OBJECTIVES

General:
The study aims to improve the knowledge of the students regarding on Ductal Carcinoma. It gives the
students the opportunity to learn different aspects regarding on the case of the patient. It broadens the
understanding of the students regarding on the body system involves. It also makes the students see the reality of
what they are studying in lecture of Medical-Surgical Nursing subject.
The study also aims to apply the different skills that the students learned from their related learning
experiences regarding on physical assessment and also on those different nursing interventions that they must
apply to the patients situation.
Aside from the knowledge and skills that this study aims to enhance, it also encompasses the attitude
aspect of the students. Their approach to the patient is important for them to establish rapport; it gives them the
opportunity to build good and trusting relationship with the patient and gather more accurate information and
achieve possible health outcomes.

Specific:

1. To be aware on how this case affects persons and how prevalent this situation is.
2. To be skill-oriented on how to identify and to properly observe the status of this case in our present time.
3. To be well-communicated with the client during the physical assessment and interviews.
4. To enhance our learned skills on assessing the client and how to classify abnormalities with different
aspects such as physical, emotional, mental and spiritual.
5. To make ourselves oriented to different laboratory results and how we can relate it with the situation of
the client.
6. To enhance our knowledge in anatomy and physiology of the system involve.
7. To practice our skills in doing the pathophysiology of the case of the client.
8. To understand the drugs and its uses according to the clients situation.
9. To provide nursing care plan and discharge plan to assure clients total wellness.
10. To know the proper attitude that an ideal nurse must possess.
11. To learn how to make the proper approach to client to get their trust.



















I. INTRODUCTION

a. Background of the Study
I. Incidence, race, gender, age, ratio and proportion

The highest rates of breast cancer occur in Western countries (more than 100
cases per 100,000 women) and the lowest among Asian countries (1015 cases per
100,000 women). Men can also have breast cancer, but the incidence is much less when
compared to women. There is a strong genetic correlation since breast cancer is more
prevalent in females who had a close relative (mother, sister, maternal aunt, or
maternal grandmother) with previous breast cancer. Increased susceptibility for
development of breast cancer can occur in females who never breastfed a baby, had a
child after age 30, started menstrual periods very early, or experienced menopause very
late.
In the United States, there were approximately 175,000 cases of breast cancer
in 1999 with more than 43,000 deaths. Breast cancer accounts for 30% of all cancer
diagnosed in American women and for 16% of all cancer deaths. Breast cancer is a
worldwide public health problem since there are approximately one million new cases
diagnosed annually. A woman's lifetime risk of developing breast cancer is one in eight.
The incidence rose 21% from 1973 to 1990, but in recent years there has been a decline.
http://www.encyclopedia.com/doc/1G2-3406200301.html
II. Rationale for Choosing the case

Our Clinical Instructor decided to choose the case of Ductal Carcinoma because
this is common among women specially age 45years old and above. This case will help
us dig deeper on how and why it happens to those persons.

Also, the patients data is somehow complicated, such as her age and
background history, which is very interesting to find out if it is parallel to be the cause of
the case. It really make us wonder how it happens to a person and how will it be
distinguish.



III. Significance of the studies

The significance of the study is to enhance and of course to gain knowledge, to develop
skills and to apply the attitudes that must be render to the client whatever the case may
be. This study will also contribute in the widening of the ideas of the student about the
topic of the case.
These are other significance of the study that would support the above statement:
To be aware on how this case affects a person and how prevalent this situation
is.
To be skill-oriented on how to identify and to properly observe the status of this
case in our present time.
To be well-communicated with the client during the physical assessment and
interviews.
To enhance our learned skills on assessing client and how to classify
abnormalities with different aspects such as physical, emotional, mental and
spiritual.
To make ourselves oriented to different laboratory results and how we can relate
it with the situation of the client.
To enhance our knowledge in anatomy and physiology of the system involve.
To practice our skills in doing the pathophysiology of the case of the client.
To understand the drugs and its uses according to the clients situation.
To provide nursing care plan and discharge plan to assure clients total wellness.
To know the proper attitude that an ideal nurse must possess.
To learn how to make the proper approach to client to get their trust.


IV. Scope and limitation of the study

The study would only focus on the information gathered from the patient, relatives of
the patient, from her records and laboratory results. This will be covering about the case
of Ductal Carcinoma, all about its anatomy and physiology and how did all of the records
may it be the medications, doctors order and nurses notes correlates to each other.

V. Conceptual Theoretical Theory

LYDIA HALLNURSING THEORY
(Core, Care, and Cure Model)













The Core. The core of human being is his/her needs to meet the Quality of Life (QOL). It is in
these needs that makeup and creates an individual.
The Care. The type of care a nurse will render in any case of altered health pattern can be in the
form of promotive, preventive, curative, rehabilitative and palliative aspects of care. Promotive care focus
on health promotion which is categorized with no source of health information, visits to well-
clinic/centers or oriented to health programs and practicing a healthy lifestyle and with good
environment.
The Cure. This identifies the level of care to be given to a person in case of altered health
pattern. Level 1 Cure covers promotive and preventive care are indications for primary health care
management. The major purposes of this level are to promote wellness and prevent illness or disability.
This level occurs at home or community and the participants in the care of geriatrics is the
private/family/community nurse, family and patients self that will emphasize the development of healthy
lifestyle and environment. Level 2, or early stage of curative phase, is an indication for secondary health
care management.


VI. Related Literature of the study

Invasive ductal carcinoma
Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma,
is the most common type of breast cancer. About 80% of all breast cancers are
invasive ductal carcinomas.
Invasive means that the cancer has invaded or spread to the surrounding
breast tissues. Ductal means that the cancer began in the milk ducts, which are the
pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers
to any cancer that begins in the skin or other tissues that cover internal organs
such as breast tissue. All together, invasive ductal carcinoma refers to cancer that
has broken through the wall of the milk duct and begun to invade the tissues of the
breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and
possibly to other areas of the body.
According to the American Cancer Society, more than 180,000 women in the
United States find out they have invasive breast cancer each year. Most of them are
diagnosed with invasive ductal carcinoma.
Although invasive ductal carcinoma can affect women at any age, it is more
common as women grow older. According to the American Cancer Society, about two-
thirds of women are 55 or older when they are diagnosed with an invasive breast
cancer. Invasive ductal carcinoma also affects men.

Symptoms
At first, invasive ductal carcinoma may not cause any symptoms. Often, an
abnormal area turns up on a screening mammogram (x-ray of the breast), which leads
to further testing.
In some cases, the first sign of invasive ductal carcinoma is a new lump or mass
in the breast that you or your doctor can feel. According to the American Cancer
Society, any of the following unusual changes in the breast can be a first sign of breast
cancer, including invasive ductal carcinoma:
swelling of all or part of the breast
skin irritation or dimpling
breast pain
nipple pain or the nipple turning inward
redness, scaliness, or thickening of the nipple or breast skin
a nipple discharge other than breast milk
a lump in the underarm area

Complications

Lead to premature death
Spread of cancer to other parts of the body
Prone

Female
Get older
Have a family history of breast cancer

Diagnosis

Diagnosing invasive ductal carcinoma usually involves a combination of procedures, including
a physical examination and imaging tests.

Physical examination of the breasts: The doctor may be able to feel a small lump in the
breast during a physical examination. He or she also will feel the lymph nodes under the
armpit and above the collarbone to see if there is any swelling or other unusual changes.
Mammography: Invasive ductal carcinoma is usually found by mammography, a test
that obtains x-ray images of the breast. Mammograms are used to screen apparently healthy
women for early signs of breast cancer. One key feature of an invasive breast cancer is
spiculated margins, which means that on the mammography film, the doctor sees an
abnormality with finger-like projections coming out of it. These projections show the
invasion of the cancer into other tissues.

If a screening mammogram highlights an area of concern, additional mammograms often will
be done to gather more information about that area. Mammography will be performed on
both breasts.
Ultrasound bounces sound waves off of the breast to obtain additional images of the
tissue. Ultrasound is sometimes used in addition to mammography.
Breast MRI: MRI, or magnetic resonance imaging, uses magnetic fields, radio waves, and
a computer to obtain images of tissues inside the body. In certain cases, a doctor may use
breast MRI to gather more information about a suspicious area within the breast.
Biopsy: If you do have a suspicious mammogram or other imaging test result, your
doctor will probably want you to have a biopsy. A biopsy involves taking out some or all of
the abnormal-looking tissue for examination by a pathologist (a doctor trained to diagnose
cancer from biopsy samples) under a microscope.

When possible, your doctor will usually use one of the quicker, less invasive approaches to
biopsy:
o Fine needle aspiration biopsy involves inserting a very small, hollow needle into the
breast. A sample of cells is removed and examined under the microscope. This method leaves
no scars.
o Core needle biopsy inserts a larger needle into the breast to remove several cylinder-
shaped samples of tissue from the area that looks suspicious. In order to get the core needle
through the skin, the surgeon must make a tiny incision. This leaves a very tiny scar that is
barely visible after a few weeks.
In cases where the doctor cannot feel the lump, he or she may need to use ultrasound or
mammograms to guide the needle to the right location. You may hear this referred to as
stereotactic needle biopsy or ultrasound-guided biopsy.

If a needle biopsy is not able to remove cells or tissue, or it does not give definite results
(inconclusive), a more involved biopsy may be necessary. These biopsies are more like
regular surgery than needle biopsies:
o Incisional biopsy removes a small piece of tissue for examination.
o Excisional biopsy attempts to remove the entire suspicious lump of tissue from the
breast.
Again, if the doctor cannot feel the lump, he or she may need to use mammography or
ultrasound to find the right spot. Your doctor also may use a procedure called needle wire
localization. Guided by either mammography or ultrasound, the doctor inserts a small hollow
needle through the breast skin into the abnormal area. A small wire is placed through the
needle and into the area of concern. Then the needle is removed. The doctor can use the
wire as a guide in finding the right spot for biopsy.

