Casebook - Breast Cancer

Case Study on Breast Cancer
2011
COLLEGE OF NURSING
Silliman University
Dumaguete City, Negros Oriental
VISION/ MISSION STATEMENT

VISION:
A leading Christian institution committed to total human development for the well-being of society and environment.
MISSION:
In this regard, the University Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted; Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith; Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion; and Promote unity among people and contribute to national development.
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January 6, 2011 MRS. LEIZL JOY C. ESCOBAR, R.N. Clinical Instructor, Surgery Rotation Silliman University College of Nursing Dumaguete City, Negros Oriental Dear Madame: Good Day! We, Maryam Fatima F. Majid and Steven Dominic T. Melodia, junior students of the Silliman University College of Nursing, currently on Surgery rotation at the Negros Oriental Provincial Hospital, would like to ask for your sincere consent to do a case study/ analysis on our patient who had Modified Radical Mastectomy last December 3, 2010 in connection with our Related Learning Experience in the said rotation. Her name is Ligaya O. Bajar, 61 years old, admitted last December 1, 2010, 1:07 pm. All facts and files are strictly kept confidential and for learning purposes only as stated in the patients bill of rights. It will be a privilege to conduct this study for it will help us improve our learned skills, enhance our knowledge and develop a desirable attitude towards the care of a client who had Breast Cancer and MRM as we present this to our fellow classmates in a form of a case presentation. Thank you very much! We hope for your positive response! God bless you! Respectfully yours, Maryam Fatima F. Majid Approved by: MS. LEIZL JOY C. ESCOBAR, R.N. Clinical Instructor, Surgery Rotation Steven Dominic T. Melodia
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Acknowledgement
We are honored to present this case analysis to those people who helped us in making this study a successful one. First of all, we want to extend our gratitude to the Almighty God, our Father, for giving us the strength and wisdom to finish this study. With a grateful heart, we thank Him for His wonderful ways in keeping us motivated to do everything with our best and reminding us the beauty of holding on in every trial. To our parents who became our greatest inspiration in life. We thank you for your unconditional love and support that helped us meet our needs physically, emotionally and financially. And also to our friends, relatives and loved ones, we thank you for the prayers. We love you all. To our client, Mr. Ligaya Bajar, who patiently shared with us her time and information to make this case a fruitful one. Thank you for the very warm treatment and cooperation you have shown to us which also helped in making our care a successful one. To the Silliman university College of Nursing (SUCN) and Negros Oriental Provincial Hospital (NOPH), the faculty, personnel and staff for giving us the opportunity to learn and work with you. We thank you for your support and patience all throughout that molded us to become competent nurses in the future. To our clinical instructor, who unconditionally supported us in every endeavor we encountered during our duty, and for the knowledge and experiences she have shared with us. Thank you for educating us without imposing too much pressure and for giving us the opportunity to learn more than what we can learn in the four walls of the classroom. We are so blessed to have you as our C.I., our second mother, and our friend as well. We love you Maam! We also wouldnt want to miss our supportive, loving, caring, and understanding C.I mates who made this journey worthwhile. Thank you for sticking around the whole time, offering the best help you can give, and sharing with us your laughter and joy to make this experience a memorable one. Just with your presence, you made us enjoy the College of Nursing. We will never forget you! Life is a race. But it is not a race to win but a race to learn. It doesnt matter how much reward you will get in every success. What matters most is the journey youve taken and the learning you gained in attaining success. Life can be worthwhile if you would travel with the people you love and the people who love you. Although life is too short, it wont stop you to enjoy it.
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Table of Contents
I. II. III. IV. Content Introduction Topic Description Objectives Psychosocial Profile A. Demographic Data B. Genogram C. Ecomap Significant Results of Nursing Assessment A. Physical Assessments Findings B. Laboratory Results/ Diagnostic Exam Results C. Functional Health Pattern D. Summary of Nursing Diagnosis Nursing Care Plans Health Teachings Medical Management Pharmacology Overview of the Condition Pathophysiology Growth and Development Evaluation of Objectives Annotated Readings Bibliography Page
V.
VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV.
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Introduction
Aging is a normal process which all of us go through. There are changes that happen as we age and part of it are changes of our physical, psychological, and emotional status. Deterioration is a constant process from the day we were born until we die. It is necessary to understand these processes so that we will be able to understand and interpret such changes that happen in ourselves holistically. Our client in this case study is on the late adulthood stage of development. In order to understand her developmental stage, we should look to her growth and development as late adult, and it is being discussed in this case study. As being said, deterioration is a constant process, therefore, effects are more profound during the end stage of life. Cells are basic unit of our body and of course, it also deteriorates as we age. Part of the changes that happen to our cells may cause mutation of genes that result to uncontrolled production of abnormal cells. This uncontrolled proliferation of abnormal cells which can develop into cancer cells may develop into different complications which are also discussed in this case study. In the case of our patient, she was diagnosed of Stage III C Breast Cancer on the right breast and Stage III B on the left breast. She underwent an operation which is modified radical mastectomy on both breasts. Basically, in this case study, we will learn more on the concepts of cancer as we relate it to the condition of our client. As student nurses, we strive to learn and the goal of the learning process is for us to become better as we go through our course and eventually our carrier in the future. This case study will help us gain new knowledge and apply what weve learned the next time we are exposed to the same case of patients.
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Placement: NCM 104, Level III; Surgery Rotation. NOPH Time Allotment: 2 hours Topic: Breast Cancer Stage III Topic Description: This 2-hour presentation deals with the care of a woman with Stage IIIC Breast Cancer on the right breast and Stage IIIB on the left breast who undergone modified radical mastectomy on both breasts. This study discusses the growth and development of a late adult, and the pathophysiology of breast cancer in relation to the case of our patient. In addition, it talks about the profile of the patient, functional health pattern, health history, physical examination and medications. It also includes the procedures done to our patient, laboratory results, nursing management, and two annotated readings related to her condition. Central Objective: At the end of the presentation, the learners shall acquire deeper knowledge on concepts related to the development of cancer, and develop desirable attitudes and values towards the enhanced care of the client with breast cancer who undergone surgical interventions especially modified radical mastectomy.
Specific Objectives: The presenters of this case study have the following objectives: 1) Discuss clearly the pathophysiology of breast cancer in accordance to the case of our patient. 2) Explain the developmental tasks of a late adult. 3) Perform a thorough assessment of our patients functional health pattern, medical history, and physical examination.
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4) Notably consider the need for giving medications to our patient. 5) Devise and formulate nursing care plans based on the identified problems noted during our care. 6) Convey and communicate desirable attitude towards caring for patients with breast cancer post-operatively.
At the end of the presentation, the learners shall: 1) Enumerate the possible causes and risk factors of breast cancer or any types of cancer. 2) State the developmental tasks of a late adult briefly. 3) Determine the pathophysiologic process of the development of cancer.
4) Accurately determine the effects of the medications and how it can help patients who undergone surgical interventions due to cancer recover post-
operatively.
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PSYCHOSOCIAL PROFILE
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DEMOGRAPHIC DATA
Name: Ligaya Oroc Bajar Address: Tupaz, Manjuyod Sex: Female Room and Bed no.: SURG PR. 3
Age: 61 years old Religion: Roman Catholic Nationality: Filipino
Civil Status: Single Occupation: Sari-sari Store Owner Physician(s) in charge: Dr. A.M Sinco
Date and Time of Admission: December 1, 2010; 1:07pm
History of Present Illness: A mass on the right breast was felt five years PTA. Severe pain during the night noted, and elicited with strenuous activities. Herbal medicine was the first management, like haplas, Lacto paffy, etc. for temporary relief of the pain until it worsen overtime. Chief Complaint: Rupture of a mass in the right breast with severe pain and purulent secretions General Impression of Client (appearance upon first contact): Received sitting on bed with legs raised on a chair. Alert, awake, coherent and responsive to stimuli. Speaks weak at first. Wears own clothes, kept clean and neat. Hair not well kept. Sits on the bed leaning on the wall with pillows on her back for support. Bed linens properly tucked in. Reports minimal pain felt on the insertion site after operation. Rates pain as 2 in a scale of 0-10. No signs of distress noted. Her aunt Eugenia is with her in the room.
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83 yrs old Nicotine excess
86 Blind A&W
66 A&W Eldest
63 Brain Tumor
CLIENT 61 yrs old Breast CA stage III
58 A&W
54 A&W
LEGEND: Female Male

49 A&W 46 A&W 44 A&W
Client Staying together Staying Separately Dead A&W = Alive and Well CA = Cancer
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Church
Barangay Health Center
Community
Ligaya Oroc Bajar 61 years old Breast Cancer stage IIIC Modified Radical Mastectomy
Sari-sari Store
Legend: Less likely attached
Farm land Relatives
Moderately attached
Neighboorhood
Strongly attached
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Head-to-toe Physical Assessment

Name of Patient: Ligaya Oroc Bajar Final Diagnosis: Breast CA (Right) Stage III-C; (Left) Stage III-B Age: 61 years old Sex: Female Date: December 9, 2010
I.
INTEGUMENTARY SYSTEM A. Health History - Changes of the skin, hair and nails are accompanied by aging. No history of surgery or hospitalization. Stated being allergic to penicillin and eggplants. Reported taking medication (Acupril) for management of her high blood pressure. Have had minor accidents at home like simple falls, cuts and bruises. B. Skin - Inspection: Skin is fair and slightly pigmented. No odor noted. Has a scar at her right proximal tibia measuring 2.2 cm in diameter. No edema noted. - Palpation: Moist, smooth and warm to touch. Has good mobility/ turgor as evidenced by skin flaps back immediately when pinched. C. Nails - Inspection: Nails are transparent with pinkish nail beds. Convex in shape and has a 160 degree angle of nail attachment. Firm in texture and has a good capillary refill as evidenced by blanching upon release within 3 seconds. D. Hair and Scalp - Inspection: Hair color is grayish, some white, not so thick, and equally distributed. Fine body hair noted but in lesser amount. Scalp is intact and free of lesions, dandruff, nits and scaliness. - Palpation: Scalp is mobile and nontender. No lumps and deformities noted.
II.
HEAD AND NECK A. Health History - First hospitalization ever since. - No history of head pain/recurring headache.

