Foundation University

COLLEGE OF NURSING
Dumaguete City

A CASE STUDY ABOUT BREAST CANCER

Prepared by:
Zenyjean Q. Gallegos

Submitted to:
Maam Christina Janice Silot BSN, RN , USRN

Date Submitted:
October 7, 2019
Christina Janice Silot BSN, RN , USRN
Clinical Instructor, Surgery Rotation
Foundation University, College of Nursing
Dumaguete City

Dear Maam ,

Good day!

I, Zenyjean Gallegos, a level III student and currently on surgery rotation at SUMC would like to apply for a case study regarding my client in connection with our hospital duty. In line with this, I
would like to ask permission in using the case of my patient, Mrs. Y. , diagnosed with Right Breast Cancer from Combado, Bacong, Negros Oriental for my case presentation. All information
about the patient will be used for educational intentions and purposes only.

Thank you and I hope for your approval.

Respectfully yours,
ZENYJEAN GALLEGOS Approved by :
Christina Janice Silot BSN, RN , USRN
Clinical Instructor
 ACKNOWLEDGEMENT

In fulfilling my tasks as a student nurse, especially in accomplishing my case study, I have received many blessings. Blessings such as meeting great
people who helped me by enlightening my mind in doing this case study. Albert Schweitzer said, “At times our own light goes out and is rekindled by
a spark from another person , each of us has a cause to think with deep Gratitude of those who have lighted the flame within us”. To those persons, I
thank all of you very much. You helped me accomplish this tasks of doing my Case Study and more than that is learning more than I expected. To my
patient, whom I wish to call ”Guinevere”,to her family, thank you for giving me the opportunity to care , and for providing the information I needed.To
my Dean, to the Faculty of Nursing, especially to Maam Janice , who challenged my neurons to work to its highest potentials, I thank you all
wholeheartedly. To the staff of Silliman University Medical Center, who also guided me and helped me adjust and understand my patient, I salute you
all. Without all of you, this case study would not be made possible.Thank you very much for being my Angels. Because of this experience, I have learned
to value negativities and turn them into inspirations.
 TABLE OF CONTENTS

FOUNDATION UNIVERSITY
Mission……………………………………………………………………………………………………………………………..................................…..5
Vision…………………………………………………………………………………………………...………….…………………….……………..……5
OBJECTIVES ……………………………………………………………………………………………………………………..…..…………....6
INTRODUCTION……………………………………………………………………………………………………………............................…..7
DEMOGRAPHIC PROFILE OF THE PATIENT………………………………………………………………………………………….….…8
DEVELOPMENTAL TASK………………………………………………………………………………………………………………….…….9
PHYSICAL ASSESSMENT………………………………………………………………………………………………………………….……10
GENOGRAM………………………………………………………………………………………………………………………………….……12
ANATOMY AND PHYSIOLOGY…………………………………………………………………………………………………………………13
PATHOPHYSIOLOGY……………………………………………………………………………………………………………………………..16
DIAGNOSTIC AND LABORATORY RESULTS………………………………………………………………………………………………..18
DRUG STUDY……………………………………………………………………………………………………………………………………….21
NCP…………………….……………………………………………………………………………………………………………………….…….47
CONCLUSION AND RECOMMENDATION……………………………………………………………………………………………….……52
REFERENCES……………………………………………………………………………………………………………………………………….54
 Foundation University
COLLEGE OF NURSING
Dumaguete City
Mission
To enhance and promote a climate of excellence relevant to the challenges of the time, where individuals are committed to pursue
new knowledge and life.

Vision:
Foundation University envisions itself as a dynamic, progressive environment that cultivates effective learning, generates creative
ideas, response to societal needs and offers equal opportunity for all.

Life Purpose:
To educate and develop individuals to become productive, creative, useful, and responsible citizens of the society.

Core Values:
Excellence
Commitment
Integrity
Service
CENTRAL OBJECTIVE :
At the end of my case study, the learners shall gain adequate knowledge on concepts related to Breast Cancer, develop skills and manifest desirable
attitudes and values in providing care to patients, families and significant others in similar situations.

SPECIFIC OBJECTIVE :

 Introduce what breast cancer is.

 Discuss the Anatomy and Physiology of systems which can be damaged by breast cancer
 Explain the pathophysiology of the disease.
 Discuss the predisposing and precipitating factors of the disease.
 Discuss the signs and symptoms of the disease.
 Discuss the possible complications of breast cancer
 Present diagnostic and laboratory procedures in detecting breast cancer
 State management goals for a patient with breast cancer
 List the types of oral and IV medications for breast cancer and their mechanisms of action.
 Impart the role of breast cancer self-management education in assisting patients with breast cancerto make required attitude changes to manage
their disease.
 INTRODUCTION

So many women you know may have had breast cancer — friends and neighbors, coworkers, relatives. It seems as if every time you turn around, breast
cancer is being talked about in the newspaper or on TV. You may be fearful of developing breast cancer for the first time or of receiving a diagnosis after
a mammogram or other testing. If you’ve had breast cancer, you may be fearful of a possible recurrence or even of the possibility that breast cancer could
take your life.

Breast cancer is an uncontrolled growth of breast cells. Cancer develops when cells in a part of the body begin to grow out of control. Although there
are many kinds of cancer, they all start because of out-of-control growth of abnormal cells. Normal body cells grow, divide, and die in an orderly fashion.
During the early years of a person's life, normal cells divide more rapidly until the person becomes an adult. After that, cells in most parts of the body
divide only to replace worn-out or dying cells and to repair injuries.

Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to
form new abnormal cells.
Cancer cells develop because of damage to DNA. This substance is in every cell and directs all its activities. Most of the time when DNA becomes
damaged the body is able to repair it.
In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a
person’s DNA becomes damaged by exposure to something in the environment, like smoking. Cancer cells can invade nearby healthy breast tissue and
make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they
then have a pathway into other parts of the body. The breast cancer’s stage refers to how far the cancer cells have spread beyond the original tumor, A
tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous).

The term “breast cancer” refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the
lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can
begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast.

Breast cancer is always caused by a genetic abnormality (a “mistake” in the genetic material). However, only 5-10% of cancers are due to an abnormality
inherited from your mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the
“wear and tear” of life in general.
 Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible
for a woman's death is about 1 in 35(about 3%). In 2008, about 40,480 women will die from breast cancer in the United States. Death rates from breast
cancer have been declining since about 1990, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier
detection through screening and increased awareness, as well as improved treatment.

The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better
diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years.

We have chosen the case because we want to broaden our knowledge about Breast Cancer regarding to the nursing interventions and medical
management. Cancer is the second leading cause of death and is a common case in the Surgical Ward of Baguio General Hospital and medical Center
(BGHMC) that also prompted the group to research on the disease. The risk of developing most types of cancer can be reduced by changes in a person's
lifestyle, for example, by quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living
for many years.
 DEMOGRAPHIC PROFILE

NAME: C. Y. AGE: 28 y.o.

DATE OF BIRTH: March 10, 1966 SEX: Female
ADDRESS: Bacong, Negros Oriental CIVIL STATUS: Married
NATIONALITY: Filipino RELIGION: Jehovah’s Witness
DATE OF ADMINISTRATION : September 16, 2019 ATTENDING PHYSICIAN : Dr. Singco

GENERAL IMPRESSION: Recieved patient awake, alert and oriented to person ,time and place with gauge 20 cannula at left metacarpal vein with ongoing PLR iL at 20
gtts/min, infusing well. No inflammation noted. Mastectomy noted at right breast, with intact dressing and two JP drains in placed.

HISTORY OF PRESENT ILLNESS: A year prior to Admission, patient complained, patient noted a mass before the incision area of the right breast. There was associated
tenderness but no discharged. Consultation was sought and surgery was scheduled, hence admission. She has also a history of Hypertension.