These surgical biopsies are done only to make the diagnosis. If invasive ductal carcinoma is
diagnosed, more surgery is needed to ensure all of the cancer is removed along with clear
margins, which means that a border of healthy tissue around the cancer is also removed.
Usually this means having lumpectomy, or in some cases, mastectomy.
Treatment

Treatment options may include:
Axillary lymph node dissection
Chemotherapy
Lumpectomy
Mastectomy
Radiation therapy
Selective Estrogen Receptor
Modulator
Sentinel Node Biopsy
Targeted Therapy



Lifestyle Changes

Massage
Meditation
Music therapy
Hypnosis
Relaxation techniques, such as guided imagery
Tai chi
Yoga
Medications
The drug tamoxifen blocks the action of estrogen a hormone that fuels some breast
cancer cells and promotes tumor growth to reduce your risk of developing invasive breast
cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone
receptor positive cancers).Tamoxifen isn't a treatment for DCIS in and of itself, but it can be
considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease
your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the
future.

Nursing Intervention
1. Support the patient emotionally and offer reassurance.
2. Administer prescribed medications.
3. Provide six small meals a day or small hourly meals as ordered.
4. Schedule care so that the patient gets plenty of rest.
5. Monitor the effectiveness of administered medications, and also watch
for adverse reactions.
6. Assess the patients nutritional status and the effectiveness of measures
used to maintain it. Weigh him regularly.
7. Teach the patient about peptic ulcer disease, and help him to recognize
its signs and symptoms.
8. Review the proper use of prescribed medications, dicussing the desired
actions and possible adverse effect of each drug.
9. Instruct the patient to take antacids 1 hour after meals.
10. Warn the patient to avoid aspirin containing drugs because they irritate
gastric mucosa.
11. Encourage the patient to make appropriate lifestyle changes.

II. CLINICAL SUMMARY
A. General Data Profile

NAME: Mrs. VAP
ADDRESS: Brgy. Mapagong, Pagbilao,Quezon
AGE: 50y/o
WEIGHT: 69kg
HEIGHT: 411 ft.
BIRTHDAY: Dec. 10, 1963
BIRTHPLACE: Masbate
SPOUSE: Mr. EX
NATIONALITY: Filipino
RELIGION: Roman Catholic
OCCUPATION: House Wife
DATE OF ADMISSION: August. 13, 2013
ADMITTING DIAGNOSIS: Breast Mass Left, Excision Biopsy
ADMITTING PHYSICIAN: Dr. Durbin William Jeffrey N. Tang

B. CHIEF COMPLAINT
-With Mass on the Left Breast for 5 years

C. Nursing History
a. Childhood Illnesses
- Common colds, cough and fever
b. Immunizations
- BCG ( 7yrs/old)
c. Allergies
- No allergy at all.
d. Accidents
-The client had no known accident.
e. Hospitalizations
-Quezon Medical Center year 2001 due to delivery of the baby via Ceasarian section
f. Medications used or currently taking
- Mefenamic if he feels pain and Herbal meds
g. Domestic Travel
- She is traveling from Palawan, Masbate and Quezon Province to visit her relatives.

D. Health History

A. Medical History
a. Chronic Illness
- The client is experiencing from Urinary Tract Infection
b.
Current Medications
Drug Dose Route Time
Atracarium 25mg IV
Propofol 80mg + 30mg IV
Butorphanol 1mg IV
Neostigmine +
Atropine Sulfate
5mg + 1mg
respectively
IV
Cefuroxime 750mg IV Every 8 hours
Keterolac 30mg IV Every 6 hours
Tramadol 50mg IV Every 4 hours
Paracetamol 300mg IV Every 4 hours
Cefuroxime 500mg Oral tab Three times a day
Celecoxib 200mg Oral tab Two times a day
c. Childhood Illness
- Common colds, cough and fever
B. Surgical History
a. Problems with anesthesia
- The client stated that she has no problem with anesthesia nor allergies with it.
b. Previous Surgeries
- The client had undergo to surgery at year 2001 due to her delivery to her baby via
Cesarean Section
























E. FAMILY HISTORY

Legend:

Male Male Death

Female Female Death


Patient







Prostitis T B





A&W A&W Tumor on A&W A&W
The colon

A&W A&

A&W Patient


A&W A&W

Mass on
Breast
89
65
12
20
17
18
21
48
12
58
8
6 61
15
19
24
70
25
5
50
17
49

17
51
39
17

F. SOCIAL HISTORY INCLUDE THEORIES AND GROWTH AND DEVELOPMENT

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE
RESOLUTION
INDICATORS OF
NEGATIVE RESOLUTION
Adulthood 25-65
years
Generativity
versus
stagnation
Creativity,
productivity,
concern for
other s
Self-indulgence,
lack of interests
and
commitments.

According to this theory adulthood had creativity, productivity, concern for other. Based
on what the client said she wanted to sustain the need of her family especially her children future
and education, in spite of her of present condition.
ACCORDING TO SIGMUND FREUD
PSYCHOSEXUALTHEORY
STAGE AGE CHARACTERISTICS IMPLICATION
Genital Puberty and after Energy is directed
toward full sexual
maturity and function
and development of
skills needed to cope
with the environment
Encourages separation
from parents,
achievement of
independence and
decision making

According to this theory, the genital stage correlates to her age because she gains
independence in decision making to do normal things. Though she experiences pain physically due
to her condition it was only now that she experiences it that affected her sexual maturity and
function and development of skills.

G. ENVIRONMENTAL/ LIVING CONDITION

The environment where they live and work is along a roadside. There are tricycle and
jeep which can be means of transportation. The type of their house not completely cemented,
but is well ventilated.



H. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT
Date of Assessment: August. 14, 2013
General Appearance: Pre-Operative
The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears
blouse and shorts exactly for her body. Upon assessment, the client is lying on bed.
BODY PART NORMAL FINDINGS ACTUAL FINDINGS
INTERPRETATION/ ANALYSIS
A. HEAD
1. SKULL

Proportional to the size
of the body, round, with
prominences in the
frontal area anteriorly

Proportional to the
size of the body,
symmetrical in all

Normal.

and the occipital area
posteriorly symmetrical
in all planes.
planes.

2. SCALP White, clean, free from
masses, lumps, scars,
nits, dandruff, and lesion
White, clean, free
from masses, lumps,
scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly
distributed and covers
the whole scalp, thick,
shiny, free from split
ends.
Black hair; evenly
distributed, thin,
bristle-like and coarse.
Normal
4. FACE Oblong/oval/square or
heart-shaped,
symmetrical, facial
expressions that is
dependent on the mood
or true feelings, smooth
and free from wrinkles,
no involuntary muscle
movements.
Oval shape.
Symmetrical, free
from wrinkles and
scars. No involuntary
muscle movements.
Normal.

B. EYES


1.EYEBROWS



Black, symmetrical,
thick, can raise and
lower eyebrows
symmetrically and
without difficulty, evenly
distributed and parallel
with each other.



Black, symmetrical.
Thin. Can raise and
lower eyebrows.




Normal

2. EYELIDS Upper lids cover a small
portion of the iris,
cornea, and the sclera
when the eyes are open.
When the eyes are
closed, the lids meet
completely. Symmetrical
color is the same as the
surrounding skin.
Upper lids cover a
small portion of the
iris, cornea, and the
sclera when the eyes
are open. When the
eyes are closed, the
lids meet completely.
Same color of
surrounding skin.
Normal

3. LID MARGINS







4. CONJUNCTIVA
Clear, without scaling or
secretions, lacrimal duct
openings are evident at
the nasal ends.



Pink, without lesions
Clear, without scaling
or secretions






Pink without lesions

Normal







Normal
5. SCLERA White and clear. White and clear. Normal
6. IRIS Proportional to the size
of the eye, round,
black/brown, and
symmetrical.
It is symmetrical,
round and
proportional to size.
Normal

7. PUPIL From pinpoint to almost
the size of the iris,
round, symmetrical,
constrict with increasing
light and
accommodation.
Symmetrical
constricted to light
and accommodated
from light.

Normal

8. CORNEA Clear Clear Normal
9. EYE MOVEMENT Able to move eyes in full
range of motion or able
to move in all directions.
Able to move eyes in
six field of gaze.
Normal
C. EARS

Pinkish, clean, with scant
amount of cerumen and
a few cilia.
Cerumen and a few
cilia.

Normal
1. HEARING ACUITY Able to hear whisper
spoken words 2 feet
away.
Able to hear whisper
spoken words 2 feet
away.
Normal
2. EAR CANAL No erythema, no scaling,
no swelling, absence of
foreign body and odor.
No erythema, no
scaling, absence of
foreign body and
odor.
Normal
D. NOSE

Midline, symmetrical,
and patent.
Midline, symmetrical,
and patent.
Normal
1. INTERNAL NARES Clean, pinkish, with few
cilia.
Clean, pinkish, with
few cilia.
Normal
2. SEPTUM Straight. Straight. Normal
E. MOUTH Pinkish, symmetrical lip
margin, well-defined,
smooth and moist.
Pinkish, symmetrical,
lip margin, well-
defined, smooth and
moist.
Normal
1. LIPS Pinkish, smooth, moist,
no swelling, no
retraction, no discharge.
Pinkish lips. No
swelling.
Normal

2. TEETH 28-32 permanent teeth,
well-aligned free from
caries or filling, no
Halitosis.
28-32 permanent
teeth, well-aligned
free from caries or
filling, no Halitosis.
Normal
3. TONGUE Large, medium, red or
pink, the lateral margins,
moist, shiny, and freely
Movable.
Medium, red, the
lateral margins, moist,
shiny, and freely
movable.
Normal
4. CHEEKS
(BUCCAL MUCOSA)
Pinkish, moist. Pinkish, moist. Normal
5. PALATE Pinkish, moist, and Moist, and smooth. Normal
SOFT PALATE

HARD PALATE
smooth.

