A Case Presentation to the Faculty of

Ateneo de Davao University

College of Nursing

Breast Cancer Stage IIB

In partial fulfillment of the requirements in Related Learning

Experience

Presented by:
Lim, Stephanie
Madrazo, Benedict
Mangitngit, Jeferson
Margaja, Dominique
Nalzaro, Sheena

Presented to:
Ma'am Sarah Manalili, RN
Clinical Instructor

July 11, 2008

 TABLE OF CONTENTS

I. Acknowledgement

II. Introduction

III. Objectives

IV. Patient’s Data

V. Family Background

VI. Developmental Data

VII. Definition of Complete Diagnosis

VIII. Physical Assessment

IX. Anatomy and Physiology

X. Etiology and Symptomatology

XI. Pathophysiology

XII. Doctor’s Order

XIII. Diagnostic Exam

XIV. Drug Study

XV. Surgical Procedure

XVI. Nursing Theories

XVII. Nursing Care Plan

XVIII. Discharge Plan

XIX. Recommendation

XX. References
 ACKNOWLEDGEMENT

We, the students from group 3 of section 3E, wish to extend our

gratitude to all of the following, for the corresponding reasons:

To the ever-powerful and ever-loving God, who watches over us

in every step of the way, may He bless all student nurses striving to

make the world a better place, one intervention at a time;

To the Ateneo de Davao University, College of Nursing, for

without its existence, this case presentation wouldn’t even exist and

thus cannot teach us very crucial lessons in the practice of Nursing;

To the Davao Medical School Foundation Hospital’s medical staff,

who really showed the group how it is to work round the clock just to

keep patients safe and healthy, may they serve as inspirations for

more and more student nurses who come to practice a very humbling

profession in their hospital;

To all our previous Clinical Instructors, who voluntarily impart

their knowledge for us to be able to work our best as Student Nurses,

may they all find it in their hearts to keep going and keep teaching the

eager young minds of tomorrow;

To our parents and family members, who unrelentingly give their

support for each of us to pursue our Nursing careers, may they remain

in our hearts throughout our profession;

 To our class, 3E, for the unending companionship throughout the

school years, may we live to see each other grow into the Nurses that

we ought to be;

To each of the group members, Blance, Stephanie, Benedict,

Jeferson and Sheena, who have dedicated and sacrificed a huge

amount of time and effort in making this Case Presentation, may this

experience serve as a booster for every skill in nursing and as a basis

to measure how much better every one of us should do next time;

To everyone mentioned above, thank you very much. You have

all contributed to the making of this Case Presentation. We hope that

in any way possible, we have contributed something to your lives as

well.
 INTRODUCTION

Cancer is a major health problem worldwide and the morbidity and

mortality from cancer give rise to much suffering. The risk of developing
cancer in an individual's lifetime is about 33%, and the risk of dying of
cancer is 25%. Cancer is not only a disease of the elderly although for
many cancers the incidence increases with age. Breast cancer in the US
and Western Europe is the commonest female cancer, and accounts for
the most cancer deaths in women. Eighteen percent of women who
develop breast cancer will be under 50 years of age and with an average
of 50% mortality this will produce a significant number of deaths in a
population of wives and mothers who are making major contributions to
the nurture of future generations and the economy. Loss of life in this age
group has very serious consequences both for society in general and for
the individual families involved. There are now major health programs
throughout the world involved in research and development into
prevention, early detection, and new treatments with the aim of reducing
the morbidity and mortality from breast cancer. It is of some considerable
interest that the East in general has amongst the lowest rates of breast
cancer in the world. This is assumed to be a combination of environmental
and genetic factors and their interaction

In the UK 30,000 new cases of breast cancer are diagnosed each

year making this the commonest malignancy in women and causing
nearly 15,000 deaths per year. Randomized studies of prevention
strategies particularly with the anti-oestrogens Tamoxifen and more
recently raloxifene, and retinoids have either been completed or are on-
going. The final analysis is awaited but it is likely that effective preventive
measures will be available in the not too distant future.

A national population-based breast-screening program was

commenced 6 years ago on the evidence from randomized trials, which
demonstrate a reduction in breast cancer mortality from screening. This
remains an area of considerable medical debate, which centers on the
question of cost-effectiveness. In the not too distant future it should be
possible to better define women who are at increased risk of breast
cancer, to discover the reasons for their increase in risk, and then to
target both specific preventive and early detection strategies at this "at
risk" population.

In Asia, the Republic of the Philippines has the highest reported

incidence rate of breast cancer. From 43.2 in 2003-2005, the age-
standardized incidence rate (ASR) is now 47.7 per 100,000 females,
and this figure exceeds the rate reported for several Western
countries, including Spain, Italy, and most Eastern European countries.

Many breast cancers are diagnosed among 35 to 50-year-old

Filipino women. In terms of breast cancer detection, a local study
revealed that the use of breast self-examination (BSE) and aspiration
biopsy/open biopsy are the most cost-effective strategies in the
Philippine setting, incurring savings for the government by almost 3
million Philippine Pesos or US $60,000 (1989 value) per year per
100,000 women. Mammography is neither readily available nor
affordable especially in the rural areas.

Cancer site 1980–82 1983–87 1988–92 1993–95

BS M F BS M F BS M F BS M F
Lung 25.8 42.3 11.5 31 46.7 14.9 40 64.7 18.8 40 64.7 18.8

Breast 0.7 40.5 0.7 44.4 0.8 43.2 0.8 43.2

Liver 13.4 20.4 7.3 14.7 20.4 8 16.8 25.6 9 16.8 25.6 9

Cervix uteri 20.5 – 20.5 22.5 – 22.5 26.4 – 26.4 26.4 – 26.4

Stomach 9.6 11.9 7.6 9.6 11.4 7.7 9.6 12.1 7.6 9.6 12.1 7.6

Colon 6.5 7.3 5.7 8 8 7.7 10.7 11.8 9.8 10.7 11.8 9.8

Oral cavity 5.9 5.4 6.3 6.9 6.4 7.3 8.6 8.5 8.3 8.6 8.5 8.3

Prostate 12.5 12.5 – 14.6 14.6 – 19.3 19.3 – 19.3 19.3 –

Rectum 5.5 6.5 2.8 6.6 7.4 5.6 7 8.1 6.2 7 8.1 6.2

Leukemia 5.2 5.7 2.9 5.7 5.6 5.5 6.6 7.2 6.2 6.6 7.2 6.2

Nasopharynx 2.5 6 1.6 5.2 6.7 3.1 6.2 8.6 4 6.2 8.6 4

Larynx 1.4 4.3 0.4 2.8 4.4 1.1 3.4 6.2 1 3.4 6.2 1

Ovary 8 – 8 9.2 – 9.2 10.8 – 10.8 10.8 – 10.8

Thyroid 2.7 1.3 6.6 5.6 2.7 8 6.6 3.1 9.8 6.6 3.1 9.8

Corpus uteri 6.1 – 6.1 5.8 – 5.8 5.2 – 5.2 5.2 – 5.2

Non-Hodgkin’s lymphoma 2 2.1 1.6 3.3 3.8 2.6 4.6 5.8 3.6 4.6 5.8 3.6

Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4)
 OBJECTIVES

General Objectives:

The group aims to present facts about breast cancer, details of

how this may affect any woman, and ways to prevent, avoid, treat, and

recover from breast anomalies.

Specific Objectives:

Cognitive:

To be able to critically understand the pathology of breast cancer

and its deviation from the normal physiologic functioning of the body

Psychomotor:

To be able to present a scientific-based, comprehensive and

significant case study with the aid of proper and complete data

gathering

Affective:

To be able to give importance and attention to the concerns and

needs of our patient and our patient’s family members through

therapeutic communication

To successfully come up with the written output of this case

study and be able to attain the general objectives, the group aims to:
• Gather information and pertinent data from the patient’s chart

and the significant others by interviewing them

• Trace the family health history and family background of the

patient

• Identify effects or expectations of the illness to the patient

herself and her family

• Trace the health history of the patient, including the history of

past illnesses and history of present illness

• Utilize and apply developmental concepts to the patient’s own

development

• Define the complete diagnosis of the patient

• Perform and discuss a complete, thorough and comprehensive

physical assessment by using inspection, percussion, palpation

and auscultation cephalocaudally

• Research and discuss about related anatomy and physiology of

the breast, the rest of the reproductive system, and the

lymphatic system.

• Research and discuss the etiology and symptomatology of the

patient’s condition

• Trace the pathophysiology of the patient’s diagnosis which would

also include the precipitating and predisposing factors of the

patients condition
• Discuss the doctor’s order, the specific date of the order and

individual rationales for each doctor’s order

• Interpret the diagnostic exams included in the patient’s chart

which would include the date the lab was ordered, the name of

the diagnostic exam, rationales for each exam, the normal

values, the result of the patient’s diagnostic exam, clinical

significance of the result and the appropriate nursing

responsibilities to be carried out for each diagnostic exam

• Research on drug studies on the drugs given to the patient which

would include the generic name of the drug, its brand name(s),

therapeutic and pharmacological classification, dosage and

frequency, the mechanism of action of the drug, indications,

contraindications, side effects, adverse reactions, and Nursing

responsibilities for each drug.

