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MINISTRY OF HEALTH GENDER ELDERY AND CHILDREN
NDANDA COLLEGE OF HEALTH AND ALLIED SCIENCE
MODULE NAME: CARE OF PATIENT WITH CANCER AND TUMOR

MODULE CODE: NMT0608
NATURE OF WORK: INDIVIDUAL CASE STUDY
TUTORS NAME: REBECA NYANDA
SIGNATURE………………………...
S/N NAME SIGNATURE SCORE

01 BETHANIA BENJAMIN
IDENTIFYING INFORMATION
NAME: A.B.A
REG NO.:57154
SEX: FEMALE
AGE: 46YRS
RESIDENCE: MTWARA-MIKINDANI
OCCUPATION: PEASANT
RELIGION: MUSLIM
TRIBE: YAO
DIGNOSIS: BREAST TUMOR
ADMISSION DATE: 13 JUNE 2022
KEY INFORMANT: HER CHILD
CHIEF COMPLAINT
A patient came to hospital on 13 June 2022 with complain of very severe breast
pain together with feel heavy in the breast like load of stone.
HISTORY OF PRESENT ILLNESS

The patient start to feel pain in the breast since many months ago ,there was
distended vein near the breast and breast start to swell slowly later she went at
Mikindani dispensary and receive only anti pain but condition not improved and
breast continue to grow wiser ,so Mikindani refer her to ligula hospital there
somehow recovery and get discharge .But she was have a clinic for further
investigation and trace medication also there condition not recovery and decide to
come Ndanda referral hospital for further management ,doctor found that is breast
tumor around all tissue of the breast, now she is post radical mastectomy.
PRESENT MEDICAL MANAGEMENT
Injection Pethidine 100mg start
IV Ringer Lactate 500mls start
IV DNS 5oomls start
Injection Diclofenac 75mg bid 3/7
Injection Ampiclox 500mg tds 3/7
INVESTIGATION AND RESULT

RADIOLOGY INVESTIGATION
X-RAY
Chest x-ray on the site of breast to assess the extent of tumor and determine type of
treatment and result was tumor spread almost all surrounding tissue in the breast.
US
US done to assess if there is any spreading of abnormal cell around other tissue
near breast and result was no spreading of abnormal cell.
LABORTORY INVESTIGATIONS
FULL BLOOD PCTURE
FBP was done to detect any abnormalities in the blood especially hemoglobin
level to assess amount of blood in the body and result was 11.9g/dl also white
blood cell (WBC level) and result was 3.31.
PHYSICAL EXAMINATION
Head to assessment done to detect any abnormalities in whole body start with
vitals including:
Temperature- Measured t assess body temperature and result was 36.7°C.
Pulse rate -Measured to assess normality of the heart rate and result was 90b/min.
Respiration -Measured to assess normality in respiratory rate and result was
18br/min.
Blood pressure-measured to assess pressure of the blood because the patient she
under taping to drain fluid and result was 120/90mmHg.
After vital signs came with head to toe assessment.
PART OF THE NORMAL ABNORMAL REMARKS
BODY
Head 
Eyes 
Nose 
Mouth 
Ears 
Neck 
Upper limbs 
Chest  Sutured wound
secondary to
mastectomy on
right site.
Abdomen 
Lower limbs 
Back 
Genitalia 
NURSING CARE PLAN
DATE ASESSMENT NURSING EXPECTED NURSING EVALUATION
AND AND DIAGNOSIS OUTCOME INTERVENTIO
TIME PROBLEM N AND
RATIONALE
15/06/202 Pain. Abdominal pain After 5 minutes the Positioning the The patient is free from pai
2 related to patient will free patient in
5:15pm- mastectomy as from pain. comfortable
5:20pm evidenced by position that will
patient prevent to
verbalization and compress wound
facial expression. and will relieve
pain.
Administer anti
pain like inj
pethidine to relieve
pain.
15/06/202 Wound. Wound related to After receiving Daily dressing to The patient continues with
2 mastectomy as proper management the site of wound dressing.
evidenced by the patient wound to facilitate wound
sutured wound on will be healed. healing by prevent
right side of breast. microorganism.
15.06.2022 Risk of Infection Risk of infection After receiving Daily dressing to The patient continue with h
related to sutured management the the site of wound management.
wound. patient will be to prevent further
prevented from the invasion of
invasion of the microorganism.
infection.
Administer
antibiotics as
prophylaxis to
prevent risk of
microorganism.
PATIENT PROGRESS
Until now patient is progressing well.
REFERENCES
Patient herself and file.
Patient´s child
Nurse on duty

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MINISTRY OF HEALTH GENDER ELDERY AND CHILDREN

NDANDA COLLEGE OF HEALTH AND ALLIED SCIENCE

MODULE NAME: CARE OF PATIENT WITH CANCER AND TUMOR

S/N NAME SIGNATURE SCORE

HISTORY OF PRESENT ILLNESS

INVESTIGATION AND RESULT

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