PAST HEALTH HISTORY: The patient doesn’t have health issues in the past as stated . She never had any serious illness such as mumps, chicken pox and dengue.
Family Medical History : Patient verbalized that she is the only one in the family that had cancer. She has stated that there were Family Medical Diseases known in their neither
family nor hereditary sickness such as hypertension and most commonly in cancer. She declared that she had cancer due to an unhealthy lifestyle established during her younger
years. Her aunt had breast cancer and survived and her cousin died due to cancer.

Social/Environmental History : Patient is married and with four children. They are living in a bungalow type of house made of cement and wood just. Purchase of mineral water
is their source of drinking water in the area. She also Garbage is collected on their area daily. She is fond of eating vegetables and fruits, less meat, and fish, and very selective on
food. She dislikes and avoids eating salty foods; she is not very fond of eating sweets. She also stated that promotes drinking water, hydrating herself by drinking lots of water
approximately 8-10 glasses a day, as she knows that it would be a benefit to her health. She also stated that she is a non-alcoholic and non-smoker.

Gynecological History : The patient was pregnant four times and delivered a four healthy children via Normal Spontaneous Delivery. During her pregnancy, she has a regular pre-
natal check-up every month. She has a normal menstrual cycle (ranging from 3 to 4 days every month). She has not undergone any abortion. She has no history of reproductive
abnormalities.

FINAL DIAGNOSIS : Right Breast Cancer

Developmental task
Generativity Versus Stagnation

Erikson’s theory of psychosocial development proposes that people pass through a series of stages centered on social and emotional development. At each point in a person’s life,
he or she faces a developmental conflict that must be resolved. People who overcome these conflicts are able to achieve psychological skills that ultimately last the rest of a
person’s life. Those who fail to master these challenges will continue to struggle.
When a person reach 19-40 yrs. old, they pass through the stage “ Intimacy vs. Isolation”. In this stage, the major conflict centers on forming intimate, loving relationships with
other people.
During this period, we begin to share ourselves more intimately with others. We explore relationships leading toward longer-term commitments with someone other than a family
member.
Successful completion of this stage can result in happy relationships and a sense of commitment, safety, and care within a relationship.
Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will lead to the virtue of love.

Correlation
Since my patient is a 28 years, she falls under Intimacy vs. Isolation stage which takes place during young adulthood. She is a very loving mother. She is very close to her mother
and other siblings. According to her husband, she is very sweet and caring too. As I evaluated her, I could say that she has accomplished Intimacy. She has built a strong and
fulfilling relationships with her loved ones and she feels happy and contented about it.
PHYSICAL ASSESSMENT

A. Psychosocial Status
Patient is 53 y/o, female; currently residing at Bacong, Negros Oriental was born on March 10, 1966 . She attained a College degree having the knowledge and ability to
read and write.
As for now, she is currently a housewife, managing the family and her sons and daughter. At present, source of income comes from her husband. As for hobbies and
interests, she certainly entertains herself by reading, cleaning and doing household chores and taking care of her family. She verbalized that the greatest gift from her is her
children.

Under Erik Erikson’s psychosocial development theory, the patient is under the stage of Generativity Versus Stagnation. She seems to have a good outlook in life.
She was attentive in conversing with the health team members. She deals well with her watcher and visitors. They seem to have good relationship.
B. Mental Status and Emotional Status
The patient was conversant and was oriented to date time, place, and people and to her present condition.
During the duty, there were observed mood swings and emotional changes. Her attitude was inconsistent all throughout. She answers questions and follow instructions
appropriately.
C. Environmental Status
The patient was admitted to Silliman University Medical Center in Surgery . The ward has adequate lighting, good ventilation and warm temperature. It was maintained clean
at all times by the cooperation of the Hospital Janitor, Staff Nurses and Watchers of each patient. The bed has side rails. There are clean blankets and pillows for the patient’s use.
There was a regular garbage collection in the hospital where in there is proper regulation. The garbage bins are placed on the hallway of the ward which is managed by the Hospital
Janitor.
D. Sensory Status

1. Visual Status
The patient’s pupils are equally rounded. There are no reduced accommodation to light changes when the penlight was directed to the eyes. Based on her age, she has
diminished visual acuity nor reduction in visual field. She does not have difficulties in seeing far away objects and recognizing people, and does wear corrective devices such
as eye glasses if needed. She has the capability to read due to good visual acuity.
2. Auditory Status
She has no difficulties in hearing soft voices upon seeing her conversing with her watcher in a whispering manner. She was able to determine from what direction the sound of
the voices were coming from as observed when she turned her head towards the direction of the person she was talking to. There was no impacted cerumen upon inspection.
The ears are symmetrical and in lined with the outer cantus of the eyes.

3. Olfactory Status
Air is felt in the nose when she exhaled. Nasal mucosa is intact, smooth and moist pink upon inspection. She was able to discriminate foul odor as noted when she
complained about the bad smell of the comfort room.

4. Gustatory Status
She is able to determine between different tastes such as sour, sweet, bitter, and salty. She could also taste any flavor or dish served to her.
5. Tactile Status
She was able to perceive hotness. She was also able to perceive cold as noted when she asked why the thermometer is cold.
6. Language Perception and Formation
The patient is fluent in Visaya , Tagalog and in English. She can understand Visayas , Tagalog and English language but fairly understands other dialects. She verbalizes her
needs.
E. Motor Status
Patient can move all her extremities very well. She has no limited movement from her bed and can barely stand on her own. She could ambulate around the ward and walks to
the comfort room to refresh herself without no assistance.

F. Nutritional Status
During her hospitalization, The doctor advised her to take in foods that would boost her immune system, eating a balanced meal composing largely on fruits and vegetables
and small amount of meat. She has a good appetite. Upon palpation, there is no abdominal tenderness.
G. Elimination Status
During hospitalization, her urination ranges from 3-5 times per day only. This must have been because she takes water at all.
On the days that we handled her, she had not defecated during our 7-3 shift. She described her stool as brownish and depending on the foods colors that she intake in.
H. Fluid and Electrolyte status
 Before the hospitalization, Mrs.Y drinks large amounts of water just about 8-10 glasses of water a day. She drinks water every after meal, as she knows that it would be a
benefit to her health.
I. Circulatory Status
Her pulse rate ranges from 62-95 beats per minute which is within the normal limits. However, her blood pressure ranges from 130/80- 180/90 which also her normal BP. She
has a history of hypertension. Her capillary refill is about 2-3 seconds which is normal.
J. Respiratory Status
Her respiration ranges from 16-22 breaths per minutes. She has no episodes of difficulty in breathing.
K. Temperature Status
During her first day of hospitalization, she has no fever. Her temperature ranges from 36.9 – 37.2 degrees centigrade which is within normal range.
L. Integumentary Status
Skin was moist. Lips and buccal mucosa were not dry. There is normal Skin turgor which goes back normally.
M. Comfort and Rest Status
During our shift, she was comfortable in sleeping but there are episodes where she cannot sleep . The lights are on and the Noise surrounding the ward could irritate her
disturbance of sleeping.
 ANATOMY AND PHYSIOLOGY

The Breasts
In order to understand breast cancer, it helps to have some basic knowledge about the normal structure of the breasts. The female breast is made up mainly of lobules (milk-
producing glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood
vessels, and lymphatic vessels).

Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other
tissues.

The Lymphatic system

 The lymph system is important to understand because it is one of the ways in which breast cancers can spread. This system has several parts. Lymph nodes are small, bean-
shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except
that they carry a clear fluid called lymph (instead of blood) away
from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells.
Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes. Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes).
Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular
nodes).
 Knowing if the cancer cells have spread to lymph nodes is important because if it has, there is a higher chance that the cells could have also gotten into the bloodstream and
spread (metastasized) to other sites in the body.

The more lymph nodes that have breast cancer, the more likely it is that the cancer may be found in other organs as well. This is important to know because it could affect your
treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases, and in some cases a woman can have negative lymph nodes and later develop
metastases.