• Formulate appropriate nursing care plans through the utilization

of the various nursing theories related to the case of the patient

• Provide health teachings and recommendations for the patient

and significant others

• Formulate a discharge plan using M.E.T.H.O.D.

• Cite the sources utilized by the group through an outlined

bibliography
Patient's Co

Na

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 FAMILY HEALTH HISTORY

All information regarding the family’s health history comes from

Patient X. According to her, no one in the past two generations has

had a breast cancer. All the sicknesses she recalls are from her

father’s side; one aunt has diabetes and one uncle has kidney failure.

Among her siblings, the second and the third eldest sons have

hypertension.

Effects/Expectations of illness to self/family.

According to Patient X, her family has this kind of practice in the

onset of an illness: Self medicate… Then go to a quack-doctor

(albularyo) for massaging with palm-oil… If still sick, then go to the

hospital.

Going to a quack-doctor helps indeed, says Patient X.

Client’s Health History

In the past, she claims to be generally healthy. Her past

sicknesses includes fever and cough. In the present, she has had
hypertension after reaching the age of 50. In the year 2001, she had
the onset of a breast mass which was removed by going through a
lumpectomy. This year, 2008, there seemed to have been some
residual neoplasm which then grew again and became another breast
mass. She then underwent MRM to remove her left breast in order to
have a cancer free life in the future.
 removal of the
(1st wife of breast mass
Paternal Paternal Maternal Maternal
Grandfather) Grandfat Grandfat Grandmothe
her her r
Paternal
Grandmother
4 offspring
7 offspring

3rd 5th Father Mother 6 offspring

Offspring Offspring 92yo 84yo

1st 3rd 5th 7th 9th 11th

Offspring Offspring Offspring Offspring Offspring Offspring

2nd Patient X 6th 8th 10th

Offspring 59yo Offspring Offspring Offspring

Hypertension Diabetes Kidney Failure Breast Cancer Female Male

Married
 DEVELOPMENTAL DATA

Psychosocial Theory:

Erikson contended that ego development is lifelong. He viewed that

life development is a continuous struggle for an emotional – social
equilibrium. According to him, a person’s personality does not
magically appear at a specific time but rather spends a life time
constructing, shaping and reshaping his personality.

His theory of psychosocial development covers eight stages across

the life span. Physiological, social, emotional, and environmental
factors all influence the formation of personality. Erikson defined
specific tasks that must be accomplished for each stage of
development. The primary task of each stage has both positive and
negative components or psychosocial crises and the person
undergoing the crises must balance both components to progress
developmentally. the person resolves the conflict of a specific stage
and attains emotional – social equilibrium when these tasks are
successfully accomplished.

The eight (8) crises according to Erik Erikson are:

a. Trust versus Mistrust (Infancy, birth to first year)
b. Autonomy versus Shame and Doubt (1 -3 years)
c. Initiative versus Guilt (Early childhood, 3 -5 years)
d. Industry versus Inferiority (Mid and late childhood, 5 – 12 years)
e. Identity versus Confusion (Adolescence or about 12 -18 years)
f. Intimacy versus Isolation (Early adulthood or 18 – 40 years)
g. Generativity versus Stagnation (Mid adulthood around 40 – 65
years)
h. Integrity versus Despair (Late adulthood or Old age)
 Our client, Patient X, is 59 years old and fell under the middle
adulthood stage. Her task is to fulfill life’s goals that involve family,
career, and society. The crisis that she is undergoing will be
generativity or stagnation.
Through the interview with the client, the watchers, and the
visitors, it was evident that Patient X has established a warm and
loving relationship with them. They talk freely, share conversation
blithely and had an easy relationship.

Not only does she show generosity and care to her immediate
family, she also helps her friends, colleagues, and siblings who are not
as well-off as her family. Her job as a teacher is something to offer
financial help to them and she does not wait for them to come to her.
Whenever she feels that they are in need, she would readily come to
them and offer comfort and helping hands.

Indeed, Patient X has succeeded in achieving the abilities of being

thoughtful and caring to others. She has opened herself to her family,
friends, and society and created a mark that will outlive her. She did
not wallow in self-absorption and cast out people who will help her in
achieving the task of her stage.
Physiological Theory:

Robert Havighurst, the proponent of Physiological Theory of growth

and development, believed that learning is basic to life and that to
understand growth and development, one must comprehend learning
and accept the premise that people continue to learn throughout life.

He defines a developmental task as one that arises at a certain

period in our lives, the successful achievement of which leads to
happiness and success with later tasks; while unaccomplished goal
leads to unhappiness, social disapproval, and difficulty with later tasks.
He identifies three (3) sources of developmental tasks:

• Tasks that arise from physical maturation. For example, learning

to walk, talk, and behave acceptably with the opposite sex
during adolescence; adjusting to menopause during middle age.
• Tasks that have their source in the pressure of society. For
example, those that emerges from the maturing personality and
takes the form of personal values and aspirations, such as
learning the necessary skills for job success.
• Tasks that have their source in the pressures of the society. For
example, learning to read or learning the role of a responsible
citizen.
 Havighurst has also identified six major age periods: infancy and
early childhood (0 – 5 years, middle childhood (6 – 12 years),
adolescence (13 – 18 years), early adulthood (19 – 20 years), middle
adulthood (30 – 60 years), and later maturity (61+).

Our client belongs to the middle age stage filled with seven tasks to
accomplish. As a good citizen of Davao City, she knows her
responsibility to keep the environment clean and create a happy home
for her family. Although they have employed someone to manage the
household chores, Patient X still gives a hand in performing daily
chores.

Being a teacher for twenty nine years contributes so much to the

family income and greatly helps in paying the house bills. On
weekends or any spare time she has, she often reads books and
magazines or watch movies with her family just to enjoy the leisure
time she has.

She has a very good relationship with her husband. It’s unavoidable
that sometimes they will have misunderstandings regarding some
matters. In dealing with this, she sometimes nags at him but keeps
quiet when she feels she has gotten through him. Silence will be
maintained until such time that each one has cooled down and then
they would talk about the problem objectively and find solution
together.

Patient X is now fifty nine years old and knows that she is not
getting any younger. Aside from the physical changes that have
occurred, like the appearance of lines on her face, she is aware that
she is presently facing her breast problems and would pose some
serious problems if not monitored all throughout.

Despite having a family of her own, Ma’am Fe has not forgotten

about her parents. She visits them regularly at her elder sister’s home.
They are in good terms and will remain that way as she claimed.

As a responsible parent, she always looks forward for the bright

future of her children. Luckily, she has two professional children
already and one graduating college student.

At this age that she is now, she has accomplished her tasks and
created a happy life.
 DIAGNOSIS WITH COMPLETE DEFINITION

Breast cancers are malignant tumors that typically begin in the

ductal-lobular epithelial cells of the breast and spread via the
lymphatic system to the axillary lymph nodes. The tumor may then
metastasize to distant regions of the body, including lungs, liver, bone,
and brain. The finding of breast cancer in the axillary lymph nodes is
an indicator of the tumor’s ability for potential distant spread and is
not merely contagious growth into adjacent region of the breast. Most
primary breast cancers are adenocarcinomas located in the upper
outer quadrant of the breast.

Bibliography: Black, J. et. al. (2002).MEDICAL-SURGICAL NURSING:

Clinical Management for Positive Outcomes. Vol. 1. Philadelphia, USA:
W.B. Saunders Company. pages 1011 – 1040.

Breast cancer is a cancer that starts in the cells of the breast in

men and women. Worldwide, breast cancer is the second most
common type of cancer after lung cancer (10.4% of all cancer
incidence, both sexes counted) and the fifth most common cause of
cancer death. Worldwide, breast cancer is by far the most common
cancer amongst women, with an incidence rate more than twice that of
colorectal cancer and cervical cancer and about three times that of
lung cancer. However breast cancer mortality worldwide is just 25%
greater than that of lung cancer in women. In 2005, breast cancer
caused 502,000 deaths worldwide (7% of cancer deaths; almost 1% of
all deaths). The number of cases worldwide has significantly increased
since the 1970s, a phenomenon partly blamed on modern lifestyles in
the Western world.
 Malignant tumors within the breast are called “breast cancer”.
Theoretically, any of the types of tissue in the breast can form a
cancer, cancer cells are most likely to develop from either the ducts or
the glands. These tumors may be referred to as “invasive ductal
carcinoma” (cancer cells developing from ducts), or “invasive lobular
carcinoma” (cancer cells developing from lobes). Sometimes,
precancerous cells may be found within breast tissue, and are referred
to as ductal carcinoma in-situ (DCIS) or lobular carcinoma in-situ
(LCIS). DCIS and LCIS are diseases in which cancerous cells are present
within breast tissue, but are not able to spread or invade other tissues.
DCIS represents about 20% of all breast cancers. Because DCIS cells
may become capable of invading breast tissue, treatment for DCIS is
usually recommended. In contrast, treatment is usually not needed for
LCIS.

