Dissecting The Nature of The Silent Assailant - FINAL

DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis ABSTRACT This
paper talks about the SILENT ASSAILANT ------ Cancer. This would significantly help in the alarming increase of cancer cases in the Philippines because through this study, interventions are laid down in the table to effectively manage the occurrence of the disease condition. On the other side of the coin, this study would further identify preventive measures to avoid development of cancer cells and halt its spread to other organs of the body. And in the event that this wont be stopped, early identification through screening and other tests should be instituted. Each chapter talks about various ideas specifically identified in association to the main topic: Chapter 1 is the expression of gratitude to people who played major roles in significantly helping the student nurses in achieving the success of this study. Chapter 2 presents the background of the disease as well as the prevalence and incidence rates while chapters 3 and 4 talk about the aims and purposes of the study. The 5th chapter is the mainstay of the study as it talks about the necessary and important details that were obtained from the client, her significant others and patients chart which directly contribute to the development of the disease condition and theory in which our study is based upon. Chapter 6 aims to discuss the anatomy and physiology of the systems involved in the condition and chapter 7, on the other hand, talks about the pathology of the condition that further explains the reason behind the various clinical manifestations seen to the client. The chapter after 7th, solidifies the claims of the client, significant others and even by the attending physician through different kinds of diagnostic exam results. Medical and surgical management will explicitly discuss in chapter 9 in order to avoid complications while chapter 10 will separately discuss the actions that nurses have made with corresponding ideal interventions that should be instituted during the whole course of the care. The 11th, conveys outcome of the nurses action in collaboration with the physicians and other members of the medical team which also includes prognosis of the client. Chapter 12 pacifies confusion and incomprehension as it defines significant terms that are important in the study. And the 13th, although considered to be an unlucky number, backs up all ideas of the study and bring luck to us, students, in solidifying our assumptions and claims through evidenced-based materials and scientific explanations provided by past researches and studies.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis As your reading progresses, may you find significant data that would further hone your nursing knowledge and clinical skills that would embody your nursing practice. Nursing is a dynamic field that requires continuous research and study: What is true before may not be true today, and what is true today may not be true tomorrow. Were also hoping that you will appreciate our efforts in formulating this study and you will grasp essential information that will be used in the future. Furthermore, were hoping that this study would be useful in future researches and studies in formulating and establishing new medications, therapy, diagnostic examinations and interventions that would promote the health of the individuals, prevent the occurrence of the disease, treat underlying cause of the disease and bringing back individuals in its optimum health.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis TABLE OF CONTENTS I. ACKNOWLWEDGEMENT II. INTRODUCTION III. SIGNIFICANCE OF THE STUDY IV. OBJECTIVES OF THE STUDY V. PATIENTS PROFILE VI. ANATOMY AN DPHYSIOLOGY VII. PATHOPHYSIOLOGY VIII. DIAGNOSTIC TESTS IX. MEDICAL AND SURGICAL MANAGEMENT X. NURSING MANAGEMENT XI. EVALUATION, RESULTS, AND DISCUSSION XII. DEFINITION OF TERMS XIII. BIBLIOGRAPHY
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis I. ACKNOWLEDGEMENT Our deepest gratitude and sincerest felicitation to the following people who contributed to the success of this case study: First and foremost to our Almighty God for equipping us with wisdom and the heart to care for our patient, for giving us the strength to endure the sleepless nights and for the divine providence for the completion of this study. To our parents, for being Gods instrument in providing our needs and for their unfailing support. To the patient and her family for the cooperation during the whole course of care, for disclosing and entrusting essential information. And lastly to our Clinical Instructor, Ms. Syvel Jane Mata-Caharian, who patiently supervise us.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis II. INTRODUCTION Cancer is a disease of the cell in which the normal mechanisms for control of growth and proliferation have been altered. It is invasive, spreading directly to surrounding tissue as well as to new sites in the body. Breast cancer, invasive or non-invasive, is the most commonly diagnosed cancer among American women, second only to lung cancer for cancer mortality. Incidence increases with age; more than 77% of women diagnosed with breast cancer are older than 50 years of age at diagnosis. Onset and progression of breast cancer appear to be intimately, but not exclusively, tied to genetic alterations. While significant progress has been made in the identification of inherited defects in the somatic genes responsible for hereditary and familial breast cancer syndromes, in aggregate, it is estimated that 5-10% of breast cancer cases occur in families with significant inherited risk. The two-hit hypothesis geneticalteration and mutation has been used to explain this phenomenon. Many women diagnosed with breast cancer have no known risk factors. (Black, 2007) Metastatic breast cancer (also called stage IV or advanced breast cancer) has spread beyond the breast to other organs in the body (most often the bones, lungs or liver). Although metastatic breast cancer has spread to another part of the body, it is still considered and treated as breast cancer. (http://ww5.komen.org). On the other hand, peritoneal metastasis, although rare in occurrence, accounts for 2% (2 out 1 million people) to people with invasive tumors (regardless of the cancer classification). In the Philippines, in a report released recently by the Department of Health, breast cancer is now the most common cancer in the Philippines, taking at least 16 percent of the 50,000 cases diagnosed with cancer. This is made even more alarming by another report from the Philippine Breast Cancer Network, which announced that the Philippines has now the highest incidence rate of breast cancer in Asia and is also considered to have the 9th highest incidence rate in the world today. This is indeed frightening for todays women. To date, breast cancer is still the leading cause of cancer among women, accounting for 28 percent of the total cases. One out of four who are diagnosed with breast cancer die within the first five years, and no less than 40% die within 10 years. And the incidence of breast cancer continues to rise and whats more distressing is the fact that all women
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis are at risk and anyone can be victim mothers, daughters, sisters, and friends regardless of age, race, social or economic status. (http://www.malaya.com.ph/07062010/liv4.html) It is also the number one cause of cancer morbidity and mortality among Filipino women accounting for almost 30 percent of all female malignancies," Ona said, adding it is estimated that there were a total of 12,262 new breast cancer cases in 2010 with 4,371 deaths. On the other hand, survival rate for breast cancer in the Philippines is below 40 percent compared to the high survival rates of 80 to 98 percent already achieved in developed countries. We chose the case because of the following reasons; to further enhance our knowledge and skills in addition to the knowledge we have learned from the book, to know the priority medical and nursing care management that were executed along the course of the disease, we also want to know the applicable palliative measures to promote quality of life.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis III. SIGNIFICANCE OF STUDY
Nursing Education. The dynamism of nursing education requires continuous update thus with this study, we believe, would contribute in nursing education as it adds up to our knowledge in intervening effectively in the existence of the disease condition and managing independently complications and other sequelae of cancer.
Nursing Practice. Knowledge and skills are intertwined in a way that whatever knowledge that will be gathered in theory should also be applied in the nursing practice to evaluate the effectiveness of the new management. Hence, whatever concepts that will be squeezed from this study, hope it will be useful in the clinical area in preventing fatal complications and, if the situation permits, maximize the health of the patients in its optimum health and lessen the potentiality for recurrence.
Nursing Research. This study is equally beneficial to nursing research as it paves way to new discoveries such as new medicines, diagnostic examinations to detect early manifestations of cancer, nursing management, surgical management and other effective interventions that will completely eradicate cancer cells in the body.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis IV. OBJECTIVES OF THE STUDY In order to learn more about the health condition of the patient, the study wants to fathom about the predisposing and precipitating factors, anatomy and physiology and the pathophysiology of the condition experienced by the client. Basically, the main goal of this study in relation to knowledge is to identify the nursing interventions after the condition of patient. The study aims to critically analyze the qualitative and quantitative data gathered in order to establish connection between the different manifestations experienced by the patient with that of the disease process. To be able to improve skills, the students also endeavors to come up with nursing care plans that will alleviate patients condition. The presentors also intend to compare and contrast the ideal management for Breast cancer with that of the actual management. In addition, the study seeks to disseminate essential information to everybody for awareness. Furthermore, by this study, the provider will be able to exercise that attitude of determination and in order to come up with a successful study. SCOPE AND LIMITATIONS This case study tackles about breast cancer specifically on the case of Patient X. It includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study and diagnostic exams done. The anatomy and physiology is also included as well as the pathophysiology of breast cancer with its associated factors. The Medical and Nursing Management along with the evaluation of patients condition and other relevant data are also being covered. The scope of the plan encompasses during the course of duty last January 26 27, 28 and February 2 and 3 of 2012 wherein the assigned students have assessed the client with cumulative interaction and good rapport to the patient and significant others. Nursing Management covers the above mentioned dates which encompasses the clients Recovery Phase. Data gathering about the Laboratory results covers from January 19 to February 4, 2011. The areas of concerns are limited to the discussions of Breast cancer and its sequelae and the quality of Nursing Care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and her medical records.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis V. PATIENTS PROFILE A. SOCIO-DEMOGRAPHIC DATA This is a case of 64 year old Female, Filipino, a resident of Lapasan, Cagayan de Oro City. She is happily married to a 64-year-old Filipino for almost 25 years who is also in good health. She only has one daughter, who works outside of the country. Patient X is an elementary graduate. She used to be a dressmaker, but when she started undergoing chemotherapy, she stopped working. Patient X was admitted last January 19, 2012 at 1:35 pm for the second time at Capitol University Medical City. Patient Xs original weight is 44.3 kg. Right after completing chemotherapy but due to her ascites she now weighs 52.5 kg, her height is 151 cm tall. The BMI is 11.8 using her original weight which falls under the underweight category. Vital Signs Upon assessment, the following data were obtained from Patient X: BP: 100/60mmHg, RR: 28 cpm (tachypneic), HR: 92 bpm, Temp.36.7. Vital signs BP Pulse Rate Respiratory Rate Temp. O2 sat. Day 1 100/60 mmHg 89 bpm 28cpm 36.5 C 97 % Day 2 100/60 mmHg 92 bpm 32cpm 36.7 C 90% Day 3 100/70 mmHg 91 bpm 18 cpm 36.6 C 96% Day 4 110/70 mmHg 98 bpm 18 cpm 36. 3 C 95% Day 5 100/60 mmHg 72 bpm 28 cpm 36.7 C 96%
Chief Complaint Patient X was brought to the hospital due to abdominal distention that prompted her to seek medical attention. History of Present Illness Patient was diagnosed of having a breast cancer stage IV with metastasis. Patient already underwent chemotherapy for 6 cycles since April 2011 and completed it on September 2011. She also underwent paracentesis on April, June, July, September and December of 2011. Patient was admitted for paracentesis & check-up.
Previous Hospitalizations/Surgeries
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Patient X was first admitted at CUMC last December 28, 2010 due to dyspnea and was found out to be caused by accumulation of fluids in her lungs so she underwent an operation which was Tube Thoracostomy at the right midaxillary. Along with that, it was discovered that she has diabetes mellitus Type II as evidenced by her blood glucose level that reached 300mg/dL upon her first admission stated by her significant other. She was also diagnosed to have Breast Cancer stage IV at the same month and year (December 28, 2010). Her Lump was seen when she had her CT-scan. Last April 2011, due to a tissue that came out from her vagina while taking a bath, she was admitted at COMC and underwent Dilatation and Curettage and was discharged. She then submitted herself for chemotherapy at CUMC from April to September of the year 2011. Instead of starting the chemotherapy right away she started undergoing it on April of 2011 due to financial problem. For the third time, she was admitted back to CUMC last January 19, 2012 due to abdominal distention. She underwent Tube Thoracostomy at the left mid-axillary. General Appearance Upon assessment, patient X looked conscious and coherent but was generally weak and pale. She can answer to questions appropriately without any delay. She is hooked with PLR 1L @ 20gtts/min infusing well at the right arm and with CTT draining light yellow color and cloudy drainage.