Fibrocystic changes
Most lumps turn out to be fibrocystic changes. The term "fibrocystic" refers to fibrosis and cysts. Fibrosis is the formation of fibrous (scar-like) tissue, and cysts are fluid-filled
sacs.

Fibrocystic changes can cause breast swelling and pain. This often happens just before a woman's menstrual period is about to begin. Her breasts may feel lumpy and,
sometimes, she may notice a clear or slightly cloudy nipple discharge.

Benign Breast Lumps

Benign breast tumors such as fibroadenomas or intraductal papillomas are abnormal growths, but they are not cancerous and do not spread outside of the breast to other
organs.They are not life threatening. Still, some benign breast conditions are important because women with these conditions have a higher risk of developing breast cancer.
PATHOPHYSIOLOGY

Predisposing ETIOLOGY: Precipitating Factors:

Factors:
Unknown  exposure to radiation
Age and certain chemicals
 having a sibling with
Gender leukemia
Somatic mutations in  HTLV-1 virus
Race the DNA  genetic abnormalities
U  chromosomal
Family HIstory translocations
Activate oncogene/
deactivate tumor-
supppresor gene

Malignant transformation
of lymphoid stem cells
s/sx:

Uncontrolled proliferation bone pain Treatment:

of lymphoblast in the bone
joint pain Analgesic
marrow

Diagnostic Treatment:
Lymphoblast replace the
Test:
normal marrow elements  Remission
BM aspiration Induction Therapy
 Consolidation and
BM biopsy Decreased production Maintenance
of normal blood cells Therapy
 BM Transplantation
 CNS prophylaxis
Breast cancer may be classified pathologically as noninvasive (in situ) or invasive (infiltrating). The noninvasive carcinomas are generally thought to be antecedents of invasive
carcinoma.
Intraductal carcinoma (ductal carcinoma in situ) is the most common noninvasive carcinoma among elderly women. It is generally multicentric, and <= 20% recur locally after
partial mastectomy. Axillary lymph nodes are involved in < 2% of cases. Lobular carcinoma in situ, often multicentric and involving both breasts, is rare after menopause.
Of the invasive carcinomas, invasive ductal carcinoma is the most common among women of all ages, comprising about 70% of all cases. The incidence of mucinous (colloid)
carcinoma, a slow-growing tumor in elderly women, increases with age. The incidence of medullary carcinoma, which is often bilateral, decreases with age. Inflammatory
carcinoma of the breast, a very aggressive tumor, is equally prevalent among premenopausal and postmenopausal women.
Paget's disease of the nipple represents spread of a ductal carcinoma to the skin of the nipple; it is usually associated with intraductal carcinoma and less so with invasive
carcinoma. A palpable breast lump is present in 50% of cases.
Although many risk factors may increase your chance of developing breast cancer, it is not yet known exactly how some of these risk factors cause cells to become cancerous.
Hormones seem to play a role in many cases of breast cancer, but just how this happens is not fully understood.
Certain changes in DNA can cause normal breast cells to become cancerous. DNA is the chemical in each of our cells that makes up our genes -- the instructions for how our
cells function. We usually resemble our parents because they are the source of our DNA. However, DNA affects more than how we look. Some genes contain instructions for
controlling when our cells grow, divide, and die. Certain genes that speed up cell division are called oncogenes. Others that slow down cell division, or cause cells to die at the
right time, are called tumor suppressor genes. Cancers can be caused by DNA mutations (changes) that "turn on" oncogenes or "turn off" tumor suppressor genes.

Inherited gene mutations

Certain inherited DNA changes can increase the risk for developing cancer and are responsible for the cancers that run in some families. Mutations in these genes can be
inherited from parents. When they are mutated, they no longer suppress abnormal growth, and cancer is more likely to develop. Women have already begun to benefit from
advances in understanding the genetic basis of breast cancer. These women can then take steps to reduce their risk of developing breast cancers
and to monitor changes in their breasts carefully to find cancer at an earlier, more treatable
stage.

19
Acquired gene mutations

Most DNA mutations related to breast cancer, however, occur in single breast cells during a woman's life rather than having been inherited. These acquired mutations of
oncogenes and/or tumor suppressor genes may result from other factors, such as radiation or cancer(22 of 121) causing chemicals. But so far, the causes of most acquired
mutations that could lead to breast cancer remain unknown. Most breast cancers have several gene mutations that are acquired.

20
 DIAGNOSTIC AND LABORATORY RESULTS

Blood type : O+ - Rh+

Result Normal Value

Coagulation ( Prothrombin time ) 10.8 secs. 10-13 secs.
Sodium 140.5 meq/L 135-145 meq/L
Potassium 4 meq/L 3.6-5 meq/L
FBS 97.45 mg/ dL 70-100 mg/ dL
Creatinine 0.6 mg/dL 0.51-1.17 mg/dL
BUN 12 mg/dL 6-23 mg/dL
Clotting time 5”30 mins. 3-6 mins.
Bleeding time 3 mins. 1-5 mins.

Radiographic Report :
Suspicious clustered pheomorphic and linear microcalcifications, right breast with no definite associated mass. Previous ultrasound however showed a hypoechoic mass in the
3 o clock position of the right breast which may represent the suspicious microcalcifications seen in this study. Findings suspicious for malignancy. Suggest biopsy correlation.
Ultrasound of the Breast :
Hypoechoic mass is seen at the right breast at 3 o clock measuring 0.9 x 0.6 cm, non compressible, the left breast shows no solid nor cystic mass. No enlarged lymph node on
the axilla.
Breast Biopsy :
Ductal Carcinoma cells present. microcalcifications identified.

21
 Drug Study

AMPICILLIN SODIUM AND SULBACTAM SODIUM

(am-pi-sill'in/sul-bak'tam)
Unasyn
Classifications: ANTIINFECTIVE; ANTIBIOTIC; AMINOPENICILLIN
Prototype: Ampicillin
Pregnancy Category: B

Availability

1.5 gm, 3 gm vials

Actions

Antibiotic agent with activity resulting from beta-lactamase inhibition. Sulbactam inhibits beta-lactamases most frequently responsible for transferred drug resistance. Because of
this action, a wide range of beta-lactamases found in organisms resistant to penicillins and cephalosporins have their growth inhibited.

Therapeutic Effects

Effective against both gram-positive and gram-negative bacteria including those that produce beta-lactamase and nonbeta-lactamase producers. Ampicillin without sulbactam is
not effective against beta-lactamase producing strains.

Uses

Treatment of infections due to susceptible organisms in skin and skin structures, intraabdominal infections, and gynecologic infections.

Contraindications

Hypersensitivity to penicillins; mononucleosis.

22
Cautious Use

Hypersensitivity to cephalosporins; pregnancy (category B) or lactation.

Route & Dosage

Administration

Intramuscular

 Reconstitute solution with sterile water for injection by adding 6.4 mL diluent to a 3 g vial. Each mL contains 250 mg ampicillin and 125 mg sulbactam.
 Give deep IM into a large muscle. Rotate injection sites.

 Store powder for injection at 15°–30° C (59°–86° F) before reconstitution. Storage times and temperatures vary for different concentrations of reconstituted solutions;
consult manufacturer's directions.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity (rash, itching, anaphylactoid reaction), fatigue, malaise, headache, chills, edema. GI: Diarrhea, nausea, vomiting, abdominal distention,
candidiasis. Hematologic: Neutropenia, thrombocytopenia. Urogenital: Dysuria. CNS: Seizures. Other: Local pain at injection site; thrombophlebitis.

Interactions

Drug: Allopurinol increases incidence of rash; effectiveness of the AMINOGLYCOSIDES may be impaired in patients with severe end stage renal
disease; chloramphenicol, erythromycin, tetracycline may reduce bactericidal effects of ampicillin—this interaction is primarily significant when low doses are used; ampicillin
may interfere with the contraceptive action of ORAL CONTRACEPTIVES—female patients should be advised to consider nonhormonal contraception while on antibiotics.