Stage II breast cancer means one of the following: cancer is no

larger than 2 centimeters but has spread to the lymph nodes in the
armpit (the axillary lymph nodes); cancer is between 2 and 5
centimeters (from 1 to 2 inches) and may have spread to the lymph
nodes in the armpit; cancer is larger than 5 centimeters (larger than 2
inches) but has not spread to the lymph nodes in the armpit. This is
the stage that describes invasive breast cancer in which the affected
lymph nodes have not yet stuck to one another or to the surrounding
tissues, a sign that the cancer has not yet advanced to stage III.

Stage II is divided into stages IIA and IIB. In stage IIA, (1) no tumor
is found in the breast, but cancer is found in the axillary lymph nodes
(the lymph nodes under the arm); or (2) the tumor is 2 centimeters or
smaller and has spread to the axillary lymph nodes; or (3) the tumor is
larger than 2 centimeters but not larger than 5 centimeters and has
not spread to the axillary lymph nodes. In stage IIB, the tumor is either
(1) larger than 2 centimeters but not larger than 5 centimeters and has
spread to the axillary lymph nodes; or (2) larger than 5 centimeters but
has not spread to the axillary lymph nodes.
 PHYSICAL ASSESSMENT

Date and Time: June 29, 2008; 12:00am

Name: Patient X
Age: 59
Sex: Female
Ward: 324 (3C)
Bed: 6
Civil Status: Maried
Religion: Roman Catholic

I. VITAL SIGNS

Temperature: 36.7˚C Cardiac Rate: 65

Blood Pressure: 120/80 Respiratory Rate: 18
Pulse Rate: 64

II. GENERAL SURVEY

Patient stands at 4 feet and 9 inches tall and weighs 59.2

kilograms. She is awake, conscious, coherent and oriented. She does
not show any signs of respiratory distress. She is a well developed
mesomorph and looks according to age. She is very calm during the
Physical Assessment.

III. SKIN

General skin color is from tan to brown and is grossly smooth.

Her skin has good skin turgor and is warm to touch. Her skin is mostly
dry with no signs of any lesions or breakage of skin integrity.

IV. HEAD

Her head is normocephalic with symmetrical facial features.

Fontanels are closed, and hair is long, black and thick with a few
strands of white hair. Her scalp is clean and shows no signs of lesions.

V. EYES

Her eyelids are symmetrical in shape and she has anicteric

sclera. Opaque lenses and equally sized pupils are observed when
exposed to light. Pupils react briskly to light and accommodation. She
is farsighted and has intact peripheral vision.

VI. EARS

She has symmetrical ears without any reports of pain or

tenderness upon palpation. There are no discharges observed upon
inspection of the external canal. Her gross hearing is symmetrical.

VII. NOSE

Her nasolabial fold and septum are along the vertical midline of
her face. Her nasal mucosa is pinkish in color. There are no
discharges noted upon inspection of nostrils. Both nostrils are patent
with symmetrical gross smelling. No pain or tenderness is reported
upon palpation of sinuses.
VIII. MOUTH

Her lips are colored pink to dark pink. Her mucosa is colored
pink and is well lubricated with saliva. The tongue is along the vertical
midline of her face and she has missing teeth which are replaced by
false teeth. Her speech is intact.

IX. PHARYNX

The uvula is along the vertical midline of her face and the
mucosa is observed to be pinkish. Tonsils are not inflamed.

X. NECK

The trachea is along the vertical midline of her face and there
are no observations of inflamed cervical lymph nodes. The thyroid
gland is not enlarged.

XI. CHEST AND LUNGS

Her breathing pattern is regular and she has symmetrical chest

expansion. No crackles are heard upon auscultation of both lung
fields. She has a surgical incision with dressing, dry and intact, located
at upper outer quadrant of left breast.
XII. HEART

Her pericardial area is flat. Her heart sounds are distinct and
regular upon auscultation.

XIII. BREAST AND AXILLAE

Patient did not allow male student nurse to assess her breasts
thoroughly but was open to answer questions verbally.

Patient’s breasts are equal in size and shape with nipples colored
dark brown. No tenderness is reported by the patient.

XIV. ABDOMEN

The patient has a symmetrically-shaped abdomen with a globular

configuration. Bowel sounds are normoactive. There were no reports
of pain or tenderness upon palpation of abdomen. The patient had a
JP drain; draining well with minimal bloody output.

XV. GENITO-URINARY
The patient did not allow male student nurse to assess her genitals but was
open to answer questions verbally.
The patient is able to urinate without any reports of pain or
burning sensations. The patient claims to have pinkish colored labia.

XVI. BACK AND EXTREMITIES

 Peripheral pulses are present and symmetrical when palpated.
Nail beds are pinkish and have good capillary refill. Range of Motion is
impaired specifically for the left upper extremity. Muscle tone on both
sides on each extremity is equally strong. The spine is along the
vertical midline of the back. Patient reports that she feels pain in her
upper right back when she checks papers in school for an extended
period of time.
 ANATOMY AND PHYSIOLOGY

Reproductive System

The breasts, or mammary tissues, are located between the third and the seventh

ribs of the anterior chest wall and are supported by the pectoral muscles and superficial

fascia. They are specialized glandular structures that have an abundant shared nervous,

vascular, and lymphatic supply. The contiguous nature of breast tissue is important in

health and illness. Men and women alike are born with rudimentary breast tissue, with the

ducts lines with epithelium. In women, the pituitary released of FSH, LH, and prolactin at

puberty stimulates the ovary to produce and released estrogen. This estrogen stimulates

the growth and development of ductile system. With the onset of ovulatory cycles,

progesterone release stimulates the growth and development of ductile and alveolar

secretory epithelium.
Structure

Structurally, the breasts consist of fat, fibrous connective tissue, and glandular

tissue. The superficial fibrous connective tissue is attached to the skin, a fact that is

important in the visual observation of skin movement over the breast during breast self-

examination. The breast mass is supported by the fascia of the pectoralis major and minor

muscles and by the fibrous connective tissue of the breast. Fibrous tissue ligaments,

called Cooper's ligaments, extend from the outer boundaries of the breast to the nipple

area in radial manner.

These ligaments support the breast and form septa that divide the breast into 15 to

25 lobes. Each lobe consists of grape like clusters, alveoli or glands, which are

interconnected by ducts. The alveoli are lined with secretory cells capable of producing

milk or fluid. The route of descent of milk and other breast secretions is from alveoli to

duct, to intra lobar duct, to lactiferous duct and reservoir, to nipple. Breast milk is

produced secondary to complex hormonal changes associated with pregnancy. Fluid is

produced and reabsorbed during the menstrual cycle. The breasts respond to the cyclic

changes in the menstrual cycle with fullness and discomfort.

The nipple is made up of epithelial, glandular, erectile, and nervous tissue.

Areolar tissue surrounds the nipple and is recognized as the darker, smooth skin between

the nipple and the breast. The small bumps or projections on the areolar surface known as

Montgomery's tubercles are sebaceous glands that keep the nipple area soft and elastic.

At puberty and during pregnancy, increased levels of estrogen and progesterone cause the

areola and nipple to become darker and more prominent and at the same time cause the
Montgomery's glands to become more active. The erectile tissue of the nipple is

responsive to psychological and tactile stimuli, which contributes to the sexual function

of the breast. There are many individual variations in breast size and shape. The shape

and texture vary with hormonal, genetic, nutritional, and endocrine factors and with

muscle tone, age, and pregnancy. A well-developed set of pectoralis muscles supports the

breast mass higher on the chest wall. Poor posture, significant weight loss, and lack of

support may cause the breast to droop.

The Lymphatic System

 The lymphatic system consists of organs, ducts, and nodes. It transports a watery

clear fluid called lymph. This fluid distributes immune cells and other factors throughout

the body. It also interacts with the blood circulatory system to drain fluid from cells and

tissues. The lymphatic system contains immune cells called lymphocytes, which protect

the body against antigens (viruses, bacteria, etc.) that invade the body.

Functions:

a.) to collect and return interstitial fluid, including plasma protein to the blood,

and thus help maintain fluid balance

b.) to defend the body against disease by producing lymphocytes

c.) to absorb lipids from the intestine and transport them to the blood.

i. Lymph organs include the bone marrow, lymph nodes,

spleen, and thymus. Precursor cells in the bone marrow produce

lymphocytes. B-lymphocytes (B-cells) mature in the bone marrow.

T-lymphocytes (T-cells) mature in the thymus gland. Besides

providing a home for lymphocytes (B-cells and T-cells), the ducts

of the lymphatic system provide transportation for proteins, fats,

and other substances in a medium called lymph.

Lymph nodes:

Structure:
 Human lymph nodes are bean-shaped and range in size from a few millimeters to

about 1-2 cm in their normal state and there are about 500-700 lymph nodes spread

throughout the body. Lymph nodes are body organs (not glands) spread throughout your

body.