Slightly pinkish.

Slightly pinkish.

Normal
6. UVULA At the center,
symmetrical, and freely
movable.
At the center,
symmetrical, and
freely movable.
Normal
7. TONSILS Pinkish, non-inflamed,
no exudates.
Pinkish, non-inflamed,
no exudates.
Normal
8. VOICE No hoarseness and well-
modulated.
No hoarseness and
well-modulated.
Normal
F. NECK

Proportional to the size
of the body and head,
symmetrical and
straight.
Proportional to the
size of the body and
head, symmetrical and
straight.
Normal
G. RANGE OF
MOTION
Freely movable with
relative ease.
Limited range of
motion especially on
the left side of the
body
Due to presence of the mass with wound
on her left breast.
H. MUSCULAR
STRENGTH
Symmetrical movements
and able to resist force
applied by the nurse.
Slightly able to move
the left upper
extremity and to resist
force.
Due to presence of the mass with wound
on her left breast.
J. ABDOMEN
Inspection

1. Abdomen skin



2. Contour and
Symmetry

3. Movements
associated w/
respiration


Unblemished skin;
uniform color.


Flat, rounded;
symmetric contour.

Symmetric movements
caused by respiration.



With scar caused by
surgical incision via CS.

Rise and fall caused by
respiration.




Due to the delivery of her baby via CS.


Normal

Palpation No tenderness; relaxed
abdomen with smooth,
consistent tension.
No area of
tenderness; no
presence of lumps and
masses absence of
lesion.
Normal
K. CHEST (THORAX)

Inspection

Chest symmetrical, skin
intact, no tenderness, no
masses.

Chest symmetrical. No
lumps, tenderness and
masses.
Respiration of 17
breaths per minute

Normal






Breast The breast has no With presence of mass Due to her condition which is to be
lesions and edema. for 5 years with
wound on the left
breast.

under Modified Radical Mastectomy.
L. UPPER
EXTREMITIES
1. ARMS
Inspection



Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, muscles
symmetrical, length
symmetrical.


Tan skin muscle,
length symmetrical,
fine hair evenly
distributed.

Normal
Palpation Warm, dry and elastic,
no areas of tenderness.
Muscle appears equal
with good muscle tone.
Warm, dry and no
areas of tenderness.

Normal
M. NAILS Nails are transparent,
smooth, & convex with
pink nail beds & white
translucent tips.

Five fingers in each
hand. As pressure is
applied to the nail bed,
it appears white or
blanched & pink color
returns immediately as
pressure is released.
Complete fingers, 5
each hand.
Nails are short, thick,
transparent, & convex
with pale nail beds &
white translucent tips.
As pressure is applied
to the nailbed, it
appears white and
color returns after 2
seconds.
Normal
N. SHOULDERS,
ARMS, ELBOWS,
HANDS & WRISTS
ABDUCTION AND
ADDUCTION.
Performs with relative
ease.

Physical mobility of
the upper extrimities
is slightly impaired,
especially on the left
side.
Due to pain associated with the presence
of surgical incision on the left breast.
O. LOWER
EXTREMITIES
1. LEGS
Inspection


Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, absence of
varicose veins, muscles
symmetrical, length
symmetrical.



Skin is uniformed in
tan color Hair evenly
distributed.



Normal
Palpation Muscles appear equal,
warm & with good
muscle tone.
Muscles appear equal,
warm & with good
muscle tone.
Normal
2. TOES
Inspection

Five toes in each foot:

Five toes in each foot.

Normal
sole and dorsal surface
is smooth: With pink nail
beds & translucent tips.
Sole and dorsal
surface is smooth
Palpation As pressure is applied,
the nail beds appear
white or blanched; pink
color returns when
pressure is released (2
seconds).
As pressured is
applied to nail beds,
color becomes white,
colors returns after
less than 2 seconds
Normal
P. LEGS, KNEES,
ANKLES, TOES
ADDUCTION AND
ABDUCTION.
Performs with relative
ease.
Performs with relative
ease.
Normal


Date of Assessment: August. 15, 2013
General Appearance: Post-Operation
The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears
blouse and shorts exactly for her body. Upon assessment, the client is lying on bed, with a blood pressure of
120/80 mmHg, pulse rate of 79 beats per minute, respiration rate of 17 breaths per minute, and temperature of
38.9 C.
BODY PART NORMAL FINDINGS ACTUAL FINDINGS
INTERPRETATION/ ANALYSIS
A. HEAD
1. SKULL

Proportional to the size
of the body, round, with
prominences in the
frontal area anteriorly
and the occipital area
posteriorly symmetrical
in all planes.

Proportional to the
size of the body,
symmetrical in all
planes.


Normal.

2. SCALP White, clean, free from
masses, lumps, scars,
nits, dandruff, and lesion
White, clean, free
from masses, lumps,
scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly
distributed and covers
the whole scalp, thick,
shiny, free from split
ends.
Black hair; evenly
distributed, thin,
bristle-like and coarse.
Normal
4. FACE Oblong/oval/square or
heart-shaped,
symmetrical, facial
expressions that is
dependent on the mood
or true feelings, smooth
and free from wrinkles,
no involuntary muscle
movements.
Oval shape.
Symmetrical, free
from wrinkles and
scars. No involuntary
muscle movements.
Normal.

B. EYES


1.EYEBROWS


Black, symmetrical,
thick, can raise and
lower eyebrows
symmetrically and
without difficulty, evenly
distributed and parallel
with each other.


Black, symmetrical.
Thin. Can raise and
lower eyebrows.



Normal

2. EYELIDS Upper lids cover a small
portion of the iris,
cornea, and the sclera
when the eyes are open.
When the eyes are
closed, the lids meet
completely. Symmetrical
color is the same as the
surrounding skin.
Upper lids cover a
small portion of the
iris, cornea, and the
sclera when the eyes
are open. When the
eyes are closed, the
lids meet completely.
Same color of
surrounding skin.
Normal

3. LID MARGINS







4. CONJUNCTIVA
Clear, without scaling or
secretions, lacrimal duct
openings are evident at
the nasal ends.



Pink, without lesions
Clear, without scaling
or secretions






Pink without lesions

Normal







Normal
5. SCLERA White and clear. White and clear. Normal
6. IRIS Proportional to the size
of the eye, round,
black/brown, and
symmetrical.
It is symmetrical,
round and
proportional to size.
Normal

7. PUPIL From pinpoint to almost
the size of the iris,
round, symmetrical,
constrict with increasing
light and
accommodation.
Symmetrical
constricted to light
and accommodated
from light.

Normal

8. CORNEA Clear Clear Normal
9. EYE MOVEMENT Able to move eyes in full
range of motion or able
to move in all directions.
Able to move eyes in
six field of gaze.
Normal
C. EARS

Pinkish, clean, with scant
amount of cerumen and
a few cilia.
Cerumen and a few
cilia.

Normal
1. HEARING ACUITY Able to hear whisper
spoken words 2 feet
away.
Able to hear whisper
spoken words 2 feet
away.
Normal
2. EAR CANAL No erythema, no scaling, No erythema, no Normal
no swelling, absence of
foreign body and odor.
scaling, absence of
foreign body and
odor.
D. NOSE

Midline, symmetrical,
and patent.
Midline, symmetrical,
and patent.
Normal
1. INTERNAL NARES Clean, pinkish, with few
cilia.
Clean, pinkish, with
few cilia.
Normal
2. SEPTUM Straight. Straight. Normal
E. MOUTH Pinkish, symmetrical lip
margin, well-defined,
smooth and moist.
Pinkish, symmetrical,
lip margin, well-
defined, smooth and
moist.
Normal
1. LIPS Pinkish, smooth, moist,
no swelling, no
retraction, no discharge.
Pinkish lips. No
swelling.
Normal

2. TEETH 28-32 permanent teeth,
well-aligned free from
caries or filling, no
Halitosis.
28-32 permanent
teeth, well-aligned
free from caries or
filling, no Halitosis.
Normal
3. TONGUE Large, medium, red or
pink, the lateral margins,
moist, shiny, and freely
Movable.
Medium, red, the
lateral margins, moist,
shiny, and freely
movable.
Normal
4. CHEEKS
(BUCCAL MUCOSA)
Pinkish, moist. Pinkish, moist. Normal
5. PALATE
SOFT PALATE

HARD PALATE
Pinkish, moist, and
smooth.

Slightly pinkish.
Moist, and smooth.

Slightly pinkish.
Normal

Normal
6. UVULA At the center,
symmetrical, and freely
movable.
At the center,
symmetrical, and
freely movable.
Normal
7. TONSILS Pinkish, non-inflamed,
no exudates.
Pinkish, non-inflamed,
no exudates.
Normal
8. VOICE No hoarseness and well-
modulated.
No hoarseness and
well-modulated.
Normal
F. NECK

Proportional to the size
of the body and head,
symmetrical and
straight.
Proportional to the
size of the body and
head, symmetrical and
straight.
Normal
G. RANGE OF
MOTION
Freely movable with
relative ease.
Limited range of
motion especially on
the left side of the
body
Due to presence of the surgical incision
on the left breast.
H. MUSCULAR
STRENGTH
Symmetrical movements
and able to resist force
applied by the nurse.
Able to resist force
applied only at the
right side of the body.
Due to presence of the surgical incision
on the left breast
I. HEART Regular beats
(60-100 beats per
minute).
Regular beats (79
beats per minute)

Normal
J. ABDOMEN
Inspection

1. Abdomen skin



2. Contour and
Symmetry

3. Movements
associated w/
respiration


Unblemished skin;
uniform color.