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Have not experienced jaw tightness or pain. No neck mass or tenderness. Have not experienced hoarseness of voice. Claims that she is allergic to penicillin and eggplant. In relation to environmental factors, claimed that she is allergic to dust. Has experienced cough and colds many times already. No other health problems except her recently Stage III cancer on both breasts. Claims that she is taking medication for the maintenance of her blood pressure. Claims that she has astigmatism. Wearing eye glasses at a grade of 350. Have her eye examined every 3 years. Claims that she has a family history of hypertension. No hearing difficulty/problems. No problems with balance. No past and recent head trauma.
B. Eyes 1. Inspection a. Eyelids - Upper eyelids cover one-half of upper iris. Palpebral fissures symmetrical. Eyelids in contact with eyeball. No lesions. b. Lacrimal ducts - No swelling, redness, or drainage. c. Conjunctiva - Palpebral conjunctiva is smooth, glistening, slightly pale pink in color, with minimal blood vessels visible. Bulbar conjunctiva is clear, slightly pale pink in color with few underlying blood vessels and white sclera visible. d. Sclera - Sclera is smooth, white, and glistening. e. Cornea - Cornea and lens clear, smooth, and glistening. Cornea reflex positive. f. Iris - Brown in color, circular in shape. g. Pupils - Equal, round, reactive to light and accommodation. Approximately 3 mm in size. 2. Visual Acuity - Reads handout easily with corrections at a distance of 14 inches.
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3. EOM -
Smooth, conjugate movement of the eyes in all directions, equal palpebral fissures without eye lag. Extraocular muscles intact.
C. Ears 1. Inspection/Palpation a. Pinna - Color is the same with surrounding areas, symmetrical. Helix is at the level of the inner and outer canthus of the eyes and is less than 10 degrees in angle. Size is greater than 4 cm vertically but less than 10 cm. Intact, no lesions. Soft and pliable, no nodules or swelling, nontender. b. Mastiod - Nontender, no nodules or swelling. 2. Otoscopic Exam a. External canal - Canal is patent, no foreign objects and free of redness and drainage. Ear wax is visible, light yellow cerumen noted. b. Tympanic - Shiny, gray in color, intact, and mobile. 3. Auditory acuity - Patient has no hearing difficulty. Can hear easily instructions without the need for repetition. D. Nose 1. Inspection a. External - Nose is at the midline, symmetrical to other facial features. No nasal flaring, no drainage. b. Internal (turbinates meatus and septum) - Nasal mucosa is pink and moist, intact, no lesions, no crusting or poylyps, septum located midline. Medial and inferior turbinates intact, pink and moist, symmetrical to other features. 2. Palpation a. Frontal sinus - No tenderness b. Maxillary sinus - No tenderness
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3. Sense of Smell (CN1) - No problems or alterations with sense of smell. E. Mouth 1. Inspection a. Lips - Is at the midline, symmetrical to other facial features, pale pink in color and moist. No unusual odors. b. Buccal mucosa - Intact, pink and moist. No bleeding. c. Gums - Consistent in color with the mucosa, intact, no bleeding. d. Palate - Intact, smooth, moist and pink. No bleeding and no lesions. e. Tongue - Tongue is pink, moist, with visible papillae. Symmetrically and freely mobile. No lesions, no discolorations. 2. Sense of Taste - No alterations or problems with taste. F. Pharynx a. Uvula movement (CN V) - Uvula is at the midline, raises as the patient says Ah. G. Neck 1. Inspection a. Masses - No masses, lumps or bulges. Thyroid not visible, no masess, no swelling or hypertrophy. b. Symmetry - Symmetrical and is at the midline, erect, not deviated. 2. Palpation of lymph nodes a. Preauricular: No tenderness, no masses, lymph nodes not enlarged. b. Postauricular: No tenderness, no masses, lymph nodes not enlarged.
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Occipital: No tenderness, no masses, lymph nodes not enlarged. Tonsilar: No tenderness, no masses, lymph nodes not enlarged. Submaxillary: No tenderness, no masses, lymph nodes not enlarged. Submental: No tenderness, no masses, lymph nodes not enlarged. Superficial cervical: No tenderness, no masses, lymph nodes not enlarged. Posterior cervical: No tenderness, no masses, lymph nodes not enlarged. Deep cervical: No tenderness, no masses, lymph nodes not enlarged. Supraclavicular: No tenderness, no masses, lymph nodes not enlarged. Infraclavicular: Tenderness noted, no masses, lymph nodes slightly palpable.
c. d. e. f. g. h. i. j. k.
3. Trachea - Is at the midline, symmetrical, not deviated. No masses, no tenderness. 4. Thyroid - Nonpalpable, firm, smooth. No nodules, enlargement, or tenderness. III. BREAST AND AXILLAE A. Health History - Has felt pain and tender mass on her right breast five years ago. Had consulted it to herbal medicines until it metastasized on to her left breast. Developed stage III breast cancer on both breasts. Has recently undergone Modified Radical Mastectomy of the two breasts last Dec. 3, 2010 that caused her hospitalization. Now, she is in her postmastectomy stage, with Jackson-Pratt drainage attached to both side of the chest to drain secretion. Has been 6 days post-op already. B. Breast - Inspection: Has reddish color of skin on her right anterior axilla. A Jackson-Pratt Drainage is attached on her right side of the chest and it drains serous secretions for 6 days postmactectomy. The left chest has the same color as the surrounding skin with a Jackson-Pratt drainage attached on it which drains serosanguinous secretions. Anterior chest was mostly covered with gauze and dressings. - Palpation: Tenderness at the right anterior axillae felt upon palpation. Rates pain as 2 in a scale of 0-10. C. Axillae - Inspection: Slightly darker in color than the surrounding skin. No foul odor noted. No lesions. - Palpation: Axillae and clavicular nodes unpalpable. No tenderness or masses noted.
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IV.
CARDIOVASCULAR SYSTEM A. Health History - First hospitalization ever since. - Has experienced cough and colds a couple of times already. - Noted mass on right breast 5 years prior to admission. Managed it by herbal medications - Has just underwent modified radical mastectomy on both breasts. - Claims that she is allergic to penicillin and eggplant. - Claims that she is also allergic to dust. - Had taken medication for her high blood pressure. - No history of cardiovascular disease. B. Inspection 1. Configuration of the thorax. - AP-to-lateral diameter ratio is approximated 1:2. - Costal angle is less than 90 degrees. - Chest symmetrical in appearance and symmetrical rise and fall when breathing. 2. Respiration - 21 cycles per minute, regular, moderate, without use of accessory muscles. 3. Nutritional Status - Diet as tolerated, has eaten regular meals. 4. Skin - Modified radical mastectomy done on both breasts. - Dressing noted without secretions. - 2 jackson pratt drainage attached on both breasts draining serous and serosanguinous secretions. 5. Chest wall pulsations - Not assessed because of dressing and drainage attached. C. Palpation 1. Apical Area (PMI) - Located at 5th intercostals space midclavicular line. Amplitude small, rate is 62 bpm, regular. Negative thrills. 2. Tricuspic Area - Systolic impulse palpated, negative thrills.
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3. Erbs Point - Slight pulsations palpated, negative thrills. 4. Pulmonary area - Slight pulsations palpated, negative thrills. 5. Aortic area - Slight pulsations palpated, negative thrills. D. Auscultation 1. Apical area - High pitched systolic, short duration. No extra heart sounds. 2. Tricuspid area - No splitting of heart sounds. 3. Erbs Point - No aortic mumurs. 4. Pulmonary area - No abnormal heart sounds. 5. Aoritc area - No murmurs.
V.
RESPIRATORY SYSTEM A. Health History - First hospitalization ever since. - Has experienced cough and colds many times already. - No history of any respiratory disease. - Recently, undergone an operation called Modified Radical Mastectomy on both breasts because of Stage III cancer. - Claims that she is allergic to penicillin and eggplant. - Claims that she is also allergic to dust in relation to environmental factors. - Lives in Manjuyod, Negros Oriental. - Non-smoker.
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B. Inspection 1. General - Skin color is the same throughout the chest, lighter compared to areas exposed to the sunlight. Skin intact, a sore of about 1.5 cm in diameter noted in posterior chest just below the level of the left scapulae. No spinal deformities, costal angle is less than 90 degrees, and anteroposterior diameter is approximately 1:2 ratio. Both breasts are removed by modified radical mastectomy. Drainage is attached individually on each breast. 2. Chest and configuration - Chest is symmetrical in appearance with symmetrical rise and falls when breathing, normal in shape. No sternal or intercostal retraction or bulging noted. 3. Respiratory rate - 23 cycles per minute.
4. Respiratory pattern - Regular in rhythm, moderate in depth, silent, and without use of accessory muscles. C. Palpation 1. Lateral and AP Chest expansion - Chest and lateral chest expansion equal. No masses. 2. Tenderness - Tenderness noted anteriorly in infraclavicular area related to surgical removal of both breasts. No masses or tenderness on other areas of the chest. 3. Trachea - Is at the midline, not deviated. No masses or tenderness. 4. Tactile fremitus - Equal bilaterally, diminished in midthorax and in the lower portion of the thorax. D. Percussion 1. Resonance - Resonance on the second intercostal space on the left, slight dullness heard in areas where there are underlying bones and organs. Posteriorly, resonance is heard in the lung area but dullness is heard in the area above the scapula. E. Auscultation 1. Breath sounds - Bronchial breath sounds heard over at the nape of the neck posteriorly are loud, high pitched, with short inspiratory phase and long expiratory phase. Bronchovesicular breath sounds heard between the scapula posteriorly are moderate sounding, medium pitched with equal inspiratory and
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expiratory phases. Vesicular sounds heard in peripheral lung fields are soft and low pitched with a long inspiratory phase and short expiratory phase. 2. Abnormal breath sounds - No crackles, wheezes, or rubs heard upon auscultation. 3. Adventitious sounds - No adventitious sounds heard. VI. ABDOMINAL SYSTEM A. Health History - First hospitalization ever since. - Have not experience recurrent abdominal pains. - Claims that she does not always empty her bowel every day. Sometimes, the interval is 2 or 3 days. - Have not undergone any abdominal surgery - Claims that she is allergic to penicillin and eggplant. Claims also that she is allergic to dust. - Appetite is good. Placed on diet as tolerated. - Health is usually good. - Recently, had modified radical mastectomy on both breasts because of Stage III cancer. - Claims that she is taking medication of the maintenance of her blood pressure. - Does not drink alcohol or use street drugs. Non-smoker. - Works in her own sari-sari store. Claims that she has been lifting heavy things. B. Inspection - Position: Located centrally between the costal margin and iliac crest, not deviated to one side. - Contour and symmetry: Abdomen is symmetrical bilaterally from costal margin to iliac crest with umbilicus at the center. No abdominal distention, contour is round. - Skin: Color is the same throughout the abdomen, lighter compared to exposed areas. No lesion or masses present. - Umbilicus: Is at the midline, inverted. No herniation noted. C. Ausculation - Bowel Sounds: Bowel sounds present at a rate of 7 clicks per minute. No borborygmi or succussion splash noted. - Circulatory Sounds: No bruits, venous hums, or friction rub noted. D. Light Palpation