Pharmacokinetics

Peak: Immediate after IV. Duration: 6–8 h. Distribution: Most body tissues; high CNS concentrations only with inflamed meninges; crosses placenta; appears in breast
milk. Metabolism: Minimal hepatic metabolism. Elimination: Excreted in urine. Half-Life: 1 h.

Nursing Implications

Assessment & Drug Effects

23
  Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens prior to therapy.
 Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results.
 Report promptly unexplained bleeding (e.g., epistaxis, purpura, ecchymoses).
 Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity and anaphylactoid reaction (see Appendix F). Serious
anaphylactoid reactions require immediate use of emergency drugs and airway management.
 Observe for and report symptoms of superinfections (see Appendix F). Withhold drug and notify physician.
 Monitor I&O ratio and pattern. Report dysuria, urine retention, and hematuria.

Patient & Family Education

 Report chills, wheezing, pruritus (itching), respiratory distress, or palpitations to physician immediately.
 Do not breast feed while taking this drug without consulting physician.

DIPHENHYDRAMINE HYDROCHLORIDE
(dye-fen-hye'dra-meen)
Allerdryl , Banophen, Belix, Ben-Allergin, Bena-D, Benadryl, Benadryl Dye-
Free, Benahist, Benoject, Benylin, Compoz, Diahist, Dihydrex, Diphen, Diphenac
en-50, Fenylhist, Hyrexin, Insomnal, Nordryl, Nytol with DPH, Sleep-Eze
3, Sominex Formula 2, Tusstat, Twilite, Valdrene, Wehdryl
Classifications: ANTIHISTAMINE; H1-RECEPTOR ANTAGONIST
Pregnancy Category: C

Availability

25 mg, 50 mg capsules, tablets; 6.25 mg/5 mL, 12.5 mg/5 mL syrup; 50 mg/mL injection

Actions

H1-receptor antagonist and antihistamine with significant anticholinergic activity. High incidence of drowsiness, but GI side effects are minor. Effects in parkinsonism and drug-
induced extrapyramidal symptoms are apparently related to its ability to suppress central cholinergic activity and to prolong action of dopamine by inhibiting its reuptake and
storage.

24
Therapeutic Effects

Competes for H1-receptor sites on effector cells, thus blocking histamine release.

Uses

Temporary symptomatic relief of various allergic conditions and to treat or prevent motion sickness, vertigo, and reactions to blood or plasma in susceptible patients. Also used in
anaphylaxis as adjunct to epinephrine and other standard measures after acute symptoms have been controlled; in treatment of parkinsonism and drug-induced extrapyramidal
reactions; as a nonnarcotic cough suppressant; as a sedative-hypnotic; and for treatment of intractable insomnia.

Contraindications

Hypersensitivity to antihistamines of similar structure; lower respiratory tract symptoms (including acute asthma); narrow-angle glaucoma; prostatic hypertrophy, bladder neck
obstruction; GI obstruction or stenosis; pregnancy (category C), lactation, premature neonates, and neonates; use as nighttime sleep aid in children <12 y.

Cautious Use

History of asthma; convulsive disorders; increased IOP; hyperthyroidism; hypertension, cardiovascular disease; diabetes mellitus; older adults, infants, and young children.

Route & Dosage

Administration

Oral

 Give with food or milk to lessen GI adverse effects.

 For motion sickness: Give the first dose 30 min before exposure to motion; give remaining doses before meals and at bedtime.

Intramuscular

 Give IM injection deep into large muscle mass; alternate injection sites. Avoid perivascular or SC injections because of its irritating effects.
 Note: Hypersensitivity reactions (including anaphylactic shock) are more likely to occur with parenteral than PO administration.

 Store in tightly covered containers at 15°–30° C (59°–86° F) unless otherwise directed by manufacturer. Keep injection and elixir formulations in light-resistant containers.

25
Adverse Effects ( 1%)

CNS: Drowsiness, dizziness, headache, fatigue, disturbed coordination, tingling, heaviness and weakness of hands, tremors, euphoria, nervousness, restlessness, insomnia;
confusion; (especially in children): excitement, fever. CV: Palpitation, tachycardia, mild hypotension or hypertension, cardiovascular collapse. Special Senses: Tinnitus, vertigo,
dry nose, throat, nasal stuffiness; blurred vision, diplopia, photosensitivity, dry eyes. GI: Dry mouth, nausea, epigastric distress, anorexia, vomiting, constipation, or
diarrhea. Urogenital: Urinary frequency or retention, dysuria. Body as a Whole: Hypersensitivity (skin rash, urticaria, photosensitivity, anaphylactic
shock). Respiratory: Thickened bronchial secretions, wheezing, sensation of chest tightness.

Diagnostic Test Interference

In common with other antihistamines, diphenhydramine should be discontinued 4 d prior to skin testing procedures for allergy because it may obscure otherwise positive
reactions.

Interactions

Drug: Alcohol and other CNS DEPRESSANTS, MAO INHIBITORS compound CNS depression.

Pharmacokinetics

Absorption: Readily absorbed from GI tract but only 40–60% reaches systemic circulation. Onset: 15–30 min. Peak: 1–4 h. Duration: 4–7 h. Distribution: Crosses placenta;
distributed into breast milk. Metabolism: Metabolized in liver; some degradation in lung and kidney. Elimination: Mostly excreted in urine within 24 h.

Nursing Implications

Assessment & Drug Effects

 Monitor cardiovascular status especially with pre-existing cardiovascular disease.

 Monitor for adverse effects especially in children and the older adult.
 Supervise ambulation and use side-rails as necessary. Drowsiness is most prominent during the first few days of therapy and often disappears with continued therapy. Older
adults are especially likely to manifest dizziness, sedation, and hypotension.

Patient & Family Education

 Do not use alcohol and other CNS depressants because of the possible additive CNS depressant effects with concurrent use.
 Do not drive or engage in other potentially hazardous activities until the response to drug is known.
26
  Increase fluid intake, if not contraindicated; drug has an atropine-like drying effect (thickens bronchial secretions) that may make expectoration difficult.
 Do not breast feed while taking this drug.

CLONIDINE HYDROCHLORIDE
(kloe'ni-deen)
Catapres, Catapres-TTS, Dixaril , Duraclon
Classifications: CARDIOVASCULAR AGENT; CENTRAL-ACTING
ANTIHYPERTENSIVE; ANALGESIC
Prototype: Methyldopa
Pregnancy Category: C

Availability

0.1 mg, 0.2 mg, 0.3 mg tablets; 0.1 mg/24 h, 0.2 mg/24 h, 0.3 mg/24 h transdermal patch; 100 mcg/mL, 500 mcg/mL injection

Actions

Centrally acting antiadrenergic derivative. Stimulates alpha2-adrenergic receptors in CNS to inhibit sympathetic vasomotor centers. Central actions reduce plasma concentrations
of norepinephrine. It decreases systolic and diastolic BP and heart rate. Orthostatic effects tend to be mild and occur infrequently. Also inhibits renin release from kidneys.

Therapeutic Effects

Decreases systolic and diastolic BP and heart rate. Orthostatic effects tend to be mild and occur infrequently. Reportedly minimizes or eliminates many of the common clinical
S&S associated with withdrawal of heroin, methadone, or other opiates.

Uses

Step 2 drug in stepped-care approach to treatment of hypertension, either alone or with diuretic or other antihypertensive agents. Epidural administration as adjunct therapy for
severe pain.

Unlabeled Uses

27
Prophylaxis for migraine; treatment of dysmenorrhea, menopausal flushing, diarrhea, paroxysmal localized hyperhidroses; alcohol, smoking, opiate, and benzodiazepine
withdrawal; in the clonidine suppression test for diagnosis of pheochromocytoma; Gilles de la Tourette syndrome; attention deficit disorder with hyperactivity (ADDH) in
children.