B. NUTRITION AND METABOLIC PATTERN Pre-hospitalization: Patient X eats three times a day, and if by chance she grabs ample time to eat snacks in between meals as long as shes not busy during her work. She consumes -1 cup of rice every meal with her desired viand in a fair appetite. She likes to eat pork, anchovies, dried fish and sweets, her most favorite. She admitted that shes been obese even before she was diagnosed to have breast cancer and before undergoing chemotherapy. She used to drink 6-8 glasses of water a day. In the morning, she drinks two cups of coffee to motivate her in working with at least 2-3 hours interval. Glucerna became part of her diet ever since she was diagnosed of Diabetes and Metformin was prescribed as her medicine. Vitamin supplements like Aminovita and Vitamin B Complex (Pizotifen) are included in her maintenance drugs, as well as Anastrozole (Arimidex) which is an anti-neoplastic drug for her breast cancer. Patient X had already been smoking for 19 years, 2 sticks per day since she was
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis 30 yrs. old and had stopped when she reached 49 years old. Shes not an alcoholic beverage drinker. During hospitalization: Patient X has fair appetite consuming only half of share. She was advised to eat any food she likes as long as she can tolerate it but opted to consume porridge which predisposes her from protein deficiency. She consumes 100 200 ml of water every shift. On 1st and 2nd day, She was hooked to an IVF of PLR 1L regulated @ 20 gtts/min. infusing well @ left arm, on the 3rd and 4th day, she was hooked to an IVF of D5LR. CTT was attached to her left chest mid-axillary draining well to a one water-sealed bottle with light-yellow color and cloudy drainage. On the first day, patients CTT had a 50 cc of output during 7-3 pm shift on January 27, 2012, and then 70 cc the second day (January 28, 2012) during the shift. On the third and fourth day (February 3-4, 2012) she had no output during the shift. Together with medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This part of the study will present the normal and regressed health function of Patient X pointing out the salient, manifestations of the disease. HEAD Day 1 Head Facial movement Fontanels Hair Scalp Closed Fine; Clean distributed Closed evenlyFine; Clean distributed Closed evenlyFine; Clean distributed Closed evenlyFine; Clean distributed Closed evenlyFine; Clean evenly distributed Symmetrical Day 2 Symmetrical Day 3 Symmetrical Day 4 Symmetrical Day 5 Symmetrical
Normocephalic Normocephalic Normocephalic Normocephalic Normocephalic
EYES Day 1 Lids region Conjunctiv Pale a Cornea & Opacity to Right Opacity to RightOpacity to RightOpacity to RightOpacity to Right Pale Pale Pale Pale and teary Symmetrical Peri-orbital Normal Day 2 Symmetrical Normal Day 3 Symmetrical Normal Day 4 Symmetrical Normal Day 5 Symmetrical Mildly bulging
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis lens Sclera Pupils Anicteric Equal 3mm; uniform Visual acuity Anicteric size:Equal brisk3mm; uniform Anicteric size:Equal brisk3mm; uniform Anicteric size:Equal brisk3mm; uniform Anicteric size:Equal brisk3mm; uniform size: brisk
reaction to light;reaction to light;reaction to light;reaction to light;reaction to light; accommodation accommodation accommodation accommodation accommodation Decreased; sheDecreased; sheDecreased; sheDecreased; sheDecreased; she can inches read 2can read 2can read 2can read 2can read 2 sizedinches sizedinches sizedinches sizedinches sized
letter at 30 cm.letter at 30 cm.letter at 30 cm.letter at 30 cm.letter at 30 cm. away from heraway from her.away from her.away from her.away from her. without She usesShe eyeglasses far distance. Normal usesShe eyeglasses far distance. Normal usesShe eyeglasses far distance. Normal uses eyeglasses. Sheeyeglasses when reading atfar distance. far distance. Peripheral vision EARS Day 1 External Pinnae External canal Tympanic membrane Gross Decreased onDecreased right side. Day 2 Midline Pinkish Both patent Normal onDecreased right side. Day 3 Midline Pinkish Both patent Normal onDecreased right side. Day 4 Midline Pinkish Both patent Normal onDecreased right side. Day 5 Midline Pinkish Both patent Normal on hearing right side. NOSE Day 1 Septum Mucosa Patency Gross Smell Sinuses No tenderness No tenderness No tenderness No tenderness No tenderness Midline Pinkish Both patent Normal No Intact abnormalNo Intact abnormalNo Intact abnormalNo Intact abnormalNo Intact abnormal discharges discharges discharges discharges discharges Normoset Day 2 Normoset Day 3 Normoset Day 4 Normoset Day 5 Normoset Normal Normal
uses eyeglasseswhen reading atwhen reading atwhen reading atwhen reading at
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis
MOUTH Day 1 Lips discoloration the lips. Day 2 atdark the lips. Day 3 Day 4 Day 5
Pallor with darkPallor with
Pallor with darkPallor with darkPallor with dark discoloration atdiscoloration atdiscoloration at the lips. the lips.
discoloration atthe lips.
Mucosa Tongue Teeth
Pallor Midline Dentures front teeth.
Pallor Midline
Pallor Midline andupper frontlower teeth. Pale
Pallor Midline andupper frontlower teeth. Pale
Pallor Midline andupper frontlower teeth. Pale and front
on Dentures on Dentures on Dentures on Dentures on lower teeth. Pale
upper and lowerupper
Gums
Pale
PHARYNX Day 1 Uvula Tonsils pharynx Midline Not inflamed Day 2 Midline Not inflamed Not inflamed Day 3 Midline Not inflamed Not inflamed Day 4 Midline Not inflamed Not inflamed Day 5 Midline Not inflamed Not inflamed
Posterior Not inflamed
NECK Trachea Thyroids Day 1 Day 2 Midline Midline Non-palpable Non-palpable Day 3 Midline Non-palpable Day 4 Midline Nonpalpable SKIN Day 1 General color Texture Turgor Wrinkled Decreased Wrinkled Decreased Wrinkled due Wrinkled toturgor due Wrinkled toskin turgor Decreased skinDecreased skinDecreased Pallor Day 2 Pallor Day 3 Pallor Day 4 Pallor Day 5 Pallor Day 5 Midline Non-palpable
skin turgor dueskin turgor dueturgor
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis to aging Temperatur Warm e ABDOMEN Day 1 General Superficial Day 2 Superficial Day 3 Superficial Day 4 Superficial Day 5 Superficial to aging Warm aging Warm aging Warm due to aging Warm
Configuration Globular 110 cm Bowel sounds Percussion clicks minute Tympanitic
=Globular = 110Globular = 110Globular = 110 Flat = 89. 8 cm perclicks minute Tympanitic cm perclicks minute Tympanitic cm 2Hypoactive: perclicks minute Tympanitic cm 3Hypoactive: 4 perclicks minute Tympanitic per
Hypoactive: 3Hypoactive: 2Hypoactive:
CARDIOVASCULAR Day 1 Point maximum impulse Heart sounds Peripheral pulses Capillary refill Irregular; bpm 2 Normal 89Irregular; bpm seconds;2 Normal 92Irregular; bpm seconds;2 Normal 96Irregular; bpm seconds;2 Normal 100Irregular; bpm seconds;2 seconds; Normal 90 space; Regular Day 2 leftspace; Regular Day 3 leftspace; Regular Day 4 leftspace; Regular Day 5 leftspace; Regular left
of 5th intercostal5th intercostal5th
intercostal5th
intercostal5th intercostal midclavicular.
midclavicular. midclavicular. midclavicular.
midclavicular.
RESPIRATORY STATUS Day 1 Breathing pattern Shape chest Lung expansion Vocal/tactile Symmetrical Symmetrical Symmetrical fremitus Breath Fine cracklesFine cracklesFine cracklesFine cracklesFine crackles Symmetrical Symmetrical Irregular; 28cpm of AP: Normal Day 2 Irregular; 32cpm 1:2;AP: Normal Day 3 Regular; cpm Day 4 18Regular; cpm Normal Symmetrical Day 5 20Irregular; cpm 1:2;AP: Normal Symmetrical 1:2; 28
1:2;AP: 1:2; Normal AP:
Symmetrical Symmetrical Symmetrical
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis sounds heard at theheard at theheard at the leftheard at the leftheard at the left side of theleft side of theside chest. Decrease chest. Decrease chest. Decrease of theside chest. Decrease of theleft side of the chest.
breath soundbreath soundbreath sound atbreath sound at at the sameat the samethe same lungthe same lung lung field waslung field wasfield was alsofield was also also noted. Cough None also noted. None noted. None noted. None None
BACK AND EXTREMITIES Day 1 Range motion of Full Day 2 Full Day 3 Full Day 4 Active ROM: Decreased on upper extremities Passive ROM: Full Day 5 Active ROM: Decreased on upper & lower extremities Passive ROM: Full Muscle tone Symmetrical Symmetrical Symmetrical inSymmetrical inSymmetrical in and strength Spine Spine midline. Normal Gait but is Spine is Spine is Spine is Spine is in size; 5/5 in size; 5/5 size; 5/5 size; 4/5 size; 4/5
midline. Normal
midline. Normal midline. Normal midline. Normal gaitBalanced gaitUncoordinated due to
Balanced gaitBalanced gaitBalanced slowbut
slowbut slow whenbut slow whengait attachedCTT
when walkingwhen walkingwalking due towalking due togeneralized due to CTTdue to CTTCTT attached her chest toattached her chest attachedweakness. toto her chest to her chest
C. ELIMINATION PATTERN Pre hospitalization: Patient X usually defecates once to 3 times on every other day, with yellowish to brownish stool, soft in consistency and no
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis discomfort felt during defecation. She takes Senakot to be able to manage her bowel movement every day. She urinates several times in a day with no definite number in frequency with estimated amber-colored urine of 50-100 ml per urination with no discomforts reported. During hospitalization: 1st Day: Patient X defecates once every other day with yellowish to brownish stool and soft in consistency with no discomfort. Her last bowel movement was last January 27, 2011. She urinated once during 7-3 pm shift with amber to yellowish in color, amounting to 100 to 250 ml of urine every shift and 600 to 750 in every 24 hours. She has no discomfort in urinating. 2nd Day: Patient X defecates once every other day with brownish stool and soft in consistency with no discomfort. She didnt defecate during the 7-3 pm shift last January 28, 2012. She urinated 100 ml of urine during the shift. She has no discomfort in urinating. 3rd Day: Patient X did not defecate during the shift. She urinated twice with 200 cc in amount with yellowish in color with no discomforts. 4th Day: Patient X defecated once during the shift with dark brown in minimal amount soft and formed. She urinated twice with 200 cc in amount with yellowish in color with no discomforts. 5th Day: Patient X defecated twice on that day with black tarry stool and formed. She urinated 490 cc in 24 hours with no discomforts.
D. ACTIVITY-EXERCISE PATTERN Pre-hospitalization: She wakes up at around 6 in the morning to jog with her husband, or if not, shell walk around their house. Otherwise, she wakes up a bit late in the morning. After exercising for a little, she sweeps their front yard; shell then cook and prepare their breakfast. After that, shell work to sew her clients clothes. Her sister and niece help her with household chores. During her chemotherapy, there were changes in her daily activities. She cannot jog every morning with her husband anymore, and she had already stopped working as a tailor. She cant cook and prepare breakfast and sweep their front yard due to her weakness and sometimes experiencing dyspnea. During hospitalization: All she does was to move from lying to sitting on bed and going to the bathroom when necessary with assistance. On the first day to third day of duty, she usually fed herself alone but during the fourth and fifth day; shes being fed by her sister due to weakness.
E. COGNITIVE-PERCEPTUAL PATTERN Patient X speaks Cebuano-Visayan language. She has no learning difficulties as evidenced by comprehension of importance of her chest tubes. She has changes with regards to her remote memory when asked when her menopausal period started but had no changes in her recent memory when asked what her breakfast was. She was oriented to time, place and person. She was conscious, able to understand and can follow on whatever the nurses teach her regarding her health. F. SLEEP-REST PATTERN Pre- hospitalization: Patient X cannot sleep early at night since her neighbor has mini casino or mahjongan wherein people who were playing were noisy. If there is no deadline to beat with regards to her work, she grabs the time to rest and sleep. Total sleep hours for the day is approximately ranging from 5 to 6 hours. During hospitalization: Patient X cannot sleep easily in the evening because shes not comfortable when the lights are on, and whenever nurses go in-and-out of the room due to medication administration and monitoring of vital signs that needs to be followed accordingly. During the day, shes able to sleep longer than her sleep hours at night since there are a lot of time to sleep during the day. Usually, she lies down all day because she cant stand moving around for a long time but she manages to turn to sides once in a while to prevent bed sores or ulcers.
G.SELF-PERCEPTION AND SELF-CONCEPT PATTERN Patient X verbalized that she lost so much weight since she was hospitalized especially at the starting course of her chemotherapy. She also stated that her activities of daily living were changed since her illness occurred.
H. ROLE-RELATIONSHIP PATTERN Pre-hospitalization and during hospitalization: Patient X has a good and sound relationship with her husband and daughter. And it got even tighter when she was hospitalized. Her daughter frequently calls her from overseas just to check out if shes fine in the hospital or to ask any health improvement. Its her
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis family that supports her emotionally and financially though they dont worry much with the expenses since an agency covers her medical fees and other necessary bills are shouldered by her daughter. Patient X is assured by her daughter. Their primordial concern is still her health. Whenever her daughter would call her, she would cry because she misses her so much. It was last March 2011, before her first cycle of chemotherapy that she saw her daughter. I.SEXUALITY-REPRODUCTIVE PATTERN Patient X had delivered her only daughter via Normal Spontaneous Vaginal Delivery (Gravida 1 Para 1). The couple didnt have any sexual relation problems since their primary concern is living their life to the fullest, growing old together. Patient X doesnt practice monthly breast-self examination. She had her first menstruation when she was 11 years old and reached menopausal stage by 1994. J. COPING -STRESS TOLERANCE PATTERN Pre-hospitalization: Patient X manages her condition by complying her medication regimen and doing different kinds of diversional activities like watching tv to lessen her anxiety. Communicating to her family helps her increase self-esteem. During Hospitalization: Patient X was worried about her condition but she can control her anxiety through diversional activities. She is not engaged with any counseling groups.
H. VALUE -BELIEF PATTERN Patient X is a Roman Catholic. According to her, she goes to church every Sunday and she does the rosary as part of their religious practices. Hospitalization does interfere with her religious activities like going to church but shes constantly praying even hospitalized
PHYSICAL ASSESSMENT
DAY 1 (January 27, 2012)