Flat, rounded;
symmetric contour.

Symmetric movements
caused by respiration.



With scar caused by
surgical incision via CS.

Rise and fall caused by
respiration.




Due to the delivery of her baby via CS.


Normal

Auscultation Audible bowel sounds
(5-30/min); absence of
arterial bruits and
friction rubs.
Audible bowel sounds
(10/min).

Normal
Palpation No tenderness; relaxed
abdomen with smooth,
consistent tension.
No area of
tenderness; no
presence of lumps and
masses absence of
lesion.
Normal
K. CHEST (THORAX)

Inspection

Chest symmetrical, skin
intact, no tenderness, no
masses.

Chest symmetrical. No
lumps, tenderness and
masses.
Respiration of 17
breaths per minute

Normal






Breast The breast has no
lesions and edema.
With presence of
surgical incision on
left breast. The right
breast has no lesions
and edema.

Due to removal of the mass on the left
breast.
L. UPPER
EXTREMITIES
1. ARMS
Inspection



Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, muscles
symmetrical, length
symmetrical.


Tan skin muscle,
length symmetrical,
fine hair evenly
distributed.

Normal
Palpation Warm, dry and elastic,
no areas of tenderness.
Warm, dry and no Normal
Muscle appears equal
with good muscle tone.
areas of tenderness.

M. NAILS Nails are transparent,
smooth, & convex with
pink nail beds & white
translucent tips.

Five fingers in each
hand. As pressure is
applied to the nail bed,
it appears white or
blanched & pink color
returns immediately as
pressure is released.
Complete fingers, 5
each hand.
Nails are short, thick,
transparent, & convex
with pale nail beds &
white translucent tips.
As pressure is applied
to the nailbed, it
appears white and
color returns after 2
seconds.

N. SHOULDERS,
ARMS, ELBOWS,
HANDS & WRISTS
ABDUCTION AND
ADDUCTION.
Performs with relative
ease.

Physical mobility of
the upper extrimities
is slightly impaired,
especially on the left
side.
Due to pain associated with the presence
of surgical incision on the left breast.
O. LOWER
EXTREMITIES
1. LEGS
Inspection


Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, absence of
varicose veins, muscles
symmetrical, length
symmetrical.



Skin is uniformed in
tan color Hair evenly
distributed.



Normal
Palpation Muscles appear equal,
warm & with good
muscle tone.
Muscles appear equal,
warm & with good
muscle tone.
Normal
2. TOES
Inspection

Five toes in each foot:
sole and dorsal surface
is smooth: With pink nail
beds & translucent tips.

Five toes in each foot.
Sole and dorsal
surface is smooth

Normal
Palpation As pressure is applied,
the nail beds appear
white or blanched; pink
color returns when
pressure is released (2
seconds).
As pressured is
applied to nail beds,
color becomes white,
colors returns after
less than 2 seconds
Normal
P. LEGS, KNEES,
ANKLES, TOES
ADDUCTION AND
ABDUCTION.
Performs with relative
ease.
Performs with relative
ease.
Normal



I. PATTERNS OF FUNCTIONING

Functional Health
Pattern
Before
Hospitalization
During
Hospitalization
(after operation)
Interpretation
Health management
pattern
She is taking
analgesics if she
feels pain and herbal
meds.
The client is
dependent on what
the physician has
ordered her to do.
She takes OTC drugs
whenever she feels
something and
herbal meds as what
the elders has told
her.
Nutritional/ Metabolic
Pattern
- Number of meals
per day

- Appetite


- Glass of water per
day

- Body Built

- Height and weight
-


3 times a day


w/ very good
appetite

6 glasses of water


w/ normal body built
411 and 69 kg


NPO








With normal body
built



Her number of meals
is now deprived
because it is needed
in preparation for
her pre and post
operation.
Elimination
- Frequency of
urination



- Amount of urine
per day

- Frequency of bowel

- Consistency of feces

- Amount defecated

6 times a day




moderate


2


Formed


Moderate

2 times a day




Moderate


1


Formed


scanty

Her frequency of
urination and
defecation is
deprived because
she is placed on NPO
and IVF acts as her
food.
Activity and Exercise
- Exercise


- Fatigability

- ADL

Daily walking


Easily get tired

Independent

Unable to performed
exercise

Easily get tired

Slightly dependent


She considers
walking as her daily
exercise but when
she is hospitalized
she became slightly
dependent and
unable to performed


her daily activities.
Cognitive/ Perceptual
- Orientation


- Responsiveness


Oriented to time
place and person

Respond
approximately to
verbal and physical
stimuli.

Oriented to time,
place and person

Respond
approximately to
verbal and physical
stimuli.

She is well oriented
and can respond to
verbal and physical
stimuli.
Roles/ Relationship
- As a daughter





- As a sister






- As a wife








- As a mother









She has a good
relationship with her
parents



She has good
relationship with her
siblings.




she has good
relationship with her
husband, they enjoy
their lives together




She has good
relationship with her
children; she cares
for them a lot.




Her parents always
supported her when
they were still alive.


Shes supported by
her siblings during
her hospitalization.




Her husband really
do support her and
settle all the things
for her during her
hospitalization




She always takes
care of her children
and supports them
with their needs.



There are good
relationship
between the family
members.
Self Perception and
concept
Have a high self
worth/ importance
Have a high self
worth/ importance
In spite of her
present condition,
she still has a high
self worth and
importance.
Coping/ Stress She seeks advice
from her husband,
and even sometimes
with her friends,
relatives and also
She trusts God for
she knows that
everything will turn
right when hes
there.
She wholly gives her
full trust to God
when shes inside
the hospital for she
knows that
with God. everything is about
His will.
Values/ Belief Shes aware and she
trust God and believe
that He did exist.
Her trust to God
boosted more and
more confident
whenever praying.
she really did trust
God ever than the
way she trust Him
before.

J. COURSE IN THE WARD
DATE
DOCTORS ORDERS
RATIONALE
August 13, 2013
10:35am







































Please admit to Female Surgery Ward
Secure Consent


TPR





NPO




CBC





Blood Typing






Urine Analysis




IVF D5LR x 8hrs


Cefuroxime 750mg IV q8 ANST

For MRM (Modified Radical Mastectomy)
Left tomorrow

In preparation for surgical
procedure
To properly have consent
from the relatives of the
patient.
To monitor if there is
deviation from normal with
regards to the temperature,
pulse and respiration of the
patient.
To prepare the patient for
the surgical procedure and to
depress the GI tract.

To monitor if there is any
deviation from normal values
of the components of blood
of the patient.

To know the blood type of
the patient so that if ever
blood transfusion will be
done, the blood to be
administered has the same
type.

To know if the patient has
any disorder regarding to her
kidney or Urinary tract.

D5LR is parenteral fluid,
electrolyte and nutrient
replenisher
It fights against bacteria
during infection.
MRM is for those patient
who has mass on their breast
and diagnosed to be
removed.
To refer if something urgent
happened to the patient.













5:00pm





Refer OR/ AROD/ SROD


Refer Accordingly

Prepare 1 u FWB (Fresh Whole Blood)
properly typed and crossed match



NPO post midnight



Discontinue present IVF

IVF of D5LR 1L to be inserted at 5am

Refer to Dr. Encanto

Refer what has been
ordered.
To be ready if ever, during
the surgical procedure, the
patient loss lots of blood.


To make the patients GI
tract depress for the surgical
procedure to be done.
To give way for the
procedure to be done.
To get ready for the
procedure.
To endorse to the doctor
who will handle the patient.
August 14, 2013
9:25am
Post OR order
DAT when fully awake





Monitor VS every 10 mins for 6hrs, then
every 15 mins until stable.





IVF D5LR1L x 8hrs
IVF D5LR 1L x 8hrs

Cefuroxime 750mg IV q8

Keterolac 30mg IV q6/amp x 4doses ANST

Oxygen inhalaton 2-3L

Refer accordingly

Tramadol 50mg IV q4
For the patient easy
recovery. DAT will be
administered when fully
awake and not during
unconscious state to avoid
the occurrence of aspiration.
To monitor the adaptation of
the patient to the procedure
and if there are any deviation
from normal value of the
patients TPR, BP.
D5LR is parenteral fluid,
electrolyte and nutrient
replenisher
It fights against bacteria
during infection
It is for relief from pain due
to surgical procedure
To support the Oxygen
inhalation of the patient
Refer what has been
ordered.
Given for pain relief due to
surgical procedure.
August 15, 2013



Continue Medications



It is being continued because
the prescribed one can
develop a resistance to
antibiotics if they are used








10:00am









To follow D5LR x KVO


Paracetamol 30mg prn
appropriately which can
make it even more difficult to
treat the client next time and
also it being continue for
faster recovery and treat for
the prevention of the
disease.
D5LR is parenteral fluid,
electrolyte and nutrient
replenisher
For the sudden increased in
temperature of the client.
August 16, 2013
DAT




IVF PNSS 1L x KVO




For repeat Hemoglobin and Hematocrit



Cefuroxime 500mg TID

Celecoxib 200mg BID
Add supplemex KVO
For the patient to eat what
the stomach can tolerate and
to return to normal function
of the GI tract.
Normal Saline is a sterile,
nonpyrogenic solution for
fluid and electrolyte
replenishment.
To check if the patient has
normal value of Hemoglobin
and Hematocrit after the
surgical procedure.
It fights against bacteria
during infection.
Use to treat pain
Supplement in IV form in
support for the recovery of
the patient.
August 17, 2013

Facilitate Bed rest


IVF same rate


Continue medications

Refer



Hgb = 7.4




Prepare and transfer 3 u Fresh Whole
Blood

To promote rest for the client
and blood circulation.
For same way of treatment.