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Muscular Tension: Abdomen is relaxed, no involuntary guarding and rigidity. Enlarged Organs: No organomegaly noted. No palpable mass noted in underlying organs. Masses: No masses and areas of tenderness.
VII.
MUSCULOSKELETAL SYSTEM A. Health History - Has no history of musculoskeletal problems or disease. Pain is felt on moving too much as verbalized. No pain medications taken for bone or muscle pain. Have never had any serious accidents or trauma affecting the bone and muscles. Reported frequent carrying of boxes at home before the illness, and has stopped doing it when the illness occurred. Cant remember being immunized with tetanus and polio but says maybe she is. Doesnt smoke or drink alcohol. Drinks coffee every morning and takes it with snacks sometimes. Consumes approximately 3-4 cups of coffee a day. B. Inspection - Posture is propulsive in connection with age, head in the midline, knees in the midline and normal curve of the spine noted. Weight is evenly distributed, both feet point straight ahead, no toeing in or out, with wider base of support as she stands. Balance is a little compromised due to age and weakness due to illness. Ambulates with knees slightly bend. - Extremities are symmetrical, no rashes and lesions noted. A scar on her right superior patella noted. No edema. C. Palpation - Unable to assess popliteal pulse. Dorsalis Pedis pulse is 62bpm, rhythmic yet weak. Posterior Tibialis pulse is 60bpm, rhythmic and weak. D. Reflexes -Wasnt able to assess deep tendon reflex. E. Range of Motion - Neck: Able to flex, extend, hyperextend, laterally flex and rotate neck. - Shoulder: Able to flex, extend, abduct and adduct both shoulders. Unable to hyperextend. Able to do internal rotation and external rotation. Unable to do circumduction. - Elbow: Able to flex and extend elbow - Forearm: Able to do supination and pronation - Wrist: Able to perform flexion, extension, hyperextention, abduction and adduction properly
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VIII.
Fingers: Able to do flexion, extension, hyperextension, abduction, adduction and opposition. Hip: Able to do flexion, extension, abduction, adduction, internal rotation and external rotation. Unable to do hyperextension and circumduction of hip Knee: Flexion and extension can be performed Feet: Able to do inversion and eversion Toes: Able to do flexion, extension, abduction and adduction Ankle: Able to do dorsiflexion and plantar flexion
GENITOURINARY SYSTEM A. Health History - had her menarche when she was 12 years of age - had her regular menstruation 3-5 days a per cycle. Menstrual flow is heavy at the first day and eventually gets slow in the succeeding days. - No discomforts or pain felt during menstruation. - Havent been to obstetrician or gynecologist before. - Has never experienced sex and use of contraceptives - No urinary symptoms or discomfort felt. If so, it may be rare as verbalized. - Havent experienced UTI or other urinary disorders ever since. B. Inspection and palpation of genitalias not done.
IX.
PERIPHERAL-VASCULAR SYSTEM A. Focused Peripheral- Vascular History - No pain, pallor, pulselessness, paresthesias or paralysis on the extremities noticed before. Have experienced coldness but suspects to be due to the weather sometimes. - Have experienced cramping, aching and heaviness at the legs. Resolves it by keeping the affected part immobile for few minutes as verbalized. - Ankles are not swollen - Had no leg pain while walking or at rest as verbalized. - No sores or ulcers on the feet or legs noticed before. - Has a history of high BP and DM in the family. - Doesnt smoke. - Has experienced high BP due to old age. Takes medications for maintenance of BP as prescribed. B. Focused Lymphatic History - Havent noticed or experienced swelling on the neck, armpits or groin. - She gets tired of a lot of physical work like carrying boxes. But it is already usual for her as verbalized.
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- Have experienced pain in the knee joint but with no swelling, redness or warmth noticed. Suspects it to be because of too much work. - Havent experienced any sores in the extremities that healed slowly. - Had blood transfusion last 12/03 and 12/05 of 2010. 2 u of 250cc PRBC was transfused. - Have never been diagnosed of chronic infection. C. Inspection - Upper Extremities: Skin color is same as the surrounding skin. No lesions or edema noted. Fingernails are of equal thickness. Positive brisk capillary refill less than 3 seconds. - Abdomen: no arterial pulsation noted. Abdominal veins barely visible. - Lower Extremities: No leg hair and altered pigmentation noted .No varicosity, swelling or edema noted. No lesions and ulcers. D. Palpation - Head and neck pulses: Temporal and carotid pulses are 66bpm, regular, smooth and strong bilaterally. - Neck lymph nodes: Cervical nodes are nonpalpable. - Upper Extremities pulses: Brachial and radial pulses are easily palpated and equal in strength and amplitude bilaterally. Ulnar pulse is difficult to palpate. Skin temperature is warm bilaterally. - Lower Extremities Pulses: Femoral pulse unable to assess. Popliteal and dorsalis pedis pulses are easily palpated, moderate in strength and amplitude bilaterally. Slightly cold feet noted influenced by environmental conditions. - Calf: No calf pain noted. E. Auscultation: - Blood pressure is 160/90mmHg.
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LABORATORY RESULTS
Clinical History: Ulcerating mass, bilateral breasts, April 2010 Pre-operative Diagnosis: R/O Breast Cancer, stage IIIC Final Pathologic Diagnosis: Ulcerating mass, Bilateral Breasts- Fine needle Aspiration. Cytology: Cytomorphologic findings consistent with ductal carcinoma. comment: Recommended Tissue Confirmation
Gross and Microscopic Description: Received are four cytocolor-stained smears. Smears are cellular and reveal neoplastic cells in loose clusters, monolayers, and attempts to form glandular and acinar structures. The neoplastic cells have hyperchromatic nuclei and exhibit mild to moderate nuclear pleomorphism. In some cells, the nucleolus is prominent. The cytoplasm is scanty to adequate.
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Lab Test and Date Done Complete 2010) Hemoglobin Hematocrit WBC Count Neutrophil (seg) Lymphocytes Blood count (Nov. 24,
Normal Value
Result
Findings
12-14 g % 37-44 vol % 5-10 T/ cumm 55-60 % 20-35 %
11.6 g % 33.8 vol % 13, 500/ cumm 79 % 16 %
Decreased, due to bleeding on the right breast PTA Decreased due to loss of blood Increased due to inflammation of the R. breast Increased due to inflammation Decreased due to proliferation of the cancer cells on the lymph nodes in the axillae Within Normal Range
Monocytes Eosinophil Platelet Count PTT IVR Complete Blood Count (Dec. 3, 2010 : Post-op) Hemoglobin
1-6 % 1-4% 150-400T/ cumm 11-15 sec
3% 2% 346, 000/ cumm 13 sec 1.18
Within Normal Range Within Normal Range Within Normal Range
12-14 g %
9.7 g %
Decreased due to blood loss during operation
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37-44 vol % 25.9 vol % 1.83 60-100mg/ dl 3.5-5.3 mmol/ L 135-145 mmol/ L 154 5.19 142.4 * Necessitates Blood Transfusion Increased Increased Within normal range Within normal range
Hematocrit Urinalysis (Dec. 3, 2010) Creatinine FBS K+ Na+ Complete Blood Count (Dec. 7, 2010 : STAT) Hemoglobin Hematocrit
12-14 g % 37-44 vol %
11.9 g % 34.8 vol %
Increased compared to the last findings. Shows the bodys compensation to newly transfused 2 u PRBC
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Priority Nursing Diagnoses: 1. Risk for infection related to surgical removal of both breasts secondary to Breast Cancer stage III 2. Deficient Knowledge related to Post-mastectomy Exercises and possible complications 3. Impaired Skin Integrity related to surgical removal of both breasts, altered circulation, changes in the skin elasticity/ sensation and tissue destruction
Possible Nursing Diagnoses: 1. Risk for Fluid Excess related to possible lymphedema secondary to Modified Radical Mastectomy 2. Activity Intolerance related to pain upon movement secondary to MRM 3. Acute Pain related to surgical incision secondary to removal of both breasts by MRM
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2011 NURSING CARE PLAN
CUES AND EVIDENCES Subjective: Bantay verbalized. Duha na ka drainage nang naka connect sa iyaha. Bantay verbalized, Ang usa ka drainage kay clear nga may dugo unya ang usa kay yellow. Client verbalized, Ako pa na imnon ang mga tambal ron alas 6.
NURSING DIAGNOSIS Risk for infection related to surgical removal of both breasts secondary to breast cancer stage III
OBJECTIVES At the end of our 2-day care, patient will not manifest any signs of infection as evidenced by: Vital signs within normal range: T = 36.5-37.5C P = 60-100 bpm R = 16-20 cpm BP = 100-140/60100 mmHg WBC count will be in normal range: WBC 450011,000 cells/cumm Absence of chilling Skin around the surgical site is intact with no purulent discharges
INTERVENTIONS Independent Monitor vital signs
RATIONALE Any alterations in vital signs especially temperature might indicate infection Hand washing reduces the risk for acquiring infection
EVALUATION At the end of our 2-day care:
Teach patient to hand wash regularly; before and after meals; before and after toileting. Do cleansing bed bath to the patient
To cleanse the patient and therefore reduces the risk for infection To promote the prevention of infection
Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Both breasts were removed by modified radical mastectomy Skin around the surgical is intact, no redness Dressing is patent, no discharges Blood discharges to the JP drainage will be minimal
Teach client techniques to care for lesion and prevent the spread of infection
Goal partial met as evidence by latest V/S results: T = 35.2 C P = 62 bpm R = 21 cpm BP = 150/70 mmHg Goal not confirmed, no further laboratory tests done
To determine the effectiveness of the regimen and to prevent infection
Collaborative: Administer medications as prescribed by the physician: Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o.
Goal met, client did not manifest chilling Goal met as evidenced by no purulent discharges around surgical site, dressing is dry and patent.
Goal met, minimal serous and serosanguinous secretions drained
2011
Good skin turgor, no edema 2 Jackson Pratt drainage is attached on both breast
Medications: Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o. Lab Results: Hemoglobin 9.7% Hematocrit 25.9% WBC 13,500/cumm Neutrophil 79% Lymphocyte 16% Monocytes 3% Eosinophil 2%
CUES AND EVIDENCES Subjective: Client verbalized, Wala man pod ko na ingnan sa nurse nga ipa isa ang akong bukton kung maghigda. Client asked. Unsa diay mahitabo kung dili nako i-isa akong bukton kung maghigda? Has not been taught or instructed on postmastectomy exercises as claimed.
NURSING DIAGNOSIS Deficient Knowledge related to post mastectomy exercises and possible complications
OBJECTIVES At the end of our 2-day care, client will have improved knowledge as evidenced by: Client participates in the learning process. Client verbalizes understanding of condition/disease process and treatment.
INTERVENTIONS Independent Ascertain level of knowledge, including anticipatory needs.
RATIONALE
Determine clients ability/readiness and barriers to learning.
Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Both breasts were removed by modified radical mastectomy 2 Jackson Pratt drainage is attached on both breast
Client exhibits increased interest/assume responsibility for own learning by beginning to look for information and ask questions. Initiate necessary lifestyle changes and participate in treatment regimen.
Identify information that needs to be remembered (cognitive) at clients level of development and education. Provide active role for client in learning process, including questions and discussion.
Learning needs can include many things (e.g., disease cause and process, factors contributing to symptoms, procedures for symptom control, needed alterations in lifestyle, ways to prevent complications). Client may not be physically, emotionally, or mentally capable at this time and may need time to work through and express emotions before learning. Enhances possibility that information will be heard and understood.
Goal met, client is cooperative and is willing to learn. Goal partially met, client verbalized reasons for her condition but not really the exact explanation what caused her health problem. Goal met, client is interested to learn and asked questions regarding her condition.
Promotes sense of control over situation.
Goal partially met, lifestyle changes not confirmed after discharge but client is compliant to the treatment regimen.
Lab Results:

Creatinine 1.83 mg/dL FBS 154 mg/dL K+ - 5.19 mmol/L Na+ - 142.4 mmol/L Hemoglobin 9.7% Hematocrit 25.9% WBC 13,500/cumm Neutrophil 79% Lymphocyte 16% Monocytes 3% Eosinophil 2% To facilitate clients learning in promote recovery. To promote compliance to mediation regimen and facilitate recovery
2011
Do health teaching on post mastectomy exercises. Teach client on the purpose of his/her medications.
CUES AND EVIDENCES Subjective: Bantay verbalized. Duha na ka drainage nang naka connect sa iyaha. Bantay verbalized, Ang usa ka drainage kay clear nga may dugo unya ang usa kay yellow.
NURSING DIAGNOSIS Impaired skin integrity related to surgical removal of both breasts, altered circulation, changes in skin elasticity/sensation, and tissue destruction
OBJECTIVES At the end of our 2-day care, effects of impaired skin integrity will be alleviated as evidenced by: Vital signs within normal range: T = 36.5-37.5C P = 60-100 bpm R = 16-20 cpm BP = 100-140/60100 mmHg Results of the laboratory exams fall within normal range. Minimal secretions is drained
INTERVENTIONS Independent Monitor for vital signs
RATIONALE
Identify underlying condition/pathology involved
Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Both breasts were removed by modified radical mastectomy Dressing is patent, no discharges Good skin turgor, no edema
Ascertain allergy history
Timely healing of skin lesions/wounds/pressur e sores without complication.
Skin around the surgical site is intact, no redness 2 Jackson-Pratt drainage is attached
Client maintains optimal nutrition/physical wellbeing. Client verbalizes feelings of increased
Assess blood supply and sensation of skin surfaces/affected area on a regular basis especially to the area affected (breasts) Keep surgical area(s) clean/dry; carefully dress wounds; support incision and stimulate circulation to surrounding areas Provide optimum
Any alterations in the vital signs might indicate complications if impaired skin integrity Skin integrity problems can be the result of (1) disease processes that affect circulation and perfusion of tissues (2) medications (3) burns/radiation and (4)nutrition and hydration Individual may be sensitive or allergic to substances that can adversely affect the skin To provide comparative baseline and opportunity for timely intervention when problems are noted To assist bodys natural process of repair
Goal partial met as evidenced by latest V/S results: T = 35.2 C P = 62 bpm R = 21 cpm BP = 150/70 mmHg Goal not confirmed, no further laboratory tests done Goal met, minimal serous and serosanguinous secretions drained Goal partially met, no discharges noted on site and dressing is patent and dry. No evidence for timely wound healing. Goal met, client is on DAT and is eating well
Goal met, client verbalized, Maayo
2011
self-esteem and ability to manage situation. nutrition To promote skin health/healing and to maintain general good health To prevent infection caused by impaired skin integrity ni, mag boxing na lang mi pag uli namo. Client is not worried about her condition and is eager to recover Goal met as evidenced by client is cooperative to health teachings such as on postmastectomy exercises.
on both breast 2 units PRBCs for Blood type O Rh + were given: 1st unit given on Dec. 3, 2010 2nd unit given on Dec. 5, 2010
Client participates in prevention measures and treatment program.
Medications: Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o. Lab Results: Creatinine 1.83 mg/dL FBS 154 mg/dL K+ - 5.19 mmol/L Na+ - 142.4 mmol/L Hemoglobin 9.7% Hematocrit 25.9% WBC 13,500/cumm Neutrophil 79% Lymphocyte 16% Monocytes 3% Eosinophil 2%
Collaborative Administer antibiotic medications as prescribed by physician Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o.
CUES AND EVIDENCES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
Subjective:
Client verbalized,
Sakit pa jud kung akong i-isa akong bukton pataas.
Activity intolerance related to pain upon movement secondary to modified radical mastectomy
At the end of our care, clients activity tolerance will be enhanced as evidenced by:
Independent Monitor vital signs
Significant changes in
vital signs might indicate increasing physiologic signs of intolerance. Helps to minimize frustration, rechannel energy.
Vital signs within

normal range: T = 36.5-37.5C P = 60-100 bpm R = 16-20 cpm BP = 100-140/60100 mmHg
Client verbalized,
Kapuy pa jud ako lawas. Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Laboratory Results: Hemoglobin 9.7% Hematocrit 25.9% WBC 13,500/cumm Neutrophil 79% Lymphocyte 16% Monocytes 3% Eosinophil 2%
Encourage expression
of feelings contributing to/resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client.
Client will identify

negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
Promote comfort
measures and provide for relief of pain.
To enhance clients
ability and desire to participate in activities.
Encourage client to use

relaxation techniques such as visualization/guided imagery as appropriate.
Client will use

identified techniques to enhance activity tolerance.
Useful in maintaining
positive attitude and enhancing sense of well-being.
Client needs assistance

in moving
Client will participate

in necessary/desired activities.
2011
Collaborative Provide referral to collaborative disciplines such as exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists.
Client is mobile but

moves slowly in bed
Client demonstrates
decrease in physiological signs of intolerance (e.g., pulse, respirations, and blood pressure remain within clients usual range).
May be needed to
develop individually appropriate therapeutic regimens.
CUES AND EVIDENCES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
Subjective: Client verbalized, Feeling nako mura kog nanghugot. Bantay verbalized, Ang usa ka drainange niya kay clear nga may dugo ug ang usa kay yello. Client verbalized, Wala man pod ko natudlu-an nga ipa saka diay ako bukton kung mag higda ko. Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Both breasts were removed by modified radical mastectomy
Risk for fluid volume excess related to possible lymphedema secondary to modified radical mastectomy
Within our care, there will be decreased risk for the client to develop fluid volume excess as evidenced by:
Vital signs within normal range: T = 36.5-37.5C P = 60-100 bpm R = 16-20 cpm BP = 100-140/60100 mmHg Client has stable weight, and free of signs of edema. Client will verbalize understanding of postmastectomy exercises and its purpose.
Review nutritional issues. Note presence of conditions that predisposes the patient to fluid volume excess Observe skin and mucous membranes. Do health teaching on post-mastectomy exercises and emphasize to the patient the importance of the performance of such exercises.
Changes in vital signs especially blood pressure might indicate that the patient has fluid volume excess. Imbalances in these areas are associated with fluid imbalances. Post-mastectomy patients have a greater chance to develop lymphedema. Edematous tissues are prone to ischemia and breakdown/ulcerati on. Post mastectomy exercises will help patient improve mobility and decrease the chance of the development of edema.

2 Jackson Pratt drainage is attached on both breast Patient is not raising arms up while lying on bed
2011
CUES AND EVIDENCES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION
Subjective: Client rates pain as 2 on a scale of 0-10 Client verbalized, Sakit pa jud kung akong i-isa pataas ang akong bukton. Objective: Vital Signs: T = 36.4C P = 70 bpm R = 23 cpm BP = 160/100 mmHg Medications: Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o. Lab Results: Hemoglobin 9.7% Hematocrit 25.9%
Acute Pain related to surgical incision secondary to removal of both breast by modified radical mastectomy
Within our care, client will experience more relief from pain as evidenced by:
Alterations in vital
signs might indicate that patient is in pain. To be able to know the current status of pain felt by the patient. To determine how the patient manages the pain. Helpful in recognizing presence of pain; however, cues not congruent with verbal reports indicate need for further evaluation.
Vital signs within

normal range: T = 36.5-37.5C P = 60-100 bpm R = 16-20 cpm BP = 100-140/60100 mmHg
Obtain clients
assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity. Identify precipitating/aggravati ng and relieving factors; observe for nonverbal cues.
Client rates pain as 0

on a scale of 0-10.
Client demonstrates
compliance to pharmacologic regimen.
Note anatomical
location of surgical incisions/procedures
This can influence the

amount of postoperative pain experienced; for example, vertical/diagonal incisions are more painful than transverse or Sshaped
Client verbalizes
methods that provide pain relief.
Client utilizes
relaxation and diversional activities as indicated.
2011
WBC 13,500/cumm Neutrophil 79% Lymphocyte 16% Monocytes 3% Eosinophil 2%
Note possible
pathophysiological/ psychological causes of pain.
Acute pain is that

which follows an injury/trauma or procedure such as surgery, or occurs suddenly with the onset of a painful condition To help the client feel comfortable and experience relief from pain.
Both breasts were removed by modified radical mastectomy 2 Jackson Pratt drainage is attached on both breasts Facial grimacing is noted when patent tries to extend the arms up
Do health teaching on
other methods of pain relief and diversional activities as indicated for the patient Collaborative Administer medications as ordered: Aubrex 200 mg 1 cap BID p.o. Ziprocap 500 mg 1 cap BID p.o. Cefuroxime 500 mg 1 tab BID p.o. Timecee 500 mg 1 tab OD p.o.
To make make client