Pale Conjunctiva, Decreased visual acuity (can read 30 cm. away) without eyeglasses. Pale, dry, lips with dark discoloration of the lips Fine crackles heard, decreased breath sounds c Chest Thoracostomy Tube, 50 cc output within 8 hours shift. Ascites. measurin g 110 cm. Dark discoloration under the nail bed.
Decreased hearing gross Palpable lump noted, 6 cm, nontender.
Hypoactive: 3 clicks per minute
Increase RR of 28 cpm
PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses
DAY 2 (January 28, 2012)
Decreased hearing gross
Pale Conjunctiva, Decreased visual acuity (can read 30 cm. away) without eyeglasses Pale, dry, lips with dark discoloration at the tip of the lips Fine crackles heard, decreased breath c Chest Thoracostomy Tube, 70 cc output within 8 hours shift. Ascites measurin g 110 cm.
Palpable lump noted, 6 cm, nontender. Increase RR of 32 cpm, O2 sat of 90%
Dark discoloration under the nail bed.
DAY 3 (February 2, 2012)
Pale Conjunctiva, Decreased visual acuity (can read 30 cm. away) without eyeglasses Pale, dry, lips with dark discoloration at the tip of the lips Fine crackles heard, decreased breath sounds. c Chest Thoracostomy Tube, no output within 8 hours shift. Ascites measurin g 110 cm.
Palpable lump noted, 6 cm, nontender.
Pale Conjunctiva, Decreased visual acuity (can read 30 cm. away) without eyeglasses Pale, dry, lips with dark discoloration at the tip of the lips Fine crackles heard, decreased breath sounds. c Chest Thoracostomy Tube, no output within 8 hours shift. Ascites measurin g 110 cm. Dark discoloration under the nail bed.
Palpable lump noted, 6 cm, nontender. Hypoactive: 3 clicks per minute PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses Active Decreased ROM: on
upper extremities Passive ROM: Full Muscle Tone and Strength: 4/5
Decreased hearing gross Palpable lump noted, 6 cm, nontender. 28 cycles per minute
Pale Conjunctiva, Decreased visual acuity (can read 30 cm. away) without eyeglasses Pale, dry, lips with dark discoloration at the tip of the lips. Fine crackles
Hypoactive: 4 clicks per minute PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses
Active Decreased
ROM: on
upper extremities Passive ROM: Full Muscle Tone and Strength:4/5
Developmental Theory: Katharine Kolcabas Theory of Comfort
Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. Also, Kolcaba described 4 contexts in which patient comfort can occur: physical, psychospiritual, environmental, and sociocultural.
Kolcaba described comfort as existing in 3 forms: relief, ease, and transcendence. If specific comfort needs of a patient are met, for example, the relief of postoperative pain by administering prescribed analgesia, the individual experiences comfort in the relief sense.
If the patient is in a comfortable state of contentment, the person experiences comfort in the ease sense, for example, how one might feel after having issues that are causing anxiety addressed.
Lastly, transcendence is described as the state of comfort in which patients are able to rise above their challenges.
Health Care Needs are those identified by the patient/family in a particular practice setting. Intervening Variables are those factors that are not likely to change and over which providers have little control (such as prognosis, financial situation, extent of social support, etc).
Comfort is an immediate desirable outcome of nursing care, according to Comfort Theory Health Seeking Behavior (HSBs): Institutional Integrity - the values, financial stability, and wholeness of health care organizations at local, regional, state, and national levels. Best Policies are protocols and procedures developed by an institution for overall use after collecting evidence.
DESCRIPTION OF THE THEORY Nursing
Nursing is described as the process of assessing the patient's comfort needs, developing and implementing appropriate nursing interventions, and evaluating patient comfort following nursing interventions.
Intentional assessment of comfort needs, the design of comfort measures to address those needs, and the reassessment of comfort levels after implementation.
Assessment may be either objective, such as in the observation of wound healing, or subjective, such as by asking if the patient is comfortable.
Health
Health is considered to be optimal functioning, as defined by the patient, group, family or community
Person/Patient
Patients can be considered as individuals, families, institutions, or communities in need of health care.
Environment
Any aspect of the patient, family, or institutional surroundings that can be manipulated by a nurse(s), or loved one(s) to enhance comfort.
CONCLUSION
Holistic comfort is defined as the immediate experience of being strengthened transcendence through met in having four the needs of for relief, ease, and contexts experience (physical,
psychospiritual, social, and environmental) (Kolcaba, 2010)
The theoretical structure of Kolcaba's comfort theory has real potential to direct the work and thinking of all healthcare providers within one institution. (March A & McCormack D, 2009).
VI. ANATOMY AND PHYSIOLOGY MAMMARY GLANDS
The breast is a mound of glandular, fatty and fibrous tissue located over the pectoralis muscles of the chest wall and attached to these muscles by fibrous strands (Cooper's ligaments). The breast itself has no muscle tissue, which is why exercises will not build up the breasts. A layer of fat surrounds the breast glands and extends throughout the breast. This fatty tissue gives the breast a soft consistency and gentle, flowing contour. The actual breast is composed of fat, glands with the capacity for milk production when stimulated by special hormones, blood vessels, milk ducts to transfer the milk from the glands to the nipples and sensory nerves that give feeling to the breast. These nerves extend upward from the muscle layer through the breast and are highly sensitive,
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis especially in the regions of the nipple and areola, which accounts for the sexual responsiveness of some women's breasts. Because the breast is made up of tissues with different textures, it may not have a smooth surface and often feels lumpy. This irregularity is especially noticeable when a woman is thin and has little breast fat to soften the contours; it becomes less obvious after menopause, when the cyclic changes and endocrine stimulation of the breast have ceased and the glandular tissue softens. Estrogen supplements after menopause can cause continued lumpiness. The breast glands drain into a collecting system of ducts that go to the base of the nipple. The ducts then extend through the nipple and open on its outer surface. In addition to serving as a channel for milk, these ducts are often the source of breast problems. The ducts end in the nipple, (which projects from the surface of the breast), and are a conduit for the milk secreted by the glands and suckled by a baby during breast-feeding. There is considerable variation in women's nipples. In some, the nipple is constantly erect; in others, it only becomes erect when stimulated by cold, physical contact or sexual activity. Still other women have inverted nipples. Surrounding the nipple is a slightly raised circle of pigmented skin called the areola. The nipple and areola contain specialized muscle fibers that make the nipple erect and give the areola its firm texture. The areola also contains Montgomery's glands, which may appear as small, raised lumps on the surface of the areola. These glands lubricate the areola and are not symptoms of an abnormal condition. Beneath the breast is a large muscle, the pectoralis major, which assists in arm movement; the breast rests on this muscle. Originating on the chest wall, the pectoralis major extends from deep under the breast to attach to the upper arm. It also helps form the axillary fold, created where the arm and chest wall meet. The axilla (armpit) is the depression behind this fold. Each woman's breasts are shaped differently. Individual breast appearance is influenced by the volume of a woman's breast tissue and fat, her age, a history of previous pregnancies and lactation, her heredity, the quality and elasticity of her breast skin and the influence of hormones.
The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing, with the average adult breathing about 12 to 20 times per minute. When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath. Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull. Pharynx The pharynx, or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords. Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs. Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream. Bronchi The trachea divides into two parts called the bronchi, which enter the lungs. Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung. Avleoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Gastrointestinal System
Ingestion and Swallowing: Swallowing is a complex event that is coordinated by the swallowing center in the lower portion of the brainstem. During this process, food passes from the mouth to the pharynx and into the esophagus. Oral phase: initially, the food bolus is moved to the back of the tongue. This triggers swallowing, by stimulating touch receptors in the pharynx. Then, the anterior of the tongue lifts to the hard palate and forces the bolus to the pharynx. Pharyngeal phase: during the pharyngeal phase, the larynx is pulled forward and upward under the tongue by muscular contraction. As the larynx rises, the epiglottis moves backwards and downwards to seal off the glottis (the entrance to the respiratory system). Esophageal phase: during the esophageal phase, the food bolus is pushed through the esophagus by involuntary muscle contractions called peristalsis.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Stomach: The stomach is a J-shaped organ, directly under the diaphragm. The uperior portion is a continuation of the esophagus. The inferior portion (pylorus) empties the stomach contents into the first segment of the small intestine. Gastric juices: The main component of gastric juices released during digestion is gastric acid. Gastric acid is hydrochloric acid produced by the parietal cells, and it makes the lumen of the stomach very acidic with a pH of 2-3. This increased acidity contributes both to the conversion of pepsinogen to pepsin and to the breakdown of foods. Liver and Gallbladder: Bile production and storage: The liver is involved in many aspects of nutrient metabolism, and the regulation of the products of digestion in the blood: (A) Carbohydrate metabolism, (B) Protein and lipid metabolism and (C) Vitamin storage. Bile is an alkaline fluid produced by hepatocytes in the liver, and it helps to emulsify fats during digestion and absorption in the small intestine. Bile contains taurocholic and deoxycholic salts; these salts combine with fat globules and break them down into small droplets for absorption in the small intestine. Pancreas Structure: The pancreas is an elongated organ, adjacent to the stomach and in close association with the first segment of the small intestine, the duodenum. Digestive enzymes: The pancreas produces a number of enzymes used in the process of digestion: (a) trypsinogen and chymotrypsinogen, (b) pancreatic lipase and (c) amylase. Small Intestine: The small intestine is 8-22 ft. in length in an adult; it is divided into three main segments: duodenum, jejunum and the ileum. The small intestine is the site were most of the nutrients from digested food takes place. Large Intestine: The large intestine is shorter in length (4-5 ft) than the small intestine, but it is so named because of its increased diameter. The large intestine is divided into four major areas: the ascending, transverse, descending and sigmoid colon.
Predisposing Factors:
Family History of Carcinoma (Maternal) VII. PATHOPHYSIOLOGY Age: 64 years old Early onset of menstruation: 11 years old Doesnt do monthly BSE Smoker for 19 years LEGEND: Precipitating Factors: 36 years of exposure to estrogen Predisposing Factors Precipitating Factors Disease Process Treatment (either through medication or surgery) Diagnostic Examination Signs and symptoms Mutation in DNA mismatches repair genes Proto-oncogens transforms to oncogenes Bodys Compensatory Mechanism Chemotherapy Effects
Alteration in the normal cell
Negatively affects the DNA repair
Tumor suppressor genes is turned off
Overstimulation of mammary epithelial cells extracellular matrix niche
Proliferation of affected cell
Quick abnormal cell growth and division
Allows unchecked cellular replication at the epithelial surface
Inability to control proliferation of affected cells
DNA repair genes is inactivated
Increased cell division causing further mutations
P53 mutations which prevent apoptosis Increases survival and proliferation of cancer cells
Prolong lifespan of affected cells Affects part of the mammary gland Continuous replication of affected cells
Increases number of malignant cells
Epidermal growth factor receptor is released in excessive amount
Presence of tumor was unrecognized
Initial damage in the mammary gland
Formation of genetically altered cells located in the superficial portions of the epithelium
Transformation takes place among the stem cell population at the ductal base
Cancerous cells migrate from the base to the surface to the lining of the lobules
Transformed stem cell replicated abnormal cells spreads laterally and downward to right mammary gland monoclonal conversion produces the monomammary carcinoma
undergoes differentiation and maturation Connects to lymphatic pathways draining to cutaneous, areolar, and glandular
loss of proliferation control
expands early by ductal fission
extends to adjacent lobules
Palpable immovable tumor at the right upper, outer breast
Anastrozole (animidex) taken OD Formation of malignant tumor in the mammary tissue IV Chemotherapy 6 cycles started April 2011 til September 2011
Decrease protein intake
Alteration in protein synthesis
Malignant cells drain to peritoneal vessel
Loss of hair
Compromise immune response