Contraindications

Pregnancy (category C), lactation. Use of clonidine patch in polyarteritis nodosa, scleroderma, SLE.

Cautious Use

Severe coronary insufficiency, recent MI, sinus node dysfunction, cerebrovascular disease; chronic renal failure; Raynaud's disease, thromboangiitis obliterans; history of mental
depression.

Administration

 Give last PO dose immediately before patient retires to ensure overnight BP control and to minimize daytime drowsiness.
 Oral dosage is increased gradually over a period of weeks so as not to lower BP abruptly (especially important in the older adult). Follow-up visits should be scheduled
every 2–4 wk until BP stabilizes, then every 2–4 mo.
 Apply transdermal patch to dry skin, free of hair and rash. Avoid irritated, abraded, or scarred skin. Recommended areas for applying transdermal patch are upper outer
arm and anterior chest. Less drug is absorbed from thighs. Rotate application sites and keep a record.
 During change from PO clonidine to transdermal system, PO clonidine should be maintained for at least 24 h after patch is applied. Consult physician.
 Do not abruptly discontinue drug. It should be withdrawn over a period of 2–4 d. Abrupt withdrawal resembles sympathetic stimulation and may result in restlessness and
headache 2–3 h after a missed dose and a hypertensive crisis within 8–18 h.
 Store in tightly closed container at 15°–30° C (59°–86° F) unless otherwise directed.

Adverse Effects ( 1%)

CV: Hypotension (epidural), postural hypotension (mild), peripheral edema, ECG changes, tachycardia, bradycardia, flushing, rapid increase in BP with abrupt
withdrawal. GI: Dry mouth, constipation, abdominal pain, pseudo-obstruction of large bowel, altered taste, nausea, vomiting, hepatitis, hyperbilirubinemia, weight gain (sodium
retention). CNS: Drowsiness, sedation, dizziness, headache, fatigue, weakness, sluggishness, dyspnea, vivid dreams, nightmares, insomnia, behavior changes, agitation,
hallucination, nervousness, restlessness, anxiety, mental depression. Skin: Rash, pruritus, thinning of hair, exacerbation of psoriasis; with transdermal patch: hyperpigmentation,
recurrent herpes simplex, skin irritation, contact dermatitis, mild erythema. Special Senses: Dry eyes. Urogenital: Impotence, loss of libido.

Diagnostic Test Interference

28
Possibility of decreased urinary excretion of aldosterone, catecholamines, and VMA (however, sudden withdrawal of clonidine may cause increases in these values); transient
increases in blood glucose; weakly positive direct antiglobulin (Coombs') tests.

Interactions

Drug: Alcohol and other CNS DEPRESSANTS add to CNS depression; TRICYCLIC ANTIDEPRESSANTS may reduce antihypertensive effects. OPIATE
ANALGESICS increase hypotension with epidural clonidine. Increased risk of bradycardia or AV block when epidural clonidine is used with digoxin, CALCIUM CHANNEL
BLOCKERS, or BETA-BLOCKERS.

Pharmacokinetics

Absorption: Readily absorbed from GI tract. Onset: 30–60 min PO; 1–3 d transdermal. Peak: 2–4 h PO; 2–3 d transdermal. Duration: 8 h PO; 7 d
transdermal. Distribution: Widely distributed; crosses blood–brain barrier; not known if crosses placenta or distributed into breast milk. Metabolism: Metabolized in
liver. Elimination: 80% excreted in urine, 20% in feces. Half-Life: 6–20 h.

Nursing Implications

Assessment & Drug Effects

 Monitor BR closely. Determine positional changes (supine, sitting, standing).

 With epidural administration, frequently monitor BP and HR. Hypotension is a common side effect that may require intervention.
 Monitor BP closely whenever a drug is added to or withdrawn from therapeutic regimen.
 Monitor I&O during period of dosage adjustment. Report change in I&O ratio or change in voiding pattern.
 Determine weight daily. Patients not receiving a concomitant diuretic agent may gain weight, particularly during first 3 or 4 d of therapy, because of marked sodium and
water retention.
 Supervise closely patients with history of mental depression, as they may be subject to further depressive episodes.

Patient & Family Education

 Although postural hypotension occurs infrequently, make position changes slowly, and in stages, particularly from recumbent to upright position, and dangle and move
legs a few minutes before standing. Lie down immediately if faintness or dizziness occurs.
 Avoid potentially hazardous activities until reaction to drug has been determined due to possible sedative effects.
 Do not omit doses or stop the drug without consulting the physician.
 Do not take OTC medications, alcohol, or other CNS depressants without prior discussion with physician.
 Examine site when transdermal patch is removed and report to physician if erythema, rash, irritation, or hyperpigmentation occurs.
29
  If transdermal patch loosens, tape it in place with adhesive. The patch should never be cut or trimmed.
 Do not breast feed while taking this drug.

AMPICILLIN SODIUM AND SULBACTAM SODIUM

(am-pi-sill'in/sul-bak'tam)
Unasyn, Silgram
Classifications: ANTIINFECTIVE; ANTIBIOTIC; AMINOPENICILLIN
Prototype: Ampicillin
Pregnancy Category: B

Availability

1.5 gm, 3 gm vials

Actions

Antibiotic agent with activity resulting from beta-lactamase inhibition. Sulbactam inhibits beta-lactamases most frequently responsible for transferred drug resistance. Because of
this action, a wide range of beta-lactamases found in organisms resistant to penicillins and cephalosporins have their growth inhibited.

Therapeutic Effects

Effective against both gram-positive and gram-negative bacteria including those that produce beta-lactamase and nonbeta-lactamase producers. Ampicillin without sulbactam is
not effective against beta-lactamase producing strains.

Uses

Treatment of infections due to susceptible organisms in skin and skin structures, intraabdominal infections, and gynecologic infections.

Contraindications

Hypersensitivity to penicillins; mononucleosis.

30
Cautious Use

Hypersensitivity to cephalosporins; pregnancy (category B) or lactation.

Administration

Intramuscular

 Reconstitute solution with sterile water for injection by adding 6.4 mL diluent to a 3 g vial. Each mL contains 250 mg ampicillin and 125 mg sulbactam.
 Give deep IM into a large muscle. Rotate injection sites.

 Store powder for injection at 15°–30° C (59°–86° F) before reconstitution. Storage times and temperatures vary for different concentrations of reconstituted solutions;
consult manufacturer's directions.

Adverse Effects ( 1%)

Body as a Whole: Hypersensitivity (rash, itching, anaphylactoid reaction), fatigue, malaise, headache, chills, edema. GI: Diarrhea, nausea, vomiting, abdominal distention,
candidiasis. Hematologic: Neutropenia, thrombocytopenia. Urogenital: Dysuria. CNS: Seizures. Other: Local pain at injection site; thrombophlebitis.

Interactions

Drug: Allopurinol increases incidence of rash; effectiveness of the AMINOGLYCOSIDES may be impaired in patients with severe end stage renal
disease; chloramphenicol, erythromycin, tetracycline may reduce bactericidal effects of ampicillin—this interaction is primarily significant when low doses are used; ampicillin
may interfere with the contraceptive action of ORAL CONTRACEPTIVES—female patients should be advised to consider nonhormonal contraception while on antibiotics.

Pharmacokinetics

Peak: Immediate after IV. Duration: 6–8 h. Distribution: Most body tissues; high CNS concentrations only with inflamed meninges; crosses placenta; appears in breast
milk. Metabolism: Minimal hepatic metabolism. Elimination: Excreted in urine. Half-Life: 1 h.

Nursing Implications

Assessment & Drug Effects

 Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other allergens prior to therapy.
31
  Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results.
 Report promptly unexplained bleeding (e.g., epistaxis, purpura, ecchymoses).
 Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity and anaphylactoid reaction (see Appendix F). Serious
anaphylactoid reactions require immediate use of emergency drugs and airway management.
 Observe for and report symptoms of superinfections (see Appendix F). Withhold drug and notify physician.
 Monitor I&O ratio and pattern. Report dysuria, urine retention, and hematuria.

Patient & Family Education

 Report chills, wheezing, pruritus (itching), respiratory distress, or palpitations to physician immediately.
 Do not breast feed while taking this drug without consulting physician.

TRAMADOL HYDROCHLORIDE
(tra'ma-dol)
Ultram, Zydol
Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANALGESIC; NARCOTIC
(OPIATE) AGONIST
Prototype: Morphine sulfate
Pregnancy Category: C

Availability

50 mg tablets; 50 mg orally disintegrating tablets

Actions

Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and serotonin, suggesting both opioid and nonopioid mechanisms of pain relief. May produce
opioid-like effects, but causes less respiratory depression than morphine.

Therapeutic Effects

Effective agent for control of moderate to moderately severe pain.

32
Uses

Management of moderate to moderately severe pain.

Contraindications

Hypersensitivity to tramadol or other opioid analgesics; patients on MAO inhibitors; patients acutely intoxicated with alcohol, hypnotics, centrally acting analgesics, opioids, or
psychotropic drugs; substance abuse; patients on obstetric preoperative medication; abrupt discontinuation; alcohol intoxication; pregnancy (category C); lactation; children <16 y.

Cautious Use

Debilitated patients; chronic respiratory disorders; respiratory depression; older adults; liver disease; renal impairment; myxedema, hypothyroidism, or hypoadrenalism; GI
disease; acute abdominal conditions; increased ICP or head injury, increased intracranial pressure; history of seizures; patients >75 y.

Route & Dosage

Administration

Oral

 Note: Dosage reduction is recommended for patients with renal insufficiency and hepatic impairment.
 Store at 15°–30° C (59°–86° F).

Adverse Effects ( 1%)

CNS: Drowsiness, dizziness, vertigo, fatigue, headache, somnolence, restlessness, euphoria, confusion, anxiety, coordination disturbance, sleep disturbances,
seizures. CV: Palpitations, vasodilation. GI: Nausea, constipation, vomiting, xerostomia, dyspepsia, diarrhea, abdominal pain, anorexia, flatulence. Body as a
Whole: Sweating, anaphylactic reaction (even with first dose), withdrawal syndrome (anxiety, sweating, nausea, tremors, diarrhea, piloerection, panic attacks, paresthesia,
hallucinations) with abrupt discontinuation. Skin: Rash. Special Senses: Visual disturbances. Urogenital: Urinary retention/frequency, menopausal symptoms.

Diagnostic Test Interference

Increased creatinine, liver enzymes; decreased hemoglobin; proteinuria.

Interactions

33
Drug: Carbamazepine significantly decreases tramadol levels (may need up to twice usual dose). Tramadol may increase adverse effects of MAO INHIBITORS. TRICYCLIC
ANTIDEPRESSANTS, cyclobenzaprine,PHENOTHIAZINES, SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIs), MAO INHIBITORS may enhance seizure risk
with tramadol. May increase CNS adverse effects when used with other CNS DEPRESSANTS. Herbal:St. John's wort may increase sedation.

Pharmacokinetics

Absorption: Rapidly absorbed from GI tract; 75% reaches systemic circulation. Onset: 30–60 min. Peak: 2 h. Duration: 3–7 h. Distribution: Approximately 20% bound to
plasma proteins; probably crosses blood–brain barrier; crosses placenta; 0.1% excreted into breast milk. Metabolism: Metabolized extensively in liver by cytochrome P450
system. Elimination: Excreted primarily in urine. Half-Life: 6–7 h.

Nursing Implications

Assessment & Drug Effects

 Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.
 Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.
 Discontinue drug and notify physician if S&S of hypersensitivity occur.
 Assess bowel and bladder function; report urinary frequency or retention.
 Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.
 Monitor ambulation and take appropriate safety precautions.

Patient & Family Education

 Exercise caution with potentially hazardous activities until response to drug is known.
 Understand potential adverse effects and report problems with bowel and bladder function, CNS impairment, and any other bothersome adverse effects to physician.
 Do not breast feed while taking this drug.

KETOPROFEN
(kee-toe-proe'fen)
Actron, Orudis, Orudis KT, Oruvail, Rhodis A
Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC; ANTIPYRETIC;
NSAID
Prototype: Ibuprofen
Pregnancy Category: B

34
Availability

12.5 mg, 25 mg, 50 mg, 75 mg capsules; 100 mg, 150 mg, 200 mg sustained release capsules

Actions

Nonsteroidal antiinflammatory drug (NSAID) structurally related to ibuprofen. Analgesic potency matches that of indomethacin and is stronger than that of aspirin. Inhibits
platelet aggregation and prolongs bleeding time. Has fewer adverse GI effects than aspirin.

Therapeutic Effects

Has analgesic, antiinflammatory, and antiplatelet properties.

Uses

Acute or long-term treatment of rheumatoid arthritis and osteoarthritis; primary dysmenorrhea; headache; symptomatic relief of postoperative, dental, and postpartum pain;
visceral pain associated with cancer.

Unlabeled Uses

Reiter's syndrome, juvenile arthritis, acute gouty arthritis, biliary pain, renal colic.

Contraindications

Patient in whom aspirin or another NSAID induces asthma, urticaria, bronchospasm, severe rhinitis, shock. Safety during pregnancy (category B), lactation, or in children <12 y is
not established.

Cautious Use

History of GI disease, GI bleeding, active ulcer; renal or hepatic impairment, patient who may be adversely affected by prolongation of bleeding time; heart failure, hypertension;
patient receiving diuretics; geriatric patient; myasthenia gravis.

35
Adverse Effects ( 1%)

CNS: Trouble in sleeping, nervousness, headache, dizziness; depression, drowsiness, confusion, migraine, vertigo. CV: Peripheral edema, palpitations, hypertension, tachycardia.
Special Senses: Visual disturbances, conjunctivitis, eye pain, retinal hemorrhage, pigmentation changes; Dry nose or throat, tinnitus, hearing impairment. GI: Dyspepsia, drug-
induced peptic ulcer, GI bleeding, nausea, vomiting, diarrhea, constipation, flatulence, stomach pain, anorexia, dry mouth, gingivitis, rectal burning and hemorrhage, melena,
jaundice, elevated ALT, AST. Hematologic: Prolonged bleeding time, anemia, purpura, agranulocytosis, thrombocytosis. Urogenital: Gynecomastia, changes in libido, urinary
tract irritation (dysuria, frequency/urgency), renal impairment. Respiratory: Laryngospasm, bronchospasm, laryngeal edema, pharyngitis. Skin: Rash, pruritus, urticaria,
erythema, photosensitivity. Endocrine: Aggravation of diabetes mellitus.

Interactions

Drug: ORAL ANTICOAGULANTS, heparin may prolong bleeding time; may increase lithium toxicity; may increase methotrexate toxicity. Herbal: Feverfew, garlic, ginger,
ginkgo increases bleeding potential.

Pharmacokinetics

Absorption: Readily absorbed from GI tract. Onset: 1–2 h. Peak: 1–2 h. Duration: 4–6 h. Metabolism: Metabolized in liver. Elimination: Excreted primarily in urine, with
some biliary excretion. Half-Life: 1.1–4 h.

Nursing Implications

Assessment & Drug Effects

 Lab tests: Monitor baseline and periodic evaluations of hemoglobin, renal and hepatic function.
 Monitor for and report tinnitus, hearing impairment, and visual disturbance, especially during prolonged or high-dose therapy.
 Monitor for S&S of GI ulceration (e.g., stool for occult blood, persistent indigestion).

Patient & Family Education

 Report promptly signs of jaundice (see Appendix F) as well as the following: blurred vision, tinnitus, urinary urgency or frequency, unexplained bleeding, weight gain with
edema.
 Note: Possible CNS adverse effects (e.g., light-headedness, dizziness, drowsiness).
 Do not drive or engage in potentially hazardous activities until response to drug is known.
 Note: Alcohol, aspirin, or other NSAIDs may increase risk of GI ulceration and bleeding tendencies and therefore should be avoided.
36
  Tell dentist or surgeon that you are taking ketoprofen.
 Do not breast feed infants while taking this drug without consulting physician.

OMEPRAZOLE
(o-me'pra-zole)
Losec , Prilosec, Prilosec OTC, Zegerid
Classifications: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR
Pregnancy Category: C

Availability

10 mg, 20 mg, 40 mg capsules; 20 mg powder for oral suspension

Actions

An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in
the parietal cells.

Therapeutic Effects

Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing.

Uses

Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term treatment of pathologic hypersecretory
conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis. In combination with clarithromycin to treat duodenal ulcers associated
with Helicobacter pylori.

Unlabeled Uses

Healing or prevention of NSAID-related ulcers.

Contraindications

37
Long-term use for gastroesophageal reflux disease (GERD), duodenal ulcers; proton pump inhibitors (PPIs), hypersensitivity; children <2 y; use of OTC formulation in children
<18 y or GI bleeding; pregnancy (category C); use of Zegerid in metabolic alkalosis, hypocalcemia, vomiting, GI bleeding.

Cautious Use

Dysphagia; metabolic or respiratory alkalosis; lactation.

Adverse Effects ( 1%)

CNS: Headache, dizziness, fatigue. GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests. Urogenital: Hematuria, proteinuria. Skin: Rash.

Diagnostic Test Interference

Omeprazole has been reported to significantly impair peak cortisol response to exogenous ACTH. This finding is undergoing further investigation.

Interactions

Drug: Concomitant administration of diazepam and omeprazole may increase diazepam concentrations. Concomitant administration of phenytoin and omeprazole may increase
phenytoin levels. Concomitant administration of warfarin and omeprazole may increase warfarin levels.

Pharmacokinetics

Absorption: Poorly absorbed from GI tract; 30–40% reaches systemic circulation. Onset: 0.5–3.5 h. Peak: Peak inhibition of gastric acid secretion: 5 d. Metabolism:
Metabolized in liver. Elimination: 80% excreted in urine, 20% in feces. Half-Life: 0.5–1.5 h.

Nursing Implications

Assessment & Drug Effects

 Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.

Patient & Family Education

 Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine.
 Report severe diarrhea; drug may need to be discontinued.
 Do not breast feed while taking this drug.
38
ACETAMINOPHEN, PARACETAMOL
(a-seat-a-mee'noe-fen)
Abenol , A'Cenol, Acephen, Anacin-3, Anuphen, APAP, Atasol , Campain , Datril
Extra Strength, Dolanex, Exdol , Halenol, Liquiprin, Panadol, Pedric, Robigesic ,
Rounox , Tapar, Tempra, Tylenol, Valadol
Classifications: CENTRAL NERVOUS SYSTEM AGENT; NONNARCOTIC ANALGESIC,
ANTIPYRETIC
Pregnancy Category: B

Availability

80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg suppositories; 80 mg, 160 mg, 325 mg, 500 mg tablets; 80 mg/0.8 mL, 80 mg/2.5 mL, 80 mg/5 mL, 120 mg/5 mL, 160 mg/5
mL, 500 mg/5 mL liquid

Actions

Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct action on hypothalamus heat-regulating center with
consequent peripheral vasodilation, sweating, and dissipation of heat. Unlike aspirin, acetaminophen has little effect on platelet aggregation, does not affect bleeding time, and
generally produces no gastric bleeding.

Therapeutic Effects

It provides temporary analgesia for mild to moderate pain. In addition, acetaminophen lowers body temperature in individuals with a fever.

Uses

Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or is contraindicated.

Contraindications

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Cautious Use
39
Children <3 y unless directed by a physician; repeated administration to patients with anemia or hepatic disease; arthritic or rheumatoid conditions affecting children <12 y;
alcoholism; malnutrition; thrombocytopenia. Safety during pregnancy (category B) or lactation is not established.

Adverse Effects ( 1%)

Body as a Whole: Negligible with recommended dosage; rash. Acute poisoning: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric or abdominal
pain, diarrhea; onset of hepatotoxicity—elevation of serum transaminases (ALT, AST) and bilirubin; hypoglycemia, hepatic coma, acute renal failure (rare). Chronic ingestion:
Neutropenia, pancytopenia, leukopenia, thrombocytopenic purpura, hepatotoxicity in alcoholics, renal damage.

Diagnostic Test Interference

False increases in urinary 5-HIAA (5-hydroxyindoleacetic acid) by-product of serotonin; false decreases in blood glucose (by glucose oxidase–peroxidase procedure); false
increases in urinary glucose (with certain instruments in glucose analyses); and false increases in serum uric acid (with phosphotungstate method). High doses or long-term
therapy: hepatic, renal, and hematopoietic function (periodically).

Interactions

Drug: Cholestyramine may decrease acetaminophen absorption. With chronic coadministration, BARBITURATES, carbamazepine, phenytoin, and rifampin may increase
potential for chronic hepatotoxicity. Chronic, excessive ingestion of alcohol will increase risk of hepatotoxicity.

Pharmacokinetics

Absorption: Rapid and almost complete absorption from GI tract; less complete absorption from rectal suppository. Peak: 0.5–2 h. Duration: 3–4 h. Distribution: Well
distributed in all body fluids; crosses placenta. Metabolism: Extensively metabolized in liver. Elimination: 90–100% of drug excreted as metabolites in urine; excreted in breast
milk. Half-Life: 1–3 h.

Nursing Implications

Assessment & Drug Effects

 Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged
periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and
excited responses).

Patient & Family Education

40
  Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other
toxic effects.
 Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician.
 Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever.
 Do not give children more than 5 doses in 24 h unless prescribed by physician.
 Do not breast feed while taking this drug without consulting physician.

FOLIC ACID (VITAMIN B9, PTEROYLGLUTAMIC ACID)

(fol'ic)
Apo-Folic , Folacin, Folvite, Novofolacid
FOLATE SODIUM
Folvite Sodium
Classifications: VITAMIN B9
Pregnancy Category: A

Availability

0.4 mg, 0.8 mg, 1 mg tablets; 5 mg/mL injection

Actions

Vitamin B complex essential for nucleoprotein synthesis and maintenance of normal erythropoiesis. Acts against folic acid deficiency that impairs thymidylate synthesis and
results in production of defective DNA that leads to megaloblast formation and arrest of bone marrow maturation.

Therapeutic Effects

Stimulates production of RBCs, WBCs, and platelets in patients with megaloblastic anemias. Include improved symptoms of glossitis, diarrhea, constipation, weight loss,
irritability, fatigue, restless legs, diffuse muscular pain, insomnia, forgetfulness, mental depression, pallor.

Uses

Folate deficiency, macrocytic anemia, and megaloblastic anemias associated with malabsorption syndromes, alcoholism, primary liver disease, inadequate dietary intake,
pregnancy, infancy, and childhood.

Contraindications

41
Folic acidalone for pernicious anemia or other vitamin B12 deficiency states; normocytic, refractory, aplastic, or undiagnosed anemia.

Cautious Use

Pregnancy (category A), lactation.

Adverse Effects ( 1%)

[Reportedly nontoxic. Slight flushing and feeling of warmth following IV administration.]

Diagnostic Test Interference

Falsely low serum folate levels may occur with Lactobacillus casei assay in patients receiving antibiotics such as TETRACYCLINES.

Interactions

Drug: Chloramphenicol may antagonize effects of folate therapy; phenytoin metabolism may be increased, thus decreasing its levels in folate-deficient patients.

Pharmacokinetics

Absorption: Readily absorbed from proximal small intestine. Peak: 30–60 min PO. Distribution: Distributed to all body tissues; high concentrations in CSF; crosses placenta;
distributed into breast milk. Metabolism: Metabolized in liver to active metabolites. Elimination: Small amounts eliminated in urine in folate-deficient patients; large amounts
excreted in urine with high doses.

Nursing Implications

Assessment & Drug Effects

 Obtain a careful history of dietary intake and drug and alcohol usage prior to start of therapy. Drugs reported to cause folate deficiency include oral contraceptives, alcohol,
barbiturates, methotrexate, phenytoin, primidone, and trimethoprim. Folate deficiency may also result from renal dialysis.
 Keep physician informed of patient's response to therapy.
 Monitor patients on phenytoin for subtherapeutic plasma levels.

Patient & Family Education

 Remain under close medical supervision while taking folic acid therapy. Adjustment of maintenance dose should be made if there is threat of relapse.
 Do not breast feed while taking this drug without consulting physician.
42
FERROUS SULFATE
(fer'rous sul'fate)
Feosol, Fer-In-Sol, Fer-Iron, Fero-Gradumet, Ferospace, Ferralyn, Ferra-
TD, Fesofor, Hematinic, Mol-Iron, Novoferrosulfa , Slow-Fe
FERROUS FUMARATE
(fer'rous foo'ma-rate)
Feco-T, Femiron, Feostat, Fersamal, Fumasorb, Fumerin, Hemocyte, Ircon-FA, Neo-Fer-
50 , Novofumar , Palafer , Palmiron
FERROUS GLUCONATE
(fer'rous gloo'koe-nate)
Fergon, Fertinic , Novoferrogluc , Simron
Classifications: BLOODS FORMERS, COAGULATORS, AND ANTICOAGULANTS; IRON
PREPARATION
Pregnancy Category: A

Availability

Ferrous Sulfate 167 mg, 200 mg, 324 mg, 325 mg tablets; 160 mg sustained release tablets, capsules; 90 mg/5 mL syrup; 220 mg/5 ml elixir; 75 mg/0.6 mL drops

Ferrous Fumarate 63 mg, 100 mg, 200 mg, 324 mg, 325 mg, 350 mg tablets; 100 mg/5 mL suspension; 45 mg/0.6 mL drops

Ferrous Gluconate 240 mg, 325 mg tablets

Actions

Ferrous sulfate: Standard iron preparation against which other oral iron preparations are usually measured. Corrects erythropoietic abnormalities induced by iron deficiency but
does not stimulate erythropoiesis. May reverse gastric, esophageal, and other tissue changes caused by lack of iron. Ferrous gluconate: Claimed to cause less gastric irritation and
be better tolerated than ferrous sulfate.

Therapeutic Effects

Experienced within 48 h as a sense of well-being, increased vigor, improved appetite, and decreased irritability (in children). Reticulocyte response begins in about 4 d; it usually
peaks in 7–10 d (reticulocytosis) and returns to normal after 2 or 3 wk. Hemoglobin generally increases by 2 g/dL and hematocrit by 6% in 3 wk. Iron supplements correct
erythropoietic abnormalities induced by iron deficiency but do not stimulate erythropoiesis.

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Uses

To correct simple iron deficiency and to treat iron deficiency (microcytic, hypochromic) anemias. Also may be used prophylactically during periods of increased iron needs, as in
infancy, childhood, and pregnancy.

Contraindications

Peptic ulcer, regional enteritis, ulcerative colitis; hemolytic anemias (in absence of iron deficiency), hemochromatosis, hemosiderosis, patients receiving repeated transfusions,
pyridoxine-responsive anemia; cirrhosis of liver.

Cautious Use

Pregnancy (category A), lactation.

Adverse Effects ( 1%)

GI: Nausea, heartburn, anorexia, constipation, diarrhea, epigastric pain, abdominal distress, black stools. Special Senses: Yellow-brown discoloration of eyes and teeth (liquid
forms.) Large Chronic Doses in Infants Rickets (due to interference with phosphorus absorption). Massive Overdosage Lethargy, drowsiness, nausea, vomiting, abdominal
pain, diarrhea, local corrosion of stomach and small intestines, pallor or cyanosis, metabolic acidosis, shock, cardiovascular collapse, convulsions, liver necrosis, coma, renal
failure, death.

Diagnostic Test Interference

By coloring feces black, large iron doses may cause false-positive tests for occult blood with orthotoluidine (Hematest, Occultist, Labstix); guaiac reagent benzidine test is
reportedly not affected.

Interactions

Drug: ANTACIDS decrease iron absorption; iron decreases absorption of TETRACYCLINES, ciprofloxacin, ofloxacin; chloramphenicol may delay iron's effects; iron may
decrease absorption of penicillamine. Food: Food decreases absorption of iron; ascorbic acid (vitamin C) may increase iron absorption.

Pharmacokinetics

Absorption: 5–10% absorbed in healthy individuals; 10–30% absorbed in iron-deficiency; food decreases amount absorbed. Distribution: Transported by transferrin to bone
marrow, where it is incorporated into hemoglobin; crosses placenta. Elimination: Most of iron released from hemoglobin is reused in body; small amounts are lost in
desquamation of skin, GI mucosa, nails, and hair; 12–30 mg/mo lost through menstruation.

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Nursing Implications

Assessment & Drug Effects

 Lab tests: Monitor Hgb and reticulocyte values during therapy. Investigate the absence of satisfactory response after 3 wk of drug treatment.
 Continue iron therapy for 2–3 mo after the hemoglobin level has returned to normal (roughly twice the period required to normalize hemoglobin concentration).
 Monitor bowel movements as constipation is a common adverse effect.

Patient & Family Education

 Note: Ascorbic acid increases absorption of iron. Consuming citrus fruit or tomato juice with iron preparation (except the elixir) may increase its absorption.
 Be aware that milk, eggs, or caffeine beverages when taken with the iron preparation may inhibit absorption.
 Be aware that iron preparations cause dark green or black stools.
 Report constipation or diarrhea to physician; symptoms may be relieved by adjustments in dosage or diet or by change to another iron preparation.
 Do not breast feed while taking this drug without consulting physician.

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 Conclusion
If a newly diagnosed Breast cancer patient asked you to define cancer, could you tell her that she has still hope? We all have heard the word "cancer" many times,
however very few people understand the disease and how it develops.
Cancer is a complex group of over 100 different types of cancer. Cancer can affect just about every organ in the human body.
All cancers are different, and require different treatment. What may be effective for prostate cancer, probably will not be for bladder cancer. Diagnosing cancer will vary
as well, depending on the organ affected.
End-of-Life Issues
Palliative care, which provides physical, emotional, and spiritual relief, must be provided with attempts for curative therapy and becomes the exclusive goal when cure
cannot be expected at all stages of breast cancer, treatment needs to be modified for life expectancy. For patients with metastatic disease for which cure is not attainable, the
physician should clarify the goals of care through frequent, clear discussions with the patient and, when appropriate, the family.
All should recognize that cognitive impairment alone does not exclude the patient from participating in decision making, because some patients with impaired cognition
are able to understand, explain the consequences of, and voice an opinion about certain treatment options. Pain from bony metastases should be treated as described above with
nonsteroidal anti-inflammatory drugs, pamidronate, local radiation, and strontium 89 rather than with opioids if possible. Palliative chemotherapy may be useful when the tumor
invades vital organs.
Recommendation

Health care providers should:

 Should continuously monitor the vital signs of the patient.
 Observe the patient to avoid development of complications.
 Promote safety of the patient.
 Educate patient and significant others about the disease, and
 Explain the procedure done to the patient. The evaluation and diagnosis of Breast Cancer is based on the presenting symptoms and history combined with a focused physical
assessment, imaging studies, and possibly a functional study of the breast.
Significant others should:
 Actively cooperate in the rendering of care for the patient.

46
 Be sensitive to the needs.
 In addition, every effort is made to retrieve and analyze breast has passed spontaneously or retrieved through aggressive interventions.
 Cooperate with the health care providers in the implementation of her Health Care programs.

47
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