comfortable and experience relief from pain.
2011
2011
Clinical History: Ulcerating mass, bilateral breasts, April 2010 Pre-op Diagnosis: R/O Breast Cancer, stage III Final Pathologic Diagnosis: (Ulcerating mass, Bilateral Breasts, Fine-needle Aspiration) Cytology: Cytomorphologic findings consistent with ductal carcinoma * Comment: Recommended tissue confirmation Gross and Microscopic Description: Received are four cytocolor-stained smears. Smears are cellular and reveal neoplastic cells in loose clusters, monolayers, and attempts to form glandular and acinar structures. The neoplastic cells have hyperchromatic nuclei and exhibit mild to moderate nuclear pleomorphism. In some cells, the nucleolus is prominent. The cytoplasm is scanty to adequate. Name of procedure: MODIFIED RADICAL MASTECTOMY Pre-operative Medications: Promethazine HCl Tramdol Ranitidine Hydrocortisone Pre-operative IV Fluids: D5LR 0.9 % NaCl 3L 1L @ 30gtts/ min @ KVO (10gtts/ min) IM IM IVTT 25mg 50mg 50 mg 250 mg
2011
Intraoperative IV Fluids: D5LR PNSS 3000 ml 2000 ml
Post-operative Doctors Order: 12/3/10 O2 inhalation @ 3L/min Medications: Parafox 1gm IVTT q 12h ANST (-) Tramadol drip 100mg HCl IV Bolus Ketorolac 220 mg IM q 8h Ranitidine 50g IVTT q 8h Fluids: D5LR 3L @30gtts/ min 0.9% NaCl 1L KVO I&O hourly 12/4/10 Continue medications IVF D5LR 3L @30gtts/ min Paracetamol 300mg IVTT now and then 200 mg q 4h PRN for fever 38.5C and above 12/5/10 Diet as Tolerated D/c IVF when consume except bloodline D/c all IVTT meds when consume
2011
Remove FBC now Continue medications: Ziprocap 500mg Tcap Aubrex 200mg Tcap Time-cee 500mg Ttab
BID BID OD
12/6/10 Cefuroxime 500mg Ttab IVF TF D5LR x 1L @KVO 12/7/10 Discontinue D5LR 1 L Continue PO Medications Blood Transfusion: 1 u 250 cc PRBC 1 u 250cc PRBC
BID
12/3 12/5
infused @ 12:55pm consumed @ 5:10 pm infused @ 1:00pm consumed @ 5:00pm
2011
Purposes of Post-op Exercises: 1. To strengthen and preserve muscle tone and restore free arm movement. 2. To promote/improve lymph drainage and thus reduce edema or swelling. 3. To prevent shortening of muscles and contracture of joints frozen shoulder
Early Post-Op Exercises (first 24-36 hours) Coughing and deep breathing exercises Flex legs every 2 hours Turn to sides every 2 hours Assist to ambulate 3rd to 6th Post-Op Exercises
To stimulate your hand and make them work again, pretend you are putting on gloves. Smooth down each finger from tip to base of thumb and fingers of the opposite
hand. Hand Squeezing a. Take a small rubber ball or similar object in the palm of your hand and make a fist around the ball, squeeze gently and relax. b. The ball should be firm enough to have to exert some pressure but soft enough to give a little when squeezed. To stretch shortened muscles, reach with one hand at one time over your head and touch the opposite earlobe. Also extend your arms directly in front of you and draw imaginary circles with your index finger. Hair brushing Rest the arm on a firm surface such as the bedside table or locker. Keep the head and shoulder upright and start by brushing hair on one side upwards and to the side. Gradually increase to cover the whole head. To tone up your arm muscles. a. Extend your arm at a time at shoulder level keeping it straight. Rotate your forearm, turning the palm of your hand over and under.
2011
b. Sitting up, square both shoulders and place a hand on each shoulder. Flap your elbows up and down like a bird flying. While lying on your back, stretch your body like a kitten making it long as possible. Inhale slowly and deeply. Yawn to loosen stiff muscles. As an aid to relaxation, try putting a small pillow under your affected shoulder and placing your affected arm on the pillow behind your head. Bring your palms together just below your chest and press one against the other. Sitting up in bed, place a pillow on your lap and press your arms downward, one at a time on the pillow. Pumping exercises in the arm and hand on the side of the surgery. - In lying or sitting position, alternately close-open hand for about 15-20 repetitions Elevation of the involved upper extremity with the use of pillows (2 or 3 pillows). Distal to proximal massage (hand to shoulder) while the hand is elevated. Use effleurage. Stretching exercises a. In lying or sitting position, tighten arm for about 6 seconds then release. Repeat 10 times. b. With hand closed, tighten arm and hand for about 6 seconds then release together with the opening of the hand.
7th Post-Op day and as recommended Arm Swings a. b. c. d. Stand with feet 8 inches apart Bend forward from waist, allowing arms to hand toward the floor Swing arms both up to sides to reach shoulder level Swing back to center. Do not bend elbow. If possible do this in front of the mirror to ensure even posture and correct motion.
Arm Circling a. Rest the unaffected arm on a firm surface such as table or back of a chair and bend forward at the waist. b. Allow the affected arm to hand loosely from the shoulder and swing backwards and forwards, from side to side and the in small circles. c. Gradually increase the size of the circles as the arm becomes more relaxed. Wall Climbing a. Start in the standard position, face the wall with toes as close to the wall as possible b. Bend elbows and place palms against the wall at shoulder level
2011
c. Gradually try to raise hands higher up the wall parallel to each other until arms are fully extended. d. Slowly, bring the hands back to shoulder level and repeat. Mark the wall at the highest point reached each day. Sometimes it may be hard to reach the previous days mark dont be discouraged, simply try again later in the day. Return to standard position as number 1, Equivalent Activities: Hanging clothes on line, washing windows, and fixing closet shelves Forehead touch a. b. c. d. Start in the standard position, face the wall at arms length distance. Slowly bend elbows, leaning forward until forehead touches the wall. Straighten elbows slowly pushing body away from the wall. Return to standard position. Rest and repeat 1.
Rope Turning a. b. c. d. Use a 6 foot clothes line rope or roller bandage tied to door with a double knot. Stand 4 feet away from the door in standard position, face the door. Take the loose end rope with the hand on the operated site. Make a know to put between your 3rd-4th fingers. Place your other hand on your hip to help u balance. Extend arm forward on operated site (dont bend elbows on waist). Turn rope in small circles at first and gradually work into as possible.
Pulley motion or rope sliding a. b. c. Use 6-feet rope or roller bandage. Shower rod or similar rod overhead. Place knots in rope at both ends. Hang a rope or cord over the top of an open door. Sit on the floor with the door held firmly between the legs, holding the lower end of the cord in the hand on the side of your surgery. Hold the higher end in the other hand. Gently pull the higher hand down and raise the lower arm, repeating gradually and raising a little higher each time until full stretch has been achieved.
Equivalent Activities:
2011
Toweling, pulling Venetian blind Toweling a. Hold a scarf or towel stretched diagonally along the back, one hand at shoulder level and the other at hip level. b. Imitate a back drying motion, moving the hand from shoulder to head and lower. c. Change hands and repeat in reverse so that the other arm is higher. The towel should be long enough to fully straighten one arm. Elbow pull-in a. b. c. d. Standard postion, extend arm sideways at shoulder level. Bend elbows clasping fingers at back of your neck. Pulls elbow in toward each other until they touch. Return to # 2 position then standard position as # 1.
Equivalent Activities: Fastening necklace, putting bubby pins on hair Arm bending a. b. c. d. e. On standard position, extend arms sideways to shoulder level. Bend elbows, touching fingers at back of neck. Extend arms sideways at shoulder levels. Bend elbows touching back of waist. Return to standard position as in # 1.
Back Scractcher or Bra Fastening a. b. c. d. Imitate the movements used to fasten a bra at back. Stand with feet apart for balance and extend the arms to shoulder level. Slowly bend the arms from the elbows, bringing the hands closer to the body to join behind the back. Raise the hands and repeat.
2011
Generic name: Ciprofloxacin HCl Brand name: Ziprocap Classification: Anti-infectives Dosage: Adults 250-750 mg BID depending on the severity & nature of infection. Action: Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria. Indications: Infections of the respiratory tract, middle ear, paranasal sinuses, eyes, kidneys and/or urinary tract, genital organs, abdominal cavity like infection of GIT or biliary tract, peritonitis. Skin and soft tissue, bones and joints; infections or imminent risk for infection (prophylaxis) in patients whose immune system has been weakened. Contraindications: Hypersensitivity to quinolones Concurrent administration with tizanidine. Drugs that inhibit peristalsis. Infants and children, growing adolescents; pregnancy & lactation. Adverse Effect: GI disturbances including nausea, vomiting, diarrhea, abdominal pain, dyspepsia, headache, dizziness & restlessness. Tremor, drowsiness, insomnia, nightmare, visual disturbances & other sensory disturbances. Nursing Responsibilities: Assess for previous sensitivity reactions Assess for signs of infection before and during treatment. Assess renal function before and during therapy. Assess for possible superinfection.
2011
Assess for S&S of GI irritation (e.g., nausea, diarrhea, vomiting, abdominal discomfort) in clients receiving high dosages and in older adults. Lab tests: Culture and sensitivity tests should be done prior to initial dose. Treatment may be implemented pending results. Administer 2 hrs before or 2hrs after antacids, zinc, iron and calcium Monitor urine pH; it should be less than 6.8, especially in the older adult and patients receiving high dosages of ciprofloxacin, to reduce the risk of crystalluria. Monitor I&O ratio and patterns: Patients should be well hydrated; assess for S&S of crystalluria. Monitor plasma theophylline concentrations, since drug may interfere with half-life. Administration with theophylline derivatives or caffeine can cause CNS stimulation. Monitor PT and INR in patients receiving coumarin therapy. Health Teachings: - Instruct patient to take all meds prescribed for the length of time ordered. The drug must be taken around the clock to maintain adequate blood levels. - Report tendon inflammation or pain. Ciprofloxacin needs to be discontinued. - Report any adverse reactions - Report sore throat, bruising, bleeding and joint pain which may indicate blood dyscrasias - Advice to rinse mouth frequently, use sugar-less candy or gum for dry mouth.
2011
Generic name: Celecoxib Brand name: Aubrex Classification: Nonsteroidal Anti-inflammatory (NSAIDs) Dosage: Osteoarthritis 200 mg daily as a single dose or in 2 divided doses. RA 100-200 mg bid. Treatment of pain & dysmenorrhea Initially, 400 mg followed by an additional 200 mg if necessary on the 1st day & 200 mg bid given thereafter. Treatment of adenomatous colorectal polyps 400 mg bid. Action: Inhibits prostaglandin synthesis by selectively inhibiting cyclo-oxygenase-2 (COX-2). Relieves pain and inflammation Indication: Treatment of RA & osteoarthritis. Adjunctive treatment of adenomatous colorectal polyps. Management of pain and dysmenorrhea. Contraindication: History of hypersensitivity to sulfonamides or allergy to NSAIDs; asthma. Stroke, heart attack, MI, CABG, uncontrolled HTN, CHF. Severe heart failure, inflammatory bowel disease & renal impairment associated w/ CrCl <30 mL/min. Adverse Effect: GI disturbances eg GI discomfort, nausea & diarrhea. Hepatotoxicity. Nursing Responsibilities: Therapeutic effectiveness is indicated by relief of joint pain. Lab tests: Periodically monitor Hct and Hgb, liver functions, BUN and creatinine, and serum electrolytes. Monitor closely lithium levels when the two drugs are given concurrently. Monitor closely PT/INR when used concurrently with warfarin. Monitor for fluid retention and edema especially in those with a history of hypertension or CHF. Monitor blood counts; watch for decreasing platelets and thrombocytopenia, drug may be discontinued. Administer with food or milk to decrease gastric symptoms Do not crush or dissolve tablets. Do not increase dosage Instruct patient to report bleeding, bruising, black tarry stools, cramping, fatigue and malaise. Blood dyscrasia may occur.
2011
Generic name: Cefuroxime Brand name: Zinacef Classification: Second-generation Cephalosporin. Antibiotic Action: binds to bacterial cell membranes, inhibits cell wall synthesis, Bactericidal. Indication: Respiratory & urinary tract, ENT, soft tissue, bone & joint, O & G infections, gonorrhea& other infections including septicemia, meningitis & peritonitis. Prophylaxis against infections in abdominal, pelvic, orthopedic, cardiac, pulmonary, oesophageal & vascular surgery where there is increased risk from infections. Contraindication: Hypersensitivity to cephalosporins. Side effects: Discomfort with IM administration, oral candidasis, mild diarrhea, mild abdominal cramping, vaginal candidiasis. Adverse Effect: Leutropenia, eosinophilia, transient rise in liver enzymes, inj site reactions eg pain & thrombophlebitis. Nursing Responsibilities: Determine history of hypersensitivity reactions to cephalosporin, penicillin, and history of allergies, particularly to drugs, before therapy is initiated. Lab tests: Perform culture and sensitivity tests before initiation of therapy and periodically during therapy if indicated. Therapy may be instituted pending test results. Monitor periodically BUN and creatinine clearance. Inspect IM and IV injection sites frequently for signs of phlebitis. Report onset of loose stools or diarrhea. Although pseudomembranous colitis (see Signs & Symptoms, Appendix F) rarely occurs, this potentially lifethreatening complication should be ruled out as the cause of diarrhea during and after antibiotic therapy. Monitor for manifestations of hypersensitivity (see Appendix F). Discontinue drug and report their appearance promptly. Monitor I&O rates and bowel pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. Be alert for superinfection: fever, vomiting, diarrhea, anal/genital pruritus, oral mucosal changes (ulceration, pain, erythema) May take with food or milk to reduce GI upset.
2011
Generic name: Ascorbic Acid Brand name: Time-cee Classification: Vitamins Dosage: Tab 500-1000 mg daily. Syr Children 7-12 yr 2 tbsp. 2-6 yr 1 tbsp. Drops Childn 1-2 yr 1.2 mL 3-12 mth 0.6 mL. <3 mth 0.3 mL. To be taken once daily for supplementation, bid-qid for therapeutic use. Action: It is essential for the formation of collagen and intercellular material, bone and teeth and for the healing of wounds. It helps maintain elasticity of the skin, aids the absorption of iron and improves resistance to infection. It is used in the treatment of scurvy. May prevent the occurrence and development of cancer. Involved in carbohydrate utilization and metabolism, as well as synthesis of carnitine, lipids, and proteins. Preserves blood vessel integrity. Indication: Dietary supplement; acidification of urine; scurvy; prevention and reduction of severity of colds. Side effects: Rare: abdominal cramps, nausea, vomiting, diarrhea, increased urination with doses exceeding 1g. Adverse Effect: May acidify urine, leading to crystalluria. Large doses of IV ascorbic acid may lead to deep vein thrombosis. Prolonged use of large doses may produce rebound ascorbic deficiency, when dosage is reduced to normal range. Nursing Responsibilities: Assess for clinical improvement (improved sense of well-being and sleep patterns). Observe for reversal deficiency syndrome (gingivitis, bleeding gums, poor wound healing, digestive difficulties, joint pain). Abrupt vitamin C withdrawal may produce rebound deficiencies. Reduce dosage gradually. Foods rich in vit. C includes guava, jelly, green peppers, spinach, strawberry and citrus fruits.
2011
Generic name: Cefoxitin Na Brand name: Parafox Classification: Second-generation Cephalosporin. Antibiotic Dosage: Adult 1-2 g IM/IV 8 hrly; up to 12 g daily in severe infections. Older infants & childn 20-40 mg/kg body wt 6-8 hrly; up to 200 mg/kg daily to a max of 12 g daily in severe infections. Neonates 1-4 wk 20-40 mg/kg body wt 8 hrly, up to 1 wk 20-40 mg/kg body wt 12 hrly. Post-op surgical infection prophylaxis Adult 2 g/IV route when inducing anesth, followed by 1-2 g inj every 2 hr until the skin has closed up.Infant & childn 30-40 mg/kg body wt 6 hrly, every 8-12 hr for neonates.Uncomplicated UTI 1 g bid IM. Uncomplicated gonorrhea 2 g IM + probenecid 1 g PO. Caesarian section 2 g IV. Action: Cefoxitin is a -lactam antibacterial antibiotic from the cephalosporin group (2nd cefoxitin sodium is a cephamycin which, like other -lactams, is bactericidal and is considered to act through the inhibition of bacterial cell wall synthesis. Cefoxitin penetrates well into brain, kidney, lung and other body tissues. Indication: Treatment of intra-abdominal & pelvic infection; for surgical infection prophylaxis. Endometritis (prophylaxis at caesarian section), pelvic inflammatory disease. Treatment of gonorrhea & UTI. Contraindication: Allergy to penicillins & cephalosporins. Use cautiously on patients with renal impairment, history of GI disease, concurrent use of nephrotoxic medications. Side effects: Discomfort with IM administration, oral candidiasis, vaginal candidiasis, mild diarrhea, mild abdominal cramping. Adverse Effect: Hypersensitivity reactions, acute renal tubular necrosis, acute interstitial nephritis. Convulsions & other signs of CNS toxicity w/ high doses. Pain at the inj site w/ IM inj & thrombophlebitis w/ IV inj. Superinfection. Nephrotoxicity with patients with history of renal impairment. Nursing Responsibilities: Administer around-the-clock rather than 4 times/day, 3 times/day, etc, (ie, 12-6-12-6, not 9-1-5-9) to promote less variation in peak and trough serum levels Modify dosage in patients with renal insufficiency. Monitor renal function tests for nephrotoxicity. Can be administered IVP over 3-5 minutes at a maximum concentration of 100 mg/mL or I.V. intermittent infusion over 10-60 minutes at a final concentration for I.V. administration not to exceed 40 mg/mL Monitor daily bowel pattern and stool consistency.
2011
Generic name: Ketorolac tromethamine Brand name: Ketodol Classification: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). Analgesic; Intraocular anti-inflammatory Dosage: Adult <65 yr Single dose of 60 mg IM or 30 mg IV. Patients w/ renal impairment &/or <50 kg body wt, elderly 65 yr 30 mg IM or 15 mg IV. Childn 2-16 yr Single dose of 1 mg/kg IM up to max of 30 mg or 0.5 mg/kg IV up to max of 15 mg. Multiple dose treatment: Adult <65 yr30 mg IM/IV 6 hrly. Max dose: 120 mg/day. Patients w/ renal impairment &/or <50 kg body wt, elderly 65 yr 15 mg IM/IV 6 hrly. Max dose: 60 mg/day. Action: Inhibits prostaglandin synthesis, reduces prostaglandin levels in aqueous humor, thus reducing intensity of pain stimulus Indication: Short-term management of mild to moderate pain; Allergic conjunctivitis; Cataract extraction; Refractive surgery Contraindication: Hypersensitivity to aspirin or other NSAIDs. Patients w/ history or active peptic ulcer disease, GI bleeding or perforation; advanced renal impairment or at risk of renal failure due to vol depletion; suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis & high risk of bleeding. Prophylactic analgesia in any major surgery. During labor & delivery. Lactation. Adverse Effect: GI ulceration, bleeding & perforation, post-op bleeding, acute renal failure, liver failure, anaphylactic & anaphylactoid reactions. Nursing Responsibilities: 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 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.
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Generic name: Ranitidine HCl Brand name: Aciran Classification: H2 receptor antagonist. Antiulcer. Dosage: Usual dose 50 mg IM/IV 6-8 hrly. IV injection must be diluted to contain 50 mg in 20 mL, given slowly over not <2 min. Action: Inhibits histamine action at H2 receptors of gastric parietal cells inhibiting gastric secretions (fasting, nocturnal, when stimulated by food, caffeine, insulin). Reduces volume, hydrogen ion concentration of gastric juice. Indication: Duodenal/gastric ulcer, GERD; Duodenal ulcer associated with H. Pylori; Erosive Esophagitis; Hypersecretory conditions Contraindication: History of acute porphyria Adverse Effect: Reversible hepatitis, blood dyscrasias occur occasionally. Nursing Responsibilities: Obtain baseline data of hepatic/ renal function tests. Monitor serum AST, ALT levels. Assess mental status in elderly. Health Teachings: - Smoking decreases effectiveness of medication - Do not take medicine within 1 hr of magnesium- or aluminum-containing antacids. - Transient burning/ pruritus may occur with IV administration - Report headache - Avoid alcohol and aspirin
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Generic Name: Tramadol Brand Name: Ultram Classification: Analgesic Action: Binds to opioid receptors, inhibits reuptake of norepinephrine, serotonin. Reduces intensity of pain stimuli incoming from sensory nerve endings. Reduces pain. Indications: Moderate to moderately severe pain. Contraindications: Acute alcohol intoxication, concurrent use of centrally acting analgesics, hypnotics, opioids, psychotropic drugs, hypersensitivity to opioids. Side Effects: Dizziness, vertigo, nausea, constipation, headache, drowsiness. Adverse Effects: Seizures reported in those receiving tramadol within recommended dosage range. May have prolonged duration of action, cumulative effect in pts with hepatic/ renal impairment Nursing Responsibilities: Monitor pulse, BP Assist with ambulation if dizziness, vertigo occurs Dry crackers and cola may receive nausea. Monitor daily bowel pattern and stool consistency Sips of tepid water may relief dry mouth Health Teaching: - Avoid alcohol, OTC medications - Avoid tasks requiring alertness, motor skills until response to drug is established. - Inform physician if severe constipation, seizures, muscle weakness, tremors, chest pain, palpitations occur.
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Overview of the condition
reast cancer, the most common cancer in American women, is the leading cause of death in women 40 to 44 years of age and the second most common killer of women of all ages after lung cancer. An increase in incidence was dramatically observed in the past 10 years. Related factors include race, gender, age, environment and familial factors. For all ages combined, white women are more likely to develop breast cancer than black women;
yet the incidence of breast cancer is high in blacks among women younger than 45 years old. Female are thrice at risk than men because they have more breast tissue and high estrogen levels especially during the menstrual cycle. Postmenopausal incidence is higher than in the premenopausal phase. But this factor is highly controversial and is yet to be approved. In most cases, hormonal factor is the most accountable cause of breast cancer. High estrogen levels impose a great risk for breast cancer. Those women who had an early menarche may have higher levels of endogenous estrogen, which is believed to have a carcinogenic effect. Carcinogens are factors that initiate the mutation of a cancer cell. The process, Carcinogenesis, initiates the mutation of a cell by altering its DNA structure and disrupt in its normal function. Initiation is an irreversible event that can lead to cancer development if the cells ability to divide is not interfered but its apoptosis (ability of the cell to selfdestruct in normal and pathogenic conditions) is suppressed. Only one cell has to undergo malignant transformation for cancer to begin. When the body is continuously exposed to these promoters, substances that promote or enhance growth of initiated cancer cell which may be hormones, drugs or a wide variety of chemicals, the initiated cancer cell may affect the other normal cells in the area, and may develop into tumors (1 cm tumor is composed of at least 1billion cancer cells). Tumors may survive in our body because they can form their own blood supply system (tumor angiogenesis factor) while suppressing the nutrition of the normal cells. Benign tumors grow by expansion, whereas malignant tumors grow by invasion. When a tumor becomes malignant, they may invade every proximal part of the area until it reaches the vital organs like the brain, heart, liver and lungs. When this happens, the disease becomes untreatable and prognosis is really low.
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The first sign of breast cancer is usually a painless lump. Lumps caused by breast tumors do not have any classic characteristics. Other signs include palpable nodes in the axilla, retraction of tissue (dimplings), or bone pain caused by metastasis to the vertebrae. Early detection of the signs may be the most helpful way in preventing the progression of the disease. Regular self-breast exam can be done at home, preferably every after menstruation. Suspected masses must be immediately referred because cancer cells may proliferate before you know it. Other diagnostic exams may include mammography, ultrasound, percutaneous needle aspiration, biopsy or Mammotome (minimally invasive biopsy). Hormone receptor assays may also be done. Among them, biopsy of breast tissue is the definitive diagnostic test. Treatment is based on the extent or stage of the cancer. The extent of the tumor at the primary site, the presence and extent of lymph node metastasis, and the presence of distant metastasis are all evaluated to determine the stage of disease. Surgery, radiation, chemotherapy, hormone therapy, biologic therapy, and bone marrow transplantation may be used to treat breast cancer. In our case, our client has stage II C breast cancer. Meaning, the tumor in the breast has spread to 10 or more lymph nodes under the arm. Additional lymph nodes around the neck and the collar bone may be involved. She underwent Modified Radical Mastectomy. It is a surgical procedure that removes the while breast tissue including the axillary lymph nodes affected by the cancer cells. This is an invasive procedure so it always requires a signed consent form the client. For most women, their breasts are one of the parts of their body that defines their essence as a woman. Without it, their body image is seriously disturbed. In caring for clients with breast cancer who underwent breast removal procedures, the nurses main responsibility aside from maintaining her physically stable is to also consider their emotional stability. It is not an easy challenge having cancer. It is a life-threatening condition that we must be aware of all the time. Because once it is there already, we cannot undo it anymore. Self-awareness is always important. With right education and information dissemination, incidence of breast cancer, and all other forms of cancer, may be reduced, and even erased.
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PATHOPHYSIOLOGY OF BREAST CANCER
I.
Predisposing Factors: Age: postmenopausal women Nulliparous women Early menarche, late menopause or no children or first child after 30 years Family history of ovarian, breast, uterine, pancreatic or colon cancer personal history of breast CA Infertility Prolonged use of fertility drugs w/ achieving pregnancy
INITIATION
Exposure of cells to carcinogens Precipitating Factors: Exposure to carcinogens Obesity High Fat diet Exposure to Lacto paffy and other haplas placed on the breasts.
Activation of Proto-oncogenes
modification of DNA of breast epithelial ductal cells by the initiators
Further assaults causing genetic damage
II.
PROMOTION
Altered cell differentiation
abnormal growth of new cells from normal cells
enlargement of tissue/ cells
increase in number of cells within a tissue
change in pattern of differentiation
abnormal degrees of variation in size, shape
Neoplasm
hypertrophy
hyperplasia
metaplasia
dysplasia
III.
PROGRESSION
increasing estrogen levels promote or enhance growth of initiated cancer cells
cancer cells grow into detectable tumors