For continuous treatment
and recovery of the patient.
To be refer accordingly due
to decreased Hgb.


There is a decreased from
the normal value (12-16 g/dl)
of patients Hemoglobin.
Since there is a decrease in
patients hemoglobin, she
needs to have blood
transfusion.
To check if there are any
changes and progress with
the patients hemoglobin and
hematocrit value.

Repeat Hemoglobin and Hematrocrit 6hrs
post bedrest


August 18, 2013 MGH


Home meds as ordered

Follow up check up on
August 23, 2013 8am at OPD.
For continuous adherence to
medication regimen.


































K. LABORATORY RESULTS:
DATE: August 13, 2013

























REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN



HEMATOCRIT


WBC COUNT


-Neutrophils

-Lymphocytes
-Monocytes
-Eosinophil
-Basophil

PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testing
blood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)







M:14-18 gm/dl
F:12-15 gm/dl


M:40-50%
F:30-40%

5,000-10,000


40%-50%

35%-45%
2%-5%
2-4%
0-1%
150,000-450,000
11.1



35.9


11,700


71%

29.7%
100%
Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.


NORMAL


Values increase in acute infections, trauma, some malignant
disease, and some cardiovascular disease

Neutrophils increase in acute infections.

Lymphocytes increase during antigen-antibody reactions.






Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN


HEMATOCRIT


WBC COUNT


-Neutrophils

-Lymphocytes
-Monocytes
-Eosinophil
-Basophil

PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testing
blood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)







M:14-18 gm/dl
F:12-15 gm/dl

M:40-50%
F:30-40%

5,000-10,000


40%-50%

35%-45%
2%-5%
2-4%
0-1%

150,000-450,000
9.7


29


11,600


69%

31%




261,000
Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.

Values decrease in anemia, leukemia, cirrhosis and
hyperthyroidism.

Values increase in acute infections, trauma, some malignant
disease, and some cardiovascular disease

Neutrophils increase in acute infections.

NORMAL.




NORMAL

REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
DATE: August 16, 2013

























REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN


HEMATOCRIT
RBC COUNT
MCV
MCH
MCHC
WBC COUNT
PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testing
blood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)







12.0-16.0


0.37-0.43
4.0-5.4
78-102
39.0-54.0
481-574
4.0-10.0
170-400
7.40


0.23




Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.

Values decrease in anemia, leukemia, cirrhosis and
hyperthyroidism.








DATE: August 16, 2013

BLOOD TYPING AND CROSSMATCHING RESULTS
PATIENTS ABOGROUP: O RH GROUP: positive
Source
of
blood
Donor
number
ABO
group
RH typing Interpretation Released
by:

Taken by Date and
time
QMC 1390-13 O Positive Saline phase
LISS/coombs-
37C

COMPATIBLE



Autocontrol Negative for agglutination


Diagnosis:
Breast mass, left, excision biopsy
INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2
POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2
INVASIVE DUCTAL CARCINOMA
Invasive means that the cancer has invaded or spread to the surrounding breast tissues. Ductal means that the cancer began in the
milk ducts, which are the pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers to any cancer that
begins in the skin or other tissues that cover internal organs such as breast tissue. All together, invasive ductal carcinoma refers
to cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal
carcinoma can spread to the lymph nodes and possibly to other areas of the body.
http://pathology.jhu.edu/breast/grade.php

Grade I or low-grade DCIS cells look very similar to normal cells or atypical ductal hyperplasia cells. Grade II or moderate-grade DCIS cells grow faster than
normal cells and look less like them. Grade I and Grade II DCIS tend to grow slowly and are sometimes described as "non-comedo" DCIS. The term non-comedo
means that there are not many dead cancer cells in the tumor. This shows that the cancer is growing slowly, because there is enough nourishment to feed all
of the cells. When a tumor grows quickly, some of its cells begin to die off.
http://www.breastcancer.org/symptoms/types/dcis/diagnosis
=POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

When LVI is present, doctors assume this means that the cancer has acquired the genetic mutation it needs to create its own blood vessels, a process called
angiogenesis. Because a tumor that has the ability to create its own blood vessels may have already begun to spread cancer cells to other parts of the body, the
presence of LVI is an indicator that treatment should most likely include chemotherapy or hormone therapy (if the tumor is hormone sensitive).
Perivascular invasion requires at least two cell types: the endothelial cells that form the vascular tubes and the tumor cells. Perivascular invasion does not
have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of
cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.




JULY 17, 2013


CHEST X-RAY
Both lung fields are clear
Heart, aorta and pulmonary vascular markings are within normal limits
Diaphragm and sinuses are preserved
Intact both thorax

IMPRESSION:
ESSENTIALLY NORMAL CHEST FINDINGS.


ECG RESULT: NORMAL
DATE: JULY 17, 2013


TEST VALUE REFERENCE
RANGE
REMARKS
CREATININE 1.63 mg/dl 0.6-1.3 Creatinine increase in certain
kidney disease and infections.
BUN 20.40 mg/dl 7-18 Values increase in response to
increased in dietary protein intake.
GLUCOSE 80.24 mg/dl 70-105 NORMAL
URIC ACID 7.17 mg/dl 2.6-7.2 NORMAL
TRIGLYCERIDES 50.61 mg/dl 0-150 NORMAL
CHOLESTEROL 142.41 mg/dl 0-200 NORMAL
DATE: July 18, 2013
NAME OF
TEST
INDICATION
MICROSCOPIC
EXAMINATIONS
RESULTS
REFERENCE
VALUE
SIGNIFICANCE OF THE RESULT
Urinalysis Urinalysis is a laboratory
diagnostic procedure which
involves testing of urine for
bacteria, protein, or other
molecules that can provide
information about patients
health.

Color Yellow YELLOW NORMAL
Transparency Slightly
Turbid
CLEAR Indicates high concentration of solutes
Reaction 5.0 4.5 7.5 NORMAL
Specific Gravity 1.030 1.015 1.025 Increased urine specific gravity may be due to:
Dehydration, Diarrhea that causes dehydration,
Glucosuria, Heart failure (related to decreased
blood flow to the kidneys), Renal arterial stenosis,
Shock, Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)


CLINICAL TEST
Sugar Negative NEGATIVE NORMAL
Albumin negative NEGATIVE NORMAL

PREGNANCY TEST - - -
URINE BILE - - -
Red Blood Cell 2-3 2 3HPF NORMAL
Epithelial Cells Few FEW NORMAL
Mucus Threads FEW RARE -
Bacteria MODERATE NEGATIVE -
Crystals - NONE -
Calcium Oxalates - - -
A. Uric Acid - 1.48
4.43mmol/day
-
Fine Granular - NONE -
Course Granular - NONE -
Hyalines - OCCASSIONAL -
Others Yeast cells many
III. CLINICAL MANIFESTATION

A . ANATOMY AND PHYSIOLOGY

Breast
The breast is the upper ventral region of the torso of a primate, in left and right sides, containing
the mammary gland which in female can secrete milk used to feed infants.
Both men and women develop breasts from the same embryological tissues. However, at
puberty, female sex hormones, mainly estrogen, promote breast development which does not occur
in men due to the higher amount of testosterone. As a result, women's breasts become far more
prominent than those of men.
During pregnancy, the breast is responsive to a complex interplay of hormones that cause tissue
development and enlargement in order to produce milk. Three such hormones are estrogen,
progesterone and prolactin, which cause glandular tissue in the breast and the uterus to change
during the menstrual cycle.
Each breast contains 1520 lobes. The subcutaneous adipose tissue covering the lobes gives the
breast its size and shape. Each lobe is composed of many lobules, at the ends of which are sacs where
milk is produced in response to hormonal signals.
Anatomy
The Breast: cross-section scheme of the mammary gland.
1. Chest wall
2. Pectoralis muscles
3. Lobules
4. Nipple
5. Areola
6. Milk duct
7. Fatty tissue
8. Skin




Morphology
The human breast has two aspects: the functional aspect and the anatomic aspect.
The functional breast
The breast is an apocrine gland that produces milk to feed an infant child; for which the nipple of
the breast is centered in (surrounded by) an areola (nipple-areola complex, NAC), the skin color of
which varies from pink to dark brown, and has many sebaceous glands.
The anatomic breast
In women, the breasts overlay the pectoralis major muscles and usually extend from the level of
the second rib to the level of the sixth rib in the front of the human rib cage; thus, the breasts cover
much of the chest area and the chest walls. At the front of the chest, the breast tissue can extend
from the clavicle (collarbone) to the middle of the sternum (breastbone). At the sides of the chest,
the breast tissue can extend into the axilla (armpit), and can reach as far to the back as the latissimus
dorsi muscle, extending from the lower back to the humerus bone (the longest bone of the upper
arm). As a mammary gland, the breast is an inhomogeneous anatomic structure composed of layers
of different types of tissue, among which predominate two types, adipose tissue and glandular tissue,
which effects the lactation functions of the breasts.
Lymphatic drainage
Approximately 75% of the lymph from the breast travels to the ipsilateral (same-side) axillary
lymph nodes, whilst 25% of the lymph travels to the parasternal nodes (beside the sternum bone), to
the other breast, and to the abdominal lymph nodes. The axillary lymph nodes include the pectoral
(chest), subscapular (under the scapula), and humeral (humerus-bone area) lymph-node groups,
which drain to the central axillary lymph nodes and to the apical axillary lymph nodes. The lymphatic
drainage of the breasts is especially relevant to oncology, because breast cancer is a cancer common
to the mammary gland, and cancer cells can metastasize (break away) from a tumors and be
dispersed to other parts of the woman's body by means of the lymphatic system.
Shape and support
The topography of the breasts indicates the glandular body, the nipple-areola complex (NAC),
and the inframammary fold (IMF).
Size
Breast size varies with race and ethnic origin. A study released in 2013 suggests the existence of a
single genetic mutation responsible for multiple characteristics of East Asians, including thicker hair,
more sweat glands and smaller breasts on women.



Hormonal change


On the skin envelope of the breast, stretch marks may indicate the relative-size increments and
decrements occurred during the life of the woman.
Because the breasts are principally composed of adipose tissue, which surrounds the milk glands,
their sizes and volumes fluctuate according to the hormonal changes particular to the larche
(sprouting of breasts), menstruation (egg production), pregnancy (reproduction), lactation (feeding of
offspring), and menopause (end of menstruation). For example, during the menstrual cycle, the
breasts are enlarged by premenstrual water retention; during pregnancy the breasts become
enlarged and denser (firmer) because of the prolactin-caused organ hypertrophy, which begins the
production of breast milk, increases the size of the nipples, and darkens the skin color of the nipple-
areola complex; these changes continue during the lactation and the breastfeeding periods.
Afterwards, the breasts generally revert to their pre-pregnancy size, shape, and volume, yet might
present stretch marks and breast ptosis. At menopause, the breasts can decrease in size when the
levels of circulating estrogen decline, followed by the withering of the adipose tissue and the milk
glands. Additional to such natural biochemical stimuli, the breasts can become enlarged consequent
to an adverse side effect of combined oral contraceptive pills; and the size of the breasts can also
increase and decrease in response to the body weight fluctuations of the woman. Moreover, the
physical changes occurred to the breasts often are recorded in the stretch marks of the skin
envelope; they can serve as historical indicators of the increments and the decrements of the size and
the volume of a woman's breasts throughout the course of her life.
REFERENCE: http://en.wikipedia.org/wiki/Breast











PATHOPHYSIOLOGY

Book based























Sign and Symptoms:
Lump in the breast
Thickening of the breast skin
Rash or redness, sore of the breast
Swelling in one breast
New pain in breast
Dimpling around the nipple or on the breast skin
Nipple pain or the nipple turning inward
Nipple discharge
Lumps in the underarm area
Changes in the appearance of the nipple or breast that is different from
the normal monthly changes a woman experiences.

Risk Factors
Early/late
menarche
Late menopause
Nulliparous or
older than 30 years
at the birth of a
first child
Genetic
Lifestyle
Environmental































Cellular Aberrations
Ca Cell Proliferation
Disrupt normal cell growth and
interfere with tissue function
Pressure
Obstruction
Pain
Effusion
Ulceration
Vascular Thrombosis, Embolism,
Thrombophlebitis
Malignant cells
produce enzymes,
hormones and other
(Paraneoplastic
Syndrome)
Anemia
Hypercalemia
Edema
DIC
Anorexia and
Cachexia Syndrome
Tissue wasting
Severe weight
loss
Severe
debilitation
Reference : Medical Surgical Nursing Concept and Clinical Application 2
nd
Edition, 2009
Author: Jose, Quiambao, Udab
And
http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/invasive_d
uctal_carcinoma.html



Client Based




















Precipitating Factor:
Lifestyle
She like to eat high in salt and fatty foods
Always wearing brassier with wire
Environment
Her breast is often bumped by his son

Predisposing Factor:
Nulliparous or older than 30
years at the birth of a first child
Late menarche
Signs and symptoms:
Lump in the breast
For 5 years
Sore of the breast
Since November 2012 up to august 13
2013
New pain in left side of breast
Cellular Aberrations
Ca Cell Proliferation
Disrupt normal cell growth and
interfere with tissue function
Pressure
Obstruction
Pain

Malignant cells produce
enzymes, hormones
and other
(Paraneoplastic
Syndrome)
Anemia
Ductal Carcinomaoma
Possible complication:
Lymphedema
Bleeding
Hematoma formation
Brachial plexus injuries

Modified Radical Mastectomy

A modified radical mastectomy is a type of mastectomy that combines the removal of all breast tissue
from the affected breast with lymph node removal from the armpit on the affected side of the body.
This surgery typically includes the removal of both the nipple and areola, but the surgery can be
performed using skin and nipple sparing techniques.
Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length
that begins on the inside of the breast, near the breast bone, and extends upward and outward toward
the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can
improve the cosmetic outcome if reconstruction is desired.
Once the breast tissue is removed, the incision is closed with either absorbable sutures or staples that
are removed during an office visit 10 to 14 days after surgery. There may also be drains in place to
decrease the amount of swelling in the area. These drains are covered with bandages to protect the
incision site and the drain placement. The drains are typically removed after discharge from the hospital
by the surgeon during a routine office visit after surgery.
REFERENCE: http://surgery.about.com/od/proceduresaz/ss/Mastectomy_3.htm

Name of
Drug
Classification Mechanism of
Action
Indication Contraindication Side Effects Nursing Responsibility
Atracarium
25mg IV
no depolarizing
neuromuscu-lar
blocker

Skeletal Muscle
Relaxant
Prevents
acetylcholine
from binding
to receptors
on muscle end
plate, thus
blocking
depolarization
and resulting
in skeletal
muscle
paralysis.
Adjunct to
general
anesthesia, to
facilitate
endotracheal
intubation and
cause skeletal
muscle
relaxation
during surgery
or mechanical
ventilation
Contraindicated
in patients
hypersensitivity
to drug
Use cautiously
in patients with
CV disease;
severe
electrolyte
disorders,
bronchogeneic
carcinoma;
hepatic, renal,
or pulmonary
impairment;
neuromuscular
diseases; or
myasthenia
gravis; and in
debilitated
patients;
CV
1)Flushing,
2)increased heart
rate,
3)bradycardia
4)hypotension
RESPI
1)Prolonged dose
related apnea,
2)wheezing,
3)increased
bronchial
secretions
SKIN
1)Erythema,
2)pruritus,
3)urticaria
Other
1)anaphylaxis
1. Obtain history of patients
neuromuscular status
before therapy and
reassess regularly
2. Be alert for adverse
reactions and interaction
3. Monitor respiration closely
until patient fully recovers
from neuromuscular
blockade, as evidence by by
tests of muscle strength
4. Give sedatives or general
anesthetic before
neuromuscular blockers.
Neuromuscular blockers
dont decrease
consciousness or alter pain
threshold.
5. Dont give by I.M injection
6. Prior use of succinycholine
doesnt prolong duration of
action but quickens onset
and may deepen
neuromuscular blockade
7. Give analgesics for pain.
Patient may have pain but
unable to express it.
8. Keep airway clear. Have
emergency equipment and
drugs available.
9. After spontaneous recovery
starts, reverse atracarium-
induced neuromuscular
blockade with an
anticholinesterase (such as
neostigmine or
endophonium). These
drugs usually are given with
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
an anticholnergic (such as
atropine)

Name of
Drug
Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility
Propofol
80mg +
30mg IV
Nonbarbiturate
Anesthetics
(General
Anesthetics)
Exerts its sedative-
hypnotic effects
through a GABAA
receptor
interaction. GABA
is the principal
inhibitory
neurotransmitter in
the CNS.
Indicated for
producing
sedation,
hypnosis,
anesthesia,
amnesia,
unconsciousness
to allow
performance of
surgical
procedures.
Status asthmaticus
b/c of the difficulty
in providing
ventilator support
to the patient and
risk of
exacerbation of
the problem with
CNS depression
Absence of suitable
vein for
intravenous
administration
Caution should be
used in cases of
severe
cardiovascular
disease,
hypotension, or
shock;
Malignant
hyperthermia

CNS
1)headache
2)prolonged
somnolence
3)delirium
CV
1)hypotension
2)shock
3)decreased
cardiac output
4)arrhythmias
RESPI
1)respiratory
depression
2)laryngospasm
3)bronchospasm
4)hiccups
5)coughing
GI
1)nausea
2)vomiting
1. Assess for any known
allergy to general
anesthetics; impaired
liver or kidney
function; myasthenia
gravis; history of
malignant
hyperthermia;
cardiac or respiratory
disease
2. Include screening for
baseline status
before beginning
therapy and for any
potential adverse
effects.
3. The drug must be
administered by
trained personnel
4. Have equipment on
standby to maintain
airway and provide
mechanical
ventilation
5. Monitor temperature
for prompt detection
and treatment of
malignant
hyperthermia
6. Monitor pulse,
respiration, blood
pressure and cardiac
output during
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition




administration
(dosage adjustment
may be needed to
alleviate potential
problems and
maximize overall
benefit with the least
toxicity
7. Monitor the patient
until recovery phase
is complete and the
patient is conscious,
able to move and
communicate to
ensure patient safety
8. Provide comfort
measures to help
patient tolerate drug
9. Provide pain relief as
appropriate, skin care
and turning to
prevent skin
breakdown, &
supportive care for
conditions such as
hypotension and
bronchospasm
10. Offer support and
encouragement to
help the patient cope
with procedure and
the drugs being used.
Name of
Drug
Classification Mechanism of Action Indication Contraindicatio
n
Side effects Nursing Responsibility
Butorphanol
1mg IV
Opioid agonist-
antagonist
Analgesic, adjunct to
anesthesia
Binds with opiate
receptors in CNS,
altering both
perception of and
emotional response
to pain through
unknown mechanism
Moderate to
severe pain
Preoperative
anesthesia or
preanesthesia
Adjunct to
balance
anesthesia
Contraindicat
ed in patients
with opioid
addiction;
may
precipitate
withdrawal
syndrome.
Patients with
hypersensitivi
ty to drug or
preservative
(benzethoniu
m chloride)
Use
cautiously in
patients with
head injury,
increase
intracranial
pressure,
acute MI,
ventricular
dysfunction,
coronary
insufficiency,
respiratory
disease or
renal and
hepatic
dysfunction.
CNS
1) sedation
2) headache
3) vertigo
4) floating sensation
5) lethargy
6) confusion
7) nervousness
8) unusual dreams
9) agitation
10) euphoria
11) hallucinations
12) flushing
CV
1) palpitations
2) fluctuation in
blood pressure
EENT
1) diplopia
2) blurred vision
3) nasal congestion
(with nasal spray)
GI
1) Nausea
2) vomiting
3) constipation
4) dry mouth
RESPI
1) Respiratory
depression
SKIN
1) Rash
2) Urticaria
3) Clamminess
4) Excessive sweating
1. Obtain history of patients pain
before therapy, and reassess
during therapy
2. Be alert for adverse reaction and
drug interactions
3. Periodically monitor post
operative vital signs and bladder
function. Drug decreases both
rate and depth respirations, &
monitoring arterial oxygen
saturation may aid in assessing
respiratory depression.
4. Caution ambulatory patient to
get out of bed slowly and walk
carefully until CNS effects are
known.
5. Warn outpatient to refrain from
driving and performing other
activities that require mental
alertness until drugs CNS effects
are known
6. Warn patient that drug can
cause physical and psychological
dependence. Tell him to use
drug only as directed and that
abrupt withdrawal after
prolonged use produces intense
withdrawal symptoms.
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
Name of Drug Classification Mechanism of
Action
Indication Contraindication Side effects Nursing Responsibility
Neostigmine 5mg
+ Atropine Sulfate
1 mg
Cholinesterase
Inhibitor
Muscle
stimulant
Inhibits
destruction of
acetylcholine
released from
parasympatheti
Myasthenia
gravis
To diagnose
myasthenia
gravis
Contraindicated
in patient
hypersensitive
to cholinergics
or bromide and
CNS
1) dizziness
2) Headache
3) Mental Confusion
CV
1) Bradycardia
1. Assess patients
condition before
starting therapy
2. Monitor patients
response after each
c and somatic
efferent
nerves.
Acetylcholine
accumulates,
increasing
stimulation of
receptor.
Postoperative
abdominal
distention and
bladder atony
Antidote for
nondepolarizing
neuromuscular
blockers
Supraventicular
tachycardia
from tricyclic
antidepressant
overdose
Decrease small
bowel transit
during
radiography
in those with
peritonitis or
mechanical
obstruction
Use cautiously
in patient with
renal
impairment,
neuromuscular
disorders or
ulcerative bowel
lesions
2) Hypotension
3) Cardiac arrest
EENT
1) Blurred vision
2) Lacrimation
3) miosis

GI
1) Nausea
2) Vomiting
3) Diarrhea
4) Abdominal cramps
5) Excessive
salivation
GU
1) Urinary frequency
MUSCULOSKELETAL
1) Muscle cramps
2) Muscle weakness
3) Muscle
fasciculation
RESPI
1) Depressed
respiratory drive
2) Bronchospasm
3) Bronchoconstricti
ons
4) Respiratory arrest
SKIN
1) Rash (with
bromide)
2) diaphoresis
Other
1) Hypersensitivity
reaction
2) Anaphylaxis
dose. Watch closely
for improvement in
strength, vision, and
pstosis 45 to 60
minutes after each
dose. Show patient
how to record
variations in muscle
strength.
3. Monitor V/S
frequently
4. Although drug is is
commonly used to
reverse effects of
nondepolarizing
neuromuscular
blockers in patient
who have
undergone surgery,
it may worsen
blockade produced
by succinylcholine
5. Patient may develop
resistance to drug
6. Give oral drug with
food or milk to
reduce GI distress

Anticholinergic,
belladonna
alkaloid
Antiarrythmic,
vagolytic
Inihibits
acetylcholine
at
parasympatheti
c neuroeffector
junction,
blocking vagal
effects on SA
node. This
enhances
Anticholinestera
e insecticide
poisoning
Preoperatively
for decreasing
secretions and
blocking cardiac
vagal reflexes
Contraindicated
in patients
hypersensitive
to drug and
those with
acute angle-
closure
glaucoma,
obstructive
uropathy,
CNS
1) Headache
2) Restlessness
3) Ataxia
4) Disorientation
5) Hallucinations
6) Delirium
7) Coma
8) Insomnia
9) Dizziness
10) Excitement
11) Agitation
12) confusion
1. Obtain history of
patients underlying
condition and
reassess regularly
2. Be alert for adverse
reaction and drug
interaction
3. Monitor patient,
especially those
receiving doses of
through AV
node and
speeds heart
rate.
obstructive
disease of GI
tract, paralytic
ileus,toxic
megacolon,
intestinal atony,
unstable CV
status in acute
hemorrhage,
asthma, or
myasthenia
gravis
Use cautiously
in patient with
Down syndrome
CV
1) Tachycardia
2) Palpitations
3) Angina
4) Arrhythmias
5) flushing
EENT
1) Photophobia
2) Blurred vision
3) Mydriasis
GI
1) Dry mouth
2) Thirst
3) Constipation
4) Nausea
5) vomiting
GU
1) Urine retention
Hematologic
1) leukocytosis
Other
1) anaphylaxis
0.4 to 0.6 mg , for
paradoxical initial
bradycardia, which
is caused by a drug
effect in CNS and
usually disappears
within 2 minutes
4. Watch for
tachycardia in
cardiac patients
because it may
cause ventricular
fibrillation
5. Give with or without
food
6. If ECG disturbances
occur, withhold
drug, obtain a
rhythm strip, and
notify prescriber
immediately
7. Have emergency
equipment and
drugs on hand to
treat new
arrhythmias. Other
anticholinergics may
increase vagal
blockage
8. Use physostigmine
salicylate as
antidote for
atropine overdose.
9. Teach patient how
to handle distressing
anticholinergic
effect.
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility
Cefuroxime
750mg IV
q8
Antibiotic,
Cephalosporin
(second
generation)
Cefuroxime binds
to one or more of
the penicillin-
binding proteins
(PBPs) which
inhibits the final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell wall,
thus inhibiting
biosynthesis and
arresting cell wall
assembly resulting
in bacterial cell
death.
Pharyngitis,
tonsillitis
caused by
Streptococcus
pyogenes
Otitis media
caused by
Streptococcus
pneumoniae, S.
pyogenes,
Haemophilus
influenzae,
Moraxella
catarrhalis
Lower
respiratory
infections
caused by S.
pneumoniae,
Haemophilus
parainfluenzae,
H. influenzae
UTIs caused by
Escherichia
coli, Klebsiella
pneumoniae
Uncomplicated
gonorrhea
(urethral and
endocervical)
Dermatologic
infections,
including
impetigo
caused by
Streptococcus
aureus, S.
pyogenes
Treatment of
Patient with
known allergy
to
cephalosporin
and penicillin
CNS
1)Headache
2)Dizziness
3)Lethargy
4)Paresthesia
GI
1)Anorexia,
Nausea &
Vomiting
RENAL
1)Nephrotoxicity
1. Dont give cephalosporin
together with amino
glycosides because it will
increase the risk for kidney
toxicity.
2. Avoid giving cephalosporin
with anticoagulant because
it will increase bleeding
tendency.
3. Obtain culture and
sensitivity test before
administering the drug
4. Monitor renal function
during the entire therapy
5. Instruct the patient to
finish the full course of the
therapy
6. Provide small frequent
meals as tolerated.
7. Take medication with food
if gastric irritations occurs
8. Provide health teachings
such as:
a. Change position
carefully
b. Avoid driving and
hazardous task,
drinks lots of fluids,
c. Avoid alcohol drinks
72 hours after
completing the
entire course
early Lyme
disease
Reference: Nursing Pharmacology 4th Edition-Amy Karch
Name of Drug Classification Mechanisms of
Action
Indication Contraindication Side effects Nursing
Responsibilities
Keterolac Nonsteroidal
anti-
inflammatory
agents
nonopioid
analagesics
Inhibits
prostaglandin
synthesis,
producing
peripherally
mediated
analgesia
Also has
antipyretic and
anti-
inflammatory
properties.
Therapeutic
effect:Decreased
pain
Short
term manage
ment of pain
Hypersensitivity
Cross-sensitivity
with other NSAIDs
may existPre- or
perioperative use
Known alcohol
intoleranceUse
cautiously in:
1) History of GI
bleeding
2) Renal impair-
ment (dosage
reduction may be
required)
3) Cardiovascular
disease
CNS
1)drowsiness
2)abnormal
thinking
3)dizziness
4)euphoria
5)headache-
RESP
1)asthma
2)dyspnea
CV
1) edema
2) pallor
3) vasodilation
GI
1) GI Bleeding
2) abnormal
taste
3) diarrhea
4) dry mouth
5) dyspepsia
6) GI pain
7) nausea
GU
1) oliguria
2) renal toxicity
3) urinary
frequency
DERM
1) pruritis
2) purpura
3) sweating
4) urticaria
HEMAT
Patients who have
asthma, aspirin-
induced allergy,
and nasal polyps
are at increased
risk for
developing
hypersensitivity
reactions. Assess
for rhinitis,
asthma, and
urticaria.
Assess pain (note
type, location,
and intensity)
prior to and 1-2 hr
following
administration.
Ketorolac therapy
should always be
given initially by
the IM or IV
route. Oral
therapy should be
used only as a
continuation of
parenteral
therapy.
Caution patient to
avoid concurrent
use of alcohol,
aspirin, NSAIDs,
acetaminophen,
or other OTC
1) prolonged
bleeding time
LOCAL
1) injection site
pain
NEURO
1) paresthesia
- MISC:
1) allergic
reaction,
anaphylaxis
medications
without
consulting health
care professional.
Advise patient to
consult if rash,
itching, visual
disturbances,
tinnitus, weight
gain, edema,
black stools,
persistent
headche, or
influenza-like
syndromes
(chills,fever,muscl
es aches, pain)
occur.
Effectiveness of
therapy can be
demonstrated by
decrease in
severity of pain.
Patients who do
not respond to
one NSAIDs may
respond to
another.