Diffuse cells are present in the epithelial wall of peritoneum Administ ered human albumin Decrease protein levels in the serum Decreas e albumin levels of 1.10
Dark discoloration of the nail beds and lips
Causative agent invades the body
Infection develops Affects adjacent structures Administered Levox 500mg IV OD 8am, Unasyn 1.5gm IVTT every 6 hours (6-12) Increase in WBC of 11, 900
Decrease plasma oncotic pressure
Affects hepatic structure Fluid escape transcellularly Fluid accumulation in the peritoneum Escape of fluid in the pleural cavity
Affects renal parenchyma
Production of erythropoietin is altered
Hooked patient to PLR 1L at 20gtts/min
Pale skin, conjunctiva and lips
Decrease blood volume
Bone marrow stimulation is disturbed Decrease in hgb (12. 3), hct (33.0), and RBC (4.36)
Glomerular cells specifically in the juxtaglomerular area is stimulated
Compression of diaphragm
Lung expansion is decreased
RBC production is decreased
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Increase RR of 28cpm Low flow oxygen of 2LPM via nasal cannula
Release of renin into the blood
Globular abdomen; 110cm (+) fluid test
Renin converts angiotensinoginase to antinogen I Paracentesis done (2/312) withdrawing 8.2 L of fluid
Diminished lung sounds upon auscultation
Angiotensin I is converted to Angiotensin II by a lung converting
Ultrasound revealed massive ascites
Thoracentesis done
Close tube thoracostomy was done
Causes release of aldosterone from the adrenal cortex
constricts portion of the arterioles in the nephron
Causes peripheral vasoconstriction
Reabsorption of sodium and water
Decrease glomerular filtration rate Decrease urine output of 100cc
Increase Heart rate 118 bpm and BP 100/70 mmHg
Decrease in plasma sodium of 150 mg/dl
Decrease urine output
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis III. DIAGNOSTIC TESTS HEMATOLOGY REPORT Complete Blood Count TEST RESULTS 2/4/2012 1/31/201 1/26/20 1/19/201 2 Hgb 10.0 11.6 12 11.0 2 12.3 13.7-16.7 g/dL A decrease may in also REFERENCE INTERPRETATIO VALUES N
RBC
decrease hemoglobin since RBC oxygen blood. hemoglobin also anemia. Hct 30.0 35.0 33.0 37.0 37.0- 47.0 gmA low hematocrit % level indicates that a person does not have a sufficient volume of red blood cells. WBC 11,200 12,600 10,200 11,900 5,000-10,000 A high white blood cell/mm3 count indicates that it is not a specific disease by itself but indicates infection, systemic illness, inflammation, allergy, leukemia and tissue injury. DIFFERENTI AL COUNT: Segmenters 78.0 88.0 73.0 69.0 45 70% Elevation of carries to the Low may indicate
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis segmenters may
indicate presence of infection which means that many band(immature) cells are present as the body fights Lymphocytes 19.0 10.0 21.0 31.0 18-45% infection. A low lymphocyte count that the indicates body's
resistance to fight infection has been substantially and one become susceptible certain infection, low types lost may more to of namely can
cancer and tumor; count cause damage to organs. Monocytes 1.0 4.0 4-8% Monocytes are a type of leukocyte or white blood cell which plays a role in immune system function. monocyte indicates sign. Eosinophil 2.0 2.0 2.0 2 3% Within range Platelet count 449,000 0 448,00 395,00 401,000 144,0000 372,000 Abnormally platelet high levels Normal a A low count bad
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis cell/mm3 (thrombocytosis) may indicate either a benign reaction to an infection, surgery, or certain medications; or a disease like polycythemia vera, in which the bone marrow produces too many platelets too quickly. RBC 3.81 3.80 3.67 4.36 4.7-6.1 10^6/uL A decrease Red blood production indicate and heart function. MCV 80.7 92.1 89.9 81.4 80.0-96.0 fL Within range MCH 26.2 30.5 29.9 26.1 27.0-31.0 pg Below range indicate because decrease normal that of may the blood anemia Normal low or cell may anemia oxygen lung
levels due to poor
concentration. MCHC 32.5 33.1 33.3 32.1 32.0-36.0% Within Range Normal
CLOTTING TIME and BLEEDING TIME January 19, 2012 Result Normal Value CLOTTING 5 Minutes 45 Seconds 2-6 minutes
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis TIME BLEEDING TIME Interpretation: Within Normal Range COAGULATION 2 Minutes 00 Seconds 1-3 minutes
TEST
RESULT
REFERENCE VALUE
INTERPRETATION
1/31/2012 PROTHROMBIN TIME Control PT PT 13.90 15.10
1/19/2012
13.90 14.70 11.8 sec. 15.1 Within Range Normal
% Activity PT RATIO INR
73.00 1.16 1.20
89.00 1.06 1.07
% ratio 0.8 1.2 Within Range Normal
CLINICAL CHEMISTRY
TEST
RESULT 1/31/2012 1/26/2012 0.53
REFERENCE VALUE 0.42 mg/dL
INTERPRETATION
Creatinine
0.55
1.09 Within Normal Range
SGPT Sodium Potassium 150.00 4.04
10.50 152.60 3.82
10 40 IU/L 135 148mmol/L 3.5 5.3mmol/L
Within Normal Range Within Normal Range Within Normal Range
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis MICROBIOLOGY CULTURE REPORT Date received: 1-31-2012 Specimen: PLEURAL FLUID Microbiology#: 0089 FINAL REPORT: Date: 2-2-12 ISOLATED GRAM STAIN REPORT SPECIMEN: PLEURAL FLUID RESULT: NO MICROORGANISM SEEN POLYMORPHONUCLEAR CELLS: PLENTY X-RAY RESULTS Findings: NO POTENTIAL PATHOGEN
January 26, 2012 Previously dated 1/9/2012 shows: Minimal pneumothorax on the left. A chest thoracostomy tube is likewise seen on the left, its tip at the level of T4. No significant interval change in the hazy density in the right middle lung. (Pleural plaque versus fissural thickening) Slight regression of the reticular and hazy densities in both lung bases. (Pneumonia and or edema) Both costophrenic sulci are still blunted. (Minimal pleural effusion and/or thickening, bilateral). Heart is within normal limits in size. Aorta is artherosclerotic. Degenarative changes are seen in the visualized osseous structures.
January 26, 2012 Follow-up exam relative to 1/20/2012 shows: There is no significant interval change in the minimal pneumothorax on the left. No significant interval change in the hazy density in the right middle to mower lung field. No significant interval change in the reticular and hazy densities in the right lung. (Interstitial pneumonia vs. interstitial edema vs lymphangitic carcinomatosis) Both costophrenic suldi are still blunted (Minimal pleural effusion and/or thickening, bilateral) Heart is within normal limits in size. Aorta is artherosclerotic. Degenarative changes are seen in the visualized osseous structures. Chest tube seen with tip at T4 level. January 30, 2012 Follow-up exam relative to 1/26/2012 shows: No significant interval change in the hazy density in the right mower lung field. No significant interval change in the reticular and hazy densities in the right lung. (Interstitial pneumonia vs. Interstitial edema vs. Lymphangitic carcinomatosis) Both costophrenic sulci are still blunted. ( Minimal pleural effusion and/or thickening, bilateral). Heart is within normal limits in size. Aorta is artherosclerotic. Degenarative changes are seen in the visualized osseous structures. Chest tube seen with tip at T4 level. Previously noted minimal pneumothorax no longer seen. IMPRESSION: AS DESCRIBED. February 1, 2012 Follow-up exam relative to 1/30/2012 shows:
No significant interval change in the hazy density in the right mower lung field. No significant interval change in the reticular and hazy densities in the right lung. (Interstitial pneumonia vs. Interstitial edema vs. Lymphangitic carcinomatosis) Both costophrenic sulci are still blunted. (Minimal pleural effusion and/or thickening, bilateral). Heart is within normal limits in size. Aorta is artherosclerotic. Degenarative changes are seen in the visualized osseous structures. Chest tube seen with tip at T4 level. IMPRESSION: AS DESCRIBED. Follow-up exam relative to 2/1/2012 shows slight progression in the hazy densities in both middle to lower lung field, more on the right. (Interstitial pneumonia vs. Interstitial edema vs. Lymphangitic carcinomatosis) Both costophrenic sulci are still blunted. (Minimal pleural effusion and/or thickening, bilateral). Heart is within normal limits in size. Aorta is artherosclerotic. Degenarative changes are seen in the visualized osseous structures. Chest tube seen with tip at T4 level. A lytic focus is seen in the left proximal humerus. (Rule out Bone Metastases. Suggest work-up clinically warranted) IMPRESSION: AS DESCRIBED. ULTRASOUND January 19, 2012 Right midhepatic length= 13.07cm (1.05cm) Left midhepatic length= 7.63cm (1.12cm) Common Bile Duct= 0.30cm Uterus= 5.45 x 4.59 x 4.25cm Left Kidney= 9.08 x 4.65 x 4.81cm Right Kidney= 8.56 x 3.62 x 4.00cm
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Spleen= 8.77cm Follow-up study since 12/12/11 shows the following findings: The liver is within normal in size with coarsened parenchymal echopattern. Hepatic outline is smooth. No discrete mass or calcification noted. The portal vein and its tributaries are normal in caliber. The gallbladder is normal in size and configuration. A 1.68 cm (previously 1.2cm) intense echo is noted within the lumen with characteristic shadowing posteriorly. The gallbladder wall is not thickened. There is no hepato-biliary duct dilatation. The spleen is normal in size and configuration. Splenic echoes are intact with no evident focal lesions. The pancreas was not properly delineated. Abdominal Aorta is artherosclerotic. A large cystic mass lesion seen anterior to the aorta measuring 5.48 x 6.03 x 4.19 cm (72.5 cc). The kidneys are low normal in size with smooth cortical outline and intact, homogenous, parenchymal echogenicity. Renal sinuses are dense with no demonstrable ectasia or calculus. The urinary bladder is empty precluding proper evaluation. The uterus is normal in size and configuration. Uterus echoes are homogenous with no demonstrable focal lesion. Endometrial stripe is atrophic. No significant interval change in the previously noted left adnexal cyst measuring 2.03 x 2.11 x 2.22cm (4.0 cc) Note of massive fluid collection in the abdomino-pelvic area. Medium level echoes noted within. The peritoneal and omental surface is nodular. IMPRESSION: 1. liver parenchymal disease.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis 2. Cholecystolithiasis 3. To consider para-aortic lymphadenopathy with cystic degeneration 4. Artherosclerotic abdominal aorta 5. Low normal sized kidneys 6. Empty urinary bladder 7. To consider peritoneal/omental metastases 8. Normal sized anteverted uterus with atrophic endometrium 9. Left adnexal cyst 10. Massive ascites 11. Normal ultrasound of the biliary ducts and spleen.
January 20, 2012 Right thyroid lobe= 5.7 x 2.6 x 2.1 cm Left thyroid lobe= 5.8 x 2.4 x 2.1 cm The thyroid gland is enlarged. Multiple echogenic well-defined nodules are seen in both thyroid lobes, three (3) in the right and two (2) on the left. The largest in the right measures 2.1 x 1.4 x 1.7 cm while the largest on the left measures 2.2 x 2.1 x 1.8 cm with note of rim calcifications. Note of capsular vascularity. No definite abnormal mass or enlarged lymph node seen adjacent to the thyroid. IMPRESSION: Multinodular goiter. January 21, 2012 No fluid collection noted in the right hemithorax. About 700ml of free fluid collection seen in the left hemithorax with note of floating medium level echoes. IMPRESSION: Moderate pleural effusion (with debris), left.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis February 07, 2012 Clinical Chemistry TESTS Creatinine RESULTS 0.40 REFERENCE 0.42 1.09 INTERPRETATION Below be due normal to
range. This may hemodilution. Sodium 127.90 135 148 Below sodium the after the area. Potassium 3.90 3.5 5.3 Within range. Albumin 1.10 3.5 5.0 Decrease plasma may decrease oncotic cause in albumin indicate plasma pressure of thirdnormal normal may be
range. The low in brought about by hemodilution drawing transcellular
back water from
which the primary space shifting.
IX. MEDICAL AND SURGICAL MANAGEMENT IDEAL MANAGEMENT I. Breast Cancer:
Biopsy a part of a tissue is obtained to test whether its malignant or benign. This is essential for the accurate TNM scoring Chemotherapy (commonly use Tamoxifen) can be administered either oral or through IV infusion. This is given either to weaken or kill cancerous cells in the body.
Surgical Management o Mastectomy to remove both or one of the breasts with the malignant tumor.
o
Breast reconstruction to achieve self-confidence and boosting self-esteem.
Monoclonal Antibody Therapy adjuvant to chemotherapy. Usually given together with the first dose of Chemotherapy. It is thought to help fight cancer cells in the body in which it helps in improving survival for cancer patients.
II. Pleural Effusion:
Thoracentesis withdrawal of fluid in the pleural cavity causing temporary relief from the fluid accumulation within the pleural spaces to allow maximal lung expansion.
Closed Tube Thoracostomy Insertion to drain fluid in the pleural cavity to accommodate maximum lung expansion. Antibiotics given as prophylaxis for the invasive procedure anfd for the greater risk of developing infection.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Hypertonic solutions because it is thought that one of the reasons of fluid escape in the pleural space is the decrease plasma oncotic pressure brought by decrease plasma solutes.
Human albumin (25%, 50%) exogenous administration of albumin to increase plasma oncotic pressure to allow fluid shift from the pleura to plasma.
Diuretic Therapy acts at the Loop of Henle to induce dieresis excreting excessive water.
III. Ascites:
Paracentesis to drain water from the peritoneum to relieve increasing abdomen causing causing compression of the diaphragm resulting to ineffective breathing pattern.
Sodium Restriction because retention of water is the problem and sodium attracts, sodium shouldnt be taken liberally, hence, should be controlled and if it persists, restriction should be made.
Diuretic Therapy acts at the Loop of Henle to induce dieresis excreting excessive water. Vasopressin Therapy also excretes excessive water in the body. Human albumin (25%, 50%) exogenous administration of albumin to increase plasma oncotic pressure to allow fluid shift from the peritoneum to plasma.
ACTUAL MANAGEMENT Breast Cancer