formation of Tumor Angiogenesis Factor ()TAF
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IV.
METASTASIS
proximal capillaries and other blood vessels are triggered to grow new branches into the tumor for its nourishments
Cancer cells break off from the main or primary neumor
enter and travel around the body through blood vessels
clumping in the BV walls to vasodilate thus widen the capilliaries
Legend:
invasion to new tissues
Initiation stage Promotion Stage Progression Stage Metastasis Stage
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Growth
and
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LATE ADULTHOOD
(60 y.o and above) The adult phase of development encompasses the years from the end of adolescence to death. Because the developmental task of young adults differ from those of older adults, adulthood is often divided into three phases: young adulthood, middle adulthood, and late adulthood. In this case study, we will focus more on Late Adulthood since our patient is already 61 years old. We will try to discuss the different stages and changes that our patient is going through at this time of her life. Changes that occur in the last part of the lifespan are part of the aging process. Late adulthood is the stage where there is gradual deterioration of body systems. Deterioration actually starts at birth but the effects are more profound during advanced age. In late adulthood, according to Berger (1994), the average individual experiences a number of biological, psychological, societal, and cultural impacts which can significantly change the ways in which one lives, perceives and presents the self, interacts with others, and copes with the strains and stresses of life. Late adulthood will be more understood as described by Baron and Byrne (2000) as that time of life when one has finished rearing children if one has chosen to have children, when retirement from a career is either imminent or has already taken place, and when one begins to contemplate one's own mortality.
http://www.lotsofessays.com/viewpaper/1694140.html
In relation to our patient, she was an old maid who decided not to marry someone. She spends her time enjoying her own sari-sari store. She doesnt have any daily exercise but she considers her job as one. She lifts heavy objects and considers it one of the factors that caused her condition. She noticed changes in her right breast 5 years prior to admission but she just used herbal medications to deal with it. The cancer cells metastasized and spread to the other breast. She was diagnosed of Stage III cancer and undergone modified radical mastectomy on both breasts. We know that one of the risk factors of cancer is advanced age where there is deterioration of body systems. Part of it may be the deterioration of cells that caused the abnormal production of cells. Physical Development Late adulthood is the final stage of physical change. The skin continues to lose elasticity as it did in middle adulthood and the result is deeper lines and wrinkles. Age spots, or brown spots on the skin, often form. Eyesight deteriorates, which causes many seniors to need glasses. Hearing also deteriorates in some people but most are caused by other factors aside from the aging process. Reflexes are diminished to reaction time also
Case Study on Breast Cancer slows.

