Dela Cruz, Kathyrine P.

BSN IV

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Fear or After 8 hrs of 1. Encourage patient to 1. Provides opportunity After 8hrs of nursing
“My breasts Anxiety nursing share thoughts and to examine realistic intervention the patient
have been related to intervention the feelings. fears and display appropriate range of
naturally situational patient will 2. Provide open misconceptions about feelings and lessened fear.
diagnosis.
cystic, but I crisis (cancer) appear relaxed environment in Appear relaxed and report
2. Helps patient feel
have a new and report which patient feels accepted in present anxiety is reduced to a
lump in my anxiety is reduced safe to discuss condition without manageable level.
right breast to a manageable feelings or to refrain feeling judged, and
that has me level. from talking. promotes sense of
concerned.” 3. Provide open dignity and control.
environment in 3. Provides assurance
OBJECTIVE: which patient feels that patient is not
 Verbal safe to discuss alone or rejected;
conveys respect for
ization feelings or to refrain
and acceptance of the
of the from talking.
person, fostering
proble 4. Promote calm, quiet trust.
m environment. 4. Facilitates rest,
 VS 5. Be alert to signs of conserves energy,
taken denial and and may enhance
BP: depression coping abilities.
130/8 (withdrawal, anger, 5. Patient may use
4 inappropriate defense mechanism of
P: 74 remarks). Determine denial and express
RR: 13 presence of suicidal hope that diagnosis is
T: ideation and assess inaccurate. Feelings of
98.2°F potential on a scale guilt, spiritual distress,
of 1–10. physical symptoms, or
lack of cure may cause
patient to become
withdrawn and
believe that suicide is
a viable alternative.
Dela Cruz, Kathyrine P.
BSN IV

DRUG NAME DOSAGE/FREQUENCY CLASSIFICATION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING

RESPONSIBILITIES
Tamoxifen Breast Cancer - Hypersensitivity - increased tumor All patients on
Dosage Forms &
(Rx) Antiestrogen Metastatic - Pregnancy or bone pain. tamoxifen should
Strengths
Brand and breast cancer - hot flashes. have routine lab
Other Names: tablet (generic) Indicated for - nausea. work including a
Soltamox  10mg the treatment - fatigue. complete blood
 20mg of adults with - mood swings. count with
oral solution estrogen - depression. platelets, serum
 10mg/5mL receptor- - headache. calcium, and liver
(Soltamox) positive - hair thinning. function tests.
metastatic Female patients
breast cancer should monitor
20-40 mg/day for abnormal
PO; doses vaginal bleeding
>20mg/day and receive a
should be breast and
divided BID gynecologic exam
(ie, morning at baseline and
and evening) routinely after.
Although the
FDA has
approved a
dosage range
of 20-40
mg/day,
clinical benefit
for doses >20
mg/day has
not been
demonstrated
Dela Cruz, Kathyrine P.
BSN IV

DATE TIME FOCUS PROGRESS NOTES

D: Pt states “I have a new lump in
11/08/2020 8:00 AM ANXIETY my right breast that has me
concerned.”
A: Emotional support provided.
Encouraged verbalizations.
Explanations given regarding
treatments and procedures.
Encourage family to provide
support.
R: Pt observed relaxed and
laughing with family. States she
feels less anxious.
Dela Cruz, Kathyrine P.
BSN IV
Dela Cruz, Kathyrine P.
BSN IV
Dela Cruz, Kathyrine P.
BSN IV

REFLECTIVE JOURNAL
Breast cancer is the most common invasive cancer in women and the second leading cause of cancer death
in women after lung cancer. Through this case study I found out that awareness of the signs and symptoms and
the need for screening yourself are important ways of reducing the risk. It is important that if you are aware of
your family history about a certain condition, early consultation to doctors will reduce the risk of developing
cancer. Aside for that, I realized that my foundation in understanding cancer, its pathophysiology, etc., are low. I
don’t understand some of the datas presented in the study. With this, i understand that I need to add more time
and effort on my studies.