Ateneo de Davao University
College of Nursing
A Case Presentation
On
Breast Cancer
In Partial Fulfillment of the Requirements in Related Learning Experience
Submitted to:
Ms. Kristina Concepcion, RN
Clinical Instructor
Submitted By:
Jonna Lisa M. Lagdameo
BSN- 4E
Date Submitted:
January 27, 2010
Acknowledgement
This case study has provided me new knowledge and ideas to understand the
condition that most women have and suffer.
With the following people, this case study has been successfully completed and
was made possible:
First, my co-worker, Jesus Christ for guiding me through and enlightening my
path by giving me enough patience and persistence to do this case study with optimism
and confidence.
Second, I would like to thank my family, for making me take up nursing and get
through this individual case presentation, for having served as my reason to strive harder
to be a successful person and for making my life complete and my journey worth beyond
a lifetime.
Third, I would like to extend my gratitude to my clinical instructors for guiding
me and correcting all my mistakes which served as lessons and for being a part of the
challenges of my basic foundation in this world of health care.
Fourth, I am grateful to the hundreds of authors of my references for about 3 years
of making a case study, whose works served as my substance and inspiration from which
I derived my answers and rationales.
Lastly, to the DMSF staff for guiding me in copying and carrying out the Doctor’s
Orders and for teaching us to become a good nurse that practice ideal nursing skills and
to my group mates from group 3 of sections F and E, you made my life happy on my
entire nursing life.
DAGHANG SALAMAT!
Introduction
“Women agonize... over cancer; we take as a personal threat the lump in every
friend's breast. “ ~Martha Weinman Lear, Heartsounds
All women are at risk, approximately 70% of breast cancers occur in women with
none of the known risk factors. Only about 5% of breast cancers are inherited, about 80%
of women diagnosed with breast cancer will be the first to be victims in their families. It
is the leading killer of women ages 35 to 54 worldwide, more than a million women
develop breast cancer without knowing it and almost 500,000 die from it every year. One
out of 4 who are diagnosed with breast cancer die within the first 5 years. No less than
40% die within 10 years. The incidence of breast cancer has been rising for the past 30
years, and the supposed authorities and experts that should know, do not know why.
The grim fact” for every 2 new cancer cases diagnosed annually, one will die
within the year”.
In the UK 30,000 new cases of breast cancer are diagnosed each year making this the
commonest malignancy in women and causing nearly 15,000 deaths per year. Randomized
studies of prevention strategies particularly with the anti-oestrogens Tamoxifen and more
recently raloxifene, and retinoids have either been completed or are on-going. The final
analysis is awaited but it is likely that effective preventive measures will be available in the
not too distant future.
In Asia, the Philippines has the highest reported incidence rate of breast cancer.
From 43.2 in 1993-1995, the age- standardized incidence rate (ASR) is now 47.7 per
100,000 females, and this figure exceeds the rate reported for several Western countries,
including Spain, Italy and moset European countries.
Many breast cancers are diagnosed among 35 to 50-year-old Filipino women. In
terms of breast cancer detection, a local study revealed that the use of breast self-
examination (BSE) and aspiration biopsy/open biopsy are the most cost-effective
strategies in the Philippine setting, incurring savings for the government by almost 3
million Philippine Pesos or US $60,000 (1989 value) per year per 100,000 women.
Mammography is neither readily available nor affordable especially in the rural areas.
Cancer site 1980–82 1983–87 1988–92 1993–95
BS M F BS M F BS M F BS M F
Lung 25.8 42.3 11.5 31 46.7 14.9 40 64.7 18.8 40 64.7 18.8
Breast 0.7 40.5 0.7 44.4 0.8 43.2 0.8 43.2
Liver 13.4 20.4 7.3 14.7 20.4 8 16.8 25.6 9 16.8 25.6 9
Cervix uteri 20.5 – 20.5 22.5 – 22.5 26.4 – 26.4 26.4 – 26.4
Stomach 9.6 11.9 7.6 9.6 11.4 7.7 9.6 12.1 7.6 9.6 12.1 7.6
Colon 6.5 7.3 5.7 8 8 7.7 10.7 11.8 9.8 10.7 11.8 9.8
Oral cavity 5.9 5.4 6.3 6.9 6.4 7.3 8.6 8.5 8.3 8.6 8.5 8.3
Prostate 12.5 12.5 – 14.6 14.6 – 19.3 19.3 – 19.3 19.3 –
Rectum 5.5 6.5 2.8 6.6 7.4 5.6 7 8.1 6.2 7 8.1 6.2
Leukemia 5.2 5.7 2.9 5.7 5.6 5.5 6.6 7.2 6.2 6.6 7.2 6.2
Nasopharynx 2.5 6 1.6 5.2 6.7 3.1 6.2 8.6 4 6.2 8.6 4
Larynx 1.4 4.3 0.4 2.8 4.4 1.1 3.4 6.2 1 3.4 6.2 1
Ovary 8 – 8 9.2 – 9.2 10.8 – 10.8 10.8 – 10.8
Thyroid 2.7 1.3 6.6 5.6 2.7 8 6.6 3.1 9.8 6.6 3.1 9.8
Corpus uteri 6.1 – 6.1 5.8 – 5.8 5.2 – 5.2 5.2 – 5.2
Non-Hodgkin’s lymphoma 2 2.1 1.6 3.3 3.8 2.6 4.6 5.8 3.6 4.6 5.8 3.6
Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4)
Objectives
General:
The researcher formulated a general objective to guide her throughout the case
study:
This study aims to present facts about breast cancer, details of how this may affect
every woman in the society and to protect them from further advancement of breast
cancer. And also for the researcher to explore, investigate, analyze and present a
comprehensive case study regarding the case of Patient Star.
Specific:
a) To establish a good rapport and therapeutic relationship with the patient to gather
much information about her personal data and her present condition through
interview
b) To gather pertinent data found in the patient’s medical chart
c) To conduct a thorough physical assessment as a part of the baseline data gathering
d) To study the anatomy and physiology of the affected system of the patient’s
current condition
e) To trace the pathophysiology of the disease process
f) To determine and interpret the medical management employed, including
laboratory and diagnostic procedures
g) To identify and study the drugs prescribed to the patient which affects her present
condition
h) To formulate nursing care plans and health teachings that are appropriate for the
patient’s problem
i) To formulate prognosis based on the gathered information
j) Enumerate the discharge planning using the M.E.T.H.O.D. system.
k) List down all the references used in the study
Patient’s Data
Personal Data
Code Name: Patient Star
Age/ Sex: 58/ Female
Address: Blk. 4 Lot 12 Stella Maris Village, Garcia Heights, Davao City
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Birth date: March 13, 1951
Birth place: Dagupan, Pangasinan
Occupation: Housewife
Clinical Data
Hospital Number: 01-80-**
Room / Bed Number: 424-2
Date of admission: December 14, 2009
Time of admission: 11:00 am
Chief Complaint: Left Breast Wound
Admitting Physician: Meliza Carla T. Agoilo, M.D
Attending Physician: Ferdinand Malubay, M.D
Vital signs upon admission:
. T P R BP
37.4◦ 128bpm 27cpm 120/70mmHg
Family Background and Health History
Patient Star, 58 years old, she lived in a simple lifestyle at Dagupan, Pangasinan. Her
paternal side was pure Ilocano, her father has 5 siblings wherein hypertension was manifested by
the three of them. Her father has Bronhcial Asthma and was already deceased. Meanwhile, her
mother side hailed from Malasiqui, Pangasinan. Her grandmother died from Diabetes which was
also caused the death of her one aunt. Hypertension was also manifested by her uncles, her
mother’s siblings. Star transferred here in Davao because of her job which was part of her Rural
Training as a nurse. Patient Star has five four siblings, one of her sister has hypertension and
died from it, while her other sister was diagnosed with colon cancer.
At present, star and her family lived at Garcia Heights his husband continued to work at
his uncle’s business. They have two children, her daughter who is already 26 years old finished
International Technology at John Paul College and is already working at Victoria Plaza Mall
while his son, 24 years of age is a personal driver of a known family in the city.
Lifestyle, Diet and Activities of Daily Living (ADL)
Patient Star wakes up early at about 4:30 am to cook breakfast for her family and clean
their house and backyard. Her daughter also testified that her mother is really hardworking, she
added that her mother feels weak if she does not work or do anything and just sit and rest the
entire day. Star shared that when she was still not feeling the pain on her breast she really wants
to do everything on their house just to make it clean and beautiful, she also makes it sure that her
family is in good condition and health. She cooks food for her family everyday and sees to it that
these foods are healthy and well- balanced. She admits that before, she really eats rice and foods
rich in carbohydrates without limit but now, she learned from it already and minimizes her intake
of those restricted foods. They sleep at around 10pm in the evening.
She is not active on her subdivision’s activities because she easily gets tired on it. Their
family is not that active on parish activities but they go to church if they have time, it is not their
routine to have a mass every Sunday.
9
Patient Star is a smoker, she consumes four sticks of cigarette everyday but she does not
drink any alcoholic beverages frequently, just occasionally. Her husband does not earn that much
of money and it brought them financial problem since they had their family life.
Client’s Past Health History
Patient Star does not have any allergic reaction towards foods, drugs and environment.
Patient stated that she had measles, mumps and chicken pox when she was young.
On year 2006, she experienced minimal amount of bleeding on her left nipple for 3 days
and after a week, she felt pain on it. She went for check-up at Davao Doctors Hospital and was
diagnosed with Mastitis and the doctor advised her to take Augmentin and to stop all her vices
mainly her smoking issue. After being diagnosed she seek help to the so called albolaryos and
quack doctors. She took Alive capsule and Green power which are herbal supplements.
She is a known Diabetic since 2006 and takes Metformin 500mg BID as her maintenance
drug.
She takes Mefenamic Acid whenever she experience headache and Paracetamol for her
fever.
Client’s Present Illness
One year prior to admission, Patient Star noted again a blood on her left nipple consulted
the physician that she had on 2006 and was given unrecalled drugs. Three months prior to
admission, patient noted crusting on the affected area, a consultation was done by the physician
and advised her for surgery but the patient failed to comply due to financial constraints, she
opted to use guava leaves and amoxicillin capsule powder instead.
Due to the pain that she felt on December 10 up to the 14 th of 2009 she was advised to be
admitted at Davao Medical School Foundation Hospital.
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Effects and Expectations of Illness to Self and Family
Patient Star understands the fact that she must be in the hospital for her to be at ease
while fighting her disease. She was just anxious and worried because of the financial aspect that
needs to be sufficient enough for her treatment. She optimistically shared that illness is just a part
of our body to respond and act against the virus and cells that spreads inside our system~ may it
be that deadly or not. She knows that her immune system is at risk during this time of her life
that is why she needs to eat nutritious foods and lessen her intake of those restricted foods that
may compromise her health.
Patient Star and her family were open about the risks of having cancer. Even though God
has given her these diseases she remained alive and kicking just like other normal persons.
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Developmental Data
Development is an increase in the complexity of function and skill progression. It is the
capacity and the skill of a person to adapt to the environment and it implies a progressive and
continuous process of change leading to a state of organized and specialized functional capacity.
Development is the behavioural aspect of growth, such as a person’s ability to walk, talk, and
run. It proceeds from simple to complex or from single acts to integrated acts. Any interpretation
of this process by a disease or a disorder is called developmental delay. These changes can be
measured quantitatively but more distinctly measured in qualitative changes.
Theory Stages Justification
Erik Erikson’s
Psychosocial Theory
Erik H. Erikson believes
that people continue to
develop throughout life. He
envisions life as a sequence
of levels of achievement.
The resolution of each task
can be complete, partial, or
unsuccessful. He believes
that the greater the tasks
achieved the healthier will
the personality of the person
be; failure to achieve a task
affects the person’s ability
to achieve the next task.
Erikson’s eight stages
Our patient belongs to
the stage of Generativity
versus stagnation (25 years
to 65) because she is already
58 years old. Generativity is
when an individual is
creative, productive and
shows concern for others.
While stagnation is when an
individual is to self-indulge,
self-concern and shows lack
of interests and
commitments.
Our patient is in the stage
of Generativity because she
is creative and productive.
Our patient does not only
think about herself but she is
also a very good mother and
wife. She does her job as a
mother and wife by taking
good care of her family. She
provides for the needs of her
family and also takes good
care of their health and
welfare. She makes sure that
she gives her family the love
and care they needed.
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reflect both positive and
negative aspects of the
critical life periods. The
resolution of the conflicts at
each stage enables the
person to function
effectively in the society.
Developmental tasks can be
viewed as a series of crises,
and successful resolution of
these crises is supportive to
the person’s ego
Robert Havighurst’s
Developmental Task
Theory
Robert Havighurst
believed that learning is
basic to life and that people
continue to learn throughout
life. He described growth
and development as
occurring in six different
stages which is associated
with different tasks. A
developmental task arises in
a certain period of an
individual’s life and leads to
Our patient is 58 years
old and belongs to the
Middle Age (40 – 65 years
old) and the following are
the task that the person must
achieve during this stage.
Developmental task
1. Achieving adult
civic and social
responsibility.
2. Establishing and
maintaining an
economic standard
√
Patient Star has not
achieved the first
developmental task because
she didn’t join in any
organizations in her
community.
Our patient has achieved
the second task because she
strives so hard to support
her family’s needs
emotionally and
physiologically by preparing
foods and providing
comfortable home to sleep
and rest.
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unhappiness and success if
is achieved and leads to
unhappiness if tasks is
failed. Through this theory it
can help provide a
framework in evaluating a
person’s accomplishment.
of living.
3. Assisting teenage
children to become
responsible and
happy adults.
√
4. Developing adult
leisure – time
activities.
√
5. Relating oneself
to one’s spouse as a
person.
√
6. Accepting and
adjusting to the
physiologic change
of middle age.
√
7. Adjusting to
aging parents.
√
Our patient had achieved
the third task because she
has 2 children and she was
the one who assisted them
while growing up. In the
present, some of her
children have their own
family and all of them are
already successful in life.
Our patient has achieved
the fourth task because
Whenever our patient is not
busy she would really rest
and spend time watching
television. Also when she is
not doing anything, she
would spend quality time
with her husband.
Our patient has achieved
the fifth task because our
patient does not only think
of herself but also for the
needs of her husband.
Whenever her husband is
having some problems she
will really give her full
support and try to console
and understand him.
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Our patient has achieved
the sixth task because she is
already quite adjusted to the
changes she is having
because she is aware that as
she grows old, many
changes would really
happen to her physically and
psychologically because she
knows that is life’s reality.
Our patient already
adjusted herself to her
husband’s father who is
already very old and many
things change. As her father
grew older and older, he
became to irritating,
annoying and kept on
nagging. Still, she possesses
her value of being patient
with him and tries to adjust
to it.
Moral Developmental
Theory by Lawrence
Kohlberg
Our patient belongs to
the Post conventional
(Social Contract Legalistic
Orientation) in which this
Our patient belongs to this
stage because she does not
base her decisions and
behaviors on the social roles
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This theory addresses
moral development in
children and adults. This
theory focuses on the
reasons an individual makes
a decision. According to
Kohlberg, this theory
progresses through three
levels and six stages, which
do not always linked to a
certain developmental stage
due to the fact that some
people progresses in a
higher level compared to
others.
person lives autonomously
and defines moral values
and principles that are
distinct from personal
identification with group
values. A person lives
according to principles that
are universally agreed on
and that the person consider
appropriate for life.
(universal focus)
but she believes a higher
moral principle such as
equality, justice or due
process.
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Definiton of Complete Diagnosis
Breast cancers are malignant tumors that typically begin in the ductal-lobular epithelial
cells of the breast and spread via the lymphatic system to the axillary lymph nodes. The tumor
may then metastasize to distant regions of the body, including lungs, liver, bone, and brain. The
finding of breast cancer in the axillary lymph nodes is an indicator of the tumor’s ability for
potential distant spread and is not merely contagious growth into adjacent region of the breast.
Most primary breast cancers are adenocarcinomas located in the upper outer quadrant of the
breast.
Bibliography:
Black, J. et. al. (2002).MEDICAL-SURGICAL NURSING: Clinical Management for Positive
Outcomes. Vol. 1. Philadelphia, USA: W.B. Saunders Company. pages 1011 – 1040.
Breast cancer is a cancer that starts in the cells of the breast in men and
women. Worldwide, breast cancer is the second most common type of cancer after
lung cancer (10.4% of all cancer incidence, both sexes counted) and the fifth most
common cause of cancer death. Worldwide, breast cancer is by far the most common
cancer amongst women, with an incidence rate more than twice that of colorectal
cancer and cervical cancer and about three times that of lung cancer. However breast
cancer mortality worldwide is just 25% greater than that of lung cancer in women. In
2005, breast cancer caused 502,000 deaths worldwide (7% of cancer deaths; almost
1% of all deaths). The number of cases worldwide has significantly increased since
the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world.
Malignant tumors within the breast are called “breast cancer”. Theoretically,
any of the types of tissue in the breast can form a cancer, cancer cells are most likely
to develop from either the ducts or the glands. These tumors may be referred to as
“invasive ductal carcinoma” (cancer cells developing from ducts), or “invasive lobular
carcinoma” (cancer cells developing from lobes). Sometimes, precancerous cells may
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be found within breast tissue, and are referred to as ductal carcinoma in-situ (DCIS)
or lobular carcinoma in-situ (LCIS). DCIS and LCIS are diseases in which cancerous
cells are present within breast tissue, but are not able to spread or invade other
tissues. DCIS represents about 20% of all breast cancers. Because DCIS cells may
become capable of invading breast tissue, treatment for DCIS is usually
recommended. In contrast, treatment is usually not needed for LCIS.
Bibliography:
The internet: http://health.yahoo.com/breastcancer-overview/breast-cancer-
topic-overview/healthwise--tv3617.html
Stage III breast cancer is divided into two categories, which are the stage IIIA and the
stage IIIB. In stage IIIA, the breast cancer will now be larger than 5 centimeters in diameter and
will already have spread to the lymph nodes located under the arm. The survival rate for stage
IIIA breast cancer is from 56% to 67% depending on how the patient responded with the
treatments.
Stage IIIB breast cancer is when the cancer has spread to the other tissues near the breast.
In this stage, the survival rate will be from 49% to 54% depending on how the patient responded
to the treatments and medications. Always remember that the key to surviving breast cancer is
through early detection. By going through breast cancer diagnoses at least once or twice a year,
you will be able to detect the cancer early on if you have it and increase your chances in getting
rid of it.
Bibliography:
The internet: http://www.breastcanceranswers.net/articles/What-should-you-know-about-
stage-3-breast-cancer.html
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PHYSICAL ASSESSMENT
Date of Assessment: December 15, 2009
Time of Assessment: 6:00pm
I. VITAL SIGNS
Temperature Pulse Rate Respiratory
Rate
Blood
Pressure
37.3ºc 92 bpm 21 cpm 120/80
mmHg
Clinical Measurement:
Height Weight
4 ft.9” 44kg.
II. GENERAL SURVEY
. She is awake, conscious, coherent and oriented. Responsive when asked and well-
conversant during interview. Her emotions were visible and vary in every situation. She does
not show any signs of respiratory distress. She is a well developed mesomorph and looks
according to age. She is very calm during the assessment, wearing white shirt and pajama.
19
III. SKIN
Skin was senile, fair in color, warm to touch, slightly moist and smooth. Returns quickly
to its original shape after being pinched. No evidence of bruising or edema on upper and lower
extremities. Nails were well- trimmed. Hair was fairly distributed all over the body.
IV. HEAD
Face and skull were symmetrical, with fair distribution of hair in the head. Hair was
black, curly with shades of dark brown and white hairs were noticed and it was also short and
dry. Scalp was flesh in color without any signs of dandruff and lice manifestation. No tenderness
and swelling were observed. Skull’s contour and size was normal. Involuntary movements and
spasmodic contractions were absent. Has an oblong- shaped face without skin pigmentations.
Forehead was furrowed with wrinkles.
V. EYES
Both eyebrows had an equal quantity of hair with no flakes and scars noted. Eyelids were
symmetrical. The lacrimal duct openings were evident at the nasal side of the upper and lower
lids. No presence of edema or hematoma. Has short eyelashes on both eyes. Blinking reflex was
present. Sclerae were anicteric, clear and white in color. Iris were dark brown in color. Pupils
briskly constrict with light and when looking at near objects; dilate when looking at far objects.
Palpebral conjuctiva were pinkish. Periorbital sections were not edematous or sunken. No
secretions observed on her eyes.
Patient verbalized that she is not using any corrective glasses or any supportive devices
on her eyes.
20
VI. EARS
Ears were symmetrical. No lesions, masses and swelling observed in both pinna. External
canals were clear with perhaps minimal cerumen. Inflammation and impacted cerumen were
absent.
Sense of hearing was normal. Whispered voice tones were heard.
VII. NOSE
Nose was symmetrical, having the same color with her face. No unusualities noted like
discharges, lesions and abnormal growth in the nasal cavity. Air moves freely through the nares
as she breathes. Nasal septum was intact and in the midline.
Sense of smell is good and she was able to distinguish different kind of scents.
VIII. MOUTH
Lips were pinkish and dry but not cracked. A red birthmark of about 1.5cm in length was
found below her lower lips. Pinkish gums were observed. Bleeding, ulceration and lacerations
were absent in the mouth. Hard and soft palates were normal with no defects or inflammation.
Tonsils were pinkish and not inflamed. A grayish discoloration was noted on the tip of her
tongue. Left molar tooth was missing. Halitosis was noted. Patient was able to masticate and
swallow.
IX. NECK
No signs of swelling, masses and lacerations noticed in the anterior and posterior of the
neck upon inspection and palpation. Range of motion was normal which includes right and left
lateral, right and left rotation, flexion, extension and hyperextension and able to move freely
21
without discomfort. A birthmark which was brown in color, 8cm in length and 4cm in width was
noted.
X. BREAST
Nipple on the right breast was dark brown in color. No discharges, scars or lesions seen.
No lumps palpated. Left breast was covered with a bandage and properly dressed. It was intact
and not soaked. No rashes or infection in the axillae noted.
A foul smell was noticeable coming from her breast wound.
XI. CHEST AND LUNGS
Thorax was symmetrical, it moved easily without impairment upon respiration. There
were neither bulges nor retraction of the intercostal spaces. The breathing pattern was regular.
No presence of dyspnea, cough or hiccup noted. Spinal deformities and chest tubes or drainage
were absent. Breath sounds were clear upon auscultation.
XII. HEART
Her pericardial area is flat. Her heart sounds are distinct and regular upon auscultation.
XIII. ABDOMEN
The general contour of the abdomen was soft and flabby. No foul odor or discharges
observed in the umbilical area. Has a normal bowel sound of 12 per minute with a gurgling
sound.
XIV. GENITO-URINARY
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No catheter attached. Patient verbalized that she urinates about 12 times daily without
any discomfort after the day of her admission. Her urine is yellow in color.
Patient added that she is already meopaused.
XV. UPPER EXTREMITIES
Peripheral pulses are present and symmetrical when palpated. Shoulder and arms were
symmetrical. Swelling and deformities were absent. No nodules and abnormal growth in the
elbows. Forearms can be flexed, supinated, pronated and extended with no pain. No missing,
deformities and tremors in the hands and fingers. Both palms were not calloused, without palmar
pallor. Has a capillary refill of less than 2 seconds. The range of motion in the upper extremities
was good.
XVI. LOWER EXTREMITIES
Absence of pain tenderness and has a good range of motion in the hips and joints. A scar
of 6 cm was found at the right lower leg due to an accident when she was still 14 years old. No
deformities, edema, rashes and amputation in both legs and knees. No missing toes in both feet.
Slightly calloused soles. Nails in the toes were not trimmed. Has a good range of motion in the
lower extremities.
23
ANATOMY AND PHYSIOLOGY
Reproductive System
The breasts, or mammary tissues, are located between the third and the seventh ribs of the
anterior chest wall and are supported by the pectoral muscles and superficial fascia. They are
specialized glandular structures that have an abundant shared nervous, vascular, and lymphatic
supply. The contiguous nature of breast tissue is important in health and illness. Men and women
alike are born with rudimentary breast tissue, with the ducts lines with epithelium. In women, the
pituitary released of FSH, LH, and prolactin at puberty stimulates the ovary to produce and
released estrogen. This estrogen stimulates the growth and development of ductile system. With
the onset of ovulatory cycles, progesterone release stimulates the growth and development of
ductile and alveolar secretory epithelium.
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Structure
Structurally, the breasts consist of fat, fibrous connective tissue, and glandular tissue. The
superficial fibrous connective tissue is attached to the skin, a fact that is important in the visual
observation of skin movement over the breast during breast self-examination. The breast mass is
supported by the fascia of the pectoralis major and minor muscles and by the fibrous connective
tissue of the breast. Fibrous tissue ligaments, called Cooper's ligaments, extend from the outer
boundaries of the breast to the nipple area in radial manner.
These ligaments support the breast and form septa that divide the breast into 15 to 25
lobes. Each lobe consists of grape like clusters, alveoli or glands, which are interconnected by
ducts. The alveoli are lined with secretory cells capable of producing milk or fluid. The route of
descent of milk and other breast secretions is from alveoli to duct, to intra lobar duct, to
lactiferous duct and reservoir, to nipple. Breast milk is produced secondary to complex hormonal
changes associated with pregnancy. Fluid is produced and reabsorbed during the menstrual cycle.
The breasts respond to the cyclic changes in the menstrual cycle with fullness and discomfort.
The nipple is made up of epithelial, glandular, erectile, and nervous tissue. Areolar tissue
surrounds the nipple and is recognized as the darker, smooth skin between the nipple and the
breast. The small bumps or projections on the areolar surface known as Montgomery's tubercles
are sebaceous glands that keep the nipple area soft and elastic. At puberty and during pregnancy,
increased levels of estrogen and progesterone cause the areola and nipple to become darker and
more prominent and at the same time cause the Montgomery's glands to become more active.
The erectile tissue of the nipple is responsive to psychological and tactile stimuli, which
25
contributes to the sexual function of the breast. There are many individual variations in breast
size and shape. The shape and texture vary with hormonal, genetic, nutritional, and endocrine
factors and with muscle tone, age, and pregnancy. A well-developed set of pectoralis muscles
supports the breast mass higher on the chest wall. Poor posture, significant weight loss, and lack
of support may cause the breast to droop.
The Lymphatic System
The lymphatic system consists of organs, ducts, and nodes. It transports a watery clear
fluid called lymph. This fluid distributes immune cells and other factors throughout the body. It
also interacts with the blood circulatory system to drain fluid from cells and tissues. The
lymphatic system contains immune cells called lymphocytes, which protect the body against
antigens (viruses, bacteria, etc.) that invade the body.
Functions:
a.) to collect and return interstitial fluid, including plasma protein to the blood,
26
and thus help maintain fluid balance
b.) to defend the body against disease by producing lymphocytes
c.) to absorb lipids from the intestine and transport them to the blood.
Lymph organs include the bone marrow, lymph nodes, spleen, and thymus. Precursor
cells in the bone marrow produce lymphocytes. B-lymphocytes (B-cells) mature in the bone
marrow. T-lymphocytes (T-cells) mature in the thymus gland. Besides providing a home for
lymphocytes (B-cells and T-cells), the ducts of the lymphatic system provide transportation for
proteins, fats, and other substances in a medium called lymph.
Lymph nodes:
Structure:
Human lymph nodes are bean-shaped and range in size from a few millimeters to about
1-2 cm in their normal state and there are about 500-700 lymph nodes spread throughout the
body. Lymph nodes are body organs (not glands) spread throughout your body.
The lymph node is surrounded by a fibrous capsule, and inside the lymph node the
fibrous capsule extends to form trabeculae. The substance of the lymph node is divided into the
outer cortex and the inner medulla surrounded by the former all around except for at the hilum,
where the medulla comes in direct contact with the surface. Thin reticular fibers, fibroblasts and
27
elastin fibers form a supporting meshwork called reticulum inside the node, within which the
white blood cells (WBCs), most prominently, lymphocytes are tightly packed as follicles in the
cortex. Elsewhere, there are only occasional WBCs.
The number and composition of follicles can change especially when challenged by an
antigen, when they develop a germinal center. A lymph sinus is a region within the lymph that is
less densely packed with WBCs and offers less resistance to the flow of lymph. It is lined by
highly branched reticular cells and macrophages. Thus, subcapsular sinus is a region immediately
deep to the capsule, and contains very sparse lymphocytes. It is continuous with similar sinuses
flanking the trabeculae. Multiple afferent lymph vessels that branch and network extensively
within the capsule, bring lymph into the lymph node. This lymph enters the subcapsular sinus.
The innermost lining of the afferent lymph vessels is continuous with the cells lining the lymph
sinuses. The lymph gets slowly filtered through the substance of the lymph node and ultimately
reaches the medulla. In its course it encounters the lymphocytes and may lead to their activation
as a part of adaptive immune response. The concave side of the lymph node is called the hilum.
The efferent attaches to the hilum by a relatively dense reticulum present there, and carries the
lymph out of the lymph node.
Function
Nodes act as filters, with an internal honeycomb of reticular connective tissue filled with
lymphocytes that collect and destroy bacteria and viruses. When the body is fighting an
infection, they begin producing large numbers of lymphocytes which causes them to swell.
Lymphatic fluid in the tissues, before it has gone into a lymph node, is called interstitial fluid.
28
Etiology and Symptomatology
BREAST CANCER
PREDISPOSING FACTORS
FACTORS RATIONALE PRESENT
/
ABSENT
JUSTIFICATION
SEX Simply being a woman is the
main risk factor for developing
breast cancer. Although women
have many more breast cells
than men, the main reason they
develop more breast cancer is
because their breast cells are
constantly exposed to the
growth-promoting effects of the
female hormones estrogen and
progesterone. Men can develop
breast cancer, but this disease is
about 100 times more common
among women than men.
www.cancer.org
This is present, since
our patient is a
FEMALE.
AGE Breast cancer can affect women
of any age. The disease is more
common in post-menopausal
women, but 25 percent of
This is present since
our patient is 58
years old and is
already menopaused.
29
women with breast cancer are
younger than 50.
www.cancer.med.umich.edu
Your risk of developing breast
cancer increases as you get
older. About 1 out of 8 invasive
breast cancers are found in
women younger than 45, while
about 2 out of 3 invasive breast
cancers are found in women
age 55 or older
www.cancer.org
According to experts
post- menopausal
women are more
predisposed to have
breast cancer.
GENETIC RISK
FACTORS
About 5% to 10% of breast
cancer cases are thought to be
hereditary, resulting directly
from gene changes (called
mutations) inherited from a
parent.
BRCA1 and BRCA2: The
most common inherited
mutations are those of the
BRCA1 and BRCA2 genes. In
normal cells, these genes help
to prevent cancer by making
proteins that help keep the cells
from growing abnormally. If
you have inherited a mutated
copy of either gene from a
parent, you are at increased risk
for breast cancer.
Women with an inherited
X
There is no test that
would support that
the patient has
genetic mutation that
would make here
predispose to breast
cancer. Patient also
stated that she does
not have any
relatives or even
family member with
breast cancer.
30
BRCA1 or BRCA2 mutation
have up to an 80% chance of
developing breast cancer during
their lifetime, and when they do
it is often at a younger age than
in women who are not born
with one of these gene
mutations. Women with these
inherited mutations also have
an increased risk for developing
ovarian cancer.
www.cancer.org
RACE White women are slightly more
likely to develop breast cancer
than are African-American
women. African-American
women are more likely to die of
this cancer. At least part of this
seems to be because African-
American women tend to have
more aggressive tumors,
although why this is the case is
not known. Asian women has
the least number of breast
cancer cases compared to that
of the Americans, Europeans
www.cancer.org
X
This is absent since
our patient is of
Asian race.
EARLY MENARCHE,
LATE MENOPAUSAL
AGE
Women who have had more
menstrual cycles because they
started menstruating at an early
The patient reported
that her menarche
was at 11 years old.
31
age (before age 12) and/or went
through menopause at a later
age (after age 55) have a
slightly higher risk of breast
cancer. This may be related to a
higher lifetime exposure to the
hormones estrogen and
progesterone.
-www.cancer.org
-Hawks and Black , Medical-
Surgical Nursing, 7th Edition,
2005
NULLIPARITY
AND
NON-BREASTFEEDING
WOMEN
Women who have had no
children or who had their first
child after age 30 have a
slightly higher breast cancer
risk. Having many pregnancies
and becoming pregnant at an
early age reduces breast cancer
risk. Pregnancy reduces a
woman's total number of
lifetime menstrual cycles,
which may be the reason for
this effect.
Some studies suggest that
breast-feeding may slightly
lower breast cancer risk,
especially if breast-feeding is
continued for 1½ to 2 years.
The explanation for this
possible effect may be that
This is absent in my
patient because she
has undergone
pregnancy for her 2
children and has
experienced
breastfeeding.
32
breast-feeding reduces a
woman's total number of
lifetime menstrual cycles
(similar to starting menstrual
periods at a later age or going
through early menopause).
33
BREAST CANCER PRECIPITATING FACTORS
FACTORS RATIONALE PRESENT/
ABSENT
JUSTIFICATION
HIGH FAT DIET Most studies have found that breast
cancer is less common in countries where
the typical diet is low in total fat, low in
polyunsaturated fat, and low in saturated
fat.
High-fat diets can lead to being
overweight or obese, which is a breast
cancer risk factor.
X
This is absent since
patient eats a wide
variety of food.
OBESITY Being overweight or obese has been
found to increase breast cancer risk,
especially for women after menopause.
Before menopause your ovaries produce
most of your estrogen, and fat tissue
produces a small amount of estrogen.
After menopause (when the ovaries stop
making estrogen), most of a woman's
estrogen comes from fat tissue. Having
more fat tissue after menopause can
increase your estrogen levels and thereby
increase your likelihood of developing
breast cancer.
The connection between weight and
breast cancer risk is complex, however.
For example, the risk appears to be
increased for women who gained weight
as an adult but may not be increased
among those who have been overweight
since childhood. Also, excess fat in the
X
This is absent since
our patient’s BMI
is 18.9, which is
interpreted as a
healthy weight
since BMI less
than 18.5 are
classified as
underweight and
more than 22.9 are
overweight.
34
waist area may affect risk more than the
same amount of fat in the hips and
thighs. Researchers believe that fat cells
in various parts of the body have subtle
differences that may explain this.
-www.cancer.org
-Hawks and Black , Medical-Surgical
Nursing, 7th Edition, 2005
LONG TERM
ESTROGEN
THERAPY
Post-menopausal hormone therapy
(PHT), also known as hormone
replacement therapy (HRT), has been
used for many years to help relieve
symptoms of menopause and to help
prevent osteoporosis (thinning of the
bones).
-www.cancer.org
-Hawks and Black , Medical-Surgical
Nursing, 7th Edition, 2005
X
This is absent since
Patient Star is not
having this
therapy.
ALCOHOL Alcohol use are associated with increased
levels of circulating estrogen, and this is
thought to be the primary means through
which they confer an increased risk of
breast cancer, since estrogen can fuel
breast cancer growth
-Fred Hutchinson Cancer Research
Center
www.sciencedaily.com
X
This is absent since
patient Star does
not consume nor
drink regularly.
LACK OF
PHYSICAL
MOBILITY
Physical activity may prevent tumor
development by lowering hormone
levels, particularly in premenopausal
women; lowering levels of insulin and
X
This is absent since
Patient Star does
all the house
chores.
35
insulin-like growth factor I (IGF-I),
improving the immune response; and
assisting with weight maintenance to
avoid a high body mass and excess body
fat
-McTiernan A, editor. Cancer Prevention
and Management Through Exercise and
Weight Control. Boca Raton: Taylor &
Francis Group, LLC, 2006.
CIGARETTE
SMOKING
Carcinogens found in tobacco smoke
pass through the alveolar membrane and
into the blood stream, by means of which
they may be transported to the breast via
plasma lipoproteins. That potential breast
carcinogens in tobacco smoke can be
taken up and metabolized in humans is
suggested by studies showing that
urinary excretion levels of such
compounds vary among individuals
according to their smoking habits. Due to
the fact that they are lipophilic, tobacco-
related carcinogens can be stored in
breast adipose tissue and then
metabolized and activated by human
mammary epithelial cells. Experimental
studies have indicated that tobacco
smoke contains potential human breast
carcinogens [including PAHs, aromatic
amines, and N-nitrosamines, and the
higher prevalence of smoking-specific
DNA adducts and p53 gene mutations
This is present
because Patient
Star is a smoker
that consumes four
sticks of cigarette
per day.
36
found in the breast tissue of smokers
compared with that in nonsmokers
supports the biological plausibility of a
positive association between cigarette
smoking and breast cancer risk.
-Cigarette Smoking and the Risk of
Breast Cancer in Women
Paul D. Terry and
Thomas E. Rohan,
http://cebp.aacrjournals.org
RADIATION
THERAPY
Women who, as children or young
adults, had radiation therapy to the chest
area as treatment for another cancer
(such as Hodgkin disease or non-
Hodgkin lymphoma) are at significantly
increased risk for breast cancer. This
varies with the patient's age when they
had radiation. If chemotherapy was also
given, the risk may be lowered if the
chemotherapy stopped ovarian hormone
production. The risk of developing breast
cancer appears to be highest if the
radiation was given during adolescence,
when the breasts were still developing.
www.cancer.org
X
This is absent since
patient is not on a
radiation therapy.
RECENT
CONTRACEPTIVE
USE
Studies have found that women using
oral contraceptives (birth control pills)
have a slightly greater risk of breast
cancer than women who have never used
them, but this risk seems to decline once
their use is stopped. Women who stopped
X This is absent since
patient is not using
any contraceptive
as reported.
37
using oral contraceptives more than 10
years ago do not appear to have any
increased breast cancer risk. When
thinking about using oral contraceptives.
-www.cancer.org
ANTIPERSPIRANT
USE
Many experts have suggested that
chemicals in underarm antiperspirants
are absorbed through the skin, interfere
with lymph circulation, cause toxins to
build up in the breast, and eventually
lead to breast cancer.
One small study has found trace levels of
parabens (used as preservatives in
antiperspirants and other products),
which have weak estrogen-like
properties, in a small sample of breast
cancer tumors.
-www.cancer.org
This is present
since patient
reported use of
antiperspirant since
adolescent age.
38
SYMPTOMATOLOGY
BREAST CANCER
FACTORS RATIONALE PRESENT/
ABSENT
JUSTIFICATION
Thickening/Lump in or
near the underarm area
A woman's breasts can feel
lumpier just before her
menstrual period. At this time
of the month, she experiences
a surge in female hormones—
estrogen, progesterone and
prolactin. These hormones
stimulate fibrous breast tissue
to grow and retain fluid.
Breast cancer first announces
itself in the form of a lump.
http://www.mothernature.com/
This is present since
patient noted
thickening or lump
in an area of her
breast.
Asymmetry Prior to each menstrual period,
the surge in estrogen and
progesterone stimulates fluid
retention and growth in breast
tissue.
http://www.mothernature.com
This is present since
patient reported very
noticeable
asymmetry of her
breast due to
swelling and
tenderness.
Bleeding and Discharge
from the nipples
Excess fluids seeps out into
the duct which causes
discharge from the nipples.
http://www.mothernature.com
This is present since
patient reported that
she had discharges or
bleeding during the
course of her illness.
39
Skin Dimpling/Orange
peeling or
Pitting of the breast
A dimpling of the breast skin
or nipple could be from the
loss of elasticity in the
supporting ligaments as you
age. But dimpling may also be
a sign that a tumor buried in
the tissues is pulling on the
skin or nipples. In the case of
a tumor, dimpling might show
up long before a lump
becomes large enough to feel.
http://www.mothernature.com
This is present since
patient reported that
there skin dimpling
or pitting of the
breast noted during
the duration of her
illness. Added by the
patient, there is also
crusting around the
pitting area.
Warmth
Redness
Swelling
Warmth, redness and swelling
are due to the inflammation
process. It is due to the
invasion and obstruction of the
dermal lymphatics by the
tumor
Medical-Surgical Nursing
Black and Hawks, 2004
This is present since
patient noted
warmth, redness,
swelling of her left
breast
40
Narrative Pathophysiology
The etiology of breast cancer and even on any type of cancer is still unknown.
Predisposing factors that are present on the case of my patient are the following, sex, age, early
menarche and her late pregnancy, while her precipitating factor is her usage of antiperspirant for
a long period of time, since she was on adolescent stage. Under the predisposing factors, these
leads to an over expressed estrogen receptor and an increase in the estrogen level with thses it is
now expose to estrogen when it is increased, also its metabolism goes up or it also increases,
which leads to an increase in cell proliferation. On the otherhand, under the precipitating factor,
there is now an absorption of chemicals particularly that of Parabens chemical which is a weak
estrogen-like substance that enters in our breast tissues and that toxins also interferes the
circulation in our lymphatic system. Toxins being impacted and stored on our breast, builds up.
When these two factors meet, Initiations phase then starts. Wherein carcinogens bind to cell’s
DNA resulting into an alteration of functions. Genotoxic waste in estrogen metabolism takes
place and there is already an error in cellular duplication. Resulting into a damaged genes of
Tumor Suppressor Cells and modifies functioning of the proto-oncogenes. When there is already
a damage and interruption on the cell proliferation, the repair and elimination process that
supposed to be is going to happen in a certain cell, is now inhibited. Oncogenes now, make it
possible for cell transformations as dividing excessively and uncontrollably/ until it proceeds to
the next phase which is the Promotion phase where a continuous duplication of mutated DNA
happens. A single cell begins to divide abnormally and a formation of new tissue or tumor
follows. Which is now the STAGE 1 of cancer, wherein if not treated, Malignant Conversion
happens, an accumulation of cancer cells in the breast, center of tumor necrotizes and begins to
chip of malignant cells to seek new blood supply and cells eventually break out of the tumor and
invades the surrounding nodes and blood vessels. Before proceeding into the next stage the
cancer cells spreads in two ways, it is either the Lymphatic or Hematologic. When Stage 2
occurs, cells penetrate the lymphatic vessles by invasion process and cells lodge in the lymph
nodes and grow. Surrounding lymph nodes and vessles around the breast become obstructed and
are a malignant one. Cancer cells continue to stream in lymph fluid and may undergo metastasis
41
destroying epithelial wall until there is already an impairment in the lymph flow and
accumulation of fluid in the chest cavity until new sites of tumor develop. In Stage 3 before it is
going to be diagnosed in that stage, diagnostic exams are being conducted first, like excisional
biopsy, blood test, mammogram and chest x-ray. Once a patient has symptoms suggestive of a
breast cancer or an abnormal screening mammogram, she will usually be referred for a
diagnostic mammogram. A diagnostic mammogram is another set of x-rays with additional
angles and close-up views. Often, and ultrasound will be performed during the same session. An
ultrasound uses high-frequency sound waves to outline the suspicious areas of the breast. It is
painless and can often distinguish between benign and malignant lesions.
Depending on the results of the mammograms and/or ultrasounds, your doctors may
recommend that you get a biopsy. A biopsy is the only way to know for sure if you have cancer,
because it allows your doctors to get cells that can be examined under a microscope. There are
different types of biopsies; they differ on how much tissue is removed. Some biopsies use a very
fine needle, while others use thicker needles or even require a small surgical procedure to
remove more tissue. Your team of doctors will decide which type of biopsy you need depending
on your particular breast mass.
Once the tissue is removed, a doctor known as a pathologist will review the specimen.
The pathologist can tell if is the cells are cancerous or not, If the tumor does represent cancer, the
pathologist will characterize it by what type of tissue it arose from, how abnormal it looks
(known as the grade), whether or not it is invading surrounding tissues, and whether or not the
entire lump was removed during surgery. The pathologist will also test the cancer cells for the
presence of estrogen and progesterone receptors as well as a receptor known as HER-2/neu. The
presence of estrogen and progesterone receptors is important because cancers that have those
receptors can be treated with hormonal therapies. HER-2/neu expression may also help predict
outcome. There are also some therapies directed specifically at tumors dependent on the presence
of HER-2/nue. On STAGE 3B if its not treated, the patient will have poor prognosis which
means that the cancer cells that are able to sutvive the environment and pressure still continue to
venous blood flow and metastize which leads to STAGE 4wherein an impairment in liver and
lungs functioning happen that results to organ failure and arrest that may lead to death.
42
43
PATHOPHYSIOLOGY
44
PREDISPOSING FACTOR-SEX-AGE
-EARLY MENARCHE-NULLIPARITY and NON-BREAST
PRECIPITATING FACTOR-LONG TERM
ANTIPERSPIRANT USE
Increased estrogen level
Increased estrogen
Over expressed estrogen receptor
Absorption of chemicals in antiperspirant through the
INCREASED ESTROGEN METABOLSIM
Initiation:Carcinogens bind to cell’s DNA
results to alteration of functions.
Toxins interfere with lymph circulations
Toxins build up in the breast
Parabens, weak estrogen-like chemicals
in antiperspirant enters breast tissues
Increased cell proliferation
45
Genotoxic waste in estrogen
metabolism
Spontaneous error of cell duplication
Modified functioning of proto-oncogenes.
Damage to the genes of Tumor Suppressor Cells
Repair or elimination of cells with damaged DNA is
inhibited.
Proto-oncogene becomes oncogene
due to genetic
Impaired program cell death
Oncogenes make it possible for cell transformations such as
dividing excessively and uncontrollably.
A single cell begins to divide abnormally
Formation of new tissue or tumor
Promotion: Continuous duplication of
mutated DNA
STAGE 1 Thickening/Lump in or near the underarm area
46
Center of Tumor Necrotizes and begins to chip of malignant cells to seek new blood supply.
Malignant Conversion:Accumulation of cancer cells in the breast
Cells break out of the tumor and Invades to surrounding lymph nodes and/or Blood
vessels.
If not treated
Blood vessels including arteries and veins carries cancer cells to organs: liver, lungs, and Blockage of Lymph
vessel draining the fluids from the breast
Inflammation of breast and swelling of
lymph nodes
Unblocked Lymph nodes drain towards the venous
blood flow.
STAGE 2LYMPHATIC SPREAD:
Dissemination of Cancer cells to the lymph channels in a process called
embolization.
Cells lodge in the lymph nodes and
grow.
Cells penetrate lymphatic vessels
by invasion process
HEMATOLOGIC SPREAD:Dissemination of Cancer
cells through blood vessels.
Surrounding lymph nodes and vessels around the breast become obstructed by malignant tumor
Cancer move to extracellular matrix by secreting enzymes
Endothelium cracks open then causes surrounding tissue to be damaged
Entry to blood vessels
47
Cancer cells continue to stream in the lymph fluid
May undergo invasive metastasis destroying epithelial
wall.Impaired Lymph flow and erosion of tumor accumulates fluid in the chest
cavity.
Cancer cells spread into the membrane linings
Irritation and build up of fluid on adjacent tissues
Increase in capillary permeability
DIAGNOSTIC EXAMS
Excisional Biopsy:
-a section of tissue is removed under general or local anesthesia and sent for mammographic and histological
Blood test:-A test done to check for a specific tumor marker, CA 15-3 for breast cancer.
Chest x-ray:- Chest films acquired in the lateral decubitus position (with the patient lying on his side) are more sensitive, and can pick up as little as 50 ml of fluid. At least 300 ml of fluid must be present before upright chest films can pick up signs of pleural effusion. A chest with >500ml of fluid is positive for pleural effusion.
Mammogram:-A mammogram is a low-dose x-ray of the breast tissue. Mammograms can detect changes in the breast tissue before they develop into a lump large enough to be
New sites of tumor STAGE 3
48
Breast Cancer Stage IIIB T4N2M0
Medical Treatment:Pharmacologic Intervention-
1. Chemotheraphy is also used as primary treatment in inflammatory breast cancer and as palliative treatment in metastatic disease or recurrence.
2. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic therapy after surgery.
3. Hormonal agents may be used in advanced disease to induce remissions that last for months to several years.
Surgical Treatment:Modified Radical Mastectomy with Split Thickness Skin Graft-
-is an en bloc removal of the breast, axillary lymph nodes, and overlying skin, with the muscles left intact
Bilateral Chest Tube Thoracostomy--it is done to drain excess fluid from the
pleural space.
Nursing Interventions:1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia. 2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain
or loss, fatigue, stomatitis, anxiety, and depression. 3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological
support to the patient throughout the diagnostic and treatment process. 4. Involve the patient in planning and treatment. 5. Describe surgical procedures to alleviate fear. 6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue. 7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy. 8. Administer I.V. fluids and hyperalimentation as indicated. 9. Help patient identify and use support persons or family or community. 10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems. 11. Teach all women the recommended cancer-screening procedure
If treated:
49
If not treated:
Poor Prognosis
Prolonged or delayed development of metastasis
Metastasis:New tumors metastasize in the
liver, lungs and lymph.
Cancer cells that are able to survive the environment and pressure still
continue to venous blood flow
Impaired functioning of the liver and lungs.
Failure of the liver and lungs. lymphedema
STAGE 4
Organ Failure
Fair Prognosis
Cardiac Arrest
DEATH
DOCTOR’S ORDER
Date Ordered Doctor’s Order Rationale Remarks
December 14,200911:00 am
Wt: 44kgBP: 120/70PR: 128bpmRR: 27 cpmT: 37.3 ◦cHgt: 219mg/dl
Please admit under the service of Dr. Malubay (PC)
Diabetic Diet
Monitor VSq4 and record please
Hospital admission is
advised for observation
and managementer of the
client.
Diabetic Diet is being
given to patients with
history of Diabetes and
high blood glucose level.
Patient Star’s Hgt value
which is 219mg/dl
revealed that she needs to
control the glucose intake
in her body.
To obtain baseline data
and check for
unusualities or deviations
from normal.
DONE
DONE
DONE
50
Labs: > CBC,PC
> Bld. Typing > CXR- PA view > ECG > HGT now > UA > S. Na, K+
Start venoclysis
with PNSS 1L at
120cc/ ◦ # 1
To evaluate the
composition and
concentration of the
cellular components of
blood which measures
the following:
the number of
red blood cells
(RBCs)
the number of
white blood
cells (WBCs)
the total
amount of
hemoglobin in
the blood
the fraction of
the blood
composed of
red blood cells
(hematocrit)
the mean
corpuscular
volume (MCV)
— the size of
the red blood
cells
DONE
DONE
51
Meds:
>Metformin
500g tab 1 tab
BID P. O
(Maintenance)
>Ketorolac 30g
IVTT q 6◦; Give
1st dose now
> Cefuroxime
750g IVTT q 8◦
ANST
For dressing with
Daikins solution
Monitor I&O q shift
Dr. Malubay
informed of this
admission ( seen
To supply water and
electrolytes (e.g.,
calcium, potassium,
sodium, chloride), either
with or without calories
(dextrose), to the body.
>Metformin is used to
minimize glucose level.
It is the patient’s
maintenance drug for her
Diabetes.
>Ketorolac is given for
short term management
of pain in her left breast.
Also used to prevent
fever and inflammation.
>Cefuroxime is used to
treat skin and soft tissue
infections. Patient Star is
having a wound at her
left breast due to breast
CA.
> Daikins solution is
used for dressing, to
prevent germ growth on
wounds.
> To maintain fluid and
electrolyte balance.
DONE
DONE
DONE
DONE
DONE
DONE
52
Signed:
Meliza Carla T.
Agoilo, MD
December 14, 2009
12: 30pm
PR)
Refer to Dr. Torno
for co mgt.
Refer to Dr.
Lamanosa for Pain
mgt.
Refer accordingly
MROD, Thank you
for this referral,will
inform Dr. Torno
Suggest to shift
antibiotic and
sulperazone 1gm q
8◦ ANST
Monitor CBG q 6◦
(5-11-5-11)
Give Humulin R,
8 units SQ now then
8 Units q 6 pm for
CBG ≥ 180mg/ dl
Include S. Crea
> To let other physicians
know if the physician is
already informed about
the patient.
>To let Dr. Torno know
about the patient’s
admission and condition.
> To manage the pain felt
by the patient on her left
breast.
>Nurse noted the ordered
referral of Dr. Agoilo
> To treat and prevent
infection and
inflammation on the
patient’s wound at left
breast.
> To monitor the patients
blood glucose level and
other blood components.
>To control
hyperglycemia. Patient is
DONE
DONE
DONE
DONE
DONE
DONE
DONE
53
Signed:
Dr. Torno
December 14, 2009
3:00 pm
Signed:
Dr. Torno
December 14, 2009
8:41 pm
Hold Cefuroxime
IV
Ciprofloxacin
500g 1tab BID 1st dose
ASAP
Clindamycin 300g
1cap q 6◦ after meal
Start Humalog
mix 20 units SQ at
breakfast, 12 units SQ
at dinner
Please secure 2
units PRBC of
patient’s Bld.
Type properly
a known diabetic.
>To know if the patient
has kidney problem.
>Before administering
Cefuroxime, physician
must know first the result
of the patient’s creatinine
value to evaluate any
renal insufficiency.
> To treat the patient’s
skin and soft tissue
infection on her breast
wound which may cause
fever and further
inflammation.
>To treat and prevent
infection on the patient’s
wound.
>To control
hyperglycemia. Patient is
a known diabetic since
2006.
>To normalize
DONE
DONE
DONE
DONE
DONE
54
Signed:
Dr. Malubay
December 15, 2009
12: 30am
crossmatched
Please transfer
once bld is
available, repeat
Hct 6 hours post
BT of 2 units
For Toilet
Mastectomy with
skin grafting
pending schedule
Please inform Dr.
Torno of plan
Refer accordingly
Please discontinue
Ketorolac for S.
Creatinine in Am,
please inform me
of result
Nalbuphine 5g
IVTT q 8◦ x 4
dose then shift to
Tramadol 100g ½
hemoglobin level, for
good blood circulation
and to maintain amount
of blood supply at
equilibrium.
>To normalize
hemoglobin level, for
good blood circulation
and to maintain amount
of blood supply at
equilibrium.
>Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with
or without distant
metastases.
>To let the physician
know the procedure to be
done on her patient
>Ketorolac may interrupt
the blood levels and
readings of the S.
Creatinine result
>To treat the patient’s
pain.
DONE
DONE
DONE
DONE
DONE
55
Signed:
Dr. Lamanosa
December 15, 2009
1:00 am
Signed:
Dr. Agoilo
December 15, 2009
7:20 am
tab BID ( pls
inform if pt.
develops
persistent N&V)
Refer for
problems
Etericoxib 120g
P.O OD
IVFTF: PNSS 1L
@ 120cc/ ◦
Ff. up availability
of blood
Refer creatinine
result please to
ROD
> To let the physician
know the patient’s
problem and to provide
relief on it.
>To relieve acute pain
being felt by the patient.
> To provide patient
with adequate amount of
fluid and electrolytes.
>To start the treatment
rehgimen in order to
normalize hemoglobin
level, for good blood
circulation and to
maintain amount of
blood supply at
equilibrium.
>To know evaluate the
patient’s condition in her
treatment and therapeutic
DONE
DONE
DONE
DONE
DONE
56
Signed:
Dr. Agoilo
December 15, 2009
9:00 am
Signed:
Dr. Agoilo
December 15, 2009
10:00 am
Signed:Dr. Torno
December 15, 200911:00 am
For dressing with
Daikins solution
c/o ROD/ surgical
clerk in-charge
IVFTF: PNSS 1L
#3 @ 120cc/ ◦
Continue meds
Schedule for
Toilet mastectomy
TF 1st case
(lapcholecystecto-
my)
Dr. Lamanosa for
anesthesia
regimen.
> Daikins solution is
used for dressing, to
prevent germ growth on
wounds.
> To provide patient
with adequate amount of
fluid and electrolytes.
> To provide the patient
medications that will
relieve the pain that she
felt and to avoid further
inflammation and
infection.
> Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with
or without distant
metastases.
>For anesthesia
administration of the
patient during the
DONE
DONE
DONE
DONE
DONE
57
Signed:
Dr. Malubay
December 15, 2009
11:50 am
Signed:Dr. Narisma
December 15, 2009
4:30 pm
Signed:Dr. Torno
Seen AC &
consult, start BT
once available
Inform OR
Refer, accordingly
Please give 1amp
Plasil now, then q
6◦ PRN for
vomiting
Hold Cipro and
Clinda p.o
Shift to Cipro
200g IV q 12; no
skin test
Hold Metformin
surgical procedure to be
done.
> To start the therapeutic
regimen and for the
patient’s body to be
ready for the procedure.
> To let the OR staff
know about the
procedure and for it to be
scheduled.
>To have a smooth
process on the
physician’s part.
>To prevent the patient
from vomiting.
> Ciprofloxacin IV drug
is used for patients who
are immunosuppressed
and with infection.
> Patient’s glucose level
is already decreased into
normal level, holding the
medicine avoids the
DONE
DONE
DONE
DONE
DONE
DONE
58
December 15, 2009
8:00 am
Signed:
Dr. Narisma
December 15, 2009
9:30am
Continue meds
Schedule for
Toilet mastectomy
tom TF 1st case
IVFTF: PNSS 1L
to run @ 120cc/ ◦
x 2 cycle #4, 5
Refer accordingly
PRE- OP Orders:
NPO post
midnight
V/S before OR
General / oral
hygiene PTOR
patient to be
hypoglycemic.
> To provide the patient
medications that will
relieve the pain that she
felt and to avoid further
inflammation and
infection.
> Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with
or without distant
metastases.
> To provide patient
with adequate amount of
fluid and electrolytes.
> To prevent any
complications during the
operation scheduled for
the next day
>To have a baseline data
before operation and to
know any unusualities
that may not allow the
patient to be operated.
>To prepare the patient
DONE
DONE
DONE
DONE
59
Signed:
Dr. Lamanosa
December 16, 2009
IVF: D5NSS 1L
@ 120cc/ ◦
Meds:
1. Diazepam 5g 1tab
at 6 am with sips of
water
2. Ranitidine 15g
1tab at 6am with sips
of H20
Secure 1 unit of
bld and crossmatch
Pls let pt. void
prior to giving
meds
Refer for problem
May resume diet,
reschedule OR
for operation.
>To provide patient with
adequate amount of
liquid and electrolytes in
the body.
>To sedate the patient
while performing the
procedure.
> Ranitidine is useful in
promoting healing of
stomach and duodenal
ulcers, and in reducing
ulcer pain.
>To normalize
hemoglobin level, for
good blood circulation
and to maintain amount
of blood supply at
equilibrium.
>To prepare and avoid
the patient from
excreting waste during
surgery.
> To let the physician
know any problems prior
to operation.
> Resuming the patient’s DONE
60
10:30 am
Signed:Dr. Malubay
December 16, 2009
12:20 pm
Signed:Dr. Malubay
December 16, 2009
5:30 pm
Signed:Dr. Malubay
tomorrow @
7:30am
For
compliance of
antibiotics
Please schedule
tomorrow @
7:30pm
NPO post midnight
Inform OR and Dr.
Lamanosa
IVFTF: D5NSS 1L
@ 120cc/ ◦
diet allows the patient to
ingest food again for
body’s supplement. NPO
diet for her is only for
OR preparation.
> To prevent infection
and inflammation on the
affected area or her
wound on breast.
> To let the OR staff and
residents know about the
procedure to be done on
the patient.
> To prevent aspiration
and for the patient to
avoid excreting waste
during the procedure.
> To let the OR staff and
residents know about the
procedure to be done on
the patient and let Dr.
Lamanosa know the
changes that happened.
> To provide the patient
adequate liquid and
electrolyte intake and
supplement.
DONE
DONE
DONE
DONE
DONE
61
Diagnostic Exams
Blood Chemistry (12-14-09)
Date Exam Normal Value
Rationale Result of
patient
N/H/L Clinical Significance
Dec. 14, 2009
Creatinine 44.0- 80.0 umol/L
Measure the level of the waste product creatinine in your blood and urine. This test tells how well your kidneys are working.
109umol/L
H There is an indication of kidney problem.
Blood Chemistry (12-15-09)
Date Exam Normal Value
Rationale Result of patient
N/H/L Clinical Significance
Dec. 15, 2009
Creatinine 53 - 115 umol/L
Measure the level of the waste product creatinine in your blood and urine. This test tells how well your kidneys are working.
109umol/L
H There is an indication of kidney problem
Potassium 3.5- 5.3 mmol/ L
This test measures the amount of potassium in the blood. Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.
4.07 mmol/ L
N There is a normal regulation on how the heart beats.
Sodium 135-148 mmol/ L
The sodium levels are measured to detect
136.06mmol/
N There is a normal sodium level in the blood.
62
whether there is a right balance of sodium and liquid in the blood to carry out those functions.
L
Hematology
Date Exam Normal Value
Rationale Result of patient
N/H/L
Clinical Significance
Dec. 14,2009
Hemoglobin M: 140- 170 g/dl
F: 120- 150g/dl
This is the amount used to measure the amount of hemoglobin per liter of blood. It is measured to evaluate blood loss, anemia, and response to therapy.
99 L A decreased result below the normal range may indicate anemia.
Hematocrit M: 0.40- 0.60
F: 0.38- 0.40
This test is used to measure the proportion of whole blood volume occupied by erythrocytes. It is useful in the evaluation of blood loss, anemia, polycythemia, and dehydration.
0.30 L There is an indication of anemia and dehydration.
RBC Count 4.06- 6.0 x10^12/L
Used to evaluate any type of decrease or increase in the number of red blood cells as measured per liter of blood.
3.06x10^12/L
L Indicates anemia.
WBC Count 5.0-10.0 x10^9/L
Used to determine the presence of an infection or leukemia.
17.1x10^9/L
N There is an indication of infections or leukemia.
63
It is also used to help monitor the body’s response to various treatments and to monitor bone marrow function.
Neutrophils 45 – 65% This test measures the amount of neutrophils in blood. Neutrophils are a type of white blood cell (WBC). This test is used to evaluate and manage immune, blood, and cancer disorders, including suspected neutropenia..
65% H There is indication of immune, blood, and cancer disorders, including neutropenia.
Lymphocytes (P)
20 – 35% This test is done to determine the lymphocyte blood count.
10% L There are low secretion antibodies which are involved in the immune system response and regulation.
Monocytes 2 – 10% This test is done to help diagnose an illness such as infection or inflammatory disease.
6% N Monocytes remove debris or foreign particles from the circulation. They also participate in immune response.
Eosinophils 1 – 4% This test counts the number of eosinophil in blood. It is used to evaluate and manage allergic conditions, blood and infectious diseases, as well as certain infections.
4% N No indication of allergic conditions, blood and infectious diseases, as well as infections.
Basophils 0 – 1% This test measures 0 N
No indication of
64
the amount of basophils in blood. This test is used to help evaluate and manage treatments including certain allergic disorders, blood disorders, neoplastic disorders, and infections caused by parasites
allergic disorders, neoplastic disorders, and infections caused by parasite.
Blood Typing
Date Result
December 14, 2009 “A” Rh Positive
X- Ray Report (12-15-09)
Chest PA: Heart is within normal limits in size. There are infiltrates in the right lower
lobe. Rest of the lung fields are clear. Lateral CP sinuses are sharp.
Impression: Infiltrates may be inflammatory or neoplastic in origin. Please correlate
clinically.
65
Drug Study
GENERIC NAME Ranitidine hydrochloride
BRAND NAME Ranitidine
CLASSIFICATION Histamine2 (H2) antagonist
ORDERED DOSAGE 50 mg q 8 hours / q 4 hors IVTT
MODE OF ACTION
Competitively inhibits the action of histamine at the H2 receptors
of the parietal cells of the stomach, inhibiting basal gastric acid
secretion and gastric acid secretion that is stimulated by food,
insulin, histamine, cholinergic agonists, gastrin and pentagastrin.
INDICATION
Intractable duodenal ulcer; pathologic hypersecretory condition;
short term therapy for patients unable to tolerate oral forms,
duodenal and gastric ulcer, maintenance therapy for duodenal
ulcer, gastroesophagial reflux disease, erosive esophagitis, self
medication for occasional heart burn, acid indigestion, and sour
stomach
DRUG INTERACTION
Drug-drug: Antacids: may interfere with ranitidine absorption,
Diazepam: May decreased diazepam absorption, Gilipizide: May
increase hypoglycaemic effect, Procainamide: May decrease renal
clearance of procainamide, Warfarin: May interfere with warfarine
clearance
Drug-lifestyle: Smoking: may increase gastric acid secretions and
worsen disease
CONTRAINDICATION Contraindicated in patients hypersensitive to drugs and its
66
components; Porphyria
SIDE EFFECTSHeadache, malaise, dizziness, rash, constipation, nausea, vomiting,
abdominal pain
ADVERSE
REACTIONS
Tachycardia, bradycardia, hepatitis, impotence or decreased
libido, leucopenia, granulocytopenia, thrombocytopenia
NURSING
RESPONSIBILITIES
Assessment
History – allergy to ranitidine, impaired renal or hepatic
function
Physical – skin lesions; orientation, affect; pulse, baseline
ECG, live evaluation, abdominal examination, normal
output, CBC, renal function test
Intervention
Decrease doses in renal and liver failure
Provide concurrent antacid therapy to relieve pain.
Arrange for regular follow – up, including blood tests, to
evaluate effects.
Patient teaching
If you also are using antacid, take it exactly as prescribed,
being careful of the times of administration.
Have regular follow – up care to evaluate your response.
You may experience these side effects: constipation or
diarrhea (request aid from your health care provider),
nausea, vomiting, impotence or decreased libido, headache
Report sore throat, fever, unusual bruising or bleeding,
tarry stools, confusions, hallucinations, dizziness, severe
headache, muscle or joint pain.
BIBLIOGRAPHY
Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company
Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)
67
Generic Name Ketorolac
Brand Name Toradol
Classification NSAID, nonopioid analgesic
Dosage 30mg q 8hr IVTT
Mode of Action Inhibits prostaglandin synthesis, producing peripherally
mediated analgesia. Also has anti-pyretic and anti-
inflammatory properties
Indications Short-term management of pain
Ocular itching caused by seasonal allergic rhinitis
Postoperative inflammation following cataract surgery
Pain and burning or stinging following corneal refractive
surgery
Contraindications Hypersensitivity to the drug or other NSAIDS
Acute peptic ulcer disease, recent GI bleeding or
perforation, history of peptic ulcer or GI bleeding
Suspected or confirmed cerebrovascular bleeding,
hemorrhagic diathesis, or incomplete hemostasis and in
those with a high risk of bleeding
Intrathecal or epidural administration( due to alcohol
content of product)
Labor, delivery, or lactation
Perioperative pain from coronary artery bypass graft
surgery
Side Effects Drowsiness, dizziness, headache, nausea, vomiting,
epigastric pain, indigestion, flatulence, constipation,
68
insomnia, dry mouth, sweating
Adverse Effects Gastric or duodenal ulcers, renal failure, peripheral edema,
dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis,
anaphylaxis
Drug Interaction Concurrent use with aspirin may decrease effectiveness
With aspirin, other NSAIDS, potassium supplements,
corticosteroids, or alcohol, adverse GI effects is increased
Chronic use with acetaminophen may increase risk of
adverse renal reactions
May decrease effectiveness of diuretics or hypertensives
Increases risk of toxicity with methotrexate
Increases risk of bleeding with cefotetan, cefoperazone,
valproic acid, clopidogrel, and ticlopidine
Increases risk of adverse heamatologic reactions with
antineoplasctic or radiation therapy
May increase risk of nephrotoxicity from cyclosporine
Probenecid increases ketorolac blood levels and the risk of
adverse reactions
Nursing
Responsibilities
Assess pain ( type, location, & intensity) before and after
drug therapy.
Assess for rhinitis, asthma, urticaria. Patients who have
asthma, aspirin-induced allergy, and nasal polyps are at
increased risk of developing hypersensitivity reactions.
Instruct patient on how and when to ask for medication
Tell patient to take medication exactly as directed. Take
missed doses as soon as remembered if not almost time for
next dose. Do not double dose.
Advise patient to avoid driving or other activities requiring
alertness until response to the medication is known
because it may cause drowsiness or dizziness.
Caution patient to avoid the concurrent use of alcohol,
69
aspirin, NSAIDS, acetaminophen or other OTC
medications without consulting health care professional
Advise patient to consult health care professional if rash,
itching, visual disturbances, tinnitus, weight gain, edema,
black stools, persistent headache, influenza-like-syndrome
( chills, fever, muscle aches, pain) occurs/
BIBLIOGRAPHY
Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company
Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)
Handbook of Drugs for Nursing Practice .2nd Ed. Mosby Year
Book, St. Louis, Missouri, U.S.A.
Foley, M, RN, BSN, et.al. (2005) Mosby’s 2005 Drug Consult for
Nurses .1st Ed. Elsevier Mosby, St. Louis Missouri, U.S.A.
70
Generic Name Tramadol
Brand Name Ultram
Classification Analgesic ( centrally acting)
Dosage 50mg q 8hr IVTT
Mode of Action Binds to mu-opioid receptors and inhibits the reuptake of
serotonin and norepinephrine in the CNS
Indications Moderate to moderately severe pain
Contraindications Contraindicated with hypersensitivity or allergy to
tramadol or opioid.
Patients who are acutely intoxicated with alcohol,
sedatives/hypnotics, centrally acting analgesics, opioid
analgesics, or psychotropic agents.
Patients who are physically dependent on opioid
analgesics.
Not recommended for use during pregnancy or lactation
Side Effects Dizziness, headache, nausea, vomiting, constipation,
sweating, hypotension, dry mouth,
Adverse Effects Seizures, anaphylactoid reactions, hypertonia, physical/
sychological dependence, tolerance, anorexia
Drug Interaction Alcohol & general anesthetics: increases respiratory
depression
Carbamazepine: decreases tramadol effect r/t increased
metabolism
CNS depressants: additive CNS depression
Cyclobenzaprine: increases risk of seizures
Digoxin: increases risk of digoxin toxicity
71
MAO inhibitors/promethazine/trycyclic antidepressants:
increases risk of seizures
Naloxone: increases risk of seizures if naloxine used for
tramadol overdose
Quinidine: increases levels of tramadol
Nursing
Responsibilities
Assess pain (type, location, and intensity) before and after
administration of the medication.
Assess blood pressure and respiratory rate before and
periodically during administration.
Assess bowel function. Prevention of constipation should
be instituted with increased intake of fluids and bulk and
laxatives to minimize constipating effects.
Monitor patient for seizures. May occur within
recommended dose range.
Explain therapeutic value of medication before
administration to enhance the analgesic effect.
Instruct patient on how and when to ask for medication
Advise patient to avoid driving or other activities requiring
alertness until response to the medication is known
because it may cause drowsiness or dizziness.
Advise patient to change positions slowly to minimize
orthostatic hypotension.
Caution patient to avoid concurrent use of alcohol or other
CNS depressants with this medication.
Encourage patient to turn, cough, and breathe deeply for
every 2 hr to prevent atelectasis
BIBLIOGRAPHYLippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company
72
GENERIC NAME Etoricoxib
BRAND NAME Arcoxia
CLASSIFICATION COX-2 inhibitor
ORDERED DOSAGE 120mg cap 1 cap OD
MODE OF ACTION
COX-2 inhibitors reduce pain and inflammation by blocking
COX-2, an enzyme in the body which plays a role in joint
inflammation and pain.
INDICATION
acute and chronic treatment of the signs and symptoms of
osteoarthritis and rheumatoid arthritis
management of ankylosing spondylitis
relief of chronic musculoskeletal pain
relief of acute pain
to treat acute gouty arthritis
DRUG INTERACTION
CONTRAINDICATION allergy to Arcoxia or allergic reaction to aspirin or other
anti-inflammatory medicines
if the patient has had heart failure, a heart attack, bypass
surgery, chest pain (angina), narrow or blocked arteries of
the extremities (peripheral arterial disease), a stroke or
mini stroke (TIA or transient ischemic attack).
high blood pressure that is not well controlled on blood
pressure medication.
If the patient is having major surgery and has conditions
which increases the risk of coronary artery disease or
atherosclerosis such as high blood pressure, diabetes, high
cholesterol or smoking.
73
If the patient is having major surgery on his heart or
arteries.
SIDE EFFECTS
Nausea, vomiting, headache, dizziness, heartburn, indigestion,
uncomfortable feeling or pain in the stomach, diarrhea, swelling of
ankles, legs or feet, increased BP
ADVERSE
REACTIONS
Allergic reactions, including rash, itching and hives; altered taste;
wheezing; insomnia; anxiety; drowsiness; mouth ulcers; diarrhea;
confusions; hallucinations; decreased platelet count; severely
increased BP; atrial fibrillations; palpitations; stomach ulcers;
hepatotoxicity; renal toxicity
NURSING
RESPONSIBILITIES
BIBLIOGRAPHY http://www.drugs.com/arcoxia.html
GENERIC NAME Clindamycin
BRAND NAME Cleocin, Dalacin C
74
CLASSIFICATION Antibiotic
ORDERED DOSAGE 300mg 1cap q8 6am-2pm-10pm
MODE OF ACTIONInhibits bacterial protein synthesis by binding to 50S subunit of
ribosome.
INDICATION
Infections caused by sensitive staphylococci, streptococci,
pneumococci, Bacteroides, Fusobacterium, Clostridium
perfringens, and other sensitive aerobic and anaerobic
organisms
Endocarditis prophylaxisfor dental procedures in patients
allergic to penicillin
Acne vulgaris
Bacterial Vaginosis
Pneumocystis jiroveci (carinii) pneumonia
Toxoplasmosis (cerebral or ocula) in immunocompromised
patients
DRUG INTERACTION
Drug-Drug
Erythromycin: May block clindamycin site of action
Kaolin: May decrease absorption of oral clindamycin
Neuromuscular blockers: May potentiate neuromuscular blockade
CONTRAINDICATION
Contraindicated in patients hypersensitive to drug or
lincomycin
Use cautiously in patient seith renal or hepatic disease,
asthma, history of GI disease, of significant allergies
Use cautiously in neonates
SIDE EFFECTS/
ADVERSE REACTIONS
CV: thrombophlebitis
EENT: pharyngitis
GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,
diarrhea, dysphagia, esophagitis, flatulence, nausea,
pseudomembranous colitis, unpleasant or bitter taste, vomiting
GU: UTI, vaginal discharge
HEMATOLOGIC: eosinophilia, thrombocytopenia, transient
75
leucopenia
SKIN: maculopapular rash, urticaria
OTHER: anaphylaxis; erythema
NURSING
RESPONSIBILITIES
Inform patient of the possible side/adverse effects and drug
interactions
Instruct patient to notify physician/prescriber if
side/adverse effects and drug interactions is noted
Give with full glass of water to prevent dysphagia
Tell patient to follow proper medication regimen
Monitor vital signs for baseline data and patient
monitoring
BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company
GENERIC NAME Ciprofloxacin
BRAND NAME Cifroxin
CLASSIFICATIONQuinolones / Eye Anti-infectives & Antiseptics / Ear Anti-
infectives & Antiseptics
ORDERED DOSAGE PO Susceptible infections 250-750 mg twice daily. Acute
uncomplicated cystitis 100 mg twice daily for 3 days.
76
Gonorrhoea 250-500 mg as a single dose. Pseudomonal lung
infections in cystic fibrosis 20 mg/kg twice daily. Max: 750 mg
twice daily. Prophylaxis of meningococcal meningitis 500 mg as
a single dose. Surgical prophylaxis 750 mg as a single dose 60--
90 mins pre-op. Acute exacerbations of cystic fibrosis
Associated w/ P. aeruginosa infection: 20 mg/kg bid. Max: 750
mg bid. IV Susceptible infections 100-400 mg twice daily.
Pseudomonal lung infections in cystic fibrosis 400 mg twice
daily. Max: 400 mg 3 times/day. Ophth Superficial ophth
infections As 0.3% soln: Apply every 15 mins for 6 hr, followed
by every 30 mins for day 1, then hrly on day 2 and 4 hrly for days
3-14. Treatment duration: ≤21 days. Otic Otitis externa; Otitis
media As 0.2 or 0.3% soln: Instill 4 drops twice daily for 7 days.
MODE OF ACTION
Ciprofloxacin promotes breakage of double-stranded DNA in
susceptible organisms and inhibits DNA gyrase, which is essential
in reproduction of bacterial DNA.
INDICATION
Infections caused by sensitive staphylococci, streptococci,
pneumococci, Bacteroides, Fusobacterium, Clostridium
perfringens, and other sensitive aerobic and anaerobic
organisms
DRUG INTERACTION Decreased absorption with concurrent sucralfate, magnesium-
aluminum antacids, calcium, iron, zinc and multivitamins.