Read more: Physical Development During Adulthood | eHow.com http://www.ehow.com/about_5333825_physical-development-during-adulthood.html#ixzz19bHm0Sh5
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In the present condition of our patient, she has difficulty in moving especially the upper extremities. She can flex and extend her wrists and elbows but she cannot do hyperextension of the arms up especially on her right side. Of course, it is normal for patients who undergone modified radical mastectomy. In conjunction with this, we conducted a health teaching on post-mastectomy exercises. We were happy that our patient was cooperative and was able to understand the purpose and the therapeutic effects of such exercises. Considering the other effects of aging, our patient has wrinkles in the face and uses correction of her eyesight. She used eyeglasses with a grade of 350. With this correction, she can read a handout with 12 font size clearly at approximately 14 inches away from her. She has no other problems with the senses. Cognitive Development This is the stage where the person experiences disorientation, loss of language skills, loss of ability to calculate and poor judgment, although, these are not normal in the aging process. Older adults take information more slowly and find it harder to apply strategies and retrieve relevant knowledge from long term memory failure increase. There are 3 common conditions affecting cognition: 1. Delirium - An acute confused state - Potentially reversible - Often due to physiologic cause: infection, F/E imbalance, hypoglycemia, or sensory deprivation in unfamiliar surroundings and emotional distress or pain Characterized by: o Fluctuation in cognition, mood, attention, arousal and self awareness o Illusions, hallucinations, occasional incoherent speech, disorientation
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2. Dementia - Generalized impairment of the intellectual functioning that interferes with social and occupational functioning - Characterized by gradual progressive and irreversible cerebral dysfunction as in ALZHEIMERs disease - Nursing Responsibility: to provide supportive nursing care, accurate information and referral assistance, if placement in a nursing care facility becomes necessary 3. Depression - The most common emotional problem of older adult - Tend to rise from loss self esteem and may be related to life situation such as loss of spouse or retirement - A feeling of gloom due to disappointment, loss on failure Our patient has an intact cognitive status. She speaks clearly even if it is not really well modulated, she has good judgment, and she has still good memory. In fact, it was her first time to be hospitalized. She has no other problems affecting cognition like delirium, dementia, or depression.
Psychosocial Development Erik Ericksons theory of Ego integrity vs. Despair involves coming to terms ones life. Adults who arrive at a sense of integrity will lead to whole, complete and satisfied with their environment. They realize that the paths they followed, abandoned and never selected were necessary for fashioning a meaningful life course. Despair occurs when elders feel they have many wrong decisions, yet time is too short to find an alternate route to integrity. Our patient is an old maid. Considering her status, she has not tried bearing children to be taken care of. For me, when it comes to Ego integrity vs. Despair, there is not enough basis for her to gauge whether she has fulfilled her purpose or not because most people gauge the purpose of their lives on the success of their own children. It makes them happy to see their children also happy and successful.
Case Study on Breast Cancer Spiritual Development
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Spirituality and faith may advance to a higher level. Older adults are in the conjunctive stage of Fowlers stage of faith development. The few people who attain this stage form an enlarged vision of an all inclusive human community. Our patient is a Roman Catholic. She is not a member of any organization of the Church. She is not really a strict Church goer but she has faith in God. In advanced age individuals, mostly are really Church goers and basing on the theories, this stage of the individuals life has the most profound spiritual development because this is the time that they repent for their sins and fight despair.
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Our care to our client has been a very good learning experience. Her condition which is breast cancer is a unique case that necessitates me and my partner to familiarize the concepts of cancer because we havent underwent a lecture on cancer yet, though some of the concepts are discussed already in the past ward classes and presentations. Making this case book a success was really a tiring but fulfilling job. We sacrificed nights to make our assigned parts and compiled it. There were also a lot of research works done in order to understand more the pathophysiological process of breast cancer and be able to interpret what our client had gone through during our care. Although this rotation was quite tiring because of the demanding paper works, it was still a good learning experience. Having able to care for clients with different conditions broaden the spectrum of our knowledge which could be useful in our succeeding rotations. Duty in the ward was really different from our previous rotation in LR-DR. In the ward, you must have good convincing skills in order to establish rapport to your patient and be able to do the procedures required. It doesnt mean that we are procedure centered but it is just a way of making ourselves productive during the shift. Clients will not ask you to this and do that for them, so it is really your responsibility to offer it for them. We have also improved our skills in charting since it was the first rotation that we were required to chart. All these things contribute to our learning experience. We will never stop learning as we go through our lives, therefore, we must always prepare ourselves to learn. Of course this rotation would not become successful without the knowledge and supervision of our clinical instructor Maam Leizl Joy C. Escobar. We would like to extend our thanks to you maam for all the things you have done to us and for the knowledge you have imparted. It will really be a contribution in making us fully-cooked nurses as we graduate.
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POST BREAST CANCER LYMPHEDEMA: PART 1

I. SUMMARY This article is part 1 of a two-part article which describes post-breast cancer lymphedema and discusses its diagnosis and measurement. Lymphedema has been called, one of the most dreaded sequelae of breast cancer treatment. Post breast-cancer lymphedema is characterized by an abnormal accumulation of lymph in the interstitial spaces leading to persistent swelling of the affected arm, shoulder, neck, breast, or thoracic region. It is usually caused by axillary node dissection but sometimes from sentinel node biopsy, radiotherapy, lumpectomy, or other trauma to the region. There are two types of lymphedema: One is Primary lymphedema which is a hereditary condition; and secondary lymphedema which has result from trauma to the lymph system, common during breast cancer treatment. 2.4 million Breast cancer survivors in United States are living with lymphedema. One large prospective study found that 42% of breast cancer survivors developed lymphedema within 5 years of treatment; authors also noted that other studies have reported three-year incidence rate of 15% to 54%. Lymphedema greatly affects the lives of survivors. Common reports of those who develop it are physical discomfort and pain, functional impairment at home and on the job, poor self-image, reduced selfesteem, interrupted relationships, and financial burden. There is no cure to lymphedema but management can keep the condition from worsening. Lymphedema can affect ones ability to perform ADLs and enjoy hobbies. A study showed that those survivors who had lymph edema in their arm had difficulty performing household chores. It can also interfere with jobs that involve heavy lifting, gripping, holding, repetitive movement, and fine motor dexterity. Some find that they must give up on their activities because it can aggravate their condition. There can be also serious emotional and psychological effects. Those who suffered complications tend to have more psychological distress and difficulty coping than those who did not have. Lymphedema can also cause enonomic burden because those who are affected spend more either being hospitalized or visiting the physician. Diagnosing post-breast cancer lymphedema is challenging because there are no universally recognized diagnostic criteria, clinicians failure to properly evaluate its symptoms, and the presence of co-existing conditions. So it is important to rule out other conditions that might cause similar symptoms. Diagnosis lymphedema can be achieved through objective and subjective measurement: 1. Quantification the most wide used methods are: water displacement, circumferential limb measurement, and infrared perometry. Bioelectrical impedance analysis is emeriging as an alternative of these methods. Lymphedema is often defined as a 2 cm or greater difference in limb girth, a 200 mL or greater difference in limb volume, or a 10% or a 10% or greater difference in limb volume. a) Water displacement patients affected arm is submerged in a container filled with water; the displaced water flow into another container and is weighed. b) Circumferential limb measurement also called as tape measurement. It involves measuring several points the hand, proximal to the metacarpals; the wrists; and every 4 cm from the wrist to the axilla. c) Infrared peromertry also called as optoelectronic volumetry. It works like CT-scan but uses infrared instead. The volume and shape of the limb can be measured and volume changes calculated in seconds. d) Bioelectrical impedance analysis a small, low frequency electrical current is passed through the body and resistance to that current is measured.
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Subjective symptoms can include feelings of swelling, tightness, heaviness, pain, burning, or numbness in the affected arm, shoulder girdle, or thoracic region and limited mobility in the affected hand, wrist, elbow, and shoulder. Such signs might indicate subclinical lymphedema. Onset of lymphedema may be gradual or sudde, and may occur early (within three years of breast cancer diagnosis) or late (more than three years after diagnosis). Initial onset has been known to occur as long as 30 years after diagnosis. STAGES OF LYMPHEDEMA SIGNS AN SYMPTOMS No visible edema No pitting Sensations of local heaviness or tightness may be present for months or years before overt swelling occurs Visible edema, with or without pitting Visible edema, usually with pitting Hardened, thickened skin and tissue (as fibrosis worsens, pitting may disappear Visible edema No pitting Enlargement of the affected area Hardened, thickened skim and tissue Lymph leaking through damage skin
STAGE 0: Latent (subclinical) lymphedema
1: Early lymphedema 2: Moderate lymphedema
3: Severe lymphedema (lymphostatic elephantiasis)
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II.
REACTION/REFLECTION Our patient was an old maid who decided not to marry. One of the risk factors identified for breast cancer is nulliparity as in the case of our patient. Mass on her right breast was noted five years prior to admission but managed it with herbal medications only. Upon admission, she was diagnosed of Breast Cancer Stage III C on the right breast and Stage III B on the left. The cancer cells metastasized and spread to her left breast. Because of this, both breasts were removed by modified radical mastectomy. Upon our contact with our patient, she had no contraptions already and Id say, she was recovering well of her condition after surgical operation. In journal about lymphedema, it has been stated that 42% of breast cancer survivors develop lymphedema within five years after treatment. In the case of our patient, all her breast tissue and some of the lymphnodes were removed, leaving only the pectoralis major. We know that there is a great risk for our patient to develop lymphedema because lymph cannot properly circulate on those areas where the lymphnodes were removed. But despite of old age we were so amazed that she did not have complications. She did not develop edema post-operatively and she has good skin turgor. Anyway, we cannot make sure that she will not develop lymphedema because that time, it was just days after the surgical operation and basing on the studies conducted, it can occur three to five years after treatment. Our patient doesnt have disturbed body image and was coping up effectively. It has contributed to her recovery. She was compliant with the medication regimen because she doesnt want to experience the same case again. She was also cooperative to the activities and we can see that our patient was willing to learn. Post-mastectomy exercises were taught to her so as not develop complications and decrease the risk of developing edema. Only complaint of our patient was pain on hyperextension of the arm, which is normal for post-operative modified radical mastectomy patients. We were just hoping that we have helped our patient by applying into practice what we have taught to her especially on post-mastectomy exercises. Day after our care, our patient was discharged. We know that there is still a great chance for her to develop lymphedema in the future but if proper practice is done like in the conduction of post-mastectomy exercises, we believe that it could really be a great help for our patient for it enhances circulation and therefore, maybe, decrease the occurrence of swelling in the lymph nodes.
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Risk of Breast Cancer Recurrence May Depend On Treating Surgeon