The lymph node is surrounded by a fibrous capsule, and inside the lymph node the

fibrous capsule extends to form trabeculae. The substance of the lymph node is divided

into the outer cortex and the inner medulla surrounded by the former all around except

for at the hilum, where the medulla comes in direct contact with the surface. Thin

reticular fibers, fibroblasts and elastin fibers form a supporting meshwork called

reticulum inside the node, within which the white blood cells (WBCs), most prominently,

lymphocytes are tightly packed as follicles in the cortex. Elsewhere, there are only

occasional WBCs.
i. The number

and composition of

follicles can change

especially when

challenged by an

antigen, when they

develop a germinal

center. A lymph sinus

is a region within the

lymph that is less

densely packed with

WBCs and offers less

resistance to the flow

of lymph. It is lined

by highly branched

reticular cells and

macrophages. Thus,

subcapsular sinus is a

region immediately

deep to the capsule,

and contains very

sparse lymphocytes. It

is continuous with
similar sinuses

flanking the

trabeculae. Multiple

afferent lymph vessels

that branch and

network extensively

within the capsule,

bring lymph into the

lymph node. This

lymph enters the

subcapsular sinus.

The innermost lining

of the afferent lymph

vessels is continuous

with the cells lining

the lymph sinuses.

The lymph gets

slowly filtered

through the substance

of the lymph node and

ultimately reaches the

medulla. In its course

it encounters the

lymphocytes and may

 lead to their activation

as a part of adaptive

immune response. The

concave side of the

lymph node is called

the hilum. The efferent

attaches to the hilum

by a relatively dense

reticulum present

there, and carries the

lymph out of the

lymph node.

Function

Nodes act as filters, with an internal honeycomb of reticular connective tissue

filled with lymphocytes that collect and destroy bacteria and viruses. When the body is

fighting an infection, they begin producing large numbers of lymphocytes which causes

them to swell. Lymphatic fluid in the tissues, before it has gone into a lymph node, is

called interstitial fluid.

 ETIOLOGY
Risk factors are the things that raise your chance of getting a
disease. There are various risk factors that may contribute to the
development of breast cancer. Some have a stronger link to breast
cancer than others. The following are some of the most significant risk
factors for developing breast cancer.

Etiologic Factors Actual Rationale

Precipitating Factors
History of abnormal Present: This was There was residual
breast biopsies the chief complaint neoplasm left from
(breast mass) of the client upon the first occurrence
submitting for of a breast mass in
check-up. 2001. These masses
are the visible results
of the neoplasia
process. They are
composed of actively
growing tissue in
which growth-
controlling
mechanisms are
permanently
impaired, permitting
progressive growth.
 Predisposing Factors
Age Present: The Increasing age is
(greater than 50 patient is already also associated with
yrs. Old) 59 years old an increasing risk of
breast cancer; the
risk is greatest after
50 years of age.
Gender (mostly Present: The Women are more
women) patient is female. prone to breast
cancer because of
the excessive
exposure to sex
hormones.
Late menopause Present: The Breast cancer is
(age >55 y) patient had her clearly related to the
menopausal period sex hormones. In
during 56 years of some types of breast
age. cancers, the
presence of the
female sex hormone
estrogen causes the
cancer cells to grow
and divide rapidly.
During puberty,
estrogen levels
dramatically
increase. During
menopause,
estrogen levels
decrease. The longer
the time the breasts
are exposed to
estrogen, the higher
the risk of
developing breast
cancer. Therefore,
breast cancer risk
may be higher in
women who started
menstruating before
age 12 or in women
who went through
menopause after age
55.
 SYMPTOMATOLOGY

Knowing the Signs and Symptoms of a disease or a sickness can really help in
early detection. When it comes to breast cancer, a technique for early detection has been
encouraged to women for a very long time already. The “Breast Self Exam” has
increased the rate of early detection of breast cancer. This is important because early
detection means early and treatments would have lesser consequences, and late detection
would require greater consequences.

Basic Actual Rationale

• A lump or Present: This is why The lump is caused by

thickening in an the patient went to the neoplasm that
area of the the hospital. formed in the area of
breast the breast.

• A change in the Present: Upon A breast can become

size or shape of assessment, Patient X
a breast shared that she
noticed that her
breasts are irregular
in shape.
smaller if a cancer is
pulling the skin in and
shortening the ducts.

• Dimpling of the Absent Dimpling, known as

skin peau d'orange, may
indicate the presence
of a tumor that is
blocking the lymph
system and causing
 fluid accumulation
under the skin.

• A change in the Absent The growth in the

shape of the breast pulls the nipple
nipple, inward.
particularly if it
turns in, sinks
into the breast
or becomes
irregular in
shape

• A blood-stained Absent The neoplasm affects

discharge from one or more breast
the nipple ducts.

• A rash on a Absent An inflammatory

nipple or response to cancer
surrounding
area
• A swelling or Absent The lump was found in
lump in the the upper outer
armpit quadrant of the left
breast.
 PATHOPHYSIOLOGY

Predisposing factors Precipitating factors:

Age History
Gender of abnormal breast
Late Menopausal biopsies

Neoplasm
formation in
the breast

Primary tumor begins

in the breast

Tumor becomes
invasive
Travel (metastasize) Progressed beyond
to other organ breast to regional
systems in the body lymph nodes

It
Becomes
systemic
 Primary cancer spreads

if treated: If not treated:

surgery
radiotherapy
chemotherapy
Interstitial laser thermotherapy Breast
cancer
spreads to
major
organs
Removal of
Breast
Tissure Compromise
the functions
of the major
organs

Cancer Cell
Destroyed
DEATH
 DOCTOR’S ORDERS
Date Doctor's Order
Remarks
Ordered Rationale
6/29/2008 >please admit patient under my service To establish a
designated doctor
to which all
pertinent
DONE
information
regarding the
patient will be
referred to.
>TPR q shift To monitor the
Vital Signs of the DONE
patient.
>DAT To signify that
the patient has
no restrictions
DONE
regarding intake
of solid or liquid
foods
>attach labs For information
regarding the
patient to be
documented,
DONE
recorded and
organized for
convenient
viewing.
>please inform me [when] admitted For the doctor to
know where to
find the patient DONE
during her
rounds.
>scheduled for FS biopsy of (L) breast mass To determine
possible MRM
whether an MRM
DONE
is needed to be
done.
>refer to Dr. Villarosa for aneth To indicate that DONE
Dr. Villarosa is
involved in a
 procedure
>profurex 1.5 for IVTT ANST 30 min prior to OR For prophylaxis;
prevention of
infection.
>no IV line/IV med on (L) upper extremity To prevent the
condition from DONE
getting worse
10pm >scheduled for OR tomorrow 6/30/08 @ 1pm DONE
12mn >NPO after 7am To prevent any
complications
during the
DONE
operation
scheduled for the
next day
>start IVF of D5LR 1L @ 120cc/˚ where on NPO To supplement
the nutrition of
DONE
the patient while
NPO
Post - op order DONE
6/30/2008 >20 PACU x 2hrs then to room. To monitor and DONE
take care of the
 patient after an
operation
4pm >DAT when fully awake. To notify the
caretakers that
the patient can
eat any tolerated DONE
food when fully
awake

>V/S q 15 min. x 2 hrs. then hourly x 6 hrs then To monitor the

q 2˚
vital signs of the
patient closely
and for the
immediate DONE
intervention to be
taken in case any
unusualities are
revealed
>cont. D5LR 1L @ 120cc/˚ To hydrate the
DONE
patient
>cont. profurex 750mg q 80 IV x 1 more dose DONE
 >ketorolac 30g q 6˚ IVTT x 4 doses given at ADMINISTERE
4pm OR D
>tramadol 50g q 6˚ IVTT x 2 doses then PRN ADMINISTERE
D
>metoclofromide 10g q 80 IV PRN for vomitting ADMINISTERE
D
>O2 at 4L/min DONE
ketoprofen 100g 1 tab BID start 12 noon tom ADMINISTERE
D
>O2 at 4L/min DONE
>mod-high back rest To promote the
breathing of the
patient DONE

>refer For the doctor to

know the
DONE
condition of the
patient
>cefuroxime (profurex) 500mg 1 tab BID DONE
10:30pm >IVFTF: D5LR 1L @ 100cc/hr For the DONE
continuation of
the IVF of the
 patient
7/1/2008 >DAT To notify care
takers that the
patient can eat DONE
any tolerated
food
1:35pm >D/C IVF To signify that
the IVF infusion is DONE
discontinued
>please instruct patients how to drain JP For the promotion
of the patient's DONE
self care
5:30pm >celcoxib 400mg 1 cap now then OD ADMINISTERE
D

Diagnostic Exam
Date Test Normal Value Patient's Result Clinical Nursing
Ordere Significance Responsibilit
d y
6/30/20 Histopathology --- gross: a tan pink piece frozen section -Explain
 08 of tissue that measures infiltrating meaning of
1.2cm ductal result
carcinoma
poorly
differentiated
5/9/200 Ultrasound Sonomammography clear Sonomammography Suspicious solid -Explain
8 delineates a hypoechoic mass, left. meaning of
solid mass at 12 o'clock result
position (L) measuring
up to 11.7 mm.
Chemical Test
5/9/200 Urinalysis Color pale color: light yellow normal Pretest Care
8 yellow to
amber
Transparency clear to protein: (-) normal Explain
slightly purpose and
hazy procedure
Glucose negative sugar: (-) normal and need to
Albumin negative appearance: slightly normal follow
hazy appropriate
Reaction reaction: 6.0 urine
Specific 1.010 - specific gravity: 1.015 normal collection
Gravity 1.035 procedures.
Pus Cells 0-3/hpf
Red Blood 0-2/hpf Microscopic Test -List patient
Cells drugs that
can affect
cells:
test
squamous cells:
outcome on
moderate
laboratory
pus cells: 2-3 normal slip or
RBC: 0-1 /hpf normal computer
Renal Cell: 2-4 /hpf normal screen.