Chemotherapy given via IV infusion in 6 cycles from April 2011 to September 2011. Anti- neoplastic drug (Anastrozole) taken once a day. She started right after the diagnosis of Breast Cancer Stage IV last December 28, 2010.
Pleural Effusion
Closed Thoracostomy Tube Insertion done first at the right side of the lung then inserted to left side of the lung. Thoracentensis done last January 19, 2011 to drain fluid in the pleural cavity.

Pleurodesis removal of the thoracostomy tube to prevent further recurrence. Levox 500cc acts as prophlaxis to prevent infection from the CTT insertion. Human Albumin 25% - given to increase plasma oncotic pressure to relieve fluid shifting in the pleaural cavity. Furosemide given post-albumin therapy to ensure excretion of excess water.
Ascites
Paracentesis done in the months of April, June, July, September, and December of 2011. Procedure is repeated February 03, 2012 draining 8.2L of fluid.
Spironolcatone potassium-sparring diuretics to excrete excessive water in the body. Human Albumin 25% - given to increase plasma oncotic pressure to relieve fluid shifting in the pleaural cavity. Furosemide given post-albumin therapy to ensure excretion of excess water.
DRUG STUDY 1.) Generic name: spironolactone Brand name: Aldactone Classification: Potassium-sparing diuretic Dosage: 25mg tab Route: PO Frequency: BID Timing: 8am-6pm MOA: Antagonizes aldosterone in the distal tubules, increasing sodium and water excretion. Indication: For Edema (ascites and pleural effusion)
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Contraindication: Contraindicated with anuria, acute or progressive renal insufficiency, or hyperkalemia. Use cautiously in patients with fluid or electrolyte imbalances, impaired renal function or hepatic disease. Adverse Effects: CNS: Headache, drowsiness, confusion, ataxia GI: diarrhea, gastric bleeding, ulceration, gastritis, vomiting GU: menstrual disturbances HEMA: agranulocytosis METABOLIC: hyponatremia, hyperkalemia, dehydration Nursing Responsibilities: To enhance absorption, give rug with meals. Monitor electrolyte levels, fluid intake and output, and blood pressure. Caution patient not to perform hazardous activities if adverse CNS reactions occur.
2.) Generic name: Levofloxacin Brand name: Levox Classification: Flouroquinolone Dosage: 500mg Route: IV Frequency: OD Timing: 8am MOA: Inhibits bacterial DNA gyrase and prevents DNA replication, transcription, repair, and recombination in susceptible bacteria. Indication: Contraindication: Use cautiously in patients with history of seizure disorders or other CNS diseases.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Adverse Effects: CNS: headache, insomnia, encephalopathy, seizure CV: chest pain, palpitation, vasodilation GI: nausea, diarrhea, pseudomembranous colitis METABOLIC: hyperglycemia SKIN: rash, photosensitivity, pruritus Nursing Responsibilities: Advise patient to avoid excessive sunlight, and wear protective clothing when outdoors. Instruct patient to stop drug and notify doctor if rash or other signs of hypersensitivity develop. Instruct Diabetic patient to monitor glucose level and notify doctor about low glucose reaction.
3.) Generic name: Ampicillin + Sulbactam Brand name: Unasyn Classification: Beta lactam antibiotic Dosage: 1.5 g Route: IVTT Frequency: q6 Timing: 6-12-6-12 MOA: Inhibits cell wall synthesis during bacterial multiplication. Indication: Intraabdominal, and skin structure infections caused by susceptible strains. Contraindicated: Use cautiously with other drug allergies because of possible cross sensitivity, and in those with mononocleusis because of high risk maculopapular rash.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Adverse Effects: CV: Thrombophlebitis, vein irritation GI: nausea, vomiting, gastritis, pseudomembranous colitis HEMA: anemia, thrombocytopenia, leukopenia SKIN: pain at injection site Nursing Responsibilities: Tell patient to report rash, fever or chills. Warn patient that IM injection may cause pain at injection site. Decrease dosage in patient with impaired renal function.
4.) Generic name: Tramadol Brand name: Tramal Classification: Opioid analgesic Dosage: 50mg Route: IVTT Frequency: prn Timing: 8am-1pm-6pm MOA: A centrally acting synthetic compound not chemically related to opioids. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin. Indication: For moderate to severe pain. Contraindicated: Use cautiously in patients at risk for seizures or respiratory depression, acute abdominal condition. Adverse Effects: CNS: dizziness, vertigo, somnolence, headache CV: vasodilation
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis EENT: visual disturbances GI: nausea, constipation, vomiting, dyspepsia GU: urine retention, urinary frequency RESPI: respiratory depression Nursing Responsibilities: Reassess patients level of pain at least 30 minutes after administration Monitor bladder and bowel function. Warn patient not to abruptly stop the drug.
5.) Generic name: Temazepam Brand name: Restor Classification: Sedative- hypotic Dosage: 20mg Route: PO Frequency: od Timing: 8am MOA: Probably acts on the limbic system, thalamus, and hypothalamus of the CNS to produce hypnotic effects. Indication: For insomnia. Contraindicated: Use cautiously in patients with chronic pulmonary
insufficiency, impaired renal function, severe mental depression. Adverse Effects: CNS: drowsiness, dizziness, lethargy EENT: Blurred vision GI: diarrhea, nausea, dry mouth Nursing Responsibilities:
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Tell patient to avoid alcohol during therapy. Assess mental status before starting therapy and reduce doses in elderly. Take precautions to prevent overdosing by patients who are depressed.
6.) Generic name: Albumin Brand name: Albuminar 25% Classification: Blood Derivative Dosage: 50cc Route: IV Frequency: OD Timing: 8pm MOA: Provides intravascular oncotic pressure in a 5:1 ratio, causing a fluid shift from interstitial spaces to the circulation and slightly increasing plasma protein level. Indication: Hypovolemia, Hypoproteinemia Contraindication: Contraindicated in patients hypersensitive ti drug and in those with severe anemia, pulmonary edema, or cardiac failure. Adverse Effects: CNS: Headache, fever CV: Vascular overload after rapid infusion, hypotension, tachycardia GI: Increase salivation, nausea, vomiting MUSCULOSKELETAL: Backpain RESPIRATORY: Altered respiration, dyspnea, pulmonary edema SKIN: rash, urticaria Nursing Responsibilities:
Monitor fluid intake and output, hemoglobin, hematocrit, protein and electrolyte levels during therapy.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Use with extreme caution in patients with hypertension, low cardiac reserve and hypervolemia. Watch for signs of fluid overload, heart failure or fluid edema.
7.) Generic name: Omeprazole Brand name: Omepron Classification: Proton-pump inhibitor Dosage: 20mg Route: PO Frequency: OD Timing: 8am MOA: Inhibits activity of acid proton pump and binds to hydrogen- potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gastric acid. Indication: Doudenal ulcer, for prophylaxis against gastric ulcer Contraindication: Contraindicated to patients who are hypersensitive to drug or its component Adverse Effects: CNS: Headache, dizziness, asthenia GI: nausea, vomiting, diarrhea, abdominal pain, constipation, flatulence MUSCULOSKELETAL: Backpain RESPIRATORY: cough, upper respiratory tract infection SKIN: rash Nursing Responsibilities:
Tell patient to swallow capsule whole and not to open, crush, or chew them.
Instruct patient to take drug 30 minutes before meals.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Caution patient to avoid hazardous activities if gets dizzy.
8.) Generic name: Furosemide Brand name: Lasix Classification: Loop diuretic Dosage: 20mg Route: IVTT Frequency: OD Timing: post albumin MOA: A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules at the ascending loop f Henle.
Indication: Hypervolemia, acute pulmonary edema, hypertension Contraindication: Contraindicated in patients hypersensitive to drug and in those with anuria. Adverse Effects: CNS: Headache, fever, vertigo CV: Orthostatic hypotension, thrombophlebitis with IV administration GI: Abdominal discomfort and pain, diarrhea, constipation, pancreatitis. MUSCULOSKELETAL: Muscle spasm GENITOURINARY: nocturia, polyuria, oliguria SKIN: dermatitis, purpura, photosensitivity reaction METABOLIC: volume depletion and dehydration, asymptomatic, hyperuricemia, impaired glucose tolerance, hypokalemia Nursing Responsibilities: Watch for signs of hypokalemia, such as muscle weakness and cramps.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Monitor uric acid level, especiall in patients with a history of gout. If oliguria or azotemia develops, drug may need to be discontinued.
X. NURSING MANAGEMENT I. Acute pain related to presence of chest tube thoracostomy Assessment Data Subjective cues: Patient complained of pain at Close thoracostomy Tube site Objective cues:

Restlessness Fatigue Facial Grimace Pain Scale 5/10 at CTT site CTT inserted at left mid-axillary line
Nursing Diagnosis
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Acute pain related to presence of chest tube thoracostomy
Goals and Objectives After 30 minutes to one hour of nursing care and interventions, the client will be able to: Report pain is relieved and controlled as evidenced by pain reduction from a scale of 5/10 to 0/10. Demonstrate use of relaxation skills and diversional activities as evidenced by doing return demonstration.
Nursing interventions Actual (Independent) Performed a comprehensive pain evaluation, including location, characteristics, onset or duration, frequency, quality, severity and precipitating/ aggravating factors.
Rationale: Provide baseline information from which a realistic pain can be developed, keeping in mind that verbal/ behavioural cues may have little direct relationship to the degree of pain perceived. Provided comfort measures such as repositioning, back rubbing, quiet environment and calm activities.
Rationale: To promote non-pharmacological pain management.
Instructed use of diversional activities such as watching TV and socialization with significant others.
Rationale: To divert attention from the pain.
Demonstrated use of relaxation techniques and encouraged patient to do return demonstration such as deep breathing and coughing exercises while splinting the surrounding tissue of the CTT site.
Rationale: Can supplement analgesic therapy especially during periods when client desires to minimize sedative effect of the medications.
Collaborative/ Dependent Administered tramadol hydrochloride 50 mg IVTT prn as ordered.
Rationale: Bind to oipiod receptors and inhibit the release of norepinephrine causing faster relief of pain.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Evaluation Goals met. After 45 minutes of nursing care and interventions, the client was able to: Report pain is relieved and controlled as evidenced by a pain scale of 0/10.
Demonstrate use of relaxation skills and diversional activities as indicated, such as by watching TV, and staying in the preferred position of comfort of semifowlers.
II. Ineffective breathing pattern related to compression of the diaphragm secondary to fluid accumulation in the peritoneum. Assessment Data Subjective cue: Patient complained difficulty of breathing Objective cues:

RR-32 cpm, irregular and tachypneic Orthopnea Restlessness Ascites-(+) fluid wave test 110 cm abdominal girth.
Nursing Diagnosis Ineffective breathing pattern related to compression of the diaphragm secondary to fluid accumulation in the peritoneum.
Goals and Objectives Short Term Goals At the end of 30 minutes to 1 hour of nursing care and interventions, the patient will be able to:
Establish an effective respiratory pattern as evidence by respiratory rate within normal range 12- 24 cycles per minute of regular rhythm. Demonstrate appropriate techniques to promote lung expansion as evidenced by return demonstration of techniques that will improve breathing pattern.
Long Term goals At the end of 2 weeks of nursing care and interventions, the patient will be able to:
Maintain an effective respiratory pattern as evidenced by respiratory rate within normal range 12- 24 cycles/ min and absence of manifestations indicating distress and reduce abdominal girth.
Nursing Interventions Actual (Independent) Placed the patient on a semi-fowlers position. Rationale: To promote physiological ease of maximal inspiration.
Demonstrated deep breathing exercises with proper splinting and use of pursed-lip technique and encouraged client to do return demonstration. Rationale: To assist patient in taking control of the situation and prevent possible respiratory alkalosis.
Assisted patient to sit up as much as possible Rationale: Promotes maximal inspiration; enhances lung expansion and ventilation.
Instructed to minimize intake of gas-forming foods and avoid overeating Rationale: To avoid further abdominal distention that causes diaphragm compression.
Instructed client to avoid wearing constricting clothes. Rationale: in order not to further compress the abdomen and to accommodate maximal lung expansion.
Dependent
Administered oxygen 2LPM via nasal cannula as ordered. Rationale: Provide supplemental oxygen to correct respiratory distress.
Assisted client in paracentesis. Rationale: Draining excessive fluid in the peritoneum relieving then the compression.
Administered Human Albumin (25%) 50cc IV OD 8pm Rationale: To increase plasma oncotic pressure allowing fluid shifting from the transcellular area to plasma for excretion.
Administered Spironolactone 25mg 1tab PO BID (8am 6pm) and Furosemide (post-albumin) 20mg IVTT OD. Rationale: To effectively excrete excessive water in the body.
Collaborative
Obtained postplacement x-rays and review serial chest x-rays Rationale: X-rays confirm proper placement and monitor progress re expansion of lung.
Evaluation Short Term Goals Goals are met. At the end of 40 minutes the client was able to: Establish an effective respiratory pattern as evidenced by respiratory rate of 18 cycles/min of regular rhythm and oxygen saturation of 97%
Demonstrate appropriate techniques to promote lung expansion as evidenced by performing deep breathing and pursed lip breathing exercises.
Long term Goals Goals partially met. At the end of 2 weeks of nursing care and interventions, the patient was not able to:
Maintain an effective respiratory pattern as evidenced by fluctuations in respiratory rate (28, 32, 18, 27cycles/ min) with manifestations indicating distress (dyspnea) but was able to reduce abdominal girth from 110- 89.8 cm.
Recommendations Ideal Interventions:
Monitor/ graft serial of Arterial blood Gas. Review vital capacity/ tidal volume measurements Rationale: Assesses status of gas exchange and ventilation, need for continuation or alterations in therapy.
Provide use of adjuncts, such as incentive spirometer. Rationale: To facilitate deeper respiratory effort.
III. Impaired gas exchange related to limitation of lung expansion secondary to fluid accumulation in the pleural cavity. Assessment Data Subjective cue: Patient complained difficulty of breathing. Objective cues:
RR-32cpm, irregular
Orthopnea Restlessness Pale skin, conjunctiva and lips Decrease hgb of 12. 3 Decrease hct of 33.0 Decrease RBC of 4.36 Decrease oxygen Saturation of 90% CTT in placed at left mid-axillary
Nursing Diagnosis Impaired gas exchange related to limitation of lung expansion secondary to fluid accumulation in the pleural cavity.
Goals and Objectives Short term goal At the end of 30 minutes to 1 hour of nursing care and interventions, the client will be able to:
Demonstrate improved ventilation and adequate oxygenation of tissues by oxygen saturation within in normal limits (95-100%) and respiratory rate within normal range absence of symptoms of respiratory distress.
Long term goal At the end of 5 days of nursing care and interventions, the client will be able to:
Display improvement of her blood chemistry such haemoglobin, hematocrit, and red blood cells count to normal level.
Nursing Interventions Actual (Independent)
Assessed level of consciousness and mentation changes, noting restlessness and reports of headache. Rationale: Detects decrease oxygenation in the brain which is an emergency situation.
Placed the patient on a semi-fowlers position. Rationale: To promote maximal inspiration and maintain airway.
Instructed to have adequate rest and limit activities within patients tolerance. Rationale: To lessen oxygen demand and consumption.
Assisted in frequent position changes and deep breathing/coughing exercises while splinting the CTT site. Rationale: To promote optimal lung expansion.
Checked the patency of the thoracostomy tube and ensure intermittent bubbling. Rationale: To ensure that thoracostomy is in placed.
Kept the bottle safe from any potential breakage. Rationale: to complications. prevent breaking the bottle causing further
Dependent:
Administered oxygen 2LPM via nasal cannula as ordered. Rationale: Provide supplemental oxygen to correct respiratory distress.
Administered Human Albumin (25%) 50cc IV OD 8pm
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Rationale: To increase plasma oncotic pressure allowing fluid shifting from the transcellular area to plasma for excretion.
Administered Spironolactone 25mg 1tab PO BID (8am 6pm) and Furosemide (post-albumin) 20mg IVTT OD. Rationale: To effectively excrete excessive water in the body.
Collaborative:
Obtained postplacement x-rays and review serial chest x-rays Rationale: X-rays confirm proper placement and monitor progress re expansion of lung.
Evaluation Short Term Goal Goal is met At the end of 45 minutes of nursing interventions the patient was able to:
Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by oxygen saturation of 97% absence of symptoms of respiratory distress such as restlessness.
Long Term Goal
Goal not met At the end of 5 days of nursing interventions the patient was not able to: Display blood chemistry (hgb, hct, Rbc) at normal levels but with significant improvement. Recommendations: Ideal Interventions:
Monitor/ graft serial of Arterial blood Gas. Review vital capacity/ tidal volume measurements
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Rationale: Assesses status of gas exchange and ventilation, need for continuation or alterations in therapy.
Provide use of adjuncts, such as incentive spirometer. Rationale: To facilitate deeper respiratory effort.
IV. Fatigue related to poor physical condition secondary to disease process Assessment cues Subjective cue: Patient verbalized of body weakness. Objective cues: Sleep deprivation Altered blood chemistry Decreased hemoglobin in 4 successive readings (10.0, 11.6, 11.0, 12.3) Decreased RBC (3.81, 3.80, 3.67, 4.36) RR of 34 cpm; irregular Fatigue scale 5/10 Muscle strength of 4/5 ADL level 2 (assist with person)
Nursing Diagnosis Fatigue related to poor physical condition secondary to disease process
Goals & objectives Short term Goals: After 8 hours of rendering nursing care and intervention, the patient will be able to: Report significant improvement in the sense of energy as evidenced by reduction of fatigue scale from 5/10 to 0/10 or as tolerated. Report increased feeling of being rested.
Long term Goal: After 1 week of rendering nursing care and intervention, the patient will be able to:
Perform activities of daily living and participate in desired activities at the level of ability such as toileting and active exercises without assistance. (correction)
Nursing interventions Actual (Independent)
Promoted bed rest, provided quiet environment, limit visitors as needed. Rationale: To promote rest and relaxation
Assisted with self care needs as indicated. Rationale: Weakness may make ADLs difficult to complete or place the patient at risk of injury during activities.
Limit exertional activities such as ambulating and active range of motion. Rationale: To decrease additional energy needs and demand.
Instructed to use of stress management techniques such as avoiding conflicts, maintaining good relationship with significant others. Rationale: To help promote relaxation, conserve energy, decrease feelings of stress.
Assisted patient to identify appropriate coping behaviours. Rationale: promotes sense of control and improves self-esteem.
Dependent: Provide supplemental oxygen as ordered at 2 LPM. Rationale: decrease RBC and haemoglobin decreases cellular oxygen uptake and contributes to fatigue.
Evaluation
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis Short term Goals: Goals partially met. After 8 hours of rendering nursing care and intervention, the patient was able to:
Report improvement in the sense of energy from a fatigue scale of 5/10 to 2/10. Report increased feeling of being rested as evidenced by sleeping for 6 consecutive hours.
Long term Goal: Goals met. After 1 week of rendering nursing care and intervention, the patient was able to:
Perform activities of daily living such as feeding, grooming, dressing and participate in desired activities such active range of motion, ambulating and bed mobility independently.
V. Moderate anxiety related to perceive threat of death. Assessment Data Subjective cue: Patient verbalized fear of the process of dying. Objective cues: Teary eye when expressing feelings of threat of dying. Diminished productivity Frequent asking about the management done and interventions given. Poor eye contact Nursing Diagnosis Moderate anxiety related to perceive threat of death. Goals and Objectives Short Term: After 1-2 days of rendering care and interventions, the client will be able to:
Identify and express feelings appropriately as evidenced by verbalization of acceptance of impending death.
Long Term:
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis After 2 weeks of rendering care and interventions, the client will be to:
Experience personal empowerment in spiritual strength and resources to find meaning and purpose in grief and loss as evidenced by acceptance of impending death and verbalization of decrease anxiety.
Nursing Interventions Independent:
Assisted development of a trusting relationship with clients family. Rationale: Trust is necessary before clients family can feel free to open personal lines of communication with the health care and address sensitive issues.
Provided open, nonjudgmental environment. Use communication skills of active-listening, acknowledgement.
therapeutic
Rationale: Promotes and encourages realistic dialogue about feelings and concerns.
Encouraged verbalization of thoughts/ concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings. Rationale: client may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.
Reinforced teaching regarding disease process and treatments and provide information as requested about dying with honesty without giving false hopes.
Rationale: Client/ SO benefit from factual information. Individuals may ask direct questions about death, and honest answers promote trust and provide reassurances that correct information will be given.
Collaborative: Encouraged significant others to contact clergy or spiritual advisor. Rationale: providing for spiritual needs, forgiveness, prayer, devotional materials, or sacraments as requested can relieve spiritual pain and provide a sense of peace.
Evaluation Goals met. Short Term: After 2 days of rendering care and interventions, the client was able to:
Identify and express feelings appropriately as evidenced by verbalization of acceptance of impending death.
Long Term: After 2 weeks of rendering care and interventions, the client was able to:
Experience personal empowerment to find meaning and purpose in grief and loss as evidenced by acceptance of impending death and verbalization of decrease anxiety.
XI. EVALUATION, RESULTS AND DISCUSSIONS
For two weeks of care to our patient with Metastatic Breast Cancer, it has been a great experience in mitigating symptomatic problems of the patient using the available resources of the hospital institution, executing independent actions that significantly helped client achieving quality of life, and working interdependently with the attending physicians and other members of the healthcare team to promote comfort.
The Continuous Care: An Update The group didnt stop in just taking full responsibility of the patients welfare during our scheduled duty days. Hence, we did follow-up assessment for updates in her general condition. Upon our visit, the patient seems weak and wasnt able to do activities independently like eating on her own. Irritability and restlessness were also noted as well as difficulty of breathing accompanied by the use of accessory muscles and decreasing muscle strength of 3/5. We were very lucky to get a chance of seeing the doctor disclosing updates in the condition of the patient and her significant others. According to the attending physician, the condition of client is getting worse and anytime she could go into arrest and given ample time to decide whether to sign Do not Resuscitate form. Three days after the first visit, we once again visited her and found out relevant updates in her condition. Because shes in the state of illness, shes exposed to infection and this was proven with her latest diagnosis of HospitalAcquired Pneumonia. Moreover, shes also diagnosed to have malnutrition as
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis evidenced by significant weight loss. This is most probably due to decrease appetite, as reported by the patient and her significant others. However, amidst her illness, we can see significant improvement in her general appearance from the last time we saw her, shes happy and was very accommodating and very excited to go home. She went home against medical advise in the same day to spend quality time with her family and to take part in actively planning for her 65 th birthday the next month.
The Recommendation Because of the late discovery of her Metastatic Breast Cancer, it is really impossible to return the health of the client into normal. Hence, we want to provide quality life to patient at the terminal stage of her condition through spending time with her loved ones and help client gradually accept impending death. Educating with the nature of the disease condition shouldnt only be confined to the patient but should also benefit the significant others in order to assist them from the anticipatory grieving. Sign and symptom management should be well-established to promote comfort as well as addressing their physiologic needs and even spiritual needs.
XII. DEFINITION OF TERMS
1. Invasive breast cancer - cancer that spreads outside the membrane of the lobule or duct into the breast tissue. The cancer can then spread into the lymph nodes in the armpit or beyond to the brain, bones, liver, or lungs. 2. Metastasis cancer cells spread to other parts of the body. It has the same name and the same type of cancer cells as the original, or primary, cancer. 3. Pleurodesis - A procedure that causes the membranes around the lung to stick together and prevents the build up of fluid in the space between the membranes through removing the thoracostomy tube. 4. Non-invasive breast cancer stay within the milk ducts or lobules in the breast. They do not grow into or invade normal tissues within or beyond the breast. 5. Proto-oncogen a normal gene that can become an oncogene due to mutations or increased expression. It is believed that these are inactivated cancel cells in the body and are activated when exposed to materials and/or food which can cause malignancy. 6. Epithelial cells extracellular matrix (ECM) is responsible for cell growth and differentiation. Research has shown to suppress apoptosis of mammary epithelial cells in tissue culture and in vivo. 7. P53 mutation the most common genetic change identified in human neoplasia and it is associated with more aggressive disease and worse overall survival.
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis 8. Apoptosis programmed cell death, is a normal component of the development and health of multicellular organisms. In patient with neoplastic cells believed that this is suppressed. 9. Epidermal growth factor receptor protein found on the surface of some cells and to which epidermal growth factor binds, causing the cells to divide. It is found at abnormally high levels on the surface of many types of cancer cells, so these cells may divide excessively in the presence of epidermal growth factor. 10. Differentiation it is the grade of the cancer. Cells can be well differentiated, moderately differentiated, or poorly differentiated. This is the same as low, medium or high grade. It is also called grades 1, 2, or 3, where grade 1 is low grade. 11. Monoclonal conversion protein marker in which its presence signals presence of neoplasm.
XIII. BIBLIOGRAPHY Books: 1. Black, J. M. & Hawks, J. H. (2009). Statistics of breast cancer. Medical Surgical Nursing: Clinical Management for Positive Outcomes 8th Edition (p. 940 967). 2. Tomey, A. M. & Alligood, M. R. (2004), theory of comfort by Kolcaba. Nursing Theorist and Their Work 5th Edition (p.430 442) 3. Hamilton, J. (1989). Comfort and the hospitalized chronically ill. Journal of Gerontological Nursing, 15(4), 28 33 4. Jenny, J. & Logon, J. (1996). Caring an d comfort metaphors used by patients in critical care. Image: Journal of Nursing Scholarship, 28(4), 349-352. 5. Doenges, M. E., Moorhouse, M. F., Murr, A. C. (2008). Nursing Diagnoses. Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.
Web Sources: 1. Kolcaba, K. (2001). The comfort Line [Online]. Available:
http://www.uakron.edu/comfort 2. Mankoff, D. (2011). Non-invasive or Invasive Breast Cancer [Online]. Available: http://www.breastcancer.org/symptoms/diagnosis/invasive.jsp 3. National Cancer Institute (2005). Metastatic Cancer [Online]. Available: http://www.cancer.gov/cancertopics/factsheet/Sites-Types/metastatic 4. Gasco, M., Shami, S., & Crook, T. (2002). The p53 pathway in breast cancer [Online]. Available: http://breast-cancer-research.com/content/4/2/70
DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis 5. National Cancer Institute. EGFR [Online]. Available:
http://www.cancer.gov/dictionary?cdrid=44397 6. CancerHelp UK. The cancer cell [Online]. Available:
http://cancerhelp.cancerresearchuk.org/about-cancer/what-is-cancer/cells/thecancer-cell

Dissecting The Nature of The Silent Assailant - FINAL

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DISSECTING THE NATURE OF THE SILENT ASSAILANT: A Case Study on Breast Cancer Stage IV with Metastasis ABSTRACT This

Normocephalic Normocephalic Normocephalic Normocephalic Normocephalic

uses eyeglasseswhen reading atwhen reading atwhen reading atwhen reading at

Pallor with darkPallor with

discoloration atthe lips.

Mucosa Tongue Teeth

Pallor Midline Dentures front teeth.

Pallor Midline andupper frontlower teeth. Pale

Pallor Midline andupper frontlower teeth. Pale

Pallor Midline andupper frontlower teeth. Pale and front

on Dentures on Dentures on Dentures on Dentures on lower teeth. Pale

upper and lowerupper

Posterior Not inflamed

skin turgor dueskin turgor dueturgor

Configuration Globular 110 cm Bowel sounds Percussion clicks minute Tympanitic

Hypoactive: 3Hypoactive: 2Hypoactive:

of 5th intercostal5th intercostal5th

intercostal5th intercostal midclavicular.

midclavicular. midclavicular. midclavicular.

1:2;AP: 1:2; Normal AP:

Symmetrical Symmetrical Symmetrical

midline. Normal midline. Normal midline. Normal gaitBalanced gaitUncoordinated due to

Balanced gaitBalanced gaitBalanced slowbut

slowbut slow whenbut slow whengait attachedCTT

DAY 1 (January 27, 2012)

Decreased hearing gross Palpable lump noted, 6 cm, nontender.

Hypoactive: 3 clicks per minute

PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses

DAY 2 (January 28, 2012)

Decreased hearing gross

Palpable lump noted, 6 cm, nontender. Increase RR of 32 cpm, O2 sat of 90%

Hypoactive: 2 clicks per minute

PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses

Dark discoloration under the nail bed.

DAY 3 (February 2, 2012)

Decreased hearing gross

Palpable lump noted, 6 cm, nontender.

Hypoactive: 2 clicks per minute

PLR 1L was hooked and regulated @ 20 gtts/min. Irregular peripheral pulses

Dark discoloration under the nail bed.

DAY 4 (February 02, 2012)

Decreased hearing gross

DAY 5 (February 03, 2012)

upper extremities Passive ROM: Full Muscle Tone and Strength:4/5

Dark discoloration under the nail bed.

Developmental Theory: Katharine Kolcabas Theory of Comfort

DESCRIPTION OF THE THEORY Nursing

psychospiritual, social, and environmental) (Kolcaba, 2010)

VI. ANATOMY AND PHYSIOLOGY MAMMARY GLANDS

Alteration in the normal cell

Negatively affects the DNA repair

Tumor suppressor genes is turned off

Overstimulation of mammary epithelial cells extracellular matrix niche

Proliferation of affected cell

Quick abnormal cell growth and division

Allows unchecked cellular replication at the epithelial surface

Inability to control proliferation of affected cells

DNA repair genes is inactivated

Increased cell division causing further mutations

Increases number of malignant cells

Epidermal growth factor receptor is released in excessive amount

Presence of tumor was unrecognized