ductal carcinoma

OBJECTIVES

General:The study aims to improve the knowledge of the students regarding on Ductal Carcinoma. It gives the

students the opportunity to learn different aspects regarding on the case of the patient. It broadens the understanding of the students regarding on the body system involves. It also makes the students see the reality of what they are studying in lecture of Medical-Surgical Nursing subject.

The study also aims to apply the different skills that the students learned from their related learning experiences regarding on physical assessment and also on those different nursing interventions that they must apply to the patient’s situation.

Aside from the knowledge and skills that this study aims to enhance, it also encompasses the attitude aspect of the students. Their approach to the patient is important for them to establish rapport; it gives them the opportunity to build good and trusting relationship with the patient and gather more accurate information and achieve possible health outcomes.

Specific:

1. To be aware on how this case affects persons and how prevalent this situation is.2. To be skill-oriented on how to identify and to properly observe the status of this case in our present time.3. To be well-communicated with the client during the physical assessment and interviews.4. To enhance our learned skills on assessing the client and how to classify abnormalities with different

aspects such as physical, emotional, mental and spiritual.5. To make ourselves oriented to different laboratory results and how we can relate it with the situation of

the client.6. To enhance our knowledge in anatomy and physiology of the system involve.7. To practice our skills in doing the pathophysiology of the case of the client.8. To understand the drugs and its uses according to the client’s situation.9. To provide nursing care plan and discharge plan to assure client’s total wellness.10. To know the proper attitude that an ideal nurse must possess. 11. To learn how to make the proper approach to client to get their trust.

I. INTRODUCTION

a. Background of the StudyI. Incidence, race, gender, age, ratio and proportion

The highest rates of breast cancer occur in Western countries (more than 100 cases per 100,000 women) and the lowest among Asian countries (10–15 cases per 100,000 women). Men can also have breast cancer, but the incidence is much less when compared to women. There is a strong genetic correlation since breast cancer is more prevalent in females who had a close relative (mother, sister, maternal aunt, or maternal grandmother) with previous breast cancer. Increased susceptibility for development of breast cancer can occur in females who never breastfed a baby, had a child after age 30, started menstrual periods very early, or experienced menopause very late.

In the United States, there were approximately 175,000 cases of breast cancer in 1999 with more than 43,000 deaths. Breast cancer accounts for 30% of all cancer diagnosed in American women and for 16% of all cancer deaths. Breast cancer is a worldwide public health problem since there are approximately one million new cases diagnosed annually. A woman's lifetime risk of developing breast cancer is one in eight. The incidence rose 21% from 1973 to 1990, but in recent years there has been a decline.http://www.encyclopedia.com/doc/1G2-3406200301.html

II. Rationale for Choosing the case

Our Clinical Instructor decided to choose the case of Ductal Carcinoma because this is common among women specially age 45years old and above. This case will help us dig deeper on how and why it happens to those persons.

Also, the patient’s data is somehow complicated, such as her age and background history, which is very interesting to find out if it is parallel to be the cause of the case. It really make us wonder how it happens to a person and how will it be distinguish.

III. Significance of the studies

The significance of the study is to enhance and of course to gain knowledge, to develop skills and to apply the attitudes that must be render to the client whatever the case may be. This study will also contribute in the widening of the ideas of the student about the topic of the case. These are other significance of the study that would support the above statement:

To be aware on how this case affects a person and how prevalent this situation is.

To be skill-oriented on how to identify and to properly observe the status of this case in our present time.

To be well-communicated with the client during the physical assessment and interviews.

To enhance our learned skills on assessing client and how to classify abnormalities with different aspects such as physical, emotional, mental and spiritual.

To make ourselves oriented to different laboratory results and how we can relate it with the situation of the client.

To enhance our knowledge in anatomy and physiology of the system involve. To practice our skills in doing the pathophysiology of the case of the client. To understand the drugs and its uses according to the client’s situation. To provide nursing care plan and discharge plan to assure client’s total wellness. To know the proper attitude that an ideal nurse must possess. To learn how to make the proper approach to client to get their trust.

IV. Scope and limitation of the study

The study would only focus on the information gathered from the patient, relatives of the patient, from her records and laboratory results. This will be covering about the case of Ductal Carcinoma, all about its anatomy and physiology and how did all of the records may it be the medications, doctors order and nurses notes correlates to each other.

V. Conceptual Theoretical Theory

LYDIA HALLNURSING THEORY(Core, Care, and Cure Model)

The Core. The core of human being is his/her needs to meet the Quality of Life (QOL). It is in these needs that makeup and creates an individual.

The Care. The type of care a nurse will render in any case of altered health pattern can be in the form of promotive, preventive, curative, rehabilitative and palliative aspects of care. Promotive care focus on health promotion which is categorized with no source of health information, visits to well-clinic/centers or oriented to health programs and practicing a healthy lifestyle and with good environment.

The Cure. This identifies the level of care to be given to a person in case of altered health pattern. Level 1 Cure covers promotive and preventive care are indications for primary health care management. The major purposes of this level are to promote wellness and prevent illness or disability. This level occurs at home or community and the participants in the care of geriatrics is the

private/family/community nurse, family and patient’s self that will emphasize the development of healthy lifestyle and environment. Level 2, or early stage of curative phase, is an indication for secondary health care management.

VI. Related Literature of the study

Invasive ductal carcinoma

Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma, is the most common type of breast cancer. About 80% of all breast cancers are invasive ductal carcinomas.

Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means that the cancer began in the milk ducts, which are the “pipes” that carry milk from the milk-producing lobules to the nipple. Carcinomarefers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. All together, “invasive ductal carcinoma” refers to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body.

According to the American Cancer Society, more than 180,000 women in the United States find out they have invasive breast cancer each year. Most of them are diagnosed with invasive ductal carcinoma.

Although invasive ductal carcinoma can affect women at any age, it is more common as women grow older. According to the American Cancer Society, about two-thirds of women are 55 or older when they are diagnosed with an invasive breast cancer. Invasive ductal carcinoma also affects men.

Symptoms

At first, invasive ductal carcinoma may not cause any symptoms. Often, an abnormal area turns up on a screening mammogram (x-ray of the breast), which leads to further testing.

In some cases, the first sign of invasive ductal carcinoma is a new lump or mass in the breast that you or your doctor can feel. According to the American Cancer Society, any of the following unusual changes in the breast can be a first sign of breast cancer, including invasive ductal carcinoma:

swelling of all or part of the breast skin irritation or dimpling

breast pain

nipple pain or the nipple turning inward

redness, scaliness, or thickening of the nipple or breast skin

a nipple discharge other than breast milk

a lump in the underarm area

Complications

Lead to premature death Spread of cancer to other parts of the body

Prone

Female Get older Have a family history of breast cancer

Diagnosis

Diagnosing invasive ductal carcinoma usually involves a combination of procedures, including a physical examination and imaging tests.

Physical examination of the breasts: The doctor may be able to feel a small lump in the breast during a physical examination. He or she also will feel the lymph nodes under the armpit and above the collarbone to see if there is any swelling or other unusual changes. Mammography: Invasive ductal carcinoma is usually found by mammography, a test that obtains x-ray images of the breast. Mammograms are used to screen apparently healthy women for early signs of breast cancer. One key feature of an invasive breast cancer is spiculated margins, which means that on the mammography film, the doctor sees an abnormality with finger-like projections coming out of it. These projections show the “invasion” of the cancer into other tissues.

If a screening mammogram highlights an area of concern, additional mammograms often will be done to gather more information about that area. Mammography will be performed on both breasts.

Ultrasound bounces sound waves off of the breast to obtain additional images of the tissue. Ultrasound is sometimes used in addition to mammography.

Breast MRI: MRI, or magnetic resonance imaging, uses magnetic fields, radio waves, and a computer to obtain images of tissues inside the body. In certain cases, a doctor may use breast MRI to gather more information about a suspicious area within the breast.

Biopsy: If you do have a suspicious mammogram or other imaging test result, your doctor will probably want you to have a biopsy. A biopsy involves taking out some or all of the abnormal-looking tissue for examination by a pathologist (a doctor trained to diagnose cancer from biopsy samples) under a microscope.

When possible, your doctor will usually use one of the quicker, less invasive approaches to biopsy:

o Fine needle aspiration biopsy involves inserting a very small, hollow needle into the breast. A sample of cells is removed and examined under the microscope. This method leaves no scars.

o Core needle biopsy inserts a larger needle into the breast to remove several cylinder-shaped samples of tissue from the area that looks suspicious. In order to get the core needle through the skin, the surgeon must make a tiny incision. This leaves a very tiny scar that is barely visible after a few weeks.

In cases where the doctor cannot feel the lump, he or she may need to use ultrasound or mammograms to guide the needle to the right location. You may hear this referred to as stereotactic needle biopsy or ultrasound-guided biopsy.

If a needle biopsy is not able to remove cells or tissue, or it does not give definite results (inconclusive), a more involved biopsy may be necessary. These biopsies are more like regular surgery than needle biopsies:o Incisional biopsy removes a small piece of tissue for examination.o Excisional biopsy attempts to remove the entire suspicious lump of tissue from the breast.

Again, if the doctor cannot feel the lump, he or she may need to use mammography or ultrasound to find the right spot. Your doctor also may use a procedure called needle wire localization. Guided by either mammography or ultrasound, the doctor inserts a small hollow needle through the breast skin into the abnormal area. A small wire is placed through the needle and into the area of concern. Then the needle is removed. The doctor can use the wire as a guide in finding the right spot for biopsy.

These surgical biopsies are done only to make the diagnosis. If invasive ductal carcinoma is diagnosed, more surgery is needed to ensure all of the cancer is removed along with “clear margins,” which means that a border of healthy tissue around the cancer is also removed. Usually this means having lumpectomy, or in some cases, mastectomy.

Treatment

Treatment options may include: Axillary lymph node dissection Chemotherapy Lumpectomy Mastectomy Radiation therapy Selective Estrogen Receptor

Modulator Sentinel Node Biopsy Targeted Therapy

Lifestyle Changes

Massage Meditation Music therapy Hypnosis Relaxation techniques, such as guided imagery Tai chi Yoga

Medications

The drug tamoxifen blocks the action of estrogen — a hormone that fuels some breast cancer cells and promotes tumor growth — to reduce your risk of developing invasive breast cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone receptor positive cancers).Tamoxifen isn't a treatment for DCIS in and of itself, but it can be considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the future.

Nursing Intervention1. Support the patient emotionally and offer reassurance.2. Administer prescribed medications.3. Provide six small meals a day or small hourly meals as ordered.4. Schedule care so that the patient gets plenty of rest.5. Monitor the effectiveness of administered medications, and also watch

for adverse reactions.6. Assess the patient’s nutritional status and the effectiveness of measures

used to maintain it. Weigh him regularly.7. Teach the patient about peptic ulcer disease, and help him to recognize

its signs and symptoms.8. Review the proper use of prescribed medications, dicussing the desired

actions and possible adverse effect of each drug.9. Instruct the patient to take antacids 1 hour after meals.10. Warn the patient to avoid aspirin containing drugs because they irritate

gastric mucosa.11. Encourage the patient to make appropriate lifestyle changes.

II. CLINICAL SUMMARY

A. General Data Profile

NAME: Mrs. VAPADDRESS: Brgy. Mapagong, Pagbilao,QuezonAGE: 50y/oWEIGHT: 69kgHEIGHT: 4’11” ft.BIRTHDAY: Dec. 10, 1963BIRTHPLACE: MasbateSPOUSE: Mr. EXNATIONALITY: FilipinoRELIGION: Roman CatholicOCCUPATION: House WifeDATE OF ADMISSION: August. 13, 2013 ADMITTING DIAGNOSIS: Breast Mass Left, Excision BiopsyADMITTING PHYSICIAN: Dr. Durbin William Jeffrey N. Tang

B. CHIEF COMPLAINT-With Mass on the Left Breast for 5 years

C. Nursing Historya. Childhood Illnesses

- Common colds, cough and feverb. Immunizations

- BCG ( 7yrs/old)c. Allergies

- No allergy at all. d. Accidents

-The client had no known accident.

e. Hospitalizations-Quezon Medical Center year 2001 due to delivery of the baby via Ceasarian section

f. Medications used or currently taking- Mefenamic if he feels pain and Herbal meds

g. Domestic Travel- She is traveling from Palawan, Masbate and Quezon Province to visit her relatives.

D. Health History

A. Medical Historya. Chronic Illness

- The client is experiencing from Urinary Tract Infectionb.

Current MedicationsDrug Dose Route Time Atracarium 25mg IVPropofol 80mg + 30mg IVButorphanol 1mg IVNeostigmine + Atropine Sulfate

5mg + 1mg respectively

IV

Cefuroxime 750mg IV Every 8 hoursKeterolac 30mg IV Every 6 hoursTramadol 50mg IV Every 4 hoursParacetamol 300mg IV Every 4 hoursCefuroxime 500mg Oral tab Three times a dayCelecoxib 200mg Oral tab Two times a day

c. Childhood Illness- Common colds, cough and fever

B. Surgical Historya. Problems with anesthesia

- The client stated that she has no problem with anesthesia nor allergies with it.b. Previous Surgeries

- The client had undergo to surgery at year 2001 due to her delivery to her baby via Cesarean Section

E. FAMILY HISTORY

Legend:

Male Male Death

Female Female Death

Patient

Prostitis T B

A&W A&W Tumor on A&W A&W The colon

A&W A&

A&W Patient

89 65

48

12

588

6 61

70

50

17

49

17

51

3917

A&W A&W

Mass on

Breast

F. SOCIAL HISTORY – INCLUDE THEORIES AND GROWTH AND DEVELOPMENT

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE RESOLUTION

INDICATORS OF NEGATIVE RESOLUTION

Adulthood 25-65 years

Generativity versus

stagnation

Creativity, productivity, concern for other s

Self-indulgence, lack of interests and commitments.

According to this theory adulthood had creativity, productivity, concern for other. Based on what the client said she wanted to sustain the need of her family especially her children future and education, in spite of her of present condition.

ACCORDING TO SIGMUND FREUDPSYCHOSEXUALTHEORY

STAGE AGE CHARACTERISTICS IMPLICATIONGenital Puberty and after Energy is directed

toward full sexual maturity and function and development of skills needed to cope with the environment

Encourages separation from parents, achievement of independence and decision making

According to this theory, the genital stage correlates to her age because she gains independence in decision making to do normal things. Though she experiences pain physically due to her condition it was only now that she experiences it that affected her sexual maturity and function and development of skills.

G. ENVIRONMENTAL/ LIVING CONDITION

The environment where they live and work is along a roadside. There are tricycle and jeep which can be means of transportation. The type of their house not completely cemented, but is well ventilated.

12

20

17

18

21

15

19

24

25 5

H. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT

Date of Assessment: August. 14, 2013General Appearance: Pre-Operative

The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears blouse and shorts exactly for her body. Upon assessment, the client is lying on bed.

BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS

A. HEAD1. SKULL

Proportional to the size of the body, round, with prominences in the frontal area anteriorly and the occipital area posteriorly symmetrical in all planes.

Proportional to the size of the body, symmetrical in all planes.

Normal.

2. SCALP White, clean, free from masses, lumps, scars, nits, dandruff, and lesion

White, clean, free from masses, lumps, scars, nits, and lesions

Normal

3. HAIR Black or whitish, evenly distributed and covers the whole scalp, thick, shiny, free from split ends.

Black hair; evenly distributed, thin, bristle-like and coarse.

Normal

4. FACE Oblong/oval/square or heart-shaped, symmetrical, facial expressions that is dependent on the mood or true feelings, smooth and free from wrinkles, no involuntary muscle movements.

Oval shape. Symmetrical, free from wrinkles and scars. No involuntary muscle movements.

Normal.

B. EYES

1.EYEBROWS Black, symmetrical, thick, can raise and lower eyebrows symmetrically and without difficulty, evenly distributed and parallel with each other.

Black, symmetrical. Thin. Can raise and lower eyebrows.

Normal

2. EYELIDS Upper lids cover a small portion of the iris, cornea, and the sclera when the eyes are open. When the eyes are closed, the lids meet

Upper lids cover a small portion of the iris, cornea, and the sclera when the eyes are open. When the eyes are closed, the

Normal

completely. Symmetrical color is the same as the surrounding skin.

lids meet completely. Same color of surrounding skin.

3. LID MARGINS

4. CONJUNCTIVA

Clear, without scaling or secretions, lacrimal duct openings are evident at the nasal ends.

Pink, without lesions

Clear, without scaling or secretions

Pink without lesions

Normal

Normal

5. SCLERA White and clear. White and clear. Normal6. IRIS Proportional to the size

of the eye, round, black/brown, and symmetrical.

It is symmetrical, round and proportional to size.

Normal

7. PUPIL From pinpoint to almost the size of the iris, round, symmetrical, constrict with increasing light and accommodation.

Symmetrical constricted to light and accommodated from light.

Normal

8. CORNEA Clear Clear Normal

9. EYE MOVEMENT Able to move eyes in full range of motion or able to move in all directions.

Able to move eyes in six field of gaze.

Normal

C. EARS Pinkish, clean, with scant amount of cerumen and a few cilia.

Cerumen and a few cilia.

Normal

1. HEARING ACUITY Able to hear whisper spoken words 2 feet away.

Able to hear whisper spoken words 2 feet away.

Normal

2. EAR CANAL No erythema, no scaling, no swelling, absence of foreign body and odor.

No erythema, no scaling, absence of foreign body and odor.

Normal

D. NOSE Midline, symmetrical, and patent.

Midline, symmetrical, and patent.

Normal

1. INTERNAL NARES Clean, pinkish, with few cilia.

Clean, pinkish, with few cilia.

Normal

2. SEPTUM Straight. Straight. Normal

E. MOUTH Pinkish, symmetrical lip margin, well-defined, smooth and moist.

Pinkish, symmetrical, lip margin, well-defined, smooth and moist.

Normal

1. LIPS Pinkish, smooth, moist, no swelling, no retraction, no discharge.

Pinkish lips. No swelling.

Normal

2. TEETH 28-32 permanent teeth, well-aligned free from caries or filling, no Halitosis.

28-32 permanent teeth, well-aligned free from caries or filling, no Halitosis.

Normal

3. TONGUE Large, medium, red or pink, the lateral margins, moist, shiny, and freely Movable.

Medium, red, the lateral margins, moist, shiny, and freely movable.

Normal

4. CHEEKS(BUCCAL MUCOSA)

Pinkish, moist. Pinkish, moist. Normal

5. PALATE SOFT PALATE

HARD PALATE

Pinkish, moist, and smooth.

Slightly pinkish.

Moist, and smooth.

Slightly pinkish.

Normal

Normal

6. UVULA At the center, symmetrical, and freely movable.

At the center, symmetrical, and freely movable.

Normal

7. TONSILS Pinkish, non-inflamed, no exudates.

Pinkish, non-inflamed, no exudates.

Normal

8. VOICE No hoarseness and well-modulated.

No hoarseness and well-modulated.

Normal

F. NECK Proportional to the size of the body and head, symmetrical and straight.

Proportional to the size of the body and head, symmetrical and straight.

Normal

G. RANGE OF MOTION

Freely movable with relative ease.

Limited range of motion especially on the left side of the body

Due to presence of the mass with wound on her left breast.

H. MUSCULAR STRENGTH

Symmetrical movements and able to resist force applied by the nurse.

Slightly able to move the left upper extremity and to resist force.

Due to presence of the mass with wound on her left breast.

J. ABDOMENInspection

1. Abdomen skin

2. Contour and Symmetry

3. Movements

Unblemished skin; uniform color.

Flat, rounded; symmetric contour.

Symmetric movements caused by respiration.

With scar caused by surgical incision via CS.

Rise and fall caused by respiration.

Due to the delivery of her baby via CS.

Normal

associated w/ respiration

Palpation No tenderness; relaxed abdomen with smooth, consistent tension.

No area of tenderness; no presence of lumps and masses absence of lesion.

Normal

K. CHEST (THORAX)

Inspection Chest symmetrical, skin intact, no tenderness, no masses.

Chest symmetrical. No lumps, tenderness and masses. Respiration of 17 breaths per minute

Normal

Breast The breast has no lesions and edema.

With presence of mass for 5 years with wound on the left breast.

Due to her condition which is to be under Modified Radical Mastectomy.

L. UPPER EXTREMITIES1. ARMSInspection Skin varies (pinkish, tan,

dark brown), skin is smooth, fine hair evenly distributed, muscles symmetrical, length symmetrical.

Tan skin muscle, length symmetrical, fine hair evenly distributed.

Normal

Palpation Warm, dry and elastic, no areas of tenderness. Muscle appears equal with good muscle tone.

Warm, dry and no areas of tenderness.

Normal

M. NAILS Nails are transparent, smooth, & convex with pink nail beds & white translucent tips.

Five fingers in each hand. As pressure is applied to the nail bed, it appears white or blanched & pink color returns immediately as pressure is released.

Complete fingers, 5 each hand. Nails are short, thick, transparent, & convex with pale nail beds & white translucent tips. As pressure is applied to the nailbed, it appears white and color returns after 2 seconds.

Normal

N. SHOULDERS, ARMS, ELBOWS, HANDS & WRISTS

Performs with relative ease.

Physical mobility of the upper extrimities is slightly impaired,

Due to pain associated with the presence of surgical incision on the left breast.

ABDUCTION AND ADDUCTION.

especially on the left side.

O. LOWER EXTREMITIES1. LEGSInspection Skin varies (pinkish, tan,

dark brown), skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles symmetrical, length symmetrical.

Skin is uniformed in tan color Hair evenly distributed.

Normal

Palpation Muscles appear equal, warm & with good muscle tone.

Muscles appear equal, warm & with good muscle tone.

Normal

2. TOESInspection

Five toes in each foot: sole and dorsal surface is smooth: With pink nail beds & translucent tips.

Five toes in each foot. Sole and dorsal surface is smooth

Normal

Palpation As pressure is applied, the nail beds appear white or blanched; pink color returns when pressure is released (2 seconds).

As pressured is applied to nail beds, color becomes white, colors returns after less than 2 seconds

Normal

P. LEGS, KNEES, ANKLES, TOES ADDUCTION AND ABDUCTION.



Normal

Date of Assessment: August. 15, 2013General Appearance: Post-Operation

The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears blouse and shorts exactly for her body. Upon assessment, the client is lying on bed, with a blood pressure of 120/80 mmHg, pulse rate of 79 beats per minute, respiration rate of 17 breaths per minute, and temperature of 38.9º C.

BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS

A. HEAD1. SKULL

Proportional to the size of the body, round, with prominences in the frontal area anteriorly and the occipital area posteriorly symmetrical in all planes.

Proportional to the size of the body, symmetrical in all planes.

Normal.

2. SCALP White, clean, free from masses, lumps, scars, nits, dandruff, and lesion

White, clean, free from masses, lumps, scars, nits, and lesions

Normal

3. HAIR Black or whitish, evenly distributed and covers the whole scalp, thick, shiny, free from split ends.

Black hair; evenly distributed, thin, bristle-like and coarse.

Normal

4. FACE Oblong/oval/square or heart-shaped, symmetrical, facial expressions that is dependent on the mood or true feelings, smooth and free from wrinkles, no involuntary muscle movements.

Oval shape. Symmetrical, free from wrinkles and scars. No involuntary muscle movements.

Normal.

B. EYES

1.EYEBROWS Black, symmetrical, thick, can raise and lower eyebrows symmetrically and without difficulty, evenly distributed and parallel with each other.

Black, symmetrical. Thin. Can raise and lower eyebrows.

Normal

2. EYELIDS Upper lids cover a small portion of the iris, cornea, and the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Symmetrical color is the same as the surrounding skin.

Upper lids cover a small portion of the iris, cornea, and the sclera when the eyes are open. When the eyes are closed, the lids meet completely. Same color of surrounding skin.

Normal

3. LID MARGINS

4. CONJUNCTIVA

Clear, without scaling or secretions, lacrimal duct openings are evident at the nasal ends.

Pink, without lesions

Clear, without scaling or secretions

Pink without lesions

Normal

Normal

5. SCLERA White and clear. White and clear. Normal6. IRIS Proportional to the size

of the eye, round, black/brown, and

It is symmetrical, round and proportional to size.

Normal

symmetrical.7. PUPIL From pinpoint to almost

the size of the iris, round, symmetrical, constrict with increasing light and accommodation.

Symmetrical constricted to light and accommodated from light.

Normal

8. CORNEA Clear Clear Normal

9. EYE MOVEMENT Able to move eyes in full range of motion or able to move in all directions.

Able to move eyes in six field of gaze.

Normal

C. EARS Pinkish, clean, with scant amount of cerumen and a few cilia.

Cerumen and a few cilia.

Normal

1. HEARING ACUITY Able to hear whisper spoken words 2 feet away.

Able to hear whisper spoken words 2 feet away.

Normal

2. EAR CANAL No erythema, no scaling, no swelling, absence of foreign body and odor.

No erythema, no scaling, absence of foreign body and odor.

Normal

D. NOSE Midline, symmetrical, and patent.

Midline, symmetrical, and patent.

Normal

1. INTERNAL NARES Clean, pinkish, with few cilia.

Clean, pinkish, with few cilia.

Normal

2. SEPTUM Straight. Straight. Normal

E. MOUTH Pinkish, symmetrical lip margin, well-defined, smooth and moist.

Pinkish, symmetrical, lip margin, well-defined, smooth and moist.

Normal

1. LIPS Pinkish, smooth, moist, no swelling, no retraction, no discharge.

Pinkish lips. No swelling.

Normal

2. TEETH 28-32 permanent teeth, well-aligned free from caries or filling, no Halitosis.

28-32 permanent teeth, well-aligned free from caries or filling, no Halitosis.

Normal

3. TONGUE Large, medium, red or pink, the lateral margins, moist, shiny, and freely Movable.

Medium, red, the lateral margins, moist, shiny, and freely movable.

Normal

4. CHEEKS(BUCCAL MUCOSA)

Pinkish, moist. Pinkish, moist. Normal

5. PALATE SOFT PALATE

Pinkish, moist, and smooth.

Moist, and smooth. Normal

HARD PALATE Slightly pinkish. Slightly pinkish. Normal

6. UVULA At the center, symmetrical, and freely movable.

At the center, symmetrical, and freely movable.

Normal

7. TONSILS Pinkish, non-inflamed, no exudates.

Pinkish, non-inflamed, no exudates.

Normal

8. VOICE No hoarseness and well-modulated.

No hoarseness and well-modulated.

Normal

F. NECK Proportional to the size of the body and head, symmetrical and straight.

Proportional to the size of the body and head, symmetrical and straight.

Normal

G. RANGE OF MOTION

Freely movable with relative ease.

Limited range of motion especially on the left side of the body

Due to presence of the surgical incision on the left breast.

H. MUSCULAR STRENGTH

Symmetrical movements and able to resist force applied by the nurse.

Able to resist force applied only at the right side of the body.

Due to presence of the surgical incision on the left breast

I. HEART Regular beats (60-100 beats per minute).

Regular beats (79 beats per minute)

Normal

J. ABDOMENInspection

1. Abdomen skin

2. Contour and Symmetry

3. Movements associated w/ respiration

Unblemished skin; uniform color.

Flat, rounded; symmetric contour.

Symmetric movements caused by respiration.

With scar caused by surgical incision via CS.

Rise and fall caused by respiration.

Due to the delivery of her baby via CS.

Normal

Auscultation Audible bowel sounds (5-30/min); absence of arterial bruits and friction rubs.

Audible bowel sounds (10/min).

Normal

Palpation No tenderness; relaxed abdomen with smooth, consistent tension.

No area of tenderness; no presence of lumps and masses absence of lesion.

Normal

K. CHEST (THORAX)

Inspection Chest symmetrical, skin Chest symmetrical. No Normal

intact, no tenderness, no masses.

lumps, tenderness and masses. Respiration of 17 breaths per minute

Breast The breast has no lesions and edema.

With presence of surgical incision on left breast. The right breast has no lesions and edema.

Due to removal of the mass on the left breast.

L. UPPER EXTREMITIES1. ARMSInspection Skin varies (pinkish, tan,

dark brown), skin is smooth, fine hair evenly distributed, muscles symmetrical, length symmetrical.

Tan skin muscle, length symmetrical, fine hair evenly distributed.

Normal

Palpation Warm, dry and elastic, no areas of tenderness. Muscle appears equal with good muscle tone.

Warm, dry and no areas of tenderness.

Normal

M. NAILS Nails are transparent, smooth, & convex with pink nail beds & white translucent tips.

Five fingers in each hand. As pressure is applied to the nail bed, it appears white or blanched & pink color returns immediately as pressure is released.

Complete fingers, 5 each hand. Nails are short, thick, transparent, & convex with pale nail beds & white translucent tips. As pressure is applied to the nailbed, it appears white and color returns after 2 seconds.

N. SHOULDERS, ARMS, ELBOWS, HANDS & WRISTS ABDUCTION AND ADDUCTION.


Physical mobility of the upper extrimities is slightly impaired, especially on the left side.

Due to pain associated with the presence of surgical incision on the left breast.

O. LOWER EXTREMITIES1. LEGSInspection Skin varies (pinkish, tan,

dark brown), skin is smooth, fine hair evenly distributed, absence of varicose veins, muscles

Skin is uniformed in tan color Hair evenly distributed.

Normal

symmetrical, length symmetrical.

Palpation Muscles appear equal, warm & with good muscle tone.

Muscles appear equal, warm & with good muscle tone.

Normal

2. TOESInspection

Five toes in each foot: sole and dorsal surface is smooth: With pink nail beds & translucent tips.

Five toes in each foot. Sole and dorsal surface is smooth

Normal

Palpation As pressure is applied, the nail beds appear white or blanched; pink color returns when pressure is released (2 seconds).

As pressured is applied to nail beds, color becomes white, colors returns after less than 2 seconds

Normal

P. LEGS, KNEES, ANKLES, TOES ADDUCTION AND ABDUCTION.



Normal

I. PATTERNS OF FUNCTIONING

Functional Health Pattern

Before Hospitalization

During Hospitalization(after operation)

Interpretation

Health management pattern

She is taking analgesics if she feels pain and herbal meds.

The client is dependent on what the physician has ordered her to do.

She takes OTC drugs whenever she feels something and herbal meds as what the elders has told her.

Nutritional/ Metabolic Pattern

- Number of meals per day

- Appetite

- Glass of water per day

- Body Built

- Height and weight-

3 times a day

w/ very good appetite

6 glasses of water

w/ normal body built4’11” and 69 kg

NPO

With normal body built

Her number of meals is now deprived because it is needed in preparation for her pre and post operation.

Elimination- Frequency of

urination

- Amount of urine per day

- Frequency of bowel

- Consistency of feces

- Amount defecated

6 times a day

moderate

2

Formed

Moderate

2 times a day

Moderate

1

Formed

scanty

Her frequency of urination and defecation is deprived because she is placed on NPO and IVF acts as her food.

Activity and Exercise- Exercise

- Fatigability

- ADL

Daily walking

Easily get tired

Independent

Unable to performed exercise

Easily get tired

Slightly dependent

She considers walking as her daily exercise but when she is hospitalized she became slightly dependent and unable to performed her daily activities.

Cognitive/ Perceptual- Orientation

- Responsiveness

Oriented to time place and person

Respond approximately to verbal and physical stimuli.

Oriented to time, place and person

Respond approximately to verbal and physical stimuli.

She is well oriented and can respond to verbal and physical stimuli.

Roles/ Relationship- As a daughter

- As a sister

- As a wife

She has a good relationship with her parents

She has good relationship with her siblings.

she has good relationship with her husband, they enjoy their lives together

Her parents always supported her when they were still alive.

She’s supported by her siblings during her hospitalization.

Her husband really do support her and settle all the things for her during her hospitalization

There are good relationship between the family members.

- As a motherShe has good relationship with her children; she cares for them a lot.

She always takes care of her children and supports them with their needs.

Self Perception and concept

Have a high self worth/ importance

Have a high self worth/ importance

In spite of her present condition, she still has a high self worth and importance.

Coping/ Stress She seeks advice from her husband, and even sometimes with her friends, relatives and also with God.

She trusts God for she knows that everything will turn right when he’s there.

She wholly gives her full trust to God when she’s inside the hospital for she knows that everything is about His will.

Values/ Belief She’s aware and she trust God and believe that He did exist.

Her trust to God boosted more and more confident whenever praying.

she really did trust God ever than the way she trust Him before.

J. COURSE IN THE WARD

DATE DOCTOR’S ORDERS RATIONALE

August 13, 201310:35am

Please admit to Female Surgery Ward Secure Consent

TPR

NPO

CBC

In preparation for surgical procedure

To properly have consent from the relatives of the patient.

To monitor if there is deviation from normal with regards to the temperature, pulse and respiration of the patient.

To prepare the patient for the surgical procedure and to depress the GI tract.

To monitor if there is any deviation from normal values of the components of blood

5:00pm

Blood Typing

Urine Analysis

IVF D5LR x 8hrs

Cefuroxime 750mg IV q8 ANST

For MRM (Modified Radical Mastectomy) Left tomorrow

Refer OR/ AROD/ SROD

Refer Accordingly

Prepare 1 “u” FWB (Fresh Whole Blood) properly typed and crossed match

NPO post midnight

Discontinue present IVF

IVF of D5LR 1L to be inserted at 5am

Refer to Dr. Encanto

of the patient.

To know the blood type of the patient so that if ever blood transfusion will be done, the blood to be administered has the same type.

To know if the patient has any disorder regarding to her kidney or Urinary tract.

D5LR is parenteral fluid, electrolyte and nutrient replenisher

It fights against bacteria during infection.

MRM is for those patient who has mass on their breast and diagnosed to be removed.

To refer if something urgent happened to the patient.

Refer what has been ordered.

To be ready if ever, during the surgical procedure, the patient loss lots of blood.

To make the patient’s GI tract depress for the surgical procedure to be done.

To give way for the procedure to be done.

To get ready for the procedure.

To endorse to the doctor who will handle the patient.

August 14, 20139:25am

Post OR order DAT when fully awake

For the patient easy recovery. DAT will be administered when fully awake and not during unconscious state to avoid the occurrence of aspiration.

Monitor VS every 10 mins for 6hrs, then every 15 mins until stable.

IVF D5LR1L x 8hrs IVF D5LR 1L x 8hrs

Cefuroxime 750mg IV q8

Keterolac 30mg IV q6/amp x 4doses ANST

Oxygen inhalaton 2-3L

Refer accordingly

Tramadol 50mg IV q4

To monitor the adaptation of the patient to the procedure and if there are any deviation from normal value of the patients TPR, BP.


It fights against bacteria during infection

It is for relief from pain due to surgical procedure

To support the Oxygen inhalation of the patient

Refer what has been ordered.

Given for pain relief due to surgical procedure.

August 15, 2013

10:00am

Continue Medications

To follow D5LR x KVO

Paracetamol 30mg prn

It is being continued because the prescribed one can develop a resistance to antibiotics if they are used appropriately which can make it even more difficult to treat the client next time and also it being continue for faster recovery and treat for the prevention of the disease.


For the sudden increased in temperature of the client.

August 16, 2013 DAT

IVF PNSS 1L x KVO

For repeat Hemoglobin and Hematocrit

Cefuroxime 500mg TID

For the patient to eat what the stomach can tolerate and to return to normal function of the GI tract.

Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment.

To check if the patient has normal value of Hemoglobin and Hematocrit after the surgical procedure.

It fights against bacteria during infection.

Use to treat pain

Celecoxib 200mg BID Add supplemex KVO

Supplement in IV form in support for the recovery of the patient.

August 17, 2013 Facilitate Bed rest

IVF same rate

Continue medications

Refer

Hgb = 7.4

Prepare and transfer 3 “u” Fresh Whole Blood

Repeat Hemoglobin and Hematrocrit 6hrs post bedrest

To promote rest for the client and blood circulation.

For same way of treatment.

For continuous treatment and recovery of the patient.

To be refer accordingly due to decreased Hgb.

There is a decreased from the normal value (12-16 g/dl) of patient’s Hemoglobin.

Since there is a decrease in patient’s hemoglobin, she needs to have blood transfusion.

To check if there are any changes and progress with the patient’s hemoglobin and hematocrit value.

August 18, 2013 MGH

Home meds as ordered

Follow up check up on August 23, 2013 8am at OPD.

For continuous adherence to medication regimen.

K. LABORATORY RESULTS:

DATE: August 13, 2013

REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)

Name of test INDICATION Normal range Results Significance of the resultHEMOGLOBIN

HEMATOCRIT

WBC COUNT

-Neutrophils

-Lymphocytes-Monocytes-Eosinophil-Basophil

PLATELET COUNTCLOTTING TIMEBLEEDING TIME

Blood test can be used to find out what is happening in many parts of the body. Testing blood is easier than obtaining a tissue sample. Any test designed to discover abnormalities in a sample of blood to determine blood groups (Merck Manual of Medical information p. 888)

M:14-18 gm/dlF:12-15 gm/dl

M:40-50%F:30-40%

5,000-10,000

40%-50%

35%-45%2%-5%2-4%0-1%150,000-450,000

11.1

35.9

11,700

71%

29.7%100%

Values decrease in anemia, hyperthyroidism, cirrhosis of the liver and severe hemorrhage.

NORMAL

Values increase in acute infections, trauma, some malignant disease, and some cardiovascular disease

Neutrophils increase in acute infections.

Lymphocytes increase during antigen-antibody reactions.


HEMATOCRIT

WBC COUNT

-Neutrophils

-Lymphocytes-Monocytes-Eosinophil-Basophil

PLATELET COUNTCLOTTING TIMEBLEEDING TIME


M:14-18 gm/dlF:12-15 gm/dl

M:40-50%F:30-40%

5,000-10,000

40%-50%

35%-45%2%-5%2-4%0-1%

150,000-450,000

9.7

29

11,600

69%

31%

261,000


Values decrease in anemia, leukemia, cirrhosis and hyperthyroidism.

Values increase in acute infections, trauma, some malignant disease, and some cardiovascular disease

Neutrophils increase in acute infections.

NORMAL.

NORMAL

REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)DATE: August 16, 2013


HEMATOCRITRBC COUNTMCVMCHMCHCWBC COUNTPLATELET COUNTCLOTTING TIMEBLEEDING TIME


12.0-16.0

0.37-0.434.0-5.478-102

39.0-54.0481-5744.0-10.0170-400

7.40

0.23


Values decrease in anemia, leukemia, cirrhosis and hyperthyroidism.

REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)

DATE: August 16, 2013

BLOOD TYPING AND CROSSMATCHING RESULTSPATIENTS ABOGROUP: O RH GROUP: positive Source

of blood

Donor number

ABO group

RH typing Interpretation Released by:

Taken by Date and time

QMC 1390-13 O Positive Saline phaseLISS/coombs-37C

COMPATIBLE

Autocontrol Negative for agglutination

Diagnosis: Breast mass, left, excision biopsyINVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2INVASIVE DUCTAL CARCINOMAInvasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means that the cancer began in the milk ducts, which are the “pipes” that carry milk from the milk-producing lobules to the nipple. Carcinomarefers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. All together, “invasive ductal carcinoma” refers to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body.http://pathology.jhu.edu/breast/grade.php

Grade I or low-grade DCIS cells look very similar to normal cells or atypical ductal hyperplasia cells. Grade II or moderate-grade DCIS cells grow faster than normal cells and look less like them. Grade I and Grade II DCIS tend to grow slowly and are sometimes described as "non-comedo" DCIS. The term non-comedo means that there are not many dead cancer cells in the tumor. This shows that the cancer is growing slowly, because there is enough nourishment to feed all of the cells. When a tumor grows quickly, some of its cells begin to die off.http://www.breastcancer.org/symptoms/types/dcis/diagnosis=POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

When LVI is present, doctors assume this means that the cancer has acquired the genetic mutation it needs to create its own blood vessels, a process called angiogenesis. Because a tumor that has the ability to create its own blood vessels may have already begun to spread cancer cells to other parts of the body, the presence of LVI is an indicator that treatment should most likely include chemotherapy or hormone therapy (if the tumor is hormone sensitive).Perivascular invasion requires at least two cell types: the endothelial cells that form the vascular tubes and the tumor cells. Perivascular invasion does not have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.

http://www.breastcancer.org/symptoms/types/dcis/diagnosis

JULY 17, 2013

CHEST X-RAYBoth lung fields are clearHeart, aorta and pulmonary vascular markings are within normal limitsDiaphragm and sinuses are preservedIntact both thorax

IMPRESSION:ESSENTIALLY NORMAL CHEST FINDINGS.

ECG RESULT: NORMAL

TEST VALUE REFERENCE RANGE

REMARKS

CREATININE 1.63 mg/dl 0.6-1.3 Creatinine increase in certain kidney disease and infections.

BUN 20.40 mg/dl 7-18 Values increase in response to increased in dietary protein intake.

GLUCOSE 80.24 mg/dl 70-105 NORMALURIC ACID 7.17 mg/dl 2.6-7.2 NORMALTRIGLYCERIDES 50.61 mg/dl 0-150 NORMALCHOLESTEROL 142.41 mg/dl 0-200 NORMAL

DATE: JULY 17, 2013

NAME OF TEST

INDICATIONMICROSCOPIC

EXAMINATIONSRESULTS

REFERENCE VALUE

SIGNIFICANCE OF THE RESULT

Urinalysis Urinalysis is a laboratory diagnostic procedure which involves testing of urine for bacteria, protein, or other molecules that can provide information about patient’s

health.

Color Yellow YELLOW NORMALTransparency Slightly

TurbidCLEAR Indicates high concentration of solutes

Reaction 5.0 4.5 – 7.5 NORMALSpecific Gravity 1.030 1.015 – 1.025 Increased urine specific gravity may be due to:

Dehydration, Diarrhea that causes dehydration, Glucosuria, Heart failure (related to decreased blood flow to the kidneys), Renal arterial stenosis, Shock, Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

CLINICAL TEST Sugar Negative NEGATIVE NORMAL Albumin negative NEGATIVE NORMAL

PREGNANCY TEST - - - URINE BILE - - -Red Blood Cell 2-3 2 – 3HPF NORMALEpithelial Cells Few FEW NORMALMucus Threads FEW RARE -Bacteria MODERATE NEGATIVE -Crystals - NONE -Calcium Oxalates - - -A. Uric Acid - 1.48 –

4.43mmol/day-

Fine Granular - NONE -Course Granular - NONE -Hyalines - OCCASSIONAL -Others Yeast cells many

DATE: July 18, 2013

http://www.nlm.nih.gov/medlineplus/ency/article/000394.htm




III. CLINICAL MANIFESTATION

A . ANATOMY AND PHYSIOLOGY

Breast

The breast is the upper ventral region of the torso of a primate, in left and right sides, containing the mammary gland which in female can secrete milk used to feed infants.

Both men and women develop breasts from the same embryological tissues. However, at puberty, female sex hormones, mainly estrogen, promote breast development which does not occur in men due to the higher amount of testosterone. As a result, women's breasts become far more prominent than those of men.

During pregnancy, the breast is responsive to a complex interplay of hormones that cause tissue development and enlargement in order to produce milk. Three such hormones are estrogen, progesterone and prolactin, which cause glandular tissue in the breast and the uterus to change during the menstrual cycle.

Each breast contains 15–20 lobes. The subcutaneous adipose tissue covering the lobes gives the breast its size and shape. Each lobe is composed of many lobules, at the ends of which are sacs where milk is produced in response to hormonal signals.

Anatomy

The Breast: cross-section scheme of the mammary gland.

1. Chest wall

2. Pectoralis muscles

3. Lobules

4. Nipple

5. Areola

6. Milk duct

7. Fatty tissue

8. Skin

Morphology

The human breast has two aspects: the functional aspect and the anatomic aspect.

The functional breast

The breast is an apocrine gland that produces milk to feed an infant child; for which the nipple of the breast is centered in (surrounded by) an areola (nipple-areola complex, NAC), the skin color of which varies from pink to dark brown, and has many sebaceous glands.

The anatomic breast

In women, the breasts overlay the pectoralis major muscles and usually extend from the level of the second rib to the level of the sixth rib in the front of the human rib cage; thus, the breasts cover much of the chest area and the chest walls. At the front of the chest, the breast tissue can extend from the clavicle (collarbone) to the middle of the sternum (breastbone). At the sides of the chest, the breast tissue can extend into the axilla (armpit), and can reach as far to the back as the latissimus dorsi muscle, extending from the lower back to the humerus bone (the longest bone of the upper arm). As a mammary gland, the breast is an inhomogeneous anatomic structure composed of layers of different types of tissue, among which predominate two types, adipose tissue and glandular tissue, which effects the lactation functions of the breasts.

Lymphatic drainage

Approximately 75% of the lymph from the breast travels to the ipsilateral (same-side) axillary lymph nodes, whilst 25% of the lymph travels to the parasternal nodes (beside the sternum bone), to the other breast, and to the abdominal lymph nodes. The axillary lymph nodes include the pectoral (chest), subscapular (under the scapula), and humeral (humerus-bone area) lymph-node groups, which drain to the central axillary lymph nodes and to the apical axillary lymph nodes. The lymphatic drainage of the breasts is especially relevant to oncology, because breast cancer is a cancer common to the mammary gland, and cancer cells can metastasize (break away) from a tumors and be dispersed to other parts of the woman's body by means of the lymphatic system.

Shape and support

The topography of the breasts indicates the glandular body, the nipple-areola complex (NAC), and the inframammary fold (IMF).

Size

Breast size varies with race and ethnic origin. A study released in 2013 suggests the existence of a single genetic mutation responsible for multiple characteristics of East Asians, including thicker hair, more sweat glands and smaller breasts on women.

Hormonal change

On the skin envelope of the breast, stretch marks may indicate the relative-size increments and decrements occurred during the life of the woman.

Because the breasts are principally composed of adipose tissue, which surrounds the milk glands, their sizes and volumes fluctuate according to the hormonal changes particular to the larche (sprouting of breasts), menstruation (egg production), pregnancy (reproduction), lactation (feeding of offspring), and menopause (end of menstruation). For example, during the menstrual cycle, the breasts are enlarged by premenstrual water retention; during pregnancy the breasts become enlarged and denser (firmer) because of the prolactin-caused organ hypertrophy, which begins the production of breast milk, increases the size of the nipples, and darkens the skin color of the nipple-areola complex; these changes continue during the lactation and the breastfeeding periods. Afterwards, the breasts generally revert to their pre-pregnancy size, shape, and volume, yet might present stretch marks and breast ptosis. At menopause, the breasts can decrease in size when the levels of circulating estrogen decline, followed by the withering of the adipose tissue and the milk glands. Additional to such natural biochemical stimuli, the breasts can become enlarged consequent to an adverse side effect of combined oral contraceptive pills; and the size of the breasts can also increase and decrease in response to the body weight fluctuations of the woman. Moreover, the physical changes occurred to the breasts often are recorded in the stretch marks of the skin envelope; they can serve as historical indicators of the increments and the decrements of the size and the volume of a woman's breasts throughout the course of her life.

REFERENCE: http://en.wikipedia.org/wiki/Breast

PATHOPHYSIOLOGY

Book based

Sign and Symptoms:

Lump in the breast

Thickening of the breast skin

Rash or redness, sore of the breast

Swelling in one breast

New pain in breast

Dimpling around the nipple or on the breast skin

Nipple pain or the nipple turning inward

Nipple discharge

Lumps in the underarm area

Risk Factors

Early/late menarche

Late menopause Nulliparous or

older than 30 years at the birth of a first child

Genetic Lifestyle Environmental

http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/nipple_discharge.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.html

Client Based

Cellular Aberrations

Ca Cell Proliferation

Disrupt normal cell growth and interfere with tissue function

Pressure Obstruction Pain Effusion Ulceration Vascular Thrombosis, Embolism,

Thrombophlebitis

Malignant cells produce enzymes, hormones and other (Paraneoplastic Syndrome)

Anemia Hypercalemia Edema DIC

Anorexia and Cachexia Syndrome

Tissue wasting Severe weight

loss Severe

debilitation

Reference : Medical Surgical Nursing Concept and Clinical Application 2nd Edition, 2009

Author: Jose, Quiambao, Udab

And

http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/invasive_ductal_carcinoma.html

Modified Radical Mastectomy

Precipitating Factor:

Lifestyle She like to eat high in salt and fatty foods Always wearing brassier with wire

Environment Her breast is often bumped by his son

Predisposing Factor:

Nulliparous or older than 30 years at the birth of a first child

Late menarche

Signs and symptoms: Lump in the breast

For 5 years Sore of the breast

Since November 2012 up to august 13 2013

New pain in left side of breast

Cellular Aberrations

Ca Cell Proliferation

Disrupt normal cell growth and interfere with tissue function

Pressure Obstruction Pain

Malignant cells produce enzymes, hormones and other (Paraneoplastic Syndrome)

Anemia

Ductal Carcinomaoma

Possible complication:

Lymphedema Bleeding Hematoma formation Brachial plexus injuries

http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.html

http://www.rightdiagnosis.com/b/brachial_plexus_injury/intro.htm

http://www.rightdiagnosis.com/medical/hematoma_formation.htm

http://www.rightdiagnosis.com/h/hemorrhage/intro.htm

http://www.rightdiagnosis.com/l/lymphedema/intro.htm

A modified radical mastectomy is a type of mastectomy that combines the removal of all breast tissue from the affected breast with lymph node removal from the armpit on the affected side of the body. This surgery typically includes the removal of both the nipple and areola, but the surgery can be performed using skin and nipple sparing techniques.

Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length that begins on the inside of the breast, near the breast bone, and extends upward and outward toward the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can improve the cosmetic outcome if reconstruction is desired.

Once the breast tissue is removed, the incision is closed with either absorbable sutures or staples that are removed during an office visit 10 to 14 days after surgery. There may also be drains in place to decrease the amount of swelling in the area. These drains are covered with bandages to protect the incision site and the drain placement. The drains are typically removed after discharge from the hospital by the surgeon during a routine office visit after surgery.

REFERENCE: http://surgery.about.com/od/proceduresaz/ss/Mastectomy_3.htm

Name of Drug

Classification Mechanism of Action

Indication Contraindication Side Effects Nursing Responsibility

Atracarium 25mg IV

no depolarizing neuromuscu-lar blocker

Skeletal Muscle Relaxant

Prevents acetylcholine from binding to receptors on muscle end plate, thus blocking depolarization and resulting in skeletal muscle paralysis.

Adjunct to general anesthesia, to facilitate endotracheal intubation and cause skeletal muscle relaxation during surgery or mechanical ventilation

Contraindicated in patients hypersensitivity to drug

Use cautiously in patients with CV disease; severe electrolyte disorders, bronchogeneic carcinoma; hepatic, renal, or pulmonary impairment; neuromuscular diseases; or myasthenia gravis; and in debilitated patients;

CV1)Flushing, 2)increased heart rate, 3)bradycardia 4)hypotensionRESPI1)Prolonged dose related apnea, 2)wheezing, 3)increased bronchial secretionsSKIN1)Erythema, 2)pruritus, 3)urticariaOther1)anaphylaxis

1. Obtain history of patients neuromuscular status before therapy and reassess regularly

2. Be alert for adverse reactions and interaction

3. Monitor respiration closely until patient fully recovers from neuromuscular blockade, as evidence by by tests of muscle strength

4. Give sedatives or general anesthetic before neuromuscular blockers. Neuromuscular blockers don’t decrease consciousness or alter pain threshold.

5. Don’t give by I.M injection6. Prior use of succinycholine

doesn’t prolong duration of action but quickens onset and may deepen neuromuscular blockade

7. Give analgesics for pain. Patient may have pain but unable to express it.

8. Keep airway clear. Have emergency equipment and drugs available.

9. After spontaneous recovery starts, reverse atracarium-induced neuromuscular blockade with an anticholinesterase (such as neostigmine or endophonium). These drugs usually are given with

an anticholnergic (such as atropine)

Reference: SPRINGHOUSE Nurse’s Drug Guide 2007 Eight Edition

Name of Drug

Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility

Propofol 80mg + 30mg IV

Nonbarbiturate Anesthetics (General Anesthetics)

Exerts its sedative-hypnotic effects through a GABAA receptor interaction. GABA is the principal inhibitory neurotransmitter in the CNS.

Indicated for producing sedation, hypnosis, anesthesia, amnesia, unconsciousness to allow performance of surgical procedures.