Intratest
 Care:

-Provide
Privacy
during urine
collection.

-Testing
5/14/20 Blood Chemistry glucose 70- 101mg/dl normal Pretest Care:
08 105mg/dl
-Explain
blood urea 10- 33.3mg/dl normal
purpose and
nitrogen 50mg/dl
procedure
creatinine ♀ 0.60- 0.95mg/dl normal
no fasting is
1.10mg/dl
required.
blood uric 2.6- 5.1mg/dl normal
acid ♀ 6.0mg/dl -Explain the
relation of
hemoglobin 110- 139g/L normal test to
150g/L potential
serious
transfusion
reactions.
hematocrit 0.38- 0.42g/L normal
0.47g/L -Recognize
WBC 5-10x10/L 6.5 normal need for
differential follow-up
count testing in
seg. 0.50-0.70 0.65 normal prenatal
neut. screening of
lymphoc 0.35 0.35 normal Rh-antibody
ytes if titer is
platelet 150- 350.0x10/L normal negative
count 400x10/L (repeat 30-
36 weeks of
pregnancy)

-List drugs
patient is
taking on lab
slip or
computer
screen

Posttest
Care:

-Monitor
venipunctur
e sites for
signs of
bleeding or
infection –
apply
pressure
dressing to
site.

-In addition
to blood
specimen,
 saliva,
semen, and
cervical
mucus
specimens
may be
5/16/20 Radiography Lung fields are clear. The Lung fields are clear. implication: Explain
08 Section heart is not enlarged. The heart is not normal chest meaning of
Both hemidiaphragms and enlarged. Both findings result
costophrenic sulci are hemidiaphragms and
intact costophrenic sulci are
intact
Generic Name Cefuroxime sodium

Brand Name
Profurex

Classification Anti- Infectives Drug;

Cephalosporins

Dosage & Frequency Adults: 750mg to 1.5g

cefuroxime sodium I.V. or I.M. q
8 hrs. for 5 to 10 days.

Mechanism of Action Second - generation

cephalosporin that inhibits cell-
wall synthesis, promoting
osmotic instability; usually
bactericidal.

Indications Serious lower respiratory

tract infection, UTI, skin or
skin-structure infections,
bone or joint infection,
septicemia, meningitis,
and gonorrhea.
Perioperative prevention
Uncomplicatd gonorrhea

Contraindications • Contraindicated in patients

hypersensitive to drug or
other cephalosporins.
• Use cautiously in patients
 hypersensitive to penicillin
because of possibility of
cross-sensitivity with other
beta-lactam antibiotics.
• Use cautiously in breast-
feeding women and in
patients with history of
colitis or renal
insufficiency.

Side Effects

• diarrhea
• stomach pain
• upset stomach
• vomiting

Adverse Reaction
• unusual bleeding or
bruising
• difficulty breathing
• itching
• rash
• hives
• sore mouth or throat

Nursing Responsibility
• Tell patient to take all of
the drug as prescribed,
even after he feels better.
• If suspension is being
used, tell patient to shake
container well before
measuring dose.
• Tell patient to notify
doctor if rash or signs and
symptoms of
superinfection occur.
• Inform patient receiving
drug I.V. to alert nurse if
 discomfort occurs at I.V.
insertion site.
• Tell patient to notify
doctor if loose stools or
diarrhea occur.

Generic Name Cefuroxime

Brand Name Ceftin

Classification Anti – Infective drugs;

Cephalosporins

Dosage & Frequency

Adults : 250 or 500 mg P.O.
b.i.d for 10 days

Mechanism of Action Second – generation

cephalosporin that inhibits cell-
wall synthesis, promoting
osmotic instability; usually
bactericidal.

Indications  Uncomplicated skin and

skin structure infection.

Contraindications * Contraindicated in patients

hypersensitivity to drug or other
 cephalosporins.
* Use cautiously in patients
hypersensitive to penicillin
because of possibility of cross-
sensitivity with other beta-
lactam antibiotics.
* Use cautiously in breast-
feeding women and in patients
with history of colitis or renal
insufficiency.

nausea
Side Effects vomiting
anorexia

Adverse Reaction CV: phlebitis

GI: diarrhea
Hematologic: thrombocytopenia
Skin: maculopapular, and
erythematous rashes
Other: anaphylaxis

Nursing Responsibilities • Tell patient to take drug

as prescribed, even after
he feels better.
• Instruct patient to take
oral form with food.
• If patient has difficulty
swallowing tablets, show
him how to dissolve or
crush tablets but warn
him that the bitter taste is
hard to mask, even with
food.
• Instruct patient to notify
prescriber about rash,
loose stools, diarrhea, or
evidence of
superinfection.
Generic Name Celecoxib

Brand Name Celebrex

Classification Nonsteroidal anti-inflammatory

drugs

Dosage & Frequency Adults: 400 mg P.O. b.i.d. with

food, for up to 6 months
Elderly patients: Start at lowest
dosage.

Mechanism of Action Thought to inhibit prostaglandin

synthesis, impeding
cyclooxygenase-2 (COX-2), to
 produce anti-inflammatory,
analgesic, and antipyretic
effects.
• Adjunctive treatment for
Indications familial adenomatous
polyposis to reduce the
number of adenomatous
colorectal polyps.
• Acute pain and primary
dysmenorrheal.
• Contraindicated in
Contraindications patients hypersensitive to
drug, sulfonamides,
aspirin, or other NSAID’s.
• Contraindicated in those
with severe hepatic
impairment and in the
treatment of
perioperative pain after
coronary artery bypass
graft surgery.
• Avoid use in the third
trimester of pregnancy.
• Use cautiously in patients
with history of ulcers or GI
bleeding, advanced renal
disease, dehydration,
anemia, symptomatic
liver disease,
hypertension, edema,
heart failure, or asthma
and in poor CYP2C9
metabolizers.
• Use cautiously in elderly
or debilitated patients.

Side Effects • dizziness or drowsiness

• Constipation
• diarrhea
• dizziness
• headache
• heartburn
 • nausea
• sore throat
• stomach upset
• stuffy nose

CV: hypertension
Adverse Reaction EENT: Pharyngitis
GI: dyspepsia
• Tell patient to report
Nursing Responsibilities history of allergic
reactions to sulfonamides,
aspirin, or other NSAIDs
before therapy.
• Instruct patient to
promptly report signs of
GI bleeding such as blood
in vomit, urine, or stool;
or black, tarry stools.
• Tell woman to notify
prescriber if she becomes
pregnant or is planning to
become pregnant during
drug therapy.
• Instruct patient to take
drug with food if stomach
upset occurs.
• Tell patient that drug may
harm the liver. Advise
patient to stop therapy
and notify prescriber
immediately if he
experiences signs and
symptoms of liver toxicity
including nausea, fatigue,
lethargy, itching,
yellowing of skin or eyes,
right upper quadrant
tenderness, and flulike
syndrome.
• Inform patient that it may
take several days before
he feels consistent pain
relief.
• Advise patient that using
OTC NSAIDs with
celecoxib may increase
the risk of GI toxicity.
Generic Name Ketorolac Tromethamine

Brand Name Toradol

Classification Central nervous system drugs;

Nonsteroidal anti-inflammatory
drugs
Dosage & Frequency

I.M.: 60 mg as a single dose or

30 mg every 6 hours (maximum
daily dose: 120 mg)

I.V.: 30 mg as a single dose or

30 mg every 6 hours (maximum
daily dose: 120 mg)

Mechanism of Action May inhibit prostaglandin

synthesis, to produce anti-
inflammatory, analgesic, and
antipyretic effects.

Indications > Short-term management of

moderately severe, acute pain
for single-dose treatment,
multiple dose treatment, and
when switching from parenteral
to oral administration.
 • Contraindicated in patients
Contraindications hypersensitive to drug and
in those with active peptic
ulcer disease, recent GI
bleeding or perforation,
advanced renal
impairment,
cerebrovascular bleeding,
hemorrhagic diathesis, or
incomplete hemostasis,
and those at risk for renal
impairment from volume
depletion or at risk of
bleeding.
• Contraindicated in children
younger than age 2 and in
patients with history of
peptic ulcer disease or GI
bleeding, past allergic
reactions to aspirin or
other NSAIDs, and during
labor and delivery or
breast-feeding.
• Contraindicated as
prophylactic analgesic
before major surgery or
intraoperatively when
hemostasis is critical; and
in patients currently
receiving aspirin, an
NSAID, or probenecid.
• Use cautiously in patients
who are elderly or have
hepatic or renal
impairment or cardiac
decompensation.
Side Effects Dizziness, drowsiness, sedation
Edema, hypertension
Diarrhea, vomiting
rash
Adverse Reaction CNS: headache
CV: arrythmias
GI: dyspepsia, GI pain, nausea
Hematologic: decreased platelet
 adhesion
Skin: diaphoresis, pruritis
• Warn patient receiving
Nursing Responsibility drug I.M. that pain may
occur at injection site.
• Teach patient signs and
symptoms of GI bleeding,
including blood in vomit;
and black, tarry stool. Tell
him to notify prescriber
immediately if any of
these occurs.
• Tell patient not to take
drug for more than 5 days
in a row.