Increased methotrexate and caffeine levels when taken
concurrently with ciprofloxacin. Probenecid reduces renal
clearance of ciprofloxacin. Potentiates oral anticoagulants and
glibenclamide. Concurrent use with corticosteroids may increase
tendon rupture. Concurrent use with ciclosporin may cause
transient increases in serum creatinine. CNS excitation may occur
77
with concurrent admin of quinolones and NSAIDs. Serum
concentrations of theophylline are markedly elevated when co-
administered with ciprofloxacin; monitor serum levels of
theophylline.
Potentially Fatal: Concurrent use with tizanidine can cause
marked elevation in serum levels of tizanidine; avoid concurrent
usage.
CONTRAINDICATION
Hypersensitivity. Not to be used concurrently with tizanidine.
Avoid exposure to strong sunlight or sun lamps during
treatment. Epilepsy, history of CNS disorders; severe renal or
hepatic dysfunction; G6PD deficiency; maintain adequate
hydration; myasthaenia gravis. Caution when used in patients
with QT prolongation or risk factors e.g. bradycardia, pre-
existing cardiac disease or uncorrected electrolyte
disturbances. Discontinue treatment if patients experience
tendon pain, inflammation or rupture. Avoid usage in
methicillin-resistant staphylococcus aureus (MRSA) infections
due to high level of resistance. May impair ability to drive or
operate machinery. Safety and efficacy have not been
established in pregnant and lactating women. Not to be used in
children <18 yr; except where benefit clearly exceeds risk.
SIDE EFFECTS/
ADVERSE REACTIONS
CV: thrombophlebitis
EENT: pharyngitis
GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,
diarrhea, dysphagia, esophagitis, flatulence, nausea,
pseudomembranous colitis, unpleasant or bitter taste, vomiting
GU: UTI, vaginal discharge
HEMATOLOGIC: eosinophilia, thrombocytopenia, transient
leucopenia
SKIN: maculopapular rash, urticaria
OTHER: anaphylaxis; erythema
78
NURSING
RESPONSIBILITIES
Inform patient of the possible side/adverse effects and drug
interactions
Instruct patient to notify physician/prescriber if
side/adverse effects and drug interactions is noted
Give with full glass of water to prevent dysphagia
Tell patient to follow proper medication regimen
Monitor vital signs for baseline data and patient
monitoring
Assess overall health status and alcohol usage before
administering acetaminophen. Patients who are
malnourished or chronically abuse alcohol are at higher
risk of developing hepatotoxicity with chronic use of usual
doses of this drug
Assess amount, frequency, and type of drugs taken in
patients self-medicating, especially with OTC drugs.
Prolonged use of acetaminophen increases the risk of
adverse renal effects.
Lab Test Considerations
• Evaluate hepatic, hematologic, and renal function
periodically during prolonged, high-dose therapy
BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company
79
Nursing Theories
Nursing theory is the term given to the body of knowledge that is used to support nursing
practice. In their professional education nurses will study a range of interconnected subjects
which can be applied to the practice setting. This knowledge may be derived from experiential
learning, from formal sources such as nursing research or from non-nursing sources.
Florence Nightingale’s Environmental Theory
Nightingale's core nursing theory has an environmental focus: She believed that the
environment is an alterable medium that can be used to improve the conditions of nature and
encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and
adequate waste management are just a some of the elements she believed could be monitored and
improved when necessary. She stated that nursing is an act of utilizing the patient’s environment
to assist him in his recovery. This involves the nurse's initiative to configure environmental
80
settings appropriate for the gradual restoration of the patient's health, and that external factors
associated with the patient's surroundings affect life or biologic and physiologic processes, and
his development.
This theory is applicable to our patient because the institution where she stayed was
following an ideal way of treating their patients. The ward where she stayed was clean with
proper ventilation, provision of light and with controlled noise. There was also an adequate
management wherein there were separate garbage bins for biodegradable, non-biodegradable and
infectious materials. These factors follows Nightingales assumptions that helps for a faster
recovery of the patient.
Faye Glen Abdellah’s Patient- Centered Approach
Faye Glenn Abdellah’s problem solving approach (twenty one nursing problems) was
created to direct the nurse. It helps the nurse have an organized approach in his or her care of the
patient. It does so by providing 21 nursing problems that serve as a guide for the patient to
pattern his or her plan of care after. It can be used for data collection, planning, and prioritizing
nursing interventions.
The client’s student nurse has the task of maintaining her health and improving her
wellbeing. Doing so entails an organized plan of care that we can get from Faye Abdella’s
theory. The nurse should gather necessary information about his condition before identifying a
therapeutic plan. The student nurse assessed her ability to maintain her proper nutrition,
elimination, fluid and electrolyte balance, the body’s response to disease, regulatory
mechanisms, and maintenance of sensory function. Last is remedial care such as identifying and
accepting feelings, maintenance of effective verbal and nonverbal communication. After
identifying the needs of the patient, nursing interventions were to be done to promote wellness of
our client. It is clear that these 21 nursing problems help organize the needs and the tasks that her
student nurse needed to accomplish.
81
DONE 1.. To promote good hygiene and physical comfort
DONE 2. To promote optimal activity, exercise, rest, and sleep
DONE 3. To promote safety through prevention of accidents, injury, or other
trauma and through the prevention of the spread of infection
DONE 4. To maintain good body mechanics and prevent and correct deformities
DONE 5. To facilitate the maintenance of a supply of oxygen to all body cells
DONE 6. To facilitate the maintenance of nutrition of all body cells
DONE 7. To facilitate the maintenance of elimination
DONE 8. To facilitate the maintenance of fluid and electrolyte balance
DONE 9. To recognize the physiologic responses of the body to disease
conditions
DONE 10. To facilitate the maintenance of regulatory mechanisms and functions
N/D 11. To facilitate the maintenance of sensory function
DONE 12. To identify and accept positive and negative expressions, feelings, and
reactions
DONE 13. To identify and accept the interrelatedness of emotions and illness
DONE 14. To facilitate the maintenance of effective verbal and nonverbal
communication
DONE 15. To promote the development of productive interpersonal relationships
DONE 16. To facilitate progress toward achievement of personal spiritual goals
DONE 17. To create and maintain a therapeutic environment
DONE 18. To facilitate awareness of self as an individual with varying physical,
emotional, and developmental needs
DONE 19. To accept the optimum possible goals in light of physical and
emotional limitations
N/ D 20. To use community resources as an aid in resolving problems arising
from illness
N/ D 21. To understand the role of social problems as influencing factors in the
cause of illness
82
Lydia Hall’s Theory
Lydia Hall’s theory is visually presented by three interlocking circles. Each circle
represents a particular aspect of nursing. The three circles represent the care, core and cure. The
major aspect of care is to achieve an interpersonal relationship with the health care provider that
will much more facilitate development. This aspect provides motherly care and comfort, provide
teaching-learning activities and support the daily biological function of the patient. The
closeness of the nurse and patient promotes the sharing and exploration of feelings with the
nurse. The core aspect emphasized the therapeutic use of self and usage of reflective technique.
The patient becomes more aware of the feeling being experienced as evidenced of making
conscious decision, understand and accept feeling. In Hall’s theory health is derived as a state of
self-awareness. The cure circle is based on pathological and therapeutic sciences like giving of
prescribed medications. These three aspects function independently but they are interrelated and
the circle’s size represents the progress in each aspect.
Hall’s theory is applicable in the case of our Client. The care aspect shows the
relationship between the patient and the health care provider who is, in her case, the student
nurse. The student nurse gives health teachings to the client like the prescribed diet, medications
and lifestyle for her condition. She is aware of her condition and listens to the student nurse’s
health teachings to avoid further complications and problems. Our client was able to verbalize
her willingness to be well with the student nurse. The student nurse should encourage support in
order to promote positive outlook of the client. The core aspect helped the patient reflect on her
situation today and in this manner the patient will learn to accept and understand her situation
and cope up with ways to promote her state of wellness. The client shows motivation on getting
well by taking her medications on time which is part of the cure aspect of Hall’s theory.
83
NURSING CARE PLAN NO. 1
DATE
CUES NEED
NURSING DIAGNOSIS
GOAL OF CARE INTERVENTIONS
1
2
-
1
4
-
0
9
7
:
0
0
p
m
SUBJECTIVE:
“ Sakit kayo akong
samad sa breast,” as
verbalized by the
patient.
OBJECTIVE:
-painscale of 7 out of
10 as 8-10 severe pain,
5-7 moderate pain, 0-4
mild pain
-grimace face noted
-guarded behavior
noted
-uncomfortable
position
-with dry and intact
dressing at left breast
-VS
BP= 120/70mmHg
RR= 34cpm
PR= 80 bpm
S
A
F
E
T
Y
A
N
D
S
E
C
U
R
I
T
Y
N
E
E
D
ACUTE PAIN
related to
Wound at left
breast secondary
to Breast cancer
R.
Unpleasant
sensory and
emotional
experience arising
from actual or
potential tissue
damage can due
to a disease
process..
Within 2-4 hours
of my care, patient
will be able to:
-verbalized that
pain is relieved or
controlled
-verbalized that
pain scale of 7 out
of 10 will
decreased within
0-3 pain scale
a. Provide with calm and quiet
environment.
R. For adequate rest and sleep.
b. Provide comfort measures.
R. To provide nonpharmacological
pain management.
c. Administer analgesics/ pain reliever
as indicated to maximal dosage.
R. To alleviate pain.
d. Encourage adequate rest periods.
R. To prevent fatigue.
e. Instruct/ encourage use of relaxation
exercises.
R. Reduces skeletal muscle tension
which will reduce the intensity of the
pain.
f. Encourage diversional activities.
R. To redirect attention and control the
pain felt.
g. Encourage verbalization of feelings
about the pain.
84
T= 37.1 C R. Be able to know the degree of pain
felt.
h. Encourage deep breathing exercises.
R. To assist in muscle and generalized
relaxation.
NURSING CARE PLAN NO. 2
DATE
CUES NEED
NURSING DIAGNOSIS
GOAL OF CARE INTERVENTIONS
1
2
-
1
4
-
0
9
7
:
0
0
p
m
SUBJECTIVE:
“Naga katol akong
samad, nagabaho pud
siya”, as verbalized by
the patient.
OBJECTIVE:
-disruption of skin
surface
-with dry, clean and
intact dressing at left
breast.
- foul odor was noted
coming from her left
breast
-Vital Signs:
S
A
F
E
T
Y
A
N
D
S
E
C
U
R
Impaired Skin
Integrity related
to left breast
wound secondary
to breast cancer.
R:
A dimpling of the
breast skin or
nipple could be
from the loss of
elasticity in the
supporting
ligaments as you
age. But dimpling
may also be a
Within my 3 days
span of care
patient will
maintain her
normal vital signs
and well being and
no further signs of
infection will be
seen or observed
on her.
1. Assess skin, note for color, turgor
and sensation.
R: establishes comparative baseline
providing opportunity for timing
intervention.
2. Demonstrate good skin hygiene
R: Maintaining clean dry skin provides
barrier to infection.
3. Instruct family to maintain clean dry
clothes preferably cotton fabric.
R: stiff or rough clothes causes skin
friction and increases risk of infection.
4. Emphasize the importance of proper
nutrition and fluid intake.
85
BP= 120/70mmHg
RR= 34cpm
PR= 80 bpm
T= 37.1 C
I
T
Y
N
E
E
D
sign that a tumor
buried in the
tissues is pulling
on the skin or
nipples. In the
case of a tumor,
dimpling might
show up long
before a lump
becomes large
enough to feel.
R: improve nutrition and hydration
will improve skin condition.
5. provide and apply wound dressing
R: wound dressing serves as barrier to
surrounding tissue.
6. encourage early ambulation
R: promotes circulation
7: assist client in understanding and
following medical regimen
R: enhances commitment to plans,
optimizing outcomes
8: encourage client to verbalize
feelings
R: to promote proper intervention to
the problem
NURSING CARE PLAN NO. 3
DATE
/ TIME
CUES NEED NURSING
DIAGNOSIS
GOAL
OF CARE
NURSING
INTERVENTION
Dec.
15,
2009
@
7:30pm
Subjective:
“Unsa kaya ang
mahimong itsura
sa akong totoy
paghuman sa
operasyon
noh?”, as
SELF-ESTEE
Disturbed body
image related to
impending surgical
procedure on her
left breast due to
Breast Cancer
At the end of my
shift, the client
will begin to
exhibit her
perception on her
baseline body
image after
1. Establish trusting
relationship or rapport to
the patient.
® To gain trust.
2. Ascertain whether
support and counseling
were initiated when the
86
verbalized by the
patient
Objective:
- Patient is
scheduled for
toilet
Mastectomy
tomorrow
morning
- dressing placed
on left breast
M
NEED
® Woman who
undergo surgery for
breast cancer
experience a sense
of loss – changes in
life routines, social
interactions, self-
concept, and body
image – and fear of
death. Recovery
during the
postoperative
period after
mastectomy
requires a great deal
of energy. A
client’s usual
coping strategies
may not be
effective. Not every
one perceives or
handles stress in the
same way. Clients
who have surgically
lost a breast may
adapt in the same
way as they would
to any loss.
surgery , as
evidenced by
verbalization of
positive
adaptation to her
impending
surgery,
possibility of and/or
necessity of mastectomy
was first discussed.
® This provides
information about patient’s
level of knowledge and
anxiety about individual
situation.
3. Encourage patient to
verbalize feelings
regarding the procedure
done. Acknowledge
normality of feelings of
anger, depression, and grief
over loss. Discuss daily
“ups and downs” that can
occur.
® It helps patient realize
that feelings are not
unusual and that guilty
about them is not necessary
or helpful. Patient needs to
recognize feelings before
they can be dealt with
effectively.
4. Note behaviors of
withdrawal, increased
dependency, manipulation,
or noninvolvement in care.
® This suggests of
problems in adjustment
87
References:
Black, J. et. al.
(2001). MEDICAL-
SURGICAL
NURSING:
Clinical
Management for
Positive Outcomes.
6 th ed. USA: W.B.
Saunders Company.
that may require further
evaluation and more
extensive therapy.
6. Provide opportunity for
patient to deal with
mastectomy through
participation in self-care.
® Independence in self-
care helps improve self-
confidence and acceptance
of situation.
7. Encourage questions
about current situation and
future expectations.
Provide emotional support
when surgical dressings are
removed.
® Loss of breast causes
many reactions, including
feeling disfigured, fear of
viewing scar, and fear of
partner’s reaction to
change in body.
8. Plan or schedule care
activities with patient.
® Promotes sense of
control and give message
that patient can handle
situation, enhancing self-
concept.
9. Maintain positive
88
approach during care
activities, avoiding
expressions of disdain or
revulsion. Do not take
angry expressions of
patient personally.
® Assists patient to accept
body changes and feel all
right about self. Anger is
most often directed at the
situation and lack of
control individual has over
what has happened
(powerlessness), not with
the individual caregiver.
10. Identify role concerns
as woman, wife, mother,
career woman, and so
forth.
® This may reveal how
patient’s self-view has
been altered.
NURSING CARE PLAN NO. 4
Date Cues Need Nursing Diagnosis Objective of Nsg.
89
Care Interventions
December
16,
2009
Objective:
-wound at left
breast
-foul smell coming
from the wound
-clean and intact
dressing at left
breast
- foul smell
coming from her
wound was noted.
- Vital Signs:
BP= 120/70mmHg
RR= 24cpm
PR= 84 bpm
T= 37.3 C
S
A
F
E
T
Y
A
N
D
S
E
C
U
R
I
T
Y
N
E
E
D
Risk for infection related
to break in skin integrity
as evidenced by left breast
wound secondary to breast
cancer
® A woman who has
breast cancer with
draining wound is at risk
for infection.
Reference:
Lemone and Burke,
Medical Surgical Nursing,
Critical Thinking in Client
Care, 2004
Within 8 hrs span
of nursing care,
patient will be
able to maintain
an optimum level
of wellness and no
progress of
infection or spread
of wound.
1. Monitor vital
signs.
R: an increase in
temperature is the
first sign of
infection.
2. Administer
prophylactic
antibiotics as
ordered.
R: to reduce and
prevent bacterial
infection
3. Orient client for
signs and
symptoms of
sepsis (systemic
infection); fever,
chills, diaphoresis,
altered level of
consciousness,
positive blood
cultures.
®Health teachings
are essential for
the complete
90
recovery of a
client
4.Stress proper
hand washing
techniques
between nurse and
patient
®kills or prevent
the spread of
microorganisms.
5. Change
dressing as needed
or as indicated.
® to prevent
growth of bacteria
and infection
6.Eat nutritious
food and
encourage to take
vitamins
® to improve
immune system
7.Promote good
hygiene
® to promote
wellness
NURSING CARE PLAN NO. 5
DATE/
TIME
CUES N
E
NURSING DIAGNOSIS OBJECTIVE OF
CARE
NURSING
INTERVENTION
91
E
DWITH RATIONALE
Dec.
14,
2009
S/O:
-RR=34cpm
-shortness of
breath
-dyspneic
- use of
accessory
muscles while
breathing
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N
Ineffective Breathing Pattern
related to disease process
secondary to Breast cancer
Rationale:
Cancer of the lung and breast
are the most common cancers
to cause breathlessness. The
former causes breathlessness
by invading and obstructing
airways in the lung. Breast
cancer on the other hand,
causes malignant pleural
effusions rather than
blocking an area in the lungs
Reference :
http://
www.virtualcancercentre.co
m/symptoms.asp?sid=15
After 8hours of
care, patient will be
able to establish
normal and
effective breathing
pattern as evidenced
by:
-RR of 16-20cpm
-be free from
cyanosis or other
symptoms of
hypoxia
Assessed respiratory
rate.
Provides a basis for
evaluating adequacy of
ventilation
Noted chest movement;
use of accessory
muscles during
respiration.
Use of accessory
muscles of respiration
may occur in response
to ineffective
ventilation.
Maintained patient on
moderate to high back
rest.
Positioning helps
maximize lung
expansion.
Encourage patient to
have adequate rest
periods between activity
To prevent fatigue
Checked for
obstructions:
accumulation of
secretions.
To maintain adequate
92
airway patency
DISCHARGE PLAN
Medications Exercise Treatment Health Teachings Out- Patient
Inform the patient of the importance of compliance of medication especially maintenance of medicines.
Inform the patient that she must take her medications at the right time prescribed by her doctor.
Since the patient is taking several medications, advise her to organize medications in a container so that it would be easier to access the medications on time.
Inform the patient not to skip medication, and if skipped, do not double the next dose.
Inform the patient that she can be ambulatory but avoid strenuous activities. Avoid lifting heavy things.
Encourage the patient to do stretching in the morning and at night as this would help in the circulation of the blood in the body.
If patient feels dizzy or weak, encourage to do range of motion exercise.
Encourage patient to do deep breathing
Inform the patient to take prescribed medications on time and with the right dosage.
If any signs and symptoms of recurrence of illness, immediately report to the doctor so that it can be intervened on.
Do not use any herbal medications to cure any sickness, immediately seek medical advice.
Avoid becoming too fatigue. Always make sure that she will be having
Encourage the patient to have adequate rest and sleep.
Advise the patient to have proper hygiene.
Encourage the patient to contact health care provider once symptoms are felt.
Relaxation technique can be done to help reduce blood pressure.
Lifestyle modification should be done because they are effective in preventing further illnesses.
Encourage the patient to have regular check-ups to monitor her health status.
Inform the patient not to self diagnose if there are cases where signs and symptoms are felt.
93
Encourage the patient to avoid taking OTC drugs unless consult has been done by the physician.
exercise. adequate rest.
Avoid stressful environment.
If dizzy, advise to sit or lie down immediately to avoid casualties.
94
Prognosis
CRITERIA GOOD FAIR POOR RATIONALE JUSTIFICATIONOnset of Illness As early as possible,
the patient should seek medical treatment when the signs and symptoms of a certain illness are manifesting. When medical attention is given early to the patient, the signs and symptoms will not lead to further complications. If the illness is diagnosed in the late stage, recovery would be slow and difficult.http://www.med.nyu.edu/patientcare/library/article.html?ChunkIID=165011
The patient seek medical help only on the event when there is already bleeding on her breast and it was still on the year 2006. She did not have any follow up check up, and now, it is already in stage 3B of the disease process.
Duration of Illness
With proper treatment by therapy and/or by medications, the client should adhere to what is being ordered by her physician during the duration of illness. Without these, the duration of illness will last longer which means the client will be at more risk of complications.http://www.healthteaching.com/pre.html
The patient only seeks and had a return check up to her physician only when her cancer progressed already.
Environment The environment affects an individual’s general health. Maintaining a good environment that is fit for the patient and aid’s in the recovery of the
The patient’s home environment is clean and comfortable to live in. The hospital is also clean and tidy which imposes
95
patient.http://www.environmentalhealth.ca/w90vision.html
proper and ideal place for their patient’s health.
Family Support Families and friends are considered to be significant others for they are the ones who provide a sick person strength, hope and encouragement. With their love and support, the patient would be able to show willingness in striving for optimum wellness.http://www.dailystrength.org/treatments/Friend_Family_Support
Patient Star has support from everyone in her family, her children visit her a lot and her current husband is very caring.
Willingness to take medications
The willingness to take medications is a good indicator that she will have a faster recovery because of the effectiveness of the drug. Ensuring that medications are taken on time, with the right dosage and route gives a big benefit to the patient.http://www.health.discovery.com/centers/articles/articles.html?chrome=c12
The patient verbalized that she really wants to get well and therefore complies with the medications and other interventions the doctor has ordered.
Precipitating Factors
The precipitating factors of the client are modifiable if proper health education is given as well as the eagerness of the client to cooperate. If these factors are modified,
I rate this as poor because the disease process is already in Stage 3B. she almost had all the precipitating factors that brought her the disease.
96
recurrence of the illness may be prevented and controlled.http://www.fcds.org/about/health/health_ed.as
Predisposing Factors
Predisposing factors are factors which cannot be changed. These factors may play crucial roles in placing a greater risk in acquiring the disease.http://www.rsirescue.com/excerpts/PredisposingFactors.htm
Although the patient is qualified for the predisposing factors for breast cancer, there are still other factors that were not manifested and even participated by Patient Star
TOTAL 3x3 2x1 1x3 14/7 = 2
LEGEND: 1 POOR= 1.0- 1.62 FAIR= 1.7-2.33 GOOD= 2.4-3.0
General Prognosis: FAIR
The patient’s prognosis is fair because patient in general is already in Stage 3B cancer
that is already in the advance stage of the disease. Although she cooperates well on the
therapeutic regimen being advised to her by the physician, family also supports her all
throughout the disease process and the patient is optimistic enough that she will gain her strength
again and be well after the surgery, still we cannot deny the fact that all the factors that brought
her the disease are present and are helping the spread of those cancer cells in her body.
97
Recommendation
To the Patient:
In order for Patient Star to achieve recovery, the researcher highly encouraged her to
maintain good nutrition by eating foods with roughage such as whole grains, raw fruits and
vegetables and try to eat less food high in salt and fats. Resumption of activities should also pace
gradually to avoid any problems, strenuous activities must be avoided and exercises or ADL’s
should be done as tolerated. Advised the importance of follow-up examinations and treatments
for these will promote faster recovery for the patient and possible complications that may arise
will be treated immediately.
To the Significant Others:
Patient Star’s family must understand the importance of early detection of the illnesses;
the researcher would like to encourage them to have routinary check ups to avoid any further
complications that may occur if not treated early. Consult a doctor if unusualities occur to the
patient so that proper medication may be prescribed to treat underlying condition. They must
extend their support, for assistance and guidance is a good way of helping the patient and
collaborate in plans to promote faster recovery. Lastly, is to always have a healthy way of living,
by doing so, the body is more ensured to be protected and armed against any diseases.
To my fellow Student Nurses:
98
In line with this case study and case presentation, we had undergone Leadership and
Training courses wherein we practiced it on our Head Nursing duties, I would like to emphasize
to practice teamwork and unity among our group. Let us be arole model in our patients. Lastly,
continue to have deep faith in our God Almighty.
Bibliography
Books: Handbook of diseases (thirds edtion) by Sarah Y. Yuan, MD, PhD Nurse’s Pocket Guide, diagnoses, prioritized interventions and rationales, by Marilynn E.
Doengers, Marry Frances Moorhouse 2008 Lippincott’s Nursing Drugs Guide by Amy Karch Fundamental of Nursing, standards and practice, third edition by Sue C. Delaune and
Patricia K. Lander Anatomy and physiology, fifth edition by Gary A. Thibodeau and Kevin T, Patton Fundamentals of Nursing, concepts, process and practice by Barbara Kozier, Glenora
ERB, Audrey Berman and Shirlee Snyder Pathophysiology made incredibly easy 4th edition. Pathophysiology Concepts of Altered Health States by Carol Mattson Porth Medical surgical Nursing, clinical management for positive Outcomes by Joyce M. black
and Jane Hokanson Hawks Springhouse Nurse’s Drug Guide 2008 MIMS 110th Edition 2006
Internet sources: http://www.smartskincare.com/reviews/product/
other_supplem_na_conzace_20040911.html http://www.rxlist.com/methergine-drug.htm http://www.umm.edu/altmed/drugs/methylergonovine-085300.htm http://www.drugs.com/pro/methergine.html http://www.answers.com/topic/scurvy http://www.rxlist.com/toradol-drug.htm www.mims.com http://www.patient.co.uk/showdoc/30002493/ www.wikipedia.com http://www.medscape.com/viewarticle/579312 http://emedicine.medscape.com/article/279116-overview http://brighamrad.harvard.edu/Cases/bwh/hcache/38/full.html http://www.personal.u-net.com/~njh/cgest.html http://www.merck.com/mmpe/sec18/ch254/ch254f.html
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