Status asthmaticus b/c of the difficulty in providing ventilator support to the patient and risk of exacerbation of the problem with CNS depression

Absence of suitable vein for intravenous administration

Caution should be used in cases of severe cardiovascular disease, hypotension, or shock;

Malignant hyperthermia

CNS1)headache2)prolonged somnolence3)deliriumCV1)hypotension2)shock3)decreased cardiac output4)arrhythmiasRESPI1)respiratory depression2)laryngospasm3)bronchospasm4)hiccups5)coughingGI1)nausea 2)vomiting

1. Assess for any known allergy to general anesthetics; impaired liver or kidney function; myasthenia gravis; history of malignant hyperthermia; cardiac or respiratory disease

2. Include screening for baseline status before beginning therapy and for any potential adverse effects.

3. The drug must be administered by trained personnel

4. Have equipment on standby to maintain airway and provide mechanical ventilation

5. Monitor temperature for prompt detection and treatment of malignant hyperthermia

6. Monitor pulse, respiration, blood pressure and cardiac output during

administration (dosage adjustment may be needed to alleviate potential problems and maximize overall benefit with the least toxicity

7. Monitor the patient until recovery phase is complete and the patient is conscious, able to move and communicate to ensure patient safety

8. Provide comfort measures to help patient tolerate drug

9. Provide pain relief as appropriate, skin care and turning to prevent skin breakdown, & supportive care for conditions such as hypotension and bronchospasm

10. Offer support and encouragement to help the patient cope with procedure and the drugs being used.


Name of Drug

Classification Mechanism of Action Indication Contraindication

Side effects Nursing Responsibility

Butorphanol 1mg IV

Opioid agonist-antagonist

Analgesic, adjunct to anesthesia

Binds with opiate receptors in CNS, altering both perception of and emotional response to pain through unknown mechanism

Moderate to severe pain

Preoperative anesthesia or preanesthesia

Adjunct to balance anesthesia

Contraindicated in patients with opioid addiction; may precipitate withdrawal syndrome.

Patients with hypersensitivity to drug or preservative (benzethonium chloride)

Use cautiously in patients with head injury, increase intracranial pressure, acute MI, ventricular dysfunction, coronary insufficiency, respiratory disease or renal and hepatic dysfunction.

CNS1) sedation2) headache3) vertigo4) floating sensation5) lethargy6) confusion7) nervousness8) unusual dreams9) agitation10) euphoria11) hallucinations12) flushingCV1) palpitations2) fluctuation in

blood pressureEENT1) diplopia2) blurred vision3) nasal congestion

(with nasal spray)GI1) Nausea2) vomiting3) constipation4) dry mouthRESPI1) Respiratory

depressionSKIN1) Rash2) Urticaria3) Clamminess4) Excessive sweating

1. Obtain history of patient’s pain before therapy, and reassess during therapy

2. Be alert for adverse reaction and drug interactions

3. Periodically monitor post operative vital signs and bladder function. Drug decreases both rate and depth respirations, & monitoring arterial oxygen saturation may aid in assessing respiratory depression.

4. Caution ambulatory patient to get out of bed slowly and walk carefully until CNS effects are known.

5. Warn outpatient to refrain from driving and performing other activities that require mental alertness until drug’s CNS effects are known

6. Warn patient that drug can cause physical and psychological dependence. Tell him to use drug only as directed and that abrupt withdrawal after prolonged use produces intense withdrawal symptoms.


Name of Drug Classification Mechanism of Action

Indication Contraindication Side effects Nursing Responsibility

Neostigmine 5mg + Atropine Sulfate 1 mg

Cholinesterase Inhibitor

Muscle stimulant

Inhibits destruction of acetylcholine released from parasympatheti

Myasthenia gravis

To diagnose myasthenia gravis

Contraindicated in patient hypersensitive to cholinergics or bromide and

CNS1) dizziness2) Headache3) Mental Confusion

CV1) Bradycardia

1. Assess patients condition before starting therapy

2. Monitor patient’s response after each

c and somatic efferent nerves. Acetylcholine accumulates, increasing stimulation of receptor.

Postoperative abdominal distention and bladder atony

Antidote for nondepolarizing neuromuscular blockers

Supraventicular tachycardia from tricyclic antidepressant overdose

Decrease small bowel transit during radiography

in those with peritonitis or mechanical obstruction

Use cautiously in patient with renal impairment, neuromuscular disorders or ulcerative bowel lesions

2) Hypotension3) Cardiac arrest

EENT1) Blurred vision2) Lacrimation3) miosis

GI1) Nausea2) Vomiting3) Diarrhea4) Abdominal cramps5) Excessive

salivationGU

1) Urinary frequencyMUSCULOSKELETAL

1) Muscle cramps2) Muscle weakness3) Muscle

fasciculationRESPI

1) Depressed respiratory drive

2) Bronchospasm3) Bronchoconstricti

ons4) Respiratory arrest

SKIN1) Rash (with

bromide)2) diaphoresis

Other1) Hypersensitivity

reaction2) Anaphylaxis

dose. Watch closely for improvement in strength, vision, and pstosis 45 to 60 minutes after each dose. Show patient how to record variations in muscle strength.

3. Monitor V/S frequently

4. Although drug is is commonly used to reverse effects of nondepolarizing neuromuscular blockers in patient who have undergone surgery, it may worsen blockade produced by succinylcholine

5. Patient may develop resistance to drug

6. Give oral drug with food or milk to reduce GI distress

Anticholinergic, belladonna alkaloid

Antiarrythmic, vagolytic

Inihibits acetylcholine at parasympathetic neuroeffector junction, blocking vagal effects on SA node. This enhances through AV

Anticholinesterae insecticide poisoning

Preoperatively for decreasing secretions and blocking cardiac vagal reflexes

Contraindicated in patients hypersensitive to drug and those with acute angle-closure glaucoma, obstructive uropathy,

CNS1) Headache2) Restlessness3) Ataxia4) Disorientation5) Hallucinations6) Delirium7) Coma8) Insomnia9) Dizziness10) Excitement11) Agitation

1. Obtain history of patient’s underlying condition and reassess regularly

2. Be alert for adverse reaction and drug interaction

3. Monitor patient, especially those receiving doses of

node and speeds heart rate.

obstructive disease of GI tract, paralytic ileus,toxic megacolon, intestinal atony, unstable CV status in acute hemorrhage, asthma, or myasthenia gravis

Use cautiously in patient with Down syndrome

12) confusionCV1) Tachycardia2) Palpitations3) Angina4) Arrhythmias5) flushing

EENT1) Photophobia2) Blurred vision3) Mydriasis

GI1) Dry mouth2) Thirst3) Constipation4) Nausea5) vomiting

GU1) Urine retention

Hematologic1) leukocytosis

Other1) anaphylaxis

0.4 to 0.6 mg , for paradoxical initial bradycardia, which is caused by a drug effect in CNS and usually disappears within 2 minutes

4. Watch for tachycardia in cardiac patients because it may cause ventricular fibrillation

5. Give with or without food

6. If ECG disturbances occur, withhold drug, obtain a rhythm strip, and notify prescriber immediately

7. Have emergency equipment and drugs on hand to treat new arrhythmias. Other anticholinergics may increase vagal blockage

8. Use physostigmine salicylate as antidote for atropine overdose.

9. Teach patient how to handle distressing anticholinergic effect.


Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing ResponsibilityCefuroxime 750mg IV q8◦

Antibiotic, Cephalosporin (second generation)

Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

Pharyngitis, tonsillitis caused by Streptococcus pyogenes

Otitis media caused by Streptococcus pneumoniae, S. pyogenes, Haemophilus influenzae, Moraxella catarrhalis

Lower respiratory infections caused by S. pneumoniae, Haemophilus parainfluenzae, H. influenzae

UTIs caused by Escherichia coli, Klebsiella pneumoniae

Uncomplicated gonorrhea (urethral and endocervical)

Dermatologic infections, including impetigo caused by Streptococcus aureus, S. pyogenes

Treatment of

Patient with known allergy to cephalosporin and penicillin

CNS1)Headache2)Dizziness3)Lethargy4)ParesthesiaGI1)Anorexia, Nausea & VomitingRENAL1)Nephrotoxicity

1. Don’t give cephalosporin together with amino glycosides because it will increase the risk for kidney toxicity.

2. Avoid giving cephalosporin with anticoagulant because it will increase bleeding tendency.

3. Obtain culture and sensitivity test before administering the drug

4. Monitor renal function during the entire therapy

5. Instruct the patient to finish the full course of the therapy

6. Provide small frequent meals as tolerated.

7. Take medication with food if gastric irritations occurs

8. Provide health teachings such as:

a. Change position carefully

b. Avoid driving and hazardous task, drinks lots of fluids,

c. Avoid alcohol drinks 72 hours after completing the entire course

early Lyme disease

Reference: Nursing Pharmacology 4th Edition-Amy Karch

Name of Drug Classification Mechanisms of Action

Indication Contraindication Side effects Nursing Responsibilities

Keterolac Nonsteroidal anti-inflammatory agents

nonopioid analagesics

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia

Also has antipyretic and anti-inflammatory properties.

Therapeutic effect:Decreased pain

Short term management of pain

Hypersensitivity Cross-sensitivity

with other NSAIDs may exist¨Pre- or perioperative use

Known alcohol intoleranceUse cautiously in:1) History of GI bleeding2) Renal impair-ment (dosage reduction may be required)3) Cardiovascular disease

CNS1)drowsiness2)abnormal thinking3)dizziness4)euphoria5)headache-RESP1)asthma2)dyspneaCV1) edema2) pallor3) vasodilationGI1) GI Bleeding2) abnormal taste3) diarrhea4) dry mouth5) dyspepsia6) GI pain7) nauseaGU1) oliguria2) renal toxicity3) urinary frequencyDERM1) pruritis2) purpura3) sweating4) urticariaHEMAT

Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.

Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration.

Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.

Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC

1) prolonged bleeding timeLOCAL1) injection site painNEURO1) paresthesia- MISC:1) allergic reaction, anaphylaxis

medications without consulting health care professional.

Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.

Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

Name of Drug Classification Mechanisms of Action

Indication Cotraindication Side effects Nursing Responsibilities

Tramadol Analgesics Binds to mu-opioid receptors and inhibits the reuptake ofnorepinephrine and serotonin; causes many effects similar to

Relief of moderate to moderately severe pain

Contraindicated with pregnancy; allergy to tramadol; acute intoxication with alcohol, opioids, psychotropic

1. Sedation,2. dizziness/vertigo3. headache4. confusion5. Dreaming6. Sweating7. Anxiety

1. Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.

2. Monitor vital signs and assess for orthostatic

theopioids--dizziness, somnolence, nausea, constipation--but does not have the respiratory depressant effects.

drugs or other centrally acting analgesics; lactation.

Use cautiously with seizures, concomitant use of CNS depressants or MAOIs, renal or hepatic impairment

8. Seizures9. Hypotension10. Tachycardia11. Bradycardia12. Sweating13. Pruritus14. Rash15. pallor,16. urticaria17. Nausea and

vomiting,18. dry mouth19. constipation 20. flatulence

hypotension or signs of CNS depression.

3. Discontinue drug and notify physician if S&S of hypersensitivity occur.

4. Assess bowel and bladder function; report urinary frequency or retention.

5. Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.

6. Monitor ambulation and take appropriate safety precautions.

REFERENCE:http://www.nursing-nurse.com/drug-study-tramadol-178/

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing ResponsibilityParacetamol 300mg IV q4

Non-narcotic analgesic

Antipyretic

Decreases fever by a hypothalamic effect leading to sweating and vasodilation

Inhibits pyrogen effect on the hypothalamic-heat-regulating centers

Inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin

Control of pain due to headache, earache, dysmenorrhea, arthralgia, myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy

reduce fever in viral and bacterial

Renal Insufficiency

AnemiaSpecial Concerns: Liver toxicity

(hepatocyte necrosis) may occur with doses not far beyond labeled dosing.

If 3 or more alcoholic drinks per day are consumed, consult a

1) Minimal GI upset.

2) Methemoglobinemia

3) Hemolytic Anemia

4) Neutropenia5) Thrombocyto

penia6) Pancytopenia7) Leukopenia8) Urticaria9) CNS

stimulation10) Hypoglycemic

coma

1. Do not exceed 4gm/24hr. in adults and 75mg/kg/day in children.

2. Do not take for >5days for pain in children, 10 days for pain in adults, or more than 3 days for fever in adults.

3. Extended-Release tablets are not to be chewed.

4. Monitor CBC, liver and renal functions.

5. Assess for fecal occult blood and nephritis.

synthesis Does not cause

ulceration of the GI tract and causes no anticoagulant action.

infections As a

substitute for aspirin in upper GI disease, bleeding disorders clients in anticoagulant therapy and gouty arthritis

physician prior use.

11) Jaundice12) Glissitis13) Drowsiness14) Liver Damage

6. Avoid using OTC drugs with Acetaminophen.

7. Take with food or milk to minimize GI upset.

8. Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.

9. Report paleness, weakness and heart beat skips

10. Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.

11. Phenmacetin may cause urine to become dark brown or wine-colored.

12. Report pain that persists for more than 3-5 days

13. Avoid alcohol.14. This drug is not for

regular use with any form of liver disease.

Reference: http://rnspeak.com/drug-study/paracetamol-biogesic-drug-study/

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing ResponsibilityCefuroxime 500mg TID

Antibiotic, Cephalosporin (second generation)

Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in

Pharyngitis, tonsillitis caused by Streptococcus pyogenes

Otitis media caused by Streptococcus pneumoniae, S. pyogenes,

Patient with known allergy to cephalosporin and penicillin

CNSHeadacheDizzinessLethargyParesthesiaGIAnorexia, Nausea & VomitingRENAL

1. Don’t give cephalosporin together with amino glycosides because it will increase the risk for kidney toxicity.

2. Avoid giving cephalosporin with anticoagulant because it will increase bleeding tendency.

3. Obtain culture and

bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

Haemophilus influenzae, Moraxella catarrhalis

Lower respiratory infections caused by S. pneumoniae, Haemophilus parainfluenzae, H. influenzae

UTIs caused by Escherichia coli, Klebsiella pneumoniae

Uncomplicated gonorrhea (urethral and endocervical)

Dermatologic infections, including impetigo caused by Streptococcus aureus, S. pyogenes

Treatment of early Lyme disease

Nephrotoxicity sensitivity test before administering the drug

4. Monitor renal function during the entire therapy

5. Instruct the patient to finish the full course of the therapy

6. Provide small frequent meals as tolerated.

7. Take medication with food if gastric irritations occurs

8. Provide health teachings such as:

a. Change position carefully

b. Avoid driving and hazardous task, drinks lots of fluids,

c. Avoid alcohol drinks 72 hours after completing the entire course



Celecoxib 200mg BID

NSAID Analgesic

(nonopioid) Specific COX-2

enzyme

Celecoxib has COX-2 specific inhibitory activity. It inhibits the

Acute and long-term treatment of signs and symptoms of

Hypersensitivity including those in who attacks of angioedema, rhinitis and urticaria has been

1) Abdominal pain

2) Diarrhea

1. Be aware that patient may be at increased risk for CV events, GI bleeding; monitor

conversion of arachidonic acid to prostaglandins while having no effect on the formation of prostaglandins that mediate the normal homeostasis in the GI tract, kidneys and platelets catalyzed by COX-1.

rheumatoid arthritis and osteoarthritis

Reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP)

Management of acute pain

Treatment of primary dysmenorrhea

Relief of signs and symptoms of anklylosing spondylitis

Relief of signs and symptoms of juvenile rheumatoid arthritis

precipitated by aspirin, NSAIDs or sulfonamides.

Severe hepatic impairment;

Severe heart failure; inflammatory bowel disease; peptic ulcer; renal impairment (CrCl <30 ml/min);

Pregnancy and lactation.

3) Nausea

4) Edema

5) Dizziness

6) Headache

7) Insomnia

8) upper respiratory tract infections

9) rash

Potentially Fatal:

1) Serious skin reactions such as exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis.

accordingly.2. Administer drug

with food or after meals if GI upset occurs.

3. Establish safety measures if CNS, visual disturbances occur.

4. Arrange for periodic ophthalmologic examination during long-term therapy.

5. If overdose occurs, institute emergency procedures—gastric lavage, induction of emesis, supportive therapy.

6. Provide further comfort measures to reduce pain (eg, positioning, environmental control) and to reduce inflammation (eg, warmth, positioning, and rest).

7. Take drug with food or meals if GI upset occurs.

8. Take only the prescribed dosage; do not increase dosage.

9. You may experience these side effects: Dizziness, drowsiness (avoid

driving or the use of dangerous machinery while taking this drug).

10. Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision.

REFERENCE:http://www.rnpedia.com/home/notes/pharmacology-drug-study-notes/celecoxib



D5LR x 8◦, 12◦ Hypertonic Nonpyrogenic Parenteral fluid Electrolyte Nutrient

replenisher

Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy.

The Dextrose 5% in Lactated Ringers Solution (D5LRS) is useful for daily maintenance of body fluids and nutrition, and for rehydration.

Hypersensitivity to any of the components.

Redness or pain at the injection site may occur.

Fever trouble

breathing swelling

1. Do not administer unless solution is clear and container is undamaged.

2. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin.

3. Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis.

4. Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus.

5. Discard unused portion.

6. In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.

7. Properly label the IV Fluid

8. Observe aseptic technique when changing IV fluid



REFERENCE:http://en.wikipedia.org/wiki/Lactated_Ringer%27s_solution

PNSS x KVO Isotonic Table salt (sodium chloride)

Normal saline solution has an osmolality of 308mOsm/L. Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF, does not cause red blood cells to shrink or swell .Isotonic fluids expand the ECF volume.

Used to give intravenous fluids to the patients suffering from salt and water deprivation

Used in blood transfusions, hyponatremia, and burn victims

Used for irrigation during surgery, to dilute medications, and to clean wounds out

Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemic shock or hypotension

None Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia.

1. Monitor pt. frequently for:a. Signs of

infiltration / sluggish flow

b. Signs of phlebitis /infection

c. Dwell time of catheter and need to be replaced

d. Condition of catheter dressing

2. Check the level of the IVF.

3. Correct solution, medication and volume.

4. Check and regulate the drop rate.

5. Change the IVF solution if needed

6. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary.

REFERENCE:http://www.rxlist.com/normal-saline-drug/side-effects-interactions.htm

Name of Drug

Classification Mechanism of Action Indication Contraindication Side effects Nursing Responsibility

Isoflurane Anesthetics It potentiates glycine receptor activity, which decreases motor function.

Isoflurane, USP may be used for induction and maintenance of

Known sensitivity to Isoflurane, USP or to other

1) increase in the white blood cell count (even in the absence of

1. Used with caution in patients with coronary artery disease

It inhibits receptor activity in the NMDA glutamate receptor subtype.

Isoflurane inhibits conduction in activated potassium channels.

Isoflurane also affects intracellular molecules.

It activates calcium ATPase by increasing membrane fluidity.

It binds to the D subunit of ATP synthase and NADH dehydrogenase.

general anesthesia. Adequate data have not been developed to establish its application in obstetrical anesthesia

halogenated agents. Known or suspected genetic susceptibility to malignant hyperthermia.

surgical stress) and also shivering

2) Nausea and vomiting (during the postoperative period).

3) Increase in heart rate Rare cases of bronchospasm

4) Rare reports of mild, moderate and severe (some fatal) post-operative hepatic dysfunction.

Adverse Reaction1) Hypotension2) Respiratory

depression3) arrhythmias

2. Monitor blood pressure and temperature to detect residual hypotension and the possibility of malignant hyperthermia.

3. Must be given with a licensed anesthesiologist

4. Emergency kit must be made available

REFERENCE:http://www.drugs.com/sfx/isoflurane-side-effects.html

IV. NURSING PROCESS

A. LONGTERM OBJECTIVE

The nursing plan aims to return the patient to its normal body feeling. It also aims to restore the healthy

body of the patient. And to ensure the physiological well-being of the patient by providing patient and family

teachings through addressing emotional and psychosocial needs.

B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM RANKING JUSTIFICATION

Acute Pain related to tissue trauma from Surgical Incision

1 Acute pain should be the first because if pain is not present or will be diminish, for it won’t be totally removed because of presence of surgical incision, the patient will be comfortable and other problem will be somehow light.

Ineffective thermoregulation related to trauma of breast tissue

2 This should be second because if the patient has fever, the activity will be limited, also this indicate that she has infection.

Disturbed body image related to loss of body part secondary to Modified Radical Mastectomy

3 This should be third because the patient needs to have a good ambulation or movement of her body parts. If she will be limited, other problem such as impaired skin integrity will follow.

Impaired skin integrity related to post operative incision secondary to surgery

4 This should be fourth because it is just present because of complimentary situations just like disturbed body image which should be managed first.

Risk for injury 5 Tchis risk should be less prioritized because it is just foreseeing the possibility that may occur.

Risk for edema 6 Impaired skin integrity related to post operative incision secondary to surgery.

Decrease hemoglobin secondary to anemia

7 This should be the last because the management of increasing hemoglobin takes a long term.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“Mababa daw ang pula ngdugokosabeng doctor” as verbalized by the patient.

OBJECTIVE: Pale in

appearance Weak Fatigue Hemoglobin

result of 7.4 gm/dL

Decrease hemoglobin secondary to Anemia

After one hour of nursing intervention the client will be able to:

Verbalizes understanding about the causes and effects of iron deficiency.

Long term:

Report in increase hemoglobin in CBC result.

Explain about the signs and symptoms of anemia.

Instructed about increase intake of iron rich food and iron supplement.

Note changes in balance/ gait disturbance, muscle weakness.

Plan activity progression with patient, including activities that the patient reviews essential. Increase levels of activities as tolerated

Recommended quiet atmosphere, bed rest if indicated.

For the patient to know about the possible Causes of anemia.

Iron is needed for formation of RBC

May indicate neurological changes associated with vitamin B12 deficiency, affecting patient’s safety or risk for injury.

Promotes gradual return to normal activity level and improved muscle tone or stamina without undue fatigue.

Enhances rest to lower body’s oxygen requirements, and reduces

After one hour of nursing intervention the client was able to verbalize understanding about the causes and effects of iron deficiency.

The nursing intervention was not met.

strain on the heart and lungs.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:“Kumportable ako pag inilalagay ko itong bag sa tabi ko”. As verbalized by the patient.

OBJECTIVE:

Seen placing shoulder bag on the operative site.

Hemoglobin level of 7.4gm/dL

Absence of Significant other for assistance.

Risk for Injury After 1-2 hours of nursing intervention the client will demonstrate behaviors to reduce risk factors and to protect self from injury.

Instructed to ask for assistance in performing ADLs.

Encourage patient to prevent doing things beyond what her body can perform.

Assess mood, coping capabilities and personality styles like aggression and impulsive behaviour.

Encourage use of techniques to reduce stress and vent emotions such as anger.

Provide adequate rest.

To promote safe physical environment and individual safety.

Impulsive behaviors may contribute and increase risk of the patient to injury.

These may result in carelessness or increased risk taking without consideration of consequence

To reduce the occurrences of injury

Adequate rest can strengthen

After 1-2 hours of nursing intervention the client was able to demonstrate behaviors to reduce risk factors and to protect self from injury.

the patient.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:“Hindi ko maitaas ang kaliwang braso ko kasi masakit”. As verbalized by the patient.

OBJECTIVE:

Unable to raise left arm

Presence of suture on left breast adjacent to armpit.

Inability to have exercise of the operative site.

Risk for edema After one hour of nursing intervention the client will able to demonstrate the instruction to prevent risk for edema.

Instructed to raise the left arm

Encourage minimal exercise on the affected area

Instructed to wear loose clothing

Do not carry purse or anything heavy on the affected site

Avoid exposure to hot object that may cause burns

Avoid the use of blood pressure cuffs to the affected area.

Raising the left arm or the operative site to promote drainage and prevent edema.

Exercise can promote proper circulation

Tight clothing can increase the pressure in the operative site

To avoid pressure and swelling on the operative site

Hot objects can further increase the risk for edema

Blood pressure cuffs can increase pressure in the operative site

After one hour of nursing intervention the client was able to demonstrate the instructions to prevent risk for edema.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATIONS: “Ang nararamdaman ko lang talaga dito sa suso ko ay yung sakit, pero di naman siya makati”,as verbalized by the patient.

Objective: Presence of surgical

wound on the left breast where incision was made

Pain rated as 10 out of 10 as 10 as the highest.

Impaired skin integrity related to post operative incision secondary to surgery

After 1-2 hours of nursing interventions, the patient will participate in prevention measures and treatment program.

Assess incision site taking note of size, color, location, temperature, texture, consistency of wound/ lesion if possible.

inspect surrounding skin for erythema, induration, maceration

assess for odors and drains coming out from the skin/ area of injury

inspect skin on a daily basis, describing lesions and changes observed

keep the area clean/dry, carefully dress wounds, support incision, and prevent

to provide comparative baseline data

to assess extent of involvement

to assess early progression of wound healing, development of hemorrhage or infection

to promote timely intervention/revision of plan of care

to assist body’s natural process of repair

After 1-2 hours of nursing intervention, the client was able to participate on the preventive measures and treatment program for her condition.

infection use appropriate

wound coverings

encourage adequate rest and sleep

encourage early ambulation and mobilization

provide position changes

practice aseptic technique in cleansing/dressing and medicating lesions

instruct proper disposal of soiled dressing

protect the wound and/or surrounding tissue

to prevent fatigue

to promote circulation and reduce risks associated with immobility

to prevent bed ulcers from occuring

to reduce risk of cross-contamination

to prevent spread of infectious agent

ASSESSMENT NSG. DIAGNOSIS

PLANNING INTERVENTION RATIONALES EVALUATION

S:”Masakit yung parte na may tahi, hindi ko nga maigalaw ng maayos yung katawan ko”, as verbalized by the patient.

Objective: Facial grimace Guarding

behavior Pain scale of 10

out of 10 as 10 as the highest.

Autonomic alteration of muscle tone

Acute pain related to tissue trauma from surgical incision

After 1-3 hours of nursing intervention, client’s pain scale will be reduced.

Monitor vital signs

Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration

Place in Semi-Fowler’s position and support head/neck in neutral position with small pillows as required in immediate postoperative phase

Instruct client to use hands to support neck during movement and to avoid hyperextension of neck

Encourage client to use relaxation

For baseline data

Useful in evaluating pain, choice of interventions, effectiveness of therapy

Prevents hyperextension of the neck and protects integrity of the suture line

Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness

Helps refocus attention and assist

S:”Masakit pa rin siya pero di na naman masyado tulad kanina kasi may tinuturok nman sila para sa kirot”,as verbalized by the patient.

Objective: Pain scale of 8

out of 10

techniques e.g., guided imagery, soft music, progressive relaxation

Administer analgesics as ordered.

client to manage pain more effectively

Reduces pain and discomfort.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION

S:”Iba na ngayon yung pakiramdam ko nung nawala yung kaliwa kong suso, ang sama ng tingnan sana hindi na mangyari dun sa kabila”,as verbalized by the patient.

Objective: Evident

removed left breast

Disturbed body image related to loss of body part secondary to modified radical mastectomy

After 1-3 hours of nursing intervention the client will verbalize understanding of body changes and acceptance of self in situation.

Assess perception of change in structure or function of body part.

Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities

.Encourage verbalization of positive or negative feelings about actual or perceived change

.Maintain therapeutic communication and demonstrate positive caring

To identify existing problem and plan certain therapeutic actions

To help the client sustain his physical and social needs while she is unable

To allow the client to express herself and release tension on feelings.

To facilitate good nurse-patient interaction and also gain clients trust to

S:”Hindi naman ako masyadong pinanghihinaan ng loob dahil lang dito, yun lang talaga sana hindi na siya mangyari dun sa kabila kung suso”, as verbalized by the patient.

Goal still on progress.

in routine activities

Teach patient adaptive behavior like using of adaptive equipment that conceals altered body part breast pad

Help patient identify ways of coping and divertional activities

cooperate.

To help the client gain back her confidence by concealing altered body part.

To make the client focus on activities she’s interested and happy instead of her altered body part

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATIONS:”Nilalamig na naman ako kasi nilagnat ako simula nung maopera ako”, as verbalized by the patient.

Objective: Flushed skin Warm to

touch Temp:

38.9®C

Ineffective Thermoregulation related to trauma of breast tissue

After 1-2 hours of nursing intervention the client will maintain core temperature within normal range

Administer fluids, electrolytes and medications, as ordered.

Monitor body temperature

Promote client safety

Maintain bedrest

Discuss importance of adequate fluid intake

To treat underlying cause

To asses baseline data

To assist with measures to reduce body temperature

To reduce metabolic demands and oxygen consumption

To prevent dehydration.

After 1-2 hours of nursing intervention the client’s body temperature reduced from 38.9 to 38.6®C

Goal partially met.

D. Discharge PlanMedications

a.) Advised the patient to take the medications prescribed by the physician for her to take continuously at home:a. Cefuroxime 500mg 1tab/three times a day (8am-1pm-6pm)b. Celecoxib 200mg 1cap/two times a day (8am-6pm)b.) Instructed to always check the expiration date before taking the medication.

Environment

a.) Provided safety measures to promote a safe environment.b.) Maintain quiet, well ventilated and cal environment for fast and good recovery of the patient.

Treatment

a.) Treatment for all types of IDC is determined by the exact type of cancer and staging. Depending on the size and spread of the tumor(s), most women will undergo a combination of any of the following treatments: Lumpectomy Mastectomy Sentinel node biopsy Axillary node dissection Breast reconstruction Radiation Chemotherapy Hormonal therapy Biologic targeted therapy

Health teaching

a.) Instructed the patient to avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed. b.) Advised the patient to elevate the arm to avoid edema on arm and hand.c.) Reiterated the importance of coping stress through stress theraphy such as stress reduction at home.

Out Patient referral check up

a.) After discharge, advised the patient to come back for follow up check up at OPD after one week (August 23, 2013) after discharge.

Diet

a.) Instructed the patient to avoid salty food.

b.) Advised the patient to resume regular diet after recovering from anesthesia.c.) Encourage the patient to Inceased fluid intake and avoid Caffeinated beverages.d.) Advised to take plenty of fruits and vegetables.

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/medical_oncology/biologic_targeted_therapy.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/medical_oncology/adjuvant_hormonal_therapy.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/medical_oncology/neoadjuvant_adjuvant_chemotherapy.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/radiation_oncology/index.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/reconstructive_breast_surgery/index.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/breast_surgical_oncology/axillary_node_dissection.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/breast_surgical_oncology/sentinel_node_biopsy.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/breast_surgical_oncology/mastectomy.html

http://www.hopkinsmedicine.org/avon_foundation_breast_center/treatments_services/breast_surgical_oncology/lumpectomy_breast_conservation.html

Manuel S. Enverga University FoundationCollege of Nursing and Allied Health Sciences

Lucena City

A Case Study of

Ductal Carcinoma

In Partial Requirement of

Nursing Care Management 103- Related Learning ExperienceSurgery Department

Quezon Medical Center

Submitted by:

BSN LEVEL III- Group II

ANCHETA, GENESISBANTOC, ROYCE ANNECAPACIA, JAN MARIZ

ESCALA, EMILYESTRADA, RAY JUNDIE

GALLANO, MARY CONCEPTIONMACASAET, LESLIE

MENDOZA, MARGOTTSARGENTO, TOM FRANCIS

Submitted to:

EDWIN Q. YABUT RN, MSNClinical Instructor

ductal carcinoma

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