Generic Name Ketoprofen

Brand Name Apo-Keto, Apo-Keto-E, Novo-

Keto-EC, Orudis, Orudis KT,
Orudis SR, Oruvail

Classification Nonsteroidal anti-inflammatory

drugs

Dosage & Frequency Adults: 25 to 50 mg P.O. q 6 to 8

hours, p.r.n. maximum dose is
300 mg daily.
Or 12.5mg q 4 to 6 hours or 75
mg in 24 hours.

Mechanism of Action Unknown. Produces anti-

inflammatory analgesic, and
antipyretic effects, possibly by
inhibiting prostaglandin
 synthesis.
 Mild to moderate pain,
Indications dysmenorrheal
 Minor aches and pain or
fever.
• Contraindicated in patients
Contraindications hypersensitive to drug and
in those with history of
aspirin-or NSAID-induced
asthma, urticaria, or other
allergic reactions.
• Avoid use during last
trimester of pregnancy.
• Drug isn’t recommended
for children or breast-
feeding women.
• Use cautiously in patients
with history of peptic ulcer
disease, renal dysfunction,
hypertension, heart
failure, or fluid retention.
Headache , dizziness ,
Side Effects Peripheral edema
Tinnitus, visual disturbances
Abdominal pain , diarrhea
Prolonged bleeding time
dyspnea
photosensitivity reactions , rash

Adverse Reaction GI: dyspepsia

GU: nephrotoxicity

• Tell client to take drug 30

Nursing Responsibility minutes before or 2 hours
after meals with a full
glass of water. If adverse
GI reactions occur, patient
may take drug with milk or
meals.
• Tell client not to crush
delayed-release or
extended-release tablets.
• Tell client that full
 therapeutic effect may be
delayed for 2 to 4 weeks.
• Teach client signs and
symptoms of GI bleeding,
including blood in vomit,
urine, or stool.
• Alert client that using with
aspirin, alcohol, other
NSAIDs, or corticosteroids
may increase risk of
adverse GI reactions.
• Warn client to avoid
hazardous activities that
require mental alertness
until CNS effects are
known.
• Because of possibility of
sensitivity to the sun,
advice clients to use a
sunblock, wear protective
clothing and avoid
prolonged exposure to
sunlight.
• Instruct patient to report
problems with vision or
hearing immediately.
• Tell client to protect drug
from direct light and
excessive heat and
humidity.
• Because NSAIDs impair
synthesis of renal
prostaglandins, they can
decrease renal blood flow
and lead to reversible
renal impairment,
especially in clients with
renal or heart failure or
liver dysfunction, in elderly
clients and in those taking
diuretics. Monitor these
client closely
Generic Name Metoclopromide hydrochloride

Brand Name Apo-metoclop, Clopra, Maxeran,

Maxolon, Octamide PFS,
Pramin, Reglan

Classification Gastrointestinal tract drugs;

Antiemetics

Dosage & Frequency Adults: 10 to 20 mg I.M. near

end of surgical procedure;
repeat q 4 to 6 hours, p.r.n.

Mechanism of Action Stimulates motility of upper GI

tract, increases lower
esophageal sphincter tone, and
blocks dopamine receptors at
the chemoreceptor trigger
zone.

Indications > to prevent or reduce

postoperative nausea and
vomiting.
• Contraindicated in
patients hypersensitive to
Contraindications drug and in those with
pheochromocytoma or
seizure disorders.
• Contraindicated in
patients for whom
stimulation of GI motility
might be dangerous.
• Use cautiously in patients
 with history of depression,
Parkinson disease, or
hypertension.

Side Effects • Decreased energy

• Diarrhea
• Dizziness
• Drowsiness
• Headache
• Nausea
• Restlessness
• Tiredness
• trouble sleeping

• lassitude
Adverse Reaction • Insomnia
• Dyspnea
• Hypotension
• hepatotoxic

• Tell patient to avoid

Nursing Responsibility activities that require
alertness for 2 hours after
doses.
• Urge patient to report
persistent or serious
adverse reactions
promptly.
• Advise patient not to
drink alcohol during
therapy.
Generic Name Tramadol

Brand Name Ultram

Classification
Central Nervous System
Drugs; Opioid analgesics
Dosage & Frequency Adult: Initially, 25mg P.O. in
the morning. Adjust by 25 mg
q 3 days to 100 mg/day.
Thereafter, adjust by 50 mg q
3 days to reach 200 mg/day.
Thereafter, give 50 to 100mg
P.O. q 4 to 6 hours, p.r.n.
maximum, 400 mg daily.
Mechanism of Action Unknown. A centrally acting
synthetic analgesic
compound not chemically
related to opioid receptors
and inhibit reuptake of
norepinephrine and
serotonin.
Indications  Moderate to moderately
severe pain.

Contraindications • Contraindicated in
patients hypersensitive
to drug or other
opioids, in
breastfeeding women,
and in those with acute
intoxication from
alcohol, hypnotics,
centrally acting
analgesics, opioids, or
psychotropic drugs.
Serious hypersensitivity
reactions can occur,
usually after the first
dose. Patients with
history of anaphylactic
reaction to codeine and
other opioids may be at
increased risk.
Side Effects • anxiety
• confusion
• vasodilation
• visual disturbances
• abdominal pain
Adverse Reaction

• CNS: dizziness,
headache, seizures
• GI: constipation,
nausea, vomiting
• Respiratory:
Respiratory depression

Nursing Responsibility • Tell patient to take drug

as prescribed and not
to increase dose or
dosage interval unless
ordered by prescriber.
• Caution ambulatory
patient to be careful
when rising and
walking. Warn
outpatient to avoid
 driving and other
potentially hazardous
activities that require
mental alertness until
drug’s CNS effects are
known.
• Advise patient to check
with prescriber before
taking OTC drugs
because drug
interactions can occur.
• Warn patient not to
stop the drug abruptly.

description rationale
Modified radical Mastectomy (MRM) MRM is performed to treat invasive
-the procedure involves the
removal of the entire breast tissue,
including the nipple-aerola complex
and a portion o f the axillary lymph
node dissection (ALND).
SURGICAL PROCEDURE
nursing responsibilities
Before surgery:
breast cancer MRM may be more
threatening to a
woman's self image than
any other type of
surgery. Be sure to
explore the client's
feeling about it. Typically
she will be afraid and
anxious. Be a supportive,
caring listener and help
her express her
concerns.
Explain that a drain or
catheter and suction
may be used to drain the
incision and that the arm
on her affected side will
be elevated. She will
have to sit up and turn in
bed by pushing up with
her unaffected arm. Tell
her she will begin arm
and shoulder exercises
shortly after surgery.
Verify that the client has
signed a consent form.
After surgery:
• When the client returns
to the unit, elevate her
arm on a pillow to
enhance circulation and
prevent edema.
• As ordered, teach the
client arm exercises to
prevent muscle
shortening and
contracture of the
shoulder and to promote
lymph drainage.
• To prevent lymphedema,
make sure no blood
pressure readings and
injectionsare performed
on the affected arm.
Place a sign bearing this
message at the head of
the client’s bed.
• Because MRM causes
emotional distress, teach
the client to conserve
her energy and to
recognize early signs of
fatigue. Gently
encourage her to look at
the operative site by
describing its
 appearance and allowing
her to express her
feelings.
Home care instructions:
• Advice client to use the
affected arm as much as
possible and to avoid
keeping it in dependent
position for a prolonged
period.
• The client should also
protect the arm from
injury to prevent trauma
to the arm.
• Instruct her to be alert
for signs of fatigue and
to rest frequently during
the day for the first few
weeks after discharge.
• Reassure the client that
she can wear the same
type of clothing she wore
before her surgery.

Description Rationale Nursing Responsibilities

Fresh Frozen Biopsy involves Fresh Frozen biopsy is used to Before Biopsy:
removing a sample of breast determine whether it is cancerous • Encourage the client to
tissue. or benign (non- cancerous). verbalize her fears,
concerns and questions.
 • Instruct the client to
discontinue any agents that
can increase the risk of
bleeding, including
products containing aspirin,
nonsteroidal anti-
inflammatory drugs,
vitamin E supplements,
herbal substances ( such as
gingko biloba and garlic
supplements), and
warfarin.
• Instruct the client not to eat
or drink for several hours
after midnight the night
before the procedure.
After Biopsy:
• Monitor the effects of
anesthesia and inspect the
surgical dressing for any
signs for bleeding.
• Once the sedation has worn
off, review the care of the
biopsy site pain
management and activity
restrictions of the client.
Home Care Instructions:
• The dressing covering the
incision should remain in
place approximately 7- 10
 days.
• Use of supportive bra
following the surgery is
encouraged to limit
movement of the breast
and reduce discomfort.
• Encourage to avoid jarring
or high- impact activities
for 1 week to promote
healing of the biopsy site.
 Nursing Theories

NEUMAN, BETTY

Betty Neuman’s Systems model presents levels of defenses

wherein a sickness may progress deeper into the individual’s core

structure. The stronger the defense that the individual has, lesser is

the probability of that person to get sick, and vice versa. It also

presents how each layer of defense brings about a level of prevention.

According to this theory, there are three levels of prevention namely:

(1) Primary prevention, which reduces the possibility of encounter with

stressors and strengthens the flexible line of defense; (2) Secondary

prevention, which is responsible for early case-finding and treatment

of symptoms; and (3) Tertiary prevention, which focuses mainly on

readaptation, reeducation for the prevention of future occurrences,

and maintainance of stability.

atient X has gone through all of the levels of prevention and

back. Her first onset of a breast mass was over and done, which put

her all the way from Secondary prevention to Tertiary prevention. But

a second onset a few years later would put her back to the second

level of prevention, and again back to the third level of prevention.

Knowing this, we must keep in mind that any patient can go from one
level of prevention to another and to another and to another, yet

again. This is mainly why Nurses exist. We are at the patient’s

bedside to offer whatever we can to ensure the welfare of each of our

patients. When it comes to Patient X, she was in the hospital and was

then in the Secondary prevention. As nurses, we were there to take

care of our patient, making sure that infection does not occur and

prepare her for a very good Tertiary prevention outside the hospital.

After treating the symptoms of her sickness, she can then readapt to

maintain the stability of her health. If all goes well during her Tertiary

level of prevention, she will have a very healthy and sickness-free life

ahead of her.
LEININGER, MADELEINE

n the 1940s Leininger (1991) recognized the importance of

caring to nursing. Statements of appreciation for nursing care made

by patients alerted her to caring values and led to her longstanding

focus on care as the dominant ethos of nursing. During the mid-

1950s, she experienced what she describes as cultural shock while she

was working in a child guidance home in the Midwestern United States.

While working as a clinical nurse specialist with disturbed children and

their parents, she observed recurrent behavioral differences among

the children and concluded that these differences had a cultural base.

She identified a lack of knowledge of the children’s cultures as the

missing link in nursing to understand the variations in care of clients.

This experience led her to become the first professional nurse in the

world to earn a doctorate in anthropology, and led to the development

of the new field of transcultural nursing as a subfield of nursing.

atient X is Filipino. She is from the Philippines and Filipino

culture runs in her veins. She is from Davao City, and she teaches in a

public school. Knowing this, we knew that it was obvious how we

should approach her: Having a warm and happy voice will immediately

catch the attention of the patient and will have a presumption that the

student nurse is friendly and approachable. Speaking in Davao’s

‘Bisaya’ will establish more rapport between the patient and the nurse

as this will ensure the clear understanding between the nurse and the

patient and vice versa. Having enough knowledge about the patient’s

culture is definitely an advantage when it comes to establishing

rapport; especially that it is usually the first step to patient care.

HENDERSON, VIRGINIA

Virginia Henderson’s definition of Nursing was very unique and

specific that –if not all- most of what she wrote can still be applied

today. It can even be applied outside the hospital setting and still

serve as a guide for healthier living. According to the theory, a person

is healthy if he/she can; (1) breathe normally, (2) eat and drink

adequately, (3) eliminate body wastes, (4) move and maintain

desirable postures, (5) sleep and rest, (6) select suitable clothes –

dress and undress, (7) maintain body temperature within normal range

by adjusting clothing and modifying the environment, (8) keep the

body clean and well groomed and protect the integument, (9) avoid

dangers in the environment and avoid injuring others, (10)

communicate with others in expressing emotions, needs, fears, or

opinions, (11) worship according to one’s faith, (12) work in such a way

that there is a sense of accomplishment, (13) play or participate in

various forms of recreation, and (14) learn, discover, or satisfy the

curiosity that leads to normal development and health and use the

available health facilities.

All of these components of nursing care are essential for the

patient to live a healthy life. The components that are usually closely

taken cared of by nurses are numbers 1, 2, 3, 4, 5, 7, 8, and 10. If

these components are not taken cared of, the nurse may have failed to

ensure the patient of a healthy life. However, there are components

that the patient his/herself can only influence, which are 6, 9, 11, 12,

13 and 14. Therefore, a healthy life isn’t provided by the nurse alone,

the patient also has a very crucial role in promoting good health. With

Patient X, we were able to ensure all of the components usually taken

cared of by nurses, especially the 8th, keeping the body clean and

protecting the integument. Having a surgical procedure done to a

person’s body greatly increases the chance for pathogens to enter and

wreak havoc. But with a nurse at bedside, this is very unlikely.

 NURSING CARE PLANS
Name: Mrs. X Age: 59 yrs old
Medical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant
Gender: Female
Chief Complaint: Breast mass Room and Bed no.:
324-6
Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3C
Date Admitted: June 29, 2008 Shift: 11-7
Date Cues Need Nursing Objective of Nsg. Evaluation
Diagnosis Care Interventions
July 30, 2008 Subjective: H Risk for infection Within 8 hrs span 1. Orient client for Goal Met:
12:00am E related to break in of nursing care, signs and
A skin integrity as patient will be symptoms of Patient did not
L evidenced by able to: sepsis (systemic show signs and
T surgical incision infection); fever, symptoms of
H under dressing. a. Recognizes chills, diaphoresis, infection; Patient
- signs and altered level of did not get an
P symptoms of consciousness, infection
E ®At increased risk infection positive blood
R for being invaded cultures.
C by pathogenic b. maintain normal
E organisms Vital Signs ®Health teachings
P are essential for
T c. knows the basic the complete
I principles of recovery of a
O preventing client
N infection
- 2.Stress proper
H hand washing
E techniques
A between nurse and
L patient
T
H ®kills or prevent
- the spread of
M microorganisms.
A
N
A
G
E
M
E
N
T
-
P
A
T
T
E
R
N
Name: Mrs. X Age: 59 yrs old
Medical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant Gender: Female
Chief Complaint: Breast mass Room and Bed no.: 324-6
Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3C
Date Admitted: June 29, 2008 Shift: 11-7
Date Cues Need Nursing Diagnosis Objective of Care Nsg. Interventions Evaluation
July ,02 Subjective A Impaired physical Within 8 hrs span of 1. Support affected body July 02, 2008
2008 C mobility related to nursing care, patient parts using pillows/foot @6am
@ 12pm “Dili nalang nako T surgical incision on the will be able to: support, air mattress, water
ilihok kay basig I affected side, loss of a. Take safety bed, and so forth GOAL MET
magsakit.” V muscle tissue with radical
precautions ®to maintain position of
I mastectomy and potential /measures and function and reduce risk of Within the 8
Objective: T lymphedema. individual treatment pressure ulcers hour shift,
Y regimen patient was
>surgical incision - ®Limitations independent b. Verbalizes 2. Identify energy- able to:
under dressing; dry E , purposeful physical understanding of conserving techniques for
and intact X movement of the body or situation/risk factors. ADL's >Take safety
>s/p MRM E of one or more ®limits fatigue, maximizing precautions to
R extremities. participation. prevent
C injuring her
I 3. Encourage participation affected.
S in self-care,occupational/
E diversional/recreational
- activities.
P ®enhances of self-concept
A and sense of independence.
T
T 4. Note
E emotional/behavioral
R responses to problems of
N immobility.
®feelings of frustration
/powerlessness may impede
attainment of goals.

5. Observe movement when

client is unaware of
observation
® note any congruencies
with reports activities

6. Encourage clients
involvement in decision
making as much as possible.
®enhance commitment to
plan, optimizing outcomes.

7.Encourage adequate intake

of fluids and nutritious
foods
®promote well-being and
maximizes energy
production

8.Administer medication
prior to activity as needed
for pain relief
® permit maximal effort/
involvement in activity
Name: Mrs. X Age: 59 yrs old
Medical Diagnosis: Breast cancer stage IIB, left breast @ upper outer quadrant Gender: Female
Chief Complaint: Breast mass Room and Bed no.: 324-6
Attending Physician: Dr. Lobo and Dr. Villarosa Ward: 3C
Date Admitted: June 29, 2008 Shift: 11-7

DATE CUES NEED NURSING GOAL NURSING EVALUATION

/ TIME DIAGNOSIS OF CARE INTERVENTION

J Subjective: S Disturbed body At the end of the 1. Establish trusting July 03, 2008
U “Unsa kaya E image related to three-day span of relationship or rapport to @ 7:00 AM
L itsura sa akong L impending changes care, the client the patient.
Y totoy karon?” F to breast or will begin to ® To gain trust. GOAL
01, “Dili pa nako - disfiguring surgical exhibit her 2. Ascertain whether PARTIALLY
2008 kaya mutan-aw P procedure and perception or support and counseling MET:
@ kay wala koh o E psychosocial present her pre- were initiated when the
12:00 kabalo kung R concern about surgical or possibility of and/or After the three-
AM. unsa akong C sexual baseline body necessity of mastectomy day span of care,
naingon.” E attractiveness as image, as was first discussed. the client was able
“Unsa kaya P manifested by evidenced by: ® This provides to exhibit
ingnon sa mga T actual change in a. verbalization information about patient’s perception or
tao ani?” I breast structure, and of positive level of knowledge and present her pre-
O negative feelings adaptation to her anxiety about individual surgical body image
Objective: N about body by not surgery, situation. as evidenced by
- Modified / looking at the b. wearing of her 3. Encourage patient to verbalization of
Radical S affected body part. usual feminine verbalize feelings positive adaptation
Mastectomy E appearance or regarding the procedure to the surgery done
(MRM) done on L ® Woman who attire after done. Acknowledge like looking
left side of the F undergo surgery for surgery, and normality of feelings of forward to the use
breast - breast cancer c. looking at the anger, depression, and grief of temporary
- dressing placed C experience a sense postoperative site. over loss. Discuss daily prosthesis and
on left breast O of loss – changes in “ups and downs” that can possible
- not looking at N life routines, social occur. reconstructive
the postoperative C interactions, self- ® It helps patient realize surgery. The client
site E concept, and body that feelings are not wore her favorite,
P image – and fear of unusual and that guilty “sexy” clothes and
T death. Recovery about them is not necessary looks good about
during the or helpful. Patient needs to her self. However,
P postoperative recognize feelings before she was not able to
A period after they can be dealt with look or take a
T mastectomy effectively. glimpse of the
T requires a great deal 4. Note behaviors of postoperative site
E of energy. A withdrawal, increased since the dressing
R client’s usual dependency, manipulation, was not yet
N coping strategies or noninvolvement in care. removed.
may not be ® This suggests of
effective. Not every problems in adjustment
one perceives or that may require further Evaluated by:
handles stress in the evaluation and more
same way. Clients extensive therapy. Stephanie Marie
who have surgically 5. Provide opportunities for Lim, St. N.
lost a breast may patient to view and touch
adapt in the same the postoperative site, Benedict Madrazo,
way as they would using the moment to point St.N
to any loss. out positive signs of
healing, normal Jeferson D.
References: appearance, and so forth. Mangitngit, St.N
Black, J. et. al. Remind patient that it will
(2001). MEDICAL- take time to adjust, both Dominique Dawn
SURGICAL physically and emotionally. Margaja, St.N
NURSING: ® Although integration of
Clinical the skin in the Sheena Ann A.
Management for postoperative site into body Nalzaro, St.N
Positive Outcomes. image can take weeks or
6th ed. USA: W.B. even months, looking at the
Saunders Company. site and hearing comments
(made in a normal, matter-
Doenges, M. et. al. of-fact manner) can help
(2002). NURSING patient with this
CARE PLANS: acceptance.
Guidelines for 6. Provide opportunity for
Individualizing patient to deal with
Patient’s Care. 6th mastectomy through
ed. USA: F.A. participation in self-care.
Davis Co. ® Independence in self-
care helps improve self-
Gulanick, M. et. al. confidence and acceptance
(2003). NURSING of situation.
CARE PLAN: 7. Encourage questions
Nursing Diagnosis about current situation and
and Intervention, 5th future expectations.
ed. St. Louis Provide emotional support
Missouri: Mosby when surgical dressings are
Publishing Co. removed.
® Loss of breast causes
Linton, A. et. al. many reactions, including
(2000). feeling disfigured, fear of
INTRODUCTORY viewing scar, and fear of
NURSING CARE partner’s reaction to
OF ADULTS, 2nd change in body.
ed. USA: W.B. 8. Plan or schedule care
Saunders Company. activities with patient.
® Promotes sense of
control and give message
that patient can handle
situation, enhancing self-
concept.
9. Maintain positive
approach during care
activities, avoiding
expressions of disdain or
revulsion. Do not take
angry expressions of
patient personally.
® Assists patient to accept
body changes and feel all
right about self. Anger is
most often directed at the
situation and lack of
control individual has over
what has happened
(powerlessness), not with
the individual caregiver.
10. Identify role concerns
as woman, wife, mother,
career woman, and so
forth.
® This may reveal how
patient’s self-view has
been altered.
11. Provide temporary soft
prosthesis, if indicated.
® Prosthesis of nylon and
Dacron fluff may be worn
in bra until incision heals if
reconstructive surgery is
not performed at the time
of mastectomy. This may
promote social acceptance
and allow patient to feel
more comfortable about
body image at the time of
discharge.
 DISCHARGE PLANNING

MEDICATION
• Encourage the client to comply with all the prescribed
medications.
• Emphasize to the client and her family of the importance of
taking the medications at the prescribed schedule, dosage and
frequency.
• Educate the client about the purpose of the drugs.
• Advice the significant others not to leave the client during
medication to secure that the client has taken the medicines.
• Explain to the client the side effects and adverse effects of the
drug she takes by describing its manifestations. Client and
significant others should be aware so that prompt medical
intervention can be given if in case such reactions occur.

Rationale:
Client and significant others must know and understand the drug’s
generic and brand name, dosage, route, frequency, purpose and side
effects for them to be knowledgeable in administering the drug and to
avoid any accidents regarding drug administration. And for the
significant others to know how important they are in contributing to
the healing process of the client.

EXERCISE
• Encourage to ambulate and assume her normal activities as long
as there will be no problems.
• Instruct client to have frequent arm exercise, the arm where the
postoperative site is located.
 • Educate the client on proper body mechanics to enable her to
relax, be comfortable and prevent strains.
• Instruct the client to balance activities with adequate rest
periods.

Rationale:
Exercise is now also known to be major contributor to health and
can improve the body in three ways: through increased stamina; more
efficient heart, lungs, and circulatory system, improved muscle tone,
through enhanced strength; and more supple joints. It is also essential
to prevent obesity and to help control weight.

TREATMENT
• Educate the client on the importance of drug and money
compliance.
• Discuss to the client the complication of the condition because
knowledge about the condition supports learning that will
decrease anxiety.
• Instruct the client to report or ask medical assistance when
abnormalities occur.
• Educate the family on how to demonstrate a correct performance
of the treatment.

Rationale:
It is important for the client, including the family, to know the
importance of drug or treatment compliance in order to achieve an
effective outcome and facilitate continuous care.
HYGIENE
• Instruct the client to do proper personal hygiene such as taking a
bath daily, brushing her teeth after eating and proper grooming.
• Stress out to the client the importance of hand washing before
and after using the comfort room and eating to deter the spread
of microorganisms.
• Encourage the client as well as the significant others to follow
physician’s instructions regarding personal hygiene and self care.

Rationale:
It is essential to both the client and the significant others to have a
hygiene and healthy lifestyle in order to promote faster recovery and
prevent causing further injury and damage to the client.

OUT-PATIENT REFERRALS
• Instruct the patient to comply with the scheduled follow up check
up to enable the physician to have continuous record on the
client’s condition.
• Advice the client to report any abnormalities observed to provide
immediate medical intervention.
• Review signs and symptoms with the client. These symptoms
may include pressure on the bladder with difficulty voiding or
urinary frequency and urgency, pressure on the rectum with
constipation, lower back and abdominal pain, as well as heavy
bleeding.

Rationale:
Regular check-up or consultation with a physician provides
continuous update on the client’s condition. With the physician’s
medical intervention and the client’s cooperation, faster recovery can
be obtained.

DIET
• Instruct the client to follow physician’s order regarding proper
food intake and tell her its importance.
• Encourage the client to avoid fatty foods and increase intake of
vegetables and fruits.
• Advice client to increase oral fluid intake to facilitate proper
circulation of blood and to provide needed nutrients and
electrolytes.

Rationale:
Having well balanced diet, prescribed foods, and proper fluid intake
facilitates in improving the health of the client.

SEXUALITY
• Inform the client that there is a breadth and depth of sexual
expression possible and that she is a person of value.
• Recognize the feelings of warmth, approval, and friendship, as
well as sharing and touching, are important.
• Inform the patient of the availability of the following services: sex
education or counseling services (individual, couples and family);
sex therapy; group discussion; audiovisual materials and
regarding materials.

Rationale:
 Sexuality is part of a person’s self-concept and involves feelings of
self-worth, acceptance, sharing, affection and intimacy, as well as
feelings of femininity. It includes physical, psychological, emotional,
and social elements and is reflected in everything a person says and
does. It also promotes to the healing process of the client.

SPIRITUALITY
• Encourage client to strengthen her faith with Almighty Father to
provide spiritual growth and promote healing.
• Advice client never to forget God, to ask for Jesus’ help and to
believe in the healing power of the Holy Spirit to promote peace
of mind and relaxation, thus promoting comfort and healing not
just to the mind but also to avoid harm and promote a soothing
and pleasant atmosphere with everyone.

Rationale:
It is important to take care of the spiritual aspect of the client
because it is one of the many factors that could promote healing to the
physical aspect, the body, but also to the client’s spirituality, the mind.