Name of Drug Classification Mechanisms of
Action
Indication Cotraindication Side effects Nursing Responsibilities
Tramadol Analgesics Binds to mu-
opioid receptors
and inhibits the
reuptake
ofnorepinephrine
and serotonin;
causes many
effects similar to
Relief of
moderate to
moderately
severe pain
Contraindicated
with pregnancy;
allergy
to tramadol;
acute intoxication
with
alcohol, opioids,
psychotropic
1. Sedation,
2. dizziness/vertigo
3. headache
4. confusion
5. Dreaming
6. Sweating
7. Anxiety
8. Seizures
1. Assess for level of pain
relief and administer
prn dose as needed
but not to exceed the
recommended total
daily dose.
2. Monitor vital signs and
assess for orthostatic
theopioids--
dizziness,
somnolence,
nausea,
constipation--but
does not have
the respiratory
depressant
effects.
drugs or other
centrally acting
analgesics;
lactation.
Use cautiously with
seizures,
concomitant use
of CNS
depressants
or MAOIs, renal
or hepatic
impairment
9. Hypotension
10. Tachycardia
11. Bradycardia
12. Sweating
13. Pruritus
14. Rash
15. pallor,
16. urticaria
17. Nausea and
vomiting,
18. dry mouth
19. constipation
20. flatulence

hypotension or signs of
CNS depression.
3. Discontinue drug and
notify physician if S&S
of hypersensitivity
occur.
4. Assess bowel and
bladder function;
report urinary
frequency or
retention.
5. Use seizure
precautions for
patients who have a
history of seizures or
who are concurrently
using drugs that lower
the seizure threshold.
6. Monitor ambulation
and take appropriate
safety precautions.

REFERENCE:http://www.nursing-nurse.com/drug-study-tramadol-178/
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility
Paracetamol
300mg IV q4
Non-
narcotic
analgesic
Antipyretic
Decreases fever
by a hypothalamic
effect leading to
sweating and
vasodilation
Inhibits pyrogen
effect on the
hypothalamic-
heat-regulating
centers
Inhibits CNS
prostaglandin
synthesis with
minimal effects
on peripheral
Control of
pain due to
headache,
earache,
dysmenorrhe
a, arthralgia,
myalgia,
musculoskelet
al pain,
arthritis,
immunization
s, teething,
tonsillectomy
reduce fever
in viral and
Renal
Insufficiency
Anemia
Special Concerns:
Liver toxicity
(hepatocyte
necrosis) may
occur with
doses not far
beyond labeled
dosing.
If 3 or more
alcoholic drinks
per day are
consumed,
1) Minimal GI
upset.
2) Methemoglob
inemia
3) Hemolytic
Anemia
4) Neutropenia
5) Thrombocyto
penia
6) Pancytopenia
7) Leukopenia
8) Urticaria
9) CNS
stimulation
10) Hypoglycemic
1. Do not exceed
4gm/24hr. in adults
and 75mg/kg/day in
children.
2. Do not take for >5days
for pain in children, 10
days for pain in adults,
or more than 3 days
for fever in adults.
3. Extended-Release
tablets are not to be
chewed.
4. Monitor CBC, liver and
renal functions.
5. Assess for fecal occult
prostaglandin
synthesis
Does not cause
ulceration of the
GI tract and
causes no
anticoagulant
action.

bacterial
infections
As a
substitute for
aspirin in
upper GI
disease,
bleeding
disorders
clients in
anticoagulant
therapy and
gouty arthritis
consult a
physician prior
use.

coma
11) Jaundice
12) Glissitis
13) Drowsiness
14) Liver Damage

blood and nephritis.
6. Avoid using OTC drugs
with Acetaminophen.
7. Take with food or milk
to minimize GI upset.
8. Report N&V. cyanosis,
shortness of breath
and abdominal pain as
these are signs of
toxicity.
9. Report paleness,
weakness and heart
beat skips
10. Report abdominal
pain, jaundice, dark
urine, itchiness or
clay-colored stools.
11. Phenmacetin may
cause urine to become
dark brown or wine-
colored.
12. Report pain that
persists for more than
3-5 days
13. Avoid alcohol.
14. This drug is not for
regular use with any
form of liver disease.
Reference: http://rnspeak.com/drug-study/paracetamol-biogesic-drug-study/
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility
Cefuroxime
500mg TID
Antibiotic,
Cephalosporin
(second
generation)
Cefuroxime binds
to one or more of
the penicillin-
binding proteins
(PBPs) which
inhibits the final
transpeptidation
step of
peptidoglycan
Pharyngitis,
tonsillitis
caused by
Streptococcus
pyogenes
Otitis media
caused by
Streptococcus
pneumoniae, S.
Patient with
known allergy
to
cephalosporin
and penicillin
CNS
Headache
Dizziness
Lethargy
Paresthesia
GI
Anorexia,
Nausea &
Vomiting
1. Dont give cephalosporin
together with amino
glycosides because it will
increase the risk for kidney
toxicity.
2. Avoid giving cephalosporin
with anticoagulant
because it will increase
bleeding tendency.
synthesis in
bacterial cell wall,
thus inhibiting
biosynthesis and
arresting cell wall
assembly
resulting in
bacterial cell
death.
pyogenes,
Haemophilus
influenzae,
Moraxella
catarrhalis
Lower
respiratory
infections
caused by S.
pneumoniae,
Haemophilus
parainfluenzae,
H. influenzae
UTIs caused by
Escherichia
coli, Klebsiella
pneumoniae
Uncomplicated
gonorrhea
(urethral and
endocervical)
Dermatologic
infections,
including
impetigo
caused by
Streptococcus
aureus, S.
pyogenes
Treatment of
early Lyme
disease
RENAL
Nephrotoxicity
3. Obtain culture and
sensitivity test before
administering the drug
4. Monitor renal function
during the entire therapy
5. Instruct the patient to
finish the full course of the
therapy
6. Provide small frequent
meals as tolerated.
7. Take medication with food
if gastric irritations occurs
8. Provide health teachings
such as:
a. Change position
carefully
b. Avoid driving and
hazardous task,
drinks lots of
fluids,
c. Avoid alcohol
drinks 72 hours
after completing
the entire course

Name of Drug Classification Mechanism of
Action
Indication Contraindication Side Effects Nursing
Responsibility
Celecoxib
200mg BID
NSAID
Analgesic
(nonopioid)
Specific COX-2
Celecoxib has
COX-2 specific
inhibitory
activity. It
Acute and long-
term treatment of
signs and
Hypersensitivity
including those in
who attacks of
angioedema, rhinitis
1) Abdominal pain
2) Diarrhea
3) Nausea
1. Be aware that
patient may be at
increased risk for
CV events, GI
enzyme inhibits the
conversion of
arachidonic
acid to
prostaglandins
while having
no effect on
the formation
of
prostaglandins
that mediate
the normal
homeostasis in
the GI tract,
kidneys and
platelets
catalyzed by
COX-1.
symptoms of
rheumatoid
arthritis and
osteoarthritis
Reduction of the
number of
colorectal polyps in
familial
adenomatous
polyposis (FAP)
Management of
acute pain
Treatment of
primary
dysmenorrhea
Relief of signs and
symptoms of
anklylosing
spondylitis
Relief of signs and
symptoms of
juvenile
rheumatoid
arthritis
and urticaria has been
precipitated by
aspirin, NSAIDs or
sulfonamides.
Severe hepatic
impairment;
Severe heart failure;
inflammatory bowel
disease; peptic ulcer;
renal impairment
(CrCl <30 ml/min);
Pregnancy and
lactation.
4) Edema
5) Dizziness
6) Headache
7) Insomnia
8) upper
respiratory
tract infections
9) rash
Potentially Fatal:
1) Serious skin
reactions such
as exfoliative
dermatitis,
Stevens-
Johnson
syndrome, and
toxic
epidermal
necrolysis.

bleeding; monitor
accordingly.
2. Administer drug
with food or after
meals if GI upset
occurs.
3. Establish safety
measures if CNS,
visual disturbances
occur.
4. Arrange for
periodic
ophthalmologic
examination
during long-term
therapy.
5. If overdose occurs,
institute
emergency
procedures
gastric lavage,
induction of
emesis, supportive
therapy.
6. Provide further
comfort measures
to reduce pain (eg,
positioning,
environmental
control) and to
reduce
inflammation (eg,
warmth,
positioning, and
rest).
7. Take drug with
food or meals if GI
upset occurs.
8. Take only the
prescribed dosage;
do not increase
dosage.
9. You may
experience these
side effects:
Dizziness,
drowsiness (avoid
driving or the use
of dangerous
machinery while
taking this drug).
10. Report sore throat,
fever, rash, itching,
weight gain,
swelling in ankles
or fingers; changes
in vision.
REFERENCE:http://www.rnpedia.com/home/notes/pharmacology-drug-study-notes/celecoxib

Name of Drug Classification Mechanism of
Action
Indication Contraindication Side Effects Nursing
Responsibility
D5LR x 8, 12 Hypertonic
Nonpyrogenic
Parