situ or DCIS, and for women seeking prophylactic mastectomies—that is, breast removal in order to prevent any possibility of
breast cancer occurring.

Woman with total (simple) mastectomy

A pink highlighted area indicates tissue removed at mastectomy

59 | P a g e
 B axillary lymph nodes: levels I

C axillary lymph nodes: levels II

D axillary lymph nodes: levels III

2. A modified radical mastectomy removes the entire breast and includes a procedure called axillary dissection, in which levels I and II (of
three levels) of the axillary lymph nodes in the underarm area) are also removed. Most women who have mastectomies today have
modified radical mastectomies.

Woman with modified radical mastectomy

A pink highlighted area indicates tissue removed at mastectomy

B axillary lymph nodes: levels I

C axillary lymph nodes: levels II

D axillary lymph nodes: levels III

3. Radical mastectomy includes removal of the entire breast, all underarm lymph nodes, and chest wall muscles under the breast. Although
it was common in the past, radical mastectomy is now rarely performed because modified radical mastectomy has proven to be just as
effective and less disfiguring. Today radical mastectomy is recommended only when cancer has spread to the chest muscles under the
breast.

Woman with radical mastectomy

A pink highlighted area indicates tissue removed at mastectomy

B axillary lymph nodes: levels I

C axillary lymph nodes: levels II

60 | P a g e
 D axillary lymph nodes: levels III

E supraclavicular lymph nodes

F internal mammary lymph nodes

Is mastectomy right for you?

Mastectomy may be right for you if:

• Cancer is found in more than one part of your breast.

• Your breast is small or is shaped so that a lumpectomy would leave you with very little breast tissue or a very deformed breast.
• You believe you would have greater peace of mind with a mastectomy.

Lympectomy

• Tumor is excised and removed.

• Lymph node dissection may also be performed.

Indication: For diagnosis of an abnormal mammographic finding or palpable breast lump if needle biopsy not performed.

Pre-operative Management

Patient education is a vital component of the surgical experience. Pre operative patient education maybe offered through conversation,
discussion, the use of audio visual aids, demonstrations and return demonstrations. It is designed to help the patient understand the surgical
experience to minimize anxiety and promote for recovery from surgery and anesthesia.

1. Begin at the patient ‘s level of understanding.

2. Plan a presentation for this individual patient or a group of patients.
3. Include family members and significant others in the teaching process.
4. Encourage active participation of patients in their care and recovery.
5. Demonstrate essential techniques, provide opportunity for patient practice and return demonstration.
6. Provide time for and encourage patient to ask questions and express concerns.
7. Provide general information and assess the patient’s level of interest or reaction to it.

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 • Explain details of pre-operative preparation and provide tour of area and view of equipment when possible.
• Offer general information on the surgery. Explain that the health care provider is the primary resource person.
• Tell when surgery is scheduled and approximately how long it will take; explain that afterward the patient will go to the recovery
room.
• Let patient know that family will be kept informed and that they will be told where to wait and when they can see; note visiting
hours.
• Explain how a procedure or test may feel during or after.
• Stress the importance of active participation in post operative recovery.
8. Use other resource people: healthcare providers, therapists, chaplain, and
9. Documents what has been taught or discussed.

General Instructions

Preoperatively, the patient will be instructed in the following postoperative activities.

Diaphragmatic Breathing

This is a mode of breathing in which the dome of the diaphragm is flattened during inspiration, resulting in enlargement of the upper abdomen
as air rushes into the chest. During expiration, abdominal muscles and the diaphragm relax. It is an effective relaxation technique.

1. assume semi-fowler’s position

2. Place both hands over lower rib cage; make a loose fist and rest the flat surface of the fingernails against the chest (to feel chest
movement)
3. Exhale slowly and fully; ribs will sink inward and downward toward the midline.
4. Inhale slowly and deeply through mouth and nose; permit abdomen to rise as lungs fill with air.
5. Hold this breath through a count of 5.
6. Exhale and let all air out through mouth and nose.
7. Repeat 15 times with a breath rest after each group of 5.
8. Practice this twice each day preoperatively.

Incentive Spirometry

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Preoperatively, the patient uses a spirometer to measure deep breaths while exerting maximum effort. The preoperative measurement
becomes the goal to be achieve as soon as possible after the operation.

1. Postoperatively, the patient is encourage to use the incentive spirometer about 10 to 12 times an hour.
2. Deep inhalations expand alveoli, which, in turn, prevents atelectasis and other pulmonary complications.
3. There is less pain with inspiratory concentration than with expiratory concentration, such as coughing.

Coughing

Coughing promotes the removal of chest secretions. Instruct the patient to:

1. Interlace the fingers and place the hands over the proposed incision site; this will act as a splint during coughing and not harm the
incision.
2. Lforward slightly while sitting in bed.
3. Breathe, using the diaphragm as described under diaphragmatic breathing.
4. Inhale fully with the mouth slightly open.
5. Let out three or four sharp “hacks”
6. Secretions should be readily cleared from the chest to prevent respiratory complications ( pneumonia, obstruction)

Turning

Changing positions from back to side-lying stimulates circulation, encourages deeper breathing and relieves pressure areas.

1. Assist the patient to move onto side assistance is needed.

2. Lace the upper most leg and a more flex position than that of the of lower leg and place a pillow comfortably between the legs.
3. Ensure that the patient is turned from one side to back and onto the other side every 2 hours.

Foot and leg exercises

Moving the legs improves circulation and muscle tone.

1. Have the patient lie on back; instruct patient to bend the knee and raise the foot – hold it in a few seconds, extend the leg and lower it
to the bed.
2. Repeat above about 5 times with one leg and then with the other. Repeat the set 5 times every 3 to 5 hours.

63 | P a g e
 3. Then have the patient lie on side; exercise the legs by pretending to pedal a bicycle.
4. Suggest the following foot exercise: trace a complete circle with the great toe.

Post operative care

To ensure continuity of care from the intraoperative phase to the immediate post operative phase, the circulating nurse,
anesthesiologist, or nurse anesthetist will thorough report to the PACU nurse.

1. Type of surgery performed and any intra operative complications.

2. Type of anesthesia ( e.g. general, local, sedation)
3. Drains and type of dressings
4. Presence of endotracheal tube or type of oxygen to be administered ( e.g. nasal cannula, T- piece)
5. Types of lines and locations (e.g. peripheral IV, arterial line)
6. Catheters or tubes such as Foley, T- tube
7. Administration of blood , colloids, and fluid and electrolyte balance
8. Drug allergies
9. Preexisting medical conditions

Initial nursing assessment

Before receiving the patient, note proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other
equipment. The following initial assessment is made by the nurse in the PACU:

1. Verify the patient’s identity, the operative procedure, and the surgeon who performed the procedure.
2. Evaluate the following signs and verify their level of stability with the anesthesiologist:

• respiratory status
• circulatory status
• pulses
• temperature
• oxygen saturation level

64 | P a g e
 • hemodynamic values

3. Determine swallowing, gag reflexes, and level of consciousness, including patient’s response to stimuli.
4. Evaluate any lines, tubes, or drains, estimated blood loss, condition of the wound (open, close, packed), medications used, infusions,
including transfusions, and output.
5. Evaluate the patients level of comfort and safety by indicators such as pain and protective reflexes.
6. Performed safety checks to verify that side rails are in place and restraints properly applied as needed, for infusions, transfusions, and
so forth.
7. Evaluate activity status; movement of extremities.
8. Review health care providers orders.

Initial nursing interventions

Maintaining a patent airway

1. Allow metal, rubber or plastic airway to remain in place until the patient begins to waken and is trying to eject the airway.

• The airway keeps the passage open and prevents the tounge from falling backward and obstructing the air passages.
• Leaving the airway in after the pharyngeal reflex has returned may cause the patient to gag and vomit.

2. Aspirate excessive secretions when they are heared in the oropharynx and nasopharynx.
Maintaining adequate respiratory function

1. Lace the patient in a lateral position with neck extended and the upper arm supported on a pillow.

• This will promote chest expansion

• Turn the patient every hour or 2 to facilitate breathing and ventilation.

2. Encourage patient to take deep breaths to aerate lungs fully and prevent hypostatic pneumonia; use incentive spirometer to aid in this
function
3. Assess lung fields frequently by auscultation
4. Evaluate periodically the patient’s orientation- response to name or command.

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 5. Administer humidified oxygen if required.

• heat and moisture are normally lost during exhalation

• dehydrated patient may require oxygen and humidity because of higher incidence of irritated of respiratory passages in this
patients.
• secretions can be kept moist to facilitate removal

6. Use mechanical ventilation to maintain adequate pulmonary ventilation if required.

Assessing status of circulating system

1. Take vital signs (BP, pulse, and respiration) per protocol,as clinical conditions indicates, until the patient is well stabilized. Check every 4
hours thereafter.

• know the patients preoperative blood pressure to make significant comparison.

• report immediately a falling systolic pressure and increasing heart rate.
• report variation, cardiac arrhythmias, respiration over 30.
• evaluate pulse pressure to determine status of perfusion ( a narrowing pulse pressure indicates impending shock)

2. Monitor I and O closely

3. Recognize the variety of factors that may alter circulating blood volume.

• reactions to anesthesia and medications.

• blood loss and organ manipulation during surgery.
• moving the patient from one position on the operating table to another on the stretcher.

4. Recognize early symptoms of shock and hemorrhage.

• cool extremities, decreased urine output, slow capillary refill, low BP, narrowing of PR, increased HR are often indicative of decreased
cardiac output.
• initiate oxygen therapy to increase oxygen availability form the circulating blood.

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 • increase parenteral fluid infusion as prescribed.
• place the patient in shock position with feet elevated ( unless contraindicated)

Assessing thermoregulatory status

1. Monitor temperature every hour to be alert for malignant hyperthermia or detect hypothermia
2. A temperature of 37. 7 degree celsius or under 36.1 is reportable.
3. Monitor for postanesthesia shivering. It is most significant in hypothermic patients 30 to 45 minutes after admission to the PACU. It
represents a heat- gain mechanism and relates to regaining thermal balance.

Promoting comfort

1. Assess pain by observing behavioral and physiologic manifestations.

2. Administer analgesics (change in vital signs may be a result of pain) and document efficacy.

Minimizing complications of skin impairment

1. Perform handwashing before and after contact with patient.

2. Inspect dressings routinely and reinforce if necessary.
3. Record amount and type of wound drainage.
4. Turn the patient frequently and maintain good body alignment.

Maintaining safety

1. Keep side rails up until the patient is fully awake.

2. Avoid nerve damage and muscle strain by properly supporting and padding pressure areas.
3. Check dressing for constriction.
4. Determine return of motor control following anesthesia- indicated by how the patient responds to a pinprick or a request to move a par
Minimizing the stress factors of sensory deficits

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 1. Know that the ability to hear returns more quickly than other senses as the patient emerges from anesthesia.
2. Avoid saying anything in the patient’s presence that may be disturbing; patient may be appear to be sleeping but still consciously hears
what is being said.
3. Explain procedures and activities at the patient’s level of understanding.
4. Minimize the patient’s exposure to emergency treatment of nearby patients by drawing curtains lowering voice and noise levels.
5. Demonstrate concern for and understanding of the patient and anticipate needs and feelings.
6. Tell the patient repeatedly that the surgery is over and that he or she is in the recovery room.

Radiation Therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Most women receive radiation therapy after
breast-sparing surgery. Some women receive radiation therapy after a mastectomy. Treatment depends on the size of the tumor and other
factors. The radiation destroys breast cancer cells that may remain in the area.

Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. Doctors use this approach when the
tumor is large or may be hard to remove. Some women also have chemotherapy or hormone therapy before surgery.

Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:
• External radiation: The radiation comes from a large machine outside the body. Most women go to a hospital or clinic for treatment.
Treatments are usually 5 days a week for several weeks.
• Internal radiation (implant radiation): Thin plastic tubes (implants) that hold a radioactive substance are put directly in the breast.
The implants stay in place for several days. A woman stays in the hospital while she has implants. Doctors remove the implants before she
goes home.
Side effects depend mainly on the dose and type of radiation and the part of your body that is treated.
It is common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. These problems will
go away over time. Toward the end of treatment, your skin may become moist and "weepy." Exposing this area to air as much as possible can
help the skin heal.

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 Bras and some other types of clothing may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during
this time. Gentle skin care also is important. You should check with your doctor before using any deodorants, lotions, or creams on the treated
area. These effects of radiation therapy on the skin will go away. The area gradually heals once treatment is over. However, there may be a
lasting change in the color of your skin.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but
doctors usually advise patients to try to stay as active as they can.
Although the side effects of radiation therapy can be distressing, your doctor can usually relieve them.

Chemotherapy
Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs
may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.

Women with breast cancer can have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some
women need to stay in the hospital during treatment.

Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:
• Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood
cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, some women
have developed leukemia(cancer of the blood cells).
• Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting,diarrhea, or mouth and lip sores.
Your doctor can suggest ways to control many of these side effects.

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 Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually goes away after
treatment is over. Other problems may not go away. In some women, the drugs used for breast cancer may weaken the heart.

Some anticancer drugs can damage the ovaries. The ovaries may stop making hormones. You may have symptoms of menopause. The
symptoms include hot flashesand vaginal dryness. Your menstrual periods may no longer be regular or may stop. Some women become
infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.

On the other hand, you may remain fertile during chemotherapy and be able to become pregnant. The effects of chemotherapy on an
unborn child are not known. You should talk to your doctor about birth control before treatment begins.

Hormone therapy
Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they
need. These hormones are estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of
tumor, you may have hormone therapy.

This treatment uses drugs or surgery:

• Drugs: Your doctor may suggest a drug that can block the natural hormone. One drug is tamoxifen, which blocks estrogen. Another
type of drug prevents the body from making the female hormone estradiol. Estradiol is a form of estrogen. This type of drug is an
aromatase inhibitor. If you have not gone through menopause, your doctor may give you a drug that stops the ovaries from making
estrogen.

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 Prognosis
A prognosis is the medical team's "best guess" in how cancer will affect a patient. There are many prognostic factors associated with
breast cancer: staging, tumor size and location, grade, whether disease is systemic (has metastasized, or traveled to other parts of the body),
recurrence of the disease, and age of patient.
s Stage is the most important, as it takes into consideration size, local involvement, lymph node status and whether metastatic disease
is present. The higher the stage at diagnosis, the worse the prognosis. Larger tumors, invasiveness of disease to lymph nodes, chest wall, skin
or beyond, and aggressiveness of the cancer cells raise the stage, while smaller tumors, cancer-free zones, and close to normal cell behavior
(grading) lower it.
Lymph node status is a significant prognostic factor. Axillary lymph node involvement and the number of lymph nodes involved remain the
most important prognostic factors for invasive breast cancer. Although 75% of the lymphatic drainage from the breast goes to the axilla and
25% to the internal mammary lymph nodes, isolated metastasis to the internal mammary lymph nodes is extremely rare (~5%).
The prognosis depending on the number of axillary lymph nodes involved in patients who received adjuvant chemotherapy is as follows:
With 0 positive nodes
• Recurrence rate at 5 years - Approximately 20%
• Survival rate at 10 years - 65-80%
With 1-3 positive nodes
• Recurrence rate at 5 years - 30-40%
• Survival rate at 10 years - 35-65%
With 4 positive nodes
• Recurrence rate at 5 years - Approximately 44%

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 • Survival rate at 10 years - Not available
With more than 4 positive nodes
• Recurrence rate at 5 years - 54-82%
• Survival rate at 10 years - 13-24%
Grading is based on how cultured biopsied cells behave. The closer to normal cancer cells are, the slower their growth and a better
prognosis. If cells are not well differentiated, they appear immature, divide more rapidly, and tend to spread. Well differentiated is given a
grade of 1, moderate is grade 2, while poor or undifferentiated is given a higher grade of 3 or 4 (depending upon the scale used).
Furthermore, the 5-year survival rate based on tumor size and axillary lymph node status is as follows:
Tumor smaller than 2 cm
• Negative nodes - 96%
• One to 3 positive nodes - 87%
• Four or more positive nodes - 66%
Tumor 2-5 cm
• Negative nodes - 89%
• One to 3 positive nodes - 79%
• Four or more positive nodes - 58%
Tumor larger than 5 cm
• Negative nodes - 82%
• One to 3 positive nodes - 73%
• Four or more positive nodes - 45%

Younger women tend to have a poorer prognosis than post-menopausal women due to several factors. Their breasts are active with their
cycles, they may be nursing infants, and may be unaware of changes in their breasts. Therefore, younger women are usually at a more
advanced stage when diagnosed.

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 The presence of estrogen and progesterone receptors in the cancer cell, while not prognostic, is important in guiding treatment. Those who
do not test positive for these specific receptors will not respond to hormone therapy.

Likewise, HER2/neu status directs the course of treatment. Patients whose cancer cells are positive for HER2/neu have more aggressive
disease and may be treated with trastuzumab, a monoclonal antibody that targets this protein.

Bibliography
Book References

Ignatavicius, D.D. and M.L. Workman. 2006. Medical- Surgical Nursing: Critical Thinking for Collaborative Care. 5 th edition, volume 1. Elsevier
Science (USA)

Manual of Nursing Practice. 2006. 8th edition. Lippincott Willians & Wilkins.

Nursing Drug Handbook. 2006. 26th edition. Lippincott Willians & Wilkins

Pagana, Kathleen Deska, et.al.2002. Mosby’s Manual of Diagnostic and Laboratory Tests. 2nd edition. Mosby.

Porth, Carol Mattson. 2005. 7th edition. Pathophysiology: Concepts of Altered Health States. Lippincott Willians & Wilkins.

Black, Joyce M. et.al. 6th edition. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Elsevier Science (Singapore) PTE LTD.

Pathophysiology Concepts of Altered Health States7th ed. By Porth, Carl Mattson (LWW)

Physical Examination and Health Assessment 4th ed. by Carolyn Jarvis (Saunders)

Textbook of Medical-Surgical Nursing 9th ed. by Bare, Brenda G. & Suzanne C. Smeltzer

Internet Sources
• http://www.ehow.com/way_5554249_exercises-breast-cancer-patients.html
• http://www.cancer.org/docroot/CRI/content/CRI_2_4_5X_What_happens_after_treatment_5.asp

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 • http://www.webmd.com/breast-cancer/exercise-nutrition-after-breast-cancer-surgery?page=3
• http://www.scribd.com/doc/21707984/Breast-Cancer
• http://emeritus.blogspot.com/2006/10/breast-cancer-in-philippines.html

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