Main Category: Breast Cancer Also Included In: Cancer / Oncology; Women's Health / Gynecology Article Date: 31 Dec 2010 - 7:00 PST Ductal carcinoma in situ (DCIS), or non-invasive breast cancer, is typically treated with either breast-conserving surgery - with or without follow-up radiation - or mastectomy. The treatment choice depends on clinical factors, the treating surgeon, and patient preferences. Long-term health outcomes (disease-free survival) depend on the treatments received. According to a study published January 3 in The Journal of the National Cancer Institute, however, health outcomes also are associated with the treating surgeon. To determine the comparative effectiveness of treatment strategies, Andrew W. Dick, Ph.D., of the RAND Corporation and colleagues conducted a retrospective study of women diagnosed with DCIS between 1985 and 2000 with as many as 18 years of follow-up. They identified the women through two large tumor registries, the Monroe County (New York) tumor registry, and the tumor registry at the Henry Ford Health System in Detroit. The researchers collected extensive data on the patients, including the rate of ipsilateral recurrence, or recurrent breast cancer in the same breast; whether the women had been treated with mastectomy or breast conserving surgery - with or without radiation therapy; and their margin status (margin of tissue surrounding their resected tumors). They defined margins as positive (in which cancer cells extend to the edge of the resected tissue), negative (cancer cells are more than 2 millimeters away from the edge of the tissue), or close (in which cancer cells are present within two millimeters of the edge). According to the researchers, the two most important determinants of recurrent breast cancer are the tumor margins and whether or not the women have received radiation therapy following breast-conserving surgery. "BCS in the absence of radiation therapy resulted in substantially lower ipsilateral event-free survival than either BCS followed by radiation therapy or mastectomy," the authors write, adding, "Regardless of treatments, positive or close margins following the last surgical treatment substantially compromised ipsilateral event-free survival." Both of these important determinants of outcomes, however, varied markedly by the treating surgeon. The authors write that the wide variability in treatment by surgeons may reflect differences in surgeons' knowledge, attitudes and beliefs, especially given the lack of consensus on what constitutes a negative margin. "Lack of knowledge about the importance of margins, and differences in beliefs about the role of radiation therapy in local control, together with differences in physician-patient communication during the decision-making process could explain the substantial variation in the acceptance of positive margins and the determination not to proceed to mastectomy," the authors write.
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Nevertheless, they estimate that with modest reductions in variation by surgeon, based only on changes among those surgeons with low rates of radiation therapy and high rates of positive or close margins, ipsilateral 5- and 10-year event rates could be reduced by 15% to 30%. In an accompanying editorial, Beth A. Virnig, Ph.D., and Todd M. Tuttle, M.D., of the University of Minnesota, write that the study poses a perplexing question. "How should women select a provider knowing that up to 35% of the variation in outcomes is based on their choice of physician but that there are no actionable characteristics that can be taken into account?" They suggest one solution could be publishing the scores for all physicians performing breast cancer surgery in a particular area. In any case, the variability in surgeons' treatment choice provides a potential opportunity to improve or standardize DCIS care. They write, "The challenge is then for the professional community to identify factors that are associated with the currently unexplained physician variability and to use that information to promote identification of high-quality providers or quality improvement activities." Source The Journal of the National Cancer Institute
Summary: Radiation therapy following mastectomy or other breast-conserving surgeries is done for local control of cancer cells formation to recur. Usually, surgeons do not advice anymore radiation therapy because of its other harmful effects on other proximal organs, especially that the heart and the lungs are located near the breast are to be exposed to radiation. But recurrence of cancer cell formation is rare only when the whole tumor is totally removed from the body. Long term disease-free survival depends on several factors: the treatment choice, the treating surgeon and the clinical factors. Since the treating surgeon is the one that removes the tumor form the affected area, he is largely accountable for any tumors left unremoved. According to researchers, the two most important determinants of recurrent breast cancer are the tumor margins and whether or not the women have received radiation therapy following breast-conserving surgery. The absence of radiation therapy after a breast-conserving surgery presents lower ipsilateral event-free survival than that with radiation therapy or mastectomy. Regardless of treatments, positive or close margins following the last surgical treatment substantially compromised ipsilateral event-free survival. Both of these important determinants of outcomes, however, varied markedly by the treating surgeon. It may be due to the differences in surgeons' knowledge, attitudes and beliefs, especially given the lack of consensus on what constitutes a negative margin. The writers suggest that it would be better if the surgeons have their record of successful operations done and number of cases where ipsilateral breast cancer recurred so as women will consider the surgeon they will choose for their operation.
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Reaction: The factors mentioned in the article are all accountable for breast cancer recurrence. I think it would be unfair if all the blame would be given to the treating surgeon. Let us remember that the health of a patient doesnt only depend on the treating surgeon. They must also participate in self-care. Although the treating surgeon may hold the accountability of every medical advice he gives to the client, it is still the job of the client to comply with the doctors advice. It was not mentioned in the study how compliant their subjects where and how did they manage their condition after the operation. It clearly shows that their study is lacking. Although I believe that the treating surgeon may impose a great impact in the patients health, more evidence must be made to say that the treating surgeon is accountable for such reccurence.
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Aubrex. (n.d.). Retrieved January 7, 2011, from MIMS Philippines: http://www.mims.com.ph/Page.aspx?menuid=mng&name=Aubrex+cap&brief=true&h=aubrex&CTRY=PH&searchstring=Aubrex Black, J. M., & Hawks, J. H. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (8th ed.). St. Louis, Missouri: Saunders Elsevier Inc. Cefoxitin. (2007). Retrieved January 7, 2011, from DRUGS area: http://drugsarea.com/Dets-Drugs/Cefoxitinpd.html#nursing-implications CEFUROXIME SODIUM. (n.d.). Retrieved January 7, 2011, from Nursingcrib.com: http://nursingcrib.com/drug-guides/cefuroxime-sodium/ CELECOXIB. (n.d.). Retrieved January 7, 2011, from Nursingcrib.com: http://nursingcrib.com/drug-guides/celecoxib/ CIPROFLOXACIN HYDROCHLORIDE. (n.d.). Retrieved January 7, 2011, from Nursingcrib.com: http://nursingcrib.com/drugguides/ciprofloxacin-hydrochloride/ Drug Study: Ketorolac (Toradol). (n.d.). Retrieved January 7, 2011, from Nursing-Nurse.com: http://www.nursing-nurse.com/drug-studytoradol-13/ Hodgson, B. & Kizior, R. (2011). Nursing Drug Handbook 2011.Elsevier Saunders: USA Huether, S., & McCane, K. (2008). Understanding Pathophysiology (4th ed.). China: Mosby Elsevier. Ignatavicius, Linda, Donna, & Workman. (2006). Medical-Surgical Nursing, Critical Thinking for Collaborative Care (6th ed.). USA: ElsevierSaunders.
2011
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Casebook - Breast Cancer

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Case Study on Breast Cancer

VISION/ MISSION STATEMENT

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV.

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Age: 61 years old Religion: Roman Catholic Nationality: Filipino

Date and Time of Admission: December 1, 2010; 1:07pm

Case Study on Breast Cancer

83 yrs old Nicotine excess

CLIENT 61 yrs old Breast CA stage III

LEGEND: Female Male

Case Study on Breast Cancer

Barangay Health Center

Legend: Less likely attached

Farm land Relatives

Case Study on Breast Cancer

Case Study on Breast Cancer

Head-to-toe Physical Assessment

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

12-14 g % 37-44 vol % 5-10 T/ cumm 55-60 % 20-35 %

11.6 g % 33.8 vol % 13, 500/ cumm 79 % 16 %

1-6 % 1-4% 150-400T/ cumm 11-15 sec

3% 2% 346, 000/ cumm 13 sec 1.18

Within Normal Range Within Normal Range Within Normal Range

Decreased due to blood loss during operation

Case Study on Breast Cancer

12-14 g % 37-44 vol %

11.9 g % 34.8 vol %

Case Study on Breast Cancer

Case Study on Breast Cancer

Case Study on Breast Cancer

2011 NURSING CARE PLAN

INTERVENTIONS Independent Monitor vital signs

EVALUATION At the end of our 2-day care:

To determine the effectiveness of the regimen and to prevent infection

Goal met, minimal serous and serosanguinous secretions drained

Case Study on Breast Cancer

Case Study on Breast Cancer

2011 NURSING CARE PLAN

INTERVENTIONS Independent Ascertain level of knowledge, including anticipatory needs.

EVALUATION At the end of our 2-day care: