In Partial Fulfillment Of the Requirements in

RLE: University of Santo Tomas Hospital

BREAST MASS RIGHT T/C FIBROCYSTIC CHANGE/FIBRO ADENOMA

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

Submitted by:
Abrea, Armand
Cuya, John Arnold
Dacillo, Ariane May
Demohina, Mylene
Duran, Joel
Fidel, Emmanuel
Gandeza, Kim Kaela
Gatchalian, Danica
Rengel, Sheila Mea
Silang, Shirlie

Holy Trinity University

College of Health and Sciences-BS in Nursing
May 28, 2010
 Chapter I

INTRODUCTION

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

This study is delimited in terms of problem, source of data or

population, locale and time frame.

Problem:
This study focuses on “Breast Cancer”, together with the
manifestations, treatment modalities of the disease and possible nursing
care plans.

Source of Data/ Population:

The population being referred in this study is the patient, significant
others, and patient’s chart.

Locale:
The study was conducted on the Female Surgical Ward of University of
Santo Tomas Hospital.

Time Frame:
The study was performed on May 26-28, 2010 at 6:00am-12pm;
though the interventions were limited for just eight hours at the Female
Surgical Ward of USTH.

Statement of the Problem

 CHAPTER II

Personal Data

Name: Mrs. Q
Age: 32 y/o
Birthday: November 25, 1973
Gender: Female
Nationality: Filipino
Civil status: Married
Address: cluster 24 ROTC Hunters Tatalon Quezon City
Religion: Roman Catholic
Date and Time of admission: May 24, 2010-11:51 am
Chief complaint: Breast mass right
Diagnosis: Breast mass right t/c fibrocystic change/fibro adenoma
Physician: Dr. Zip
Source of data: patient’s subjective and objective cues, SO and chart
Past Medical History

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

Present Medical History

December 2009, client experienced intermittent sharp stabbing pain on right

breast, specifically on the right and left upper quadrants with Pain Scale of
4/10. No meds taken since this only last for 1-2 minutes, adequate rest
served as remedy to relieve the pain felt.
February 2010, she noticed a painful immovable mass on the right outer
quadrant of the breast approximately 1-2 cm in diameter. She decided to
consult at USTH OPD. Physical examination of breast was done and was
advised to have ultrasound. Due to financial constraints, unable to comply
needed diagnostic procedures.

March 2010, client noticed gradual enlargement of breast and decided to

come back @ USTH for follow up check up and then advised removal of
mass, have ultrasound of right breast including the axillary part and biopsy.
Due to financial constraints, only ultrasound was completed and the result
revealed 3x3 cm mass on right upper outer quadrant of breast, firm, and
immovable. She was again advised to comply biopsy and removal of mass.
Hence, these prompted admission.

Nursing History

She was delivered normally and spontaneously in cephalic presentation

assisted by a midwife. Has complete immunization status. Childhood
illnesses are cough and colds, fever, headache usually treated at home with
paracetamol, calamansi juice and adequate rest which afforded her relief.
Heredo-familial diseases are diabetes and hypertension in paternal side and
with family history of leukemia.
 SPECIFIC BASIC NEEDS

A. PERCEPTION AND EXPECTATION OF ILLNESS/ HOSPITALIZATION

“Akala ko dati basta bukol lang sya na tumubo, nung nalaman ko na cancer
ang sakit ko hindi na ko mapalagay. Natatakot ako dahil pag cancer hindi mo
alam kung mabubuhay ka pa ng normal at matagal”, as verbalized. She is
sometimes anxious about the treatment that is being done to her because it
was her first time to be brought to the hospital for admission. She still
believes and expects that hospitalization and operation will greatly make her
feel better and be back to her usual work/activities.

B. SPECIFIC BASIC NEEDS

B.1. Rest and comfort

Prior to hospitalization: Her usual sleeping pattern is 7-8 hours, usually from
9pm to 5 am. Even though she works for the whole day she always finds time
to take a nap for 1-2 hours usually at noon. She can do whatever she wants
comfortably and independently. She takes a bath everyday usually in the
morning before going to work. Form of leisure / recreation?

During hospitalization: According to her, she has an average sleeping

duration of 6-7 hours a day but with interruptions such as hospital routines
and environment. “Minsan nakakatulog din ako ng maayos pero kalimitan
talaga paputol- putol lalo na pag may iinumin akong gamot tapos medyo
kumikirot yung sugat ko at mainit pa dito”, as verbalized. Her daily hygiene
is provided by her SO.

Analysis: She is quite dependent to her SO now specially after her operation.
Her sleeping pattern is also disturbed because of hospital routines and
environment.

Nursing Diagnosis: Sleep pattern Disturbance r/t hospital routines and

environment

B.2. Safety needs

Prior to hospitalization: Their house is located at sub-urban area near in a
main highway. As verbalized, their home and environment is safe and
convenient for them. She can perform daily activities without assistance.
Client has no known visual and hearing impairments.

During hospitalization: She is sometimes dependent to her SO and health

team. Her bed is 1 m above the ground with side rails on both sides and also
pillows for support. Her SO stays with her at all times to take good care of
her, provides her needs, and doing all means to ensure her fast recovery.
GCS= 15/15 (E=4;V=5;M=6).

Analysis: There is no alterations with her safety needs.

B.3. Oxygenation

Prior to hospitalization: Their living place is adequately ventilated with trees

at the vicinity. Their house has 4 windows and facilities that can be used in
providing ventilation such as electric fans. She is exposed to second hand
smoking. No any unusualities reported.

During hospitalization: Ward has electric fans and windows. Not in

respiratory distress. Can breathe normally without the aid of oxygen
therapy. RR= 17-20 bpm.

Analysis: No alterations noted.

B.4. Fluids and Nutrition

Prior to hospitalization: Her diet is usually consist of fish, meat and

vegetables and 1 ½ -2 cups of rice. She loves to eat fish and vegetables like
fried fish, sinigang with swam cabbage and horse radish. She rarely eats
meat, once or twice a week. She drinks 7-8 glasses (approximately 1680 to
1920ml) of water/ fluids a day. She had no allergies to any food. Does she
take coffee/ juices or any snacks in between meals?

During hospitalization: As verbalized, “hindi naman nawawala ang gana ko

kumain, nauubos ko naman ang mga binibigay sakin”;consumes 1 cup of
rice, 1 serving of fish or meat, and fruit; was placed on NPO from May 25
midnight to May 26 afternoon; on May 26 night, was placed on DAT.
Consumes 4-5 cups of water approximately 840-1080 ml a day.

Analysis: Because of her present condition and environment, her eating

pattern is affected such as quality and quantity though she is on DAT.
Nursing Diagnosis:

B.5. Elimination

Prior to hospitalization: patient has normal pattern of bowel movement. She

defecates for at least once a day (time varies) to a brown, soft formed stool
in moderate amount approximately180-200cc a day and voids approximately
4-5x a day into a yellowish urine approximately 30-50cc per void.

During hospitalization: Since admission on May 24, 2010, defecated twice to

a brown well-formed stool approximately 140 to 160 cc a day, voids
approximately 3-4x a day into a yellow urine approximately 30cc/void.

Analysis: There are alterations with regards to her elimination due to

decreased physical activity.

Nursing Diagnosis: Risk for constipation r/t decreased physical mobility

B.6. Sexuality

Generally feminine in the way she appears, speaks and dressed. She is
married for 11 years and has 3 children. Able to maintain intimacy with her
husband.

B.7. Allergies
No reported allergies to any food, drugs/medicine, and pollens.

B.8. Communication
Able to speak Bisaya, Tagalog and English dialect as her language and to
express her needs.

Physical Assessment

HEENT

Mental Status: Awake, alert, oriented to person, place and time;

with GCS of 15/15

Head: Normocephalic; hair is worn long and evenly distributed along

scalp with black; approximately 8-9 inches in length; (-) lesion and scars
noted;able to rotate head up to 180 degree; free from lice, knits and
dandruff; scalp is soft to touch; hair is smooth and shiny; no tenderness;
able to feel touch on his scalp (CN V – Trigeminal intact)

Eyes: Eyebrows are 0.3 cm long and eyelids are intact, arched along bony
prominences above orbits; lashes present on upper and lower lids; (-)
swelling of lacrimal gland or duct; anicteric sclera noted; with pinkish
conjunctivae; with symmetrical pupils equally round and reactive to light
accommodation; with pupillary size of 2-3 mm on both eyes; medial
movement of both eyes, symmetric movement of eyelids observed, able to
follow moving objects (CN III – Oculomotor intact); inferior movement of the
eyes (CN IV – Trochlear intact); lateral movement of eyes (CN VI – Abducens
intact)

Ears: Same color with the facial skin; top of pinna in line with the outer
canthus of the eye; moderate amount of cerumen on both ears; no
discharge; responsive to sound stimuli and able to count sound provided (CN
VIII – Acoustic intact)

Nose: Symmetrical; with patent nares, (-) nasal flaring noted; septum
at midline, straight and intact; slightly pointed; mucosa pale pink in color;
able to identify 2 different smell (CN I - Olfactory is intact)

Mouth/Throat: Lips are intact in reddish color; pinkish buccal mucosa

membrane; able to stick out tongue and (-) deviation noted (CN XII –
Hypoglossal intact); with gag and swallowing reflexes, able to speak and
cough; able to chew (CN – Trigeminal V intact); uvula intact at the midline of
nasopharyngeal cavity; with grade 0 of tonsil; regular equal carotid pulses;
trachea at the midline; (-) palpable non tender lymph nodes; thyroid and
parathyroid are not inflamed; (+) gag reflex (CN IX – Glossopahryngeal
intact)

Chest and Lungs

Inspection:
With fair complexion; downward equal slope of ribcage noted,
anteroposterior diameter less than transverse diameter with approx. ratio of
1:2; dark brown areola noted on left breast with a diameter of approximately
4-5mm;; with symmetrical thoracic excursion during respiration;
diaphragmatic breathing noted, RR- 17-21 cpm with regular deep breathing
pattern; right and left shoulder are at the same height;
Right Breast: with post operative wound on right chest approximately 26 cm
in length secondary to removal of right breast and lymph nodes on right
axilla; with jackson pratt inserted @ right axilla area draining to
approximately 30 cc level into a bloody discharge
Left Breast: intact; everted nipple; areola is rounded with dark-brown color;
(-) dimpling of nipple noted; (-) orange peel skin observed; (-) lesion; no
discharge, visible mass and retraction seen
Palpation:
Posterior – with equal tactile fremitus on both lung fields
Anterior – uniform temperature on the anterior thorax noted; skin intact; (-)
palpable mass on all quadrants of the breasts including the axilla; (-)
tenderness on left breast upon palpation
Percussion:
Resonant sound heard on anterior lung fields only upon percussion at
intercostals spaces
Auscultation:
Wheezing sound heard on both lung fields
Heart sounds: S1-S2 sounds heard over 5th midclavicular intercostals spaces;
cardiac rate of 72 bpm

Abdomen
I – With fair complexion; convex abdomen noted; (+) symmetric movement
during respiration; visible abdominal pulsation
A – With active hypoactive bowel sounds @ 20-30 seconds interval per
minute of the peri-umbilical region
P – Dullness heard upon percussion of the RUQ and LUQ
P – Soft to touch, non-tender, rounded abdominal contour

Genito-Urinary
Unable to perform thorough physical assessment

Skin-Extremities/Musculoskeletal

Fair complexion on her upper and lower area; complete digits of both upper
and lower extremities; pale nail beds noted with capillary refill of 1-2 seconds
of all extremities; clubbing of finger nails; (+3-easy to palpate) radial and
brachial pulses of both upper extremities; (+3-easy to palpate) popliteal and
dorsalis pedis pulse of the right lower extremity, and dorsalis pedis pulse of
the left leg; with apical pulse of 72bpm, radial pulse of 71bpm and dorsalis
pedis of 70bpm (with pulse deficit of 1-2bpm); with BP ranging from
80/60mmhg to 100/60mmhg (with pulse pressure of 20-40mmhg); with
muscle grade of 4/5 on both upper and lower extremities; cold clammy skin
to touch; heplock is inserted at left basilic vein; no edema formation seen;
(+) triceps, biceps, knee jerk and ankle jerk reflexes; (+) pain right upper
extremity upon moving.

General Condition

Conscious and coherent with GCS of 15; with post-operative wound on her
right chest approximately 26 cm long secondary to surgical removal of right
breast and lymph nodes in axilla; dry mouth noted; irritability observed; with
poor eye contact; frequent questioning; staring with blank mood and affect;
for recovery.

DEVELOPMENTAL TASKS
PSYCHOSOCIAL THEORY BY ERIK ERIKSON
STAGE DEV’TAL BOOK PROFILE ACTUAL PROFILE
TASK
Infancy Trust vs. An individual can At age 0-18 months,
(0-18 Mistrust differentiate self she was close in
months) from the bonding with her
environment and mother most due to
begin to develop her dependence. Her
 self-concept and basic needs are
relationship with immediately
the caring person. attended by her
mother.
Toddler Autonomy An individual During toddlerhood,
(18 vs. Shame learns to control she was toilet-
months – & Doubt bowel and begin to trained. She began
3 years develop his/her to learn language
old) identity. Also, it is skills. She has also
a stage on which begun to develop
he develops motor independence by
skills and learns to learning to feed
talk. herself and dress her
own.
Pre- Initiative An individual She was informed
schooler vs. Guilt begins to relate that she was fond of
(3-6 with another or learning new things
years play with the same through experiences
old) age children. He and exploring. She
also begins to was not restricted for
fantasize about the seeking new
future and ask learning. She was
“why”. allowed to play with
the other children of
the same age.
School Industry A person starts to At this stage, certain
age (6-12 vs. have mastery of responsibilities were
years Inferiority skills and work. already expected of
old) Intellectual growth her (i.e. simple
sets in. household
chores).Her parents
gives her recognition
for every
accomplishment she
had done .He was
also able to gain
more friends in
school and
participate in school
activities
Adolesce Identity An individual She became more
nts (12- vs. Shame learns to have bonded to her
18 years & Doubt sense of self. friends rather than
old) with her family at
this stage but her
bond with her family
 was still felt. She
started to seek self
identity through
going out with
friends.
Young Intimacy Learn to establish At this stage, she
Adult vs. relationship with began to build a
(19-28 Isolation partner. Gratifying family of her own.
years social relationship. She met her
old) husband and they
were married. They
have three children.
Middle Generativ Generativity is At this age, she
Adult ity vs. reflected in the helps in the finances
(28-41 Stagnatio individual of her family. She
years n establishment and her husband
old) building the next provides their basic
generation. A needs such as food,
negative revolution shelter, clothing and
is self-absorption education. She is the
and result in sense one who does the
of stagnation. budgeting of their
finances.
 Chapter III

LABORATORY EXAMS & DAGNOSTIC PROCEDURE

Complete Blood Count (CBC)

Rationale: RBCs, HGB, and HCT are important to the oxygen-carrying

capacity of the blood; WBCs are indicators of immune function
Date ordered: May 24, 2010
DIAGNOSTIC RESULT NORMAL INTERPRETATION RATIONALE
PROCEDURE VALUES
S
Hemoglobin 124g/L 120- Within normal To determine the
(Hgb) 170g/L range which amount of Hgb in
indicates the blood and is a
sufficient oxygen good indicator of
supply in the the blood’s ability
body though to carry O2
capillary refill is throughout the
normal. body.
Hematocrit 0.37 0.37-0.54 Within normal To measure the
(Hct) range which space (volume) of
indicates plasma occupied
sufficient volume by the RBC.
of RBC contained
in a given plasma
MCV 91 87+-5 u^3 Result is within The MCV
the normal range, describes
which indicates individual red cell
that there is size. It is the ratio
neither anemia of the volume of
nor any liver packed cells to
diseases or folate the red cell count.
or vitamin B12
deficiencies.
MCH 33.9 29 Above normal MCH measures
 +-2 pg range. the weight of
hemoglobin in an
average red cell.
It is related to
MCV, because the
weight of a red
blood cell
increases when its
amount of
hemoglobin, and
therefore its size,
increases.
MCHC 33.9 34+-2 g/dL Within normal MCHC measures
range which the portion of
implies normal hemoglobin in an
count of Hgb in average cell. It is
an average cell. the ratio of the
weight of
hemoglobin to the
volume of red
blood cells.
Platelet 204 x 10 150-450x Within the normal To determine
g/L 10 g/L range indicating capability of the
effective blood body to maintain
coagulation. endothelial
integrity, to
release a
substance that
begins the
coagulation
process. Along
with fibrin, they
form the network
for a clot to form,
necessary in
wound healing
Differential
count:
Lymphocyte 0.36 0.20-0.40 Within normal, Resides at
s indicating lymphatic tissues,
effective ability to where they play
develop immune an important role
response. in the immune
 response. This is
to determine to
identify the body’s
ability to develop
immune response
against invading
pathogens.
Monocytes 0.01 0.00-0.07 Within normal To determine
range indicating number of WBC
sufficient ability capable of
to engulf engulfing
pathogens. pathogens.
Eosinophils 0.04 0.00-0.05 Within normal To determine any
range, which parasitic infection.
indicates no
presence of
parasitic
infection.
Neutrophils 0.59 50-70% within normal, To determine
which indicates body’s capability
adequate second to fight against
line defense invading infection
against infection. through
phagocytosis.

X-ray of Chest
Date ordered: May 24, 2010
Impression: Consider cavitary Koch’s infection common entirely rule out
concomitant pneumonia minimal volume loss, ® upper lobe
Rationale: To visualize underlying organs through indirect visualization.

ECG
Date ordered: May 24, 2010
Impression: Normal Sinus Rhythm
Rationale: To detect and monitor abnormalities in heart rate and rhythm.

ABO group/RH typing

Date ordered: May 25, 2010
Result: AB positive
Rationale: To determine the compatibility of the blood

Frozen section report

Date ordered: May 26, 2010
Impression: Invasive Ductal Carcinoma
Rationale: to confirm the malignancy of the mass

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

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

The mammary gland

is a milk-producing structure that is composed largely of fat cells (cells
capable of storing fat). The fat deposits are laid down in the breast under the
 influence of the female hormone estrogen. Just as the surge of estrogens at
adolescence encourages this process, androgens, such as testosterone,
discourage it.
Within the mammary gland there is a complex network of branching ducts
(tubes or channels). These ducts exit from sac-like structures called
lobules.The lobules in the breast are the glands that can produce milk in
females when they receive the appropriate hormonal stimulation. The breast
ducts transport milk from the lobules out to the nipple. The ducts exit from
the breast at the nipple.
Human breasts function somewhat differently than those of other primates.
In other primates, the breasts grow only when the female is producing milk
(lactating). When the non-human primate female has weaned her young, her
breasts flatten back down. In humans, the breasts develop at adolescence
usually well before any pregnancy has occurred and the breasts stay
enlarged throughout the remainder of life.

During pregnancy the breasts grow further. This growth is much more
uniform than that at adolescence. The breasts of women with small breasts
tend to grow about as much during pregnancy as those of women with large
breasts. The amount of milk-producing tissue is essentially the same. This is
the reason that when milk production begins, small-breasted women produce
as much milk as do large-breasted women.

The nipple becomes erect because of such stimuli as a cold environment,

breastfeeding, and sexual activity. The nipple of the post-partum female is
used by the infant to breastfeed.
The small darkened (pigmented) area around the nipple is called the areola.
(The word "areola" is the diminutive of the Latin "area" meaning a small
space.) In pregnancy the areola darkens further and spreads in size. The
areola contains small modified sweat glands (Montgomery's glands) that
secrete moisture that acts as a lubricant for breastfeeding.

The lobules and ducts in the breast are supported by surrounding fatty tissue
and the suspensory ligaments of the breast. There are no muscles in the
breast. The characteristic bounce of the breast comes from the elasticity of
the matrix of connective tissue fibers in the breast.

There are blood vessels and lymphatics in the breast. The lymphatics are
thin channels similar to blood vessels; they do not carry blood but collect and
carry tissue fluid which ultimately re-enters the blood stream. Breast tissue
fluid drains through the lymphatics into the lymph nodes located in the
underarm (axilla) and behind the breast bone
Pathophysiology
 MEDICAL MANAGEMENT
IVF THERAPY
Date Name of Type of Indication
Ordered Solution Solution
May 26,
2010
PLRS Isotonic Volume expanders with
500ml osmolarity almost the
same as serum, thus they
stay inside the
intravascular
compartment.

DIET THERAPY

Type of Diet Date Rationale

Ordered
NPO May 25, This diet restricts the client from intake
(Nothing 2010 of foods or fluids by mouth and to serve
per Orem) as a preparation for upcoming surgical
procedure.

DAT (Diet as May 26, This diet would not restrict patient in
tolerated) 2010 eating foods which he needs in order to
maintain body requirements such as
carbohydrates, proteins, vitamins and
minerals including fluid and
electrolytes. This is also to support his
immune system in fighting against
opportunistic microorganisms.
Others
 Type of Date Ordered Rationale
contraptions
Jackson Pratt May 25, 2010 It is use to remove
fluids that build up in
areas of body.
Unwanted fluid can
collect in areas of
infection, areas
where surgery has
been done.
Heplock May 26, 2010 This will serve as a
route for medication
administration.

Surgical procedure:
Total Mastectomy
Date performed: May 26, 2010
Rationale: to remove the mass and entire affected part to prevent
complications

MEDICATION THERAPY

Date ordered: May 25, 2010

Generic name: ranitidine hydrochloride
Brand name: Zantac
Pharmacologic class: Histamine 2-receptor antagonist
Therapeutic class: Antiulcer drug
Dosage:
Usual dose: 150 mg IV b.i.d
Actual dose: 150 mg IV STAT
Available forms:
Capsules (liquid-filled): 150 mg, 300 mg
Solution for injection: 25 mg/ml in 2, 6, and 40 ml vials
Syrup: 15 mg/ml
Tablets: 150 mg, 300 mg

Indications
To reduce risk of duodenal ulcers
Action
Reduces gastric acid secretion and increases gastric mucus and bicarbonate
production, creating protective coating on gastric mucosa and easing
discomfort from excess gastric acid.
Side effects:
CNS: headache, dizziness
GI: abdominal pain, nausea, vomiting, constipation, flatulence, abdominal
discomfort
 Skin: rash.
Adverse reactions
Hepatic: Hepatitis
Hematologic: reversible granulocytopenia, thrombocytopenia
Interactions:
Drug-drug
Antacid: May decrease ranitidine absorption.
Drug-diagnostic test:
Creatinine: slight elevation
Contraindications
Contraindicated in patients hypersensitive to drug or its components.
Nursing considerations
 Assess patient’s vital signs
 Monitor CBC and liver function test
 Monitor intake and output
 Instruct patient to take drug oral drug with or without food.
 Caution patient to avoid hazardous activities if he gets dizzy.
 Advise patient to report abdominal pain and blood in stool or emesis.

Rationale:
This drug is given in order prevent possible ulceration.
Date ordered: May 25, 2010
Generic name: albuterol sulfate
Brand name: Combivent
Pharmacologic class: Symphatomimetic (beta2-adrenergic agonist)
Therapeutic class: Bronchodilator, antiasthmatic
Dosage:
Usual dose: 2.5 mg/neb. TID
Actual dose: 1 neb. STAT
Available forms
Capsules for inhalation: 200 mcg‡
Solution for inhalation: 0.083%, 0.5%, 0.63 mg/ml, 1.25 mg/3 ml
Syrup: 2 mg/5 ml
Tablets: 2 mg, 4 mg
Tablets (extended-release): 4 mg, 8 mg

Indications
To prevent or treat bronchospasm in patients with reversible obstructive
airway disease
Action
Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta2
receptors.

Side effects:
CNS: nervousness, dizziness, headache, weakness
CV: tachycardia, hypertension.
GI: nausea, vomiting
Musculoskeletal: muscle cramps.
Respiratory: cough, wheezing, dyspnea, bronchitis

Adverse reactions
Respiratory: bronchospasm
Others: hypersensitivity reactions

Interactions
Drug-drug
CNS stimulants: May increase CNS stimulation. Avoid using together.
Digoxin: May decrease digoxin level. Monitor digoxin level closely.
MAO inhibitors, tricyclic antidepressants: May increase adverse CV effects.
Monitor patient closely.
Propranolol, other beta blockers: May cause mutual antagonism. Monitor
patient carefully.
Drug-diagnostic test:
Potassium: may decrease level.

Contraindications
Contraindicated in patients hypersensitive to drug or its components.

Nursing considerations
 Teach patient to perform oral inhalation correctly. Clear nasal
passages and throat.
 Breathe out, expelling as much air from lungs as possible.
 Instruct patient to notify prescriber immediately if prescribed dosage
fails to provide usual relief, because this may indicate seriously
worsening asthma.
 Hold breath for several seconds, remove mouthpiece, and exhale
slowly.
 Tell patient to remove canister and wash inhaler with warm, soapy
water at least once a week.

Rationale:
Combivent is a bronchodilator that relaxes muscles in the airways and
increases air flow to the lungs. The client was given to treat or prevent
bronchospasm with reversible obstructive airway disease.

Date ordered: May 25, 2010

Generic name: cefuroxime axetil
Brand name: Ceftin
Dosage:
Usual dose:
Actual dose: 75 mg IV
Available forms
Suspension: 125 mg/5 ml, 250 mg/5 ml
Tablets: 125 mg, 250 mg, 500 mg

Indications
Skin and skin-structure infections,; Perioperative prevention
Action
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting
osmotic instability; usually bactericidal.

Side effects
CNS: headache
GI: nausea, vomiting, abdominal pain
Skin: maculopapular and erythematous rashes, urticaria, pain, induration,
sterile abscesses, temperature elevation, tissue sloughing at I.M. injection
site.
Other: hypersensitivity reactions

Adverse reactions
CNS: seizures
Hematologic: anemia, hemorrhage

Interactions
Drug-drug
Aminoglycosides: May cause synergistic activity against some organisms;
may increase nephrotoxicity. Monitor patient's renal function closely.
Loop diuretics May increase risk of adverse renal reactions. Monitor renal
function test results closely.
Drug-food
Any food: May increase absorption. Give drug with food.
Drug-diagnostic test:
ALT, AST, alkaline phosphatase, bilirubin, and LDH levels: may increase
levels
Hemoglobin, hematocrit, neutrophil, platelet: may decrease level

Contraindications
Contraindicated in patients hypersensitive to drug or other cephalosporins;
Use cautiously in patients hypersensitive to penicillin because of possibility
of cross-sensitivity with other beta-lactam antibiotics.

Nursing considerations
 Before administration, ask patient if he is allergic to penicillins or
cephalosporins.
  Absorption of cefuroxime axetil is enhanced by food.
 Cefuroxime axetil tablets may be crushed, if absolutely necessary, for
patients who can't swallow tablets. Tablets may be dissolved in small
amounts of apple, orange, or grape juice or chocolate milk. However,
the drug has a bitter taste that is difficult to mask, even with food.
 Instruct patient to notify prescriber about rash or evidence of
superinfection.
 Advise patient receiving drug I.V. to report discomfort at I.V. insertion
site.
 Tell patient to notify prescriber about loose stools or diarrhea.

Rationale:
This was given as prophylaxis for possible infection for upcoming
surgical procedure.

Date ordered: May 26, 2010

Generic name: ketorolac tromithamine
Brand name: Acular
Pharmacologic class: Nonsteroidal anti-inflammatory drug (NSAID)
Therapeutic class: Analgesics, antipyretic, anti-inflammatory
Dosage:
Usual dose: 30 mg IV q 6 hours
Actual dose: 30 mg IV q 6 hours

Available forms
Injection: 15 mg/ml in 1 ml preloaded syringes, 30 mg/ml in 1 and 2 ml
preloaded syringes
Tablets: 10 mg
Indications
Moderately severe pain

Action
Interferes with prostaglandin biosynthesis by inhibiting cylooxygenase
pathway of arachhidonic acid metabolism; also acts as potent inhibitor of
platelet aggregation.

Side effects:
CNS: drowsiness, dizziness, headache
GI: nausea, constipation, vomiting, epigastric pain, flatulence, stomatitis
Skin: diaphoresis, rash.
Adverse reactions
Hematologic: thrombocytopenia

Interactions
Drug-drug
Anticoagulants: prolonged prothrombin time
Corticosteroid, other NSAID’s: additive adverse GI effects
Diuretics: decreased diuretic effect
Drug-diagnostic test:
Bleeding time: prolonged for 24 to 48 hours after therapy.

Contraindications
Contraindicated in patients hypersensitive to drug, its components, aspirin,
or other NSAID’s; peptic ulcer disease; advanced renal impairment

Nursing considerations
 Monitor for adverse reactions, especially prolonged bleeding time and
CNS reaction.
 Monitor fluid intake and output
 Advise patient to minimize GI upset by eating small, frequent serving
of healthy foods.
 Instruct to avoid any hazardous activity until she knows how drug
affect concentration and alertness.
 Tell patient to take drug as prescribed and not to increase dose or
dosage interval unless ordered by prescriber.
 Warn patient not to stop the drug abruptly.

Rationale:
The patient was given with this drug to relive pain caused surgery.

Date ordered: May 26, 2010

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

Available forms
Capsules: 100 mg, 200 mg

Indications
Rheumatoid arthritis

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

Side effects:
CNS: dizziness, headache, insomnia.
EENT: rhinitis, sinusitis.
GI: abdominal pain, dyspepsia, flatulence, nausea.
Musculoskeletal: back pain.
Skin: rash.
Adverse reactions:
CNS: stroke
GI: GI bleeding
GU: renal failure
Hematologic: neutropenia, leukopenia, thrombocytopenia,
granulocytopenia
Interactions
Drug-drug
Aspirin: May increase risk of ulcers; low aspirin dosages can be used safely to
reduce the risk of CV events. Monitor patient for signs and symptoms of GI
bleeding.
Furosemide, thiazides: May reduce sodium excretion caused by diuretics,
leading to sodium retention. Monitor patient for swelling and increased blood
pressure.
Warfarin: May increase PT and bleeding complications. Monitor PT and INR,
and check for signs and symptoms of bleeding.
Drug-diagnostic test:
BUN, ALT, AST, and chloride: may increase levels
phosphate : may decrease level

Contraindications
Contraindicated in patients hypersensitive to drug, sulfonamides, aspirin, or
other NSAIDs; in those with severe hepatic impairment.

Nursing considerations
 Alert: Patients may be allergic to drug if they are allergic to or have
had anaphylactic reactions to sulfonamides, aspirin, or other NSAIDs.
 Patient with history of ulcers or GI bleeding is at higher risk for GI
bleeding while taking NSAIDs such as celecoxib. Other risk factors for
GI bleeding include treatment with corticosteroids or anticoagulants,
 longer duration of NSAID treatment, smoking, alcoholism, older age,
and poor overall health.
 Watch for signs and symptoms of overt and occult bleeding.
 NSAIDs such as celecoxib can cause fluid retention; monitor patient
with hypertension, edema, or heart failure.
 Drug may be hepatotoxic; watch for signs and symptoms of liver
toxicity.
 Before starting drug therapy, rehydrate dehydrated patient.
 Drug can be given without regard to meals, but food may decrease GI
upset.
 Instruct patient to promptly report signs of GI bleeding such as blood in
vomit, urine, or stool; or black, tarry stools.
 Advise patient to immediately report rash, unexplained weight gain, or
swelling.

Rationale: It was given to relieve pain.

Chapter V

Prioritization of Nursing Problems

1. Acute moderate intermittent pain

R/T surgical procedure (total mastectomy)

2. Sleep pattern disturbance r/t pain

3. Mild Anxiety r/t perception of condition

4. Impaired Skin Integrity r/t destruction of 1st to 3rd layers of skin

s/t post operative wound

5. Risk for Infection R/T destruction of first line defense

secondary to post total mastectomy

 Assessment Statement of Planning Nursing Outcome
Problem Intervention
S: “Masakit na Acute moderate Established trust “medyo nawawala
parang tinutusok intermittent pain STG: at the end of and rapport. na yung sakit sa
ang sugat banda sa R/T surgical 1 hour, will be able ®to gain trust and kili-kili ko”,
kili-kili ko kapag procedure (total to demonstrate rapport to effective Latest PS= 5/10;
ginagalaw ” as mastectomy) measures that will assessment and semi fowler’s in
verbalized. decrease pain intervention. position when last
Definition: sensation as seen.
Pain Scale: 7/10 evidenced by a Accepted
It is unpleasant decreased PS from description of pain. STG: met
O: sensory and 7/10 to at least ®Pain is a LTG: Partially met
-Slightly pale in emotional 5/10. subjective
appearance experience arising experience and
-grimaced face from actual or LTG: at the end of cannot be felt by
noted potential tissue 2 days, will be able others.
-guarding damage or describe to continually Encouraged
behaviour noted in terms of such demonstrate verbalization of
- with the incision damage. measures that will feelings about the
site @ right breast lessen and manage pain felt.
approx. 26 cm Background pain sensation. ®allows outlet of
-With JP drain of Theory: According for emotions and
30cc to Virginia may enhance
-Vital signs of: Henderson the coping mechanism.
BP-100/60 unique function of Provided comfort
PR-78 the nurse to assist measures such as
RR-19 the individual, sick deep breathing
T-36.8 or well, in the exercise.
performance of ®These measures
those activities reduce muscle
contributing to the tension or spasm;
 health or its redistribute
recovery (or to a pressure in the
peaceful death); body part and help
that he would focus on non pain
perform unaided if related matters.
he has the Encouraged to talk
necessary strength, with SO.
will or knowledge, ®to divert
and to do this in attention from pain.
such a way as to Instructed
help him gain adequate rest
independence as period.
rapidly as possible. ®rest may improve
pain tolerance and
reduce oxygen
consumption.
Dependent:
PRN medications
given by NOD
®to relieve pain
 Assessment Nursing Planning Interventions Evaluation
Diagnosis

Subjective cue: Risk for STG: Independent STG:

none Infection R/T At the end of 2 1. Performed hygienic measures SO ensured
destruction of hrs nursing such as bedside care clean bedside;
Objective cues: first line intervention will ®This promotes cleanliness and Jackson Pratt
defense be able to, lessens harboring of drained by
> with post- secondary to demonstrate microorganism from the client’s NOD
operative wound post total assistive environment. Consumed 840
on her right chest mastectomy measures to to 1, 080 of
approximately 26 prevent 2. Demonstrated proper hand fluids a day
cm long secondary Definition: infection washing technique and
to surgical At increased risk instructed to perform this
removal of right of being invaded frequently.
breast and lymph by pathogenic LTG: ® Hand washing procedure is a
nodes in axilla microorganisms At the end of 2 first line defense to prevent
days nursing transfer of microorganism. To
> destruction of Background intervention, will prevent cross-infection.
skin integrity (1st Knowledge: be able to
to 3rd layers of the According to continue to 3. Instructed client not to touch
skin) Florence demonstrate with bare hands the post-
Nightingale, measures to operative site.
> Skin color is Nursing is the act prevent ® promotes cleanliness and
slightly pinkish of utilizing the infection harboring of microorganisms.
around the post-op environment in through the use
wound area. order to hasten of assistive 4. Explained the importance of
the patient’s measures and proper changing of wound
> use of steel recovery. show no further dressing and maintained dry and
staples inflammatory clean the affected site.
signs. ® to prevent hindering of
>JP drainage of microorganisms
approx. 30 cc level

5. Jackson Pratt kept intact and

advised SO to inform the NOD
when it is almost full.
® to facilitate drainage and to
prevent ascending affection.

6. Instructed to increase OFI to

 Assessment Nursing Planning Interventions Evaluation
Diagnosis

Subjective cue:
none Impaired Skin STG: at the end Post op intervention: Amenable to
Integrity r/t of 30 minutes interventions
Objective cues: destruction of nursing 1. Elevate the post op site done AEB “lagi
1st to 3rd intervention the with one pillow na akong
> with post- layers of skin patient will be magpapabili ng
operative wound s/t post able to verbalize R: to facilitate drainage orange”;
on her right chest operative ways to maintain
approximately 26 wound skin integrity and 2. Proper wound > seen eating
cm long secondary fast wound dressing ,change done orange fruits.
to surgical removal healing. aseptically
of right breast and
lymph nodes in Definition: R: to prevent further
axilla complication
Destruction of LTG: @ the end of
> destruction of integumentary 3 days nursing 3. Encouraged early
skin integrity (1st to system (skin interventions, will ambulation/mobilization
3rd layers of the layres) be able to
skin) demonstrate R: promotes circulation
ways for timely and reduces risks
> Skin color is wound healing associated eith immobility
slightly pinkish Background without any signs
around the post-op 4. Instructed patient to
wound area. Knowledge of infection. increase intake of fluids

> use of steel Lydia Hall, R: increase fluid to prevent

staples dehydration in and aid in
Nursing centre circulating blood volume
>JP inserted @ around three
right in axilla part components of 5. Encouraged to eat foods
drain approx. 30 cc CARE, CORE, rich in vitamin C such as
level and CURE. Care fruits such as orange and
represents calamansi
nurturance and
exclusive to R: to increase and boost
nursing. Core immune system and for
involves fast wound healing
therapeutic use
self and 6. advised to have high
emphasizes the protein diet intake
use of
reflection. Cure R: for timely wound
focuses on healing and tissue repair
nursing related
to the 7. kept dressing clean and
physician’s dry
orders.
R: to prevent further
complication like infection

8. maintained Jackson
pratt on the site of
operative wound

R: to facilitate drainage
 Assessment Nursing Planning Intervention Evaluation
Diagnosis

Subjective cue:
Mild Anxiety STG: at the end 1. Established therapeutic Display (+)
“Nung nalaman r/t perception of 8 hours relationship response on the
ko na cancer ang of condition nursing interventions
sakit ko hindi na interventions R: to facilitate trust and made AEB
ko mapalagay. will be able: rapport “salamat pala sa
Natatakot ako impormasyon na
dahil pag cancer Definition: 1. Verbalize 2. V/S taken and recorded binahagi nyo sa
hindi mo alam feelings about akin,
kung mabubuhay Vague uneasy her condition R: to assess any changes in
ka pa nang feeling of vital signs > passive and
normal at discomfort or 2. Identify active ROM
matagal”, as dread support system 3. Accepted client as is exercise seen
verbalized. accompanied by effectively doing and while
autonomic R: to promote belongingness on assessing
response (the
source often 4. Active listening and talking > participated in
Objective cues: nonspecific or LTG: at the end performing DBE
unknown to the of 2 days R: to establish therapeutic
 dry mouth individual) nursing relationship > asleep when
noted interventions, last seen
 irritability will be able to: 5. Encouraged to
observed acknowledge and express
 poor eye Background 1. Appear and verbalization of feelings
contact Knowledge: relaxed and about her condition
 teary eyes report of feeling
noted anxiety R: to further assess feeling of
anxious
 frequent
2. Demonstrate
questioning
healthy ways to 6. Provided accurate
 staring with
deal with and information about the
blank mood and
express anxiety condition
affect
 with BP R: to aid in self-awareness
ranging from
80/60mmhg to 7. Performed DBE
100/60mmhg
 Assessment Nursing Planning Nursing Interventions Evaluation
Diagnosis
Subjective: Sleep STG: at the end • V/S taken and recorded STG: The client
“Nahihirapan akong pattern of 2hrs. nursing R:for baseline data identify
matulog sumasakit disturbance intervention the individual
pa kasi tong sugat r/t pain patient will be • Placed in comfortable appropriate
ko tapos minsan able to semi-fowlers position intervention to
nasasagi pa ng verbalized and bed side care done promote sleep
braso ko kaya understanding R:to promote comfort such as
nagigising ako”. Definition: of sleep drinking 1
disturbance • Instructed to drink a glass of milk;
Objective: A disruption in glass of warm milk BP of
the before sleeping 100/60hmmg
• Received individual’s R:milk contain tryptophan
awake on usual diurnal LTG: at the end that helps to promote LTG: The client
bed in sitting pattern of of 2 days sleep reported
position; sleep and nursing improvement
• Post-op wakefulness intervention the • Discussed effective of sleep & rest
wound on that may be patient will be appropriate bed time pattern
right breast temporary or able to rituals such as reading
approximatel chronic achieved and listening to music
y 26 cm; optimal amount R: to enhance clients
• Restlessness of sleep as ability to fall asleep
noted evidenced by
• With frequent rested • Performed Sponge
blinking of appearance bathing and oral care
eyes noted; and and changed into light
improvement in clothing
• (+) dark
sleep pattern
circles under
eyes ; R: to facilitate fresh
• With frequent feeling and promote
yawning comfort and relaxation
• Bp of 100/60
hmmg • Provided room air
ventilation

R: to promote comfort

• Straighten linens and

puff pillows

R: to provide comfort and

prevent body irritants
 DISCHARGE PLAN

Assessment Statement of Nursing Expected

problem Planning Intervention Outcome
S: “Ano pa ba ang Readiness for STG: At the end of To demonstrate
pwedeng enhanced 1 hour will be able See separate page activities that could
makatulong sa akin Therapeutic to verbalized for intervention. promote health.
paglabas ko rito?” Regimen understanding
as verbalized. Management R/T about treatment
(to be developed) regimen.
O: Frequent
questioning Definition: A LTG: At the end of
regarding pattern of 3 days will be able
treatment regulating and to demonstrate
modalities. integrating into activities that will
daily living a aid in health
program for promotion.
treatment of illness
and its sequelae
that is sufficient for
meeting health-
related goals and
can be
strengthened.

Background
Theory:
Imogene King’s
Nursing as a
helping profession
that assist
individual and
groups to attain,
maintain and
restore health.
INTERVENTIONS
 Nursing Intervention
Medication:
Continue taking prescribed home
medication if any.
Exercise
 Encourage performing moderate
exercise such as walking and limited
ROM like flexion, extension &
hyperextension of arms, feet, wrist,
neck.
 Perform breathing exercise.
Treatment
 Change wound dressing regularly
Health Teaching
 Encourage to perform self-care
activities daily such as bathing.
 Practice proper Hand washing.
OPD
 Advised to have follow-up check after
discharge
Diet
 Eat foods rich in vitamin C such as citrus
fruits, proteins such as eggs and meat
products
Instruct the patient to follow special diet
as ordered.
Spiritual
 Encouraged to pray and always seek
God’s help, always have faith that
everything has a purpose and it happens
according to God’s will
Rationale
® To ensure that the patient will achieve the
desired effect of the medications.
® To promote good circulation and
relaxation; Promotes rapid recovery.
®To promote oxygen supply thereby relaxes
muscle and relieves anxiety.
® To prevent the growth of microorganisms
and possible complications.
® To promote a sense of well being
® bathing promotes good circulation of in the
body
® To prevent transfer of microorganisms and
spread of infection.
® To further evaluate clients health status
after discharge and to monitor progress.
® To provide positive nitrogen balance to aid
in healing process and boosts resistance
against infection
®To regain strength
® To maintain appropriate sugar level
® To strengthen faith that will help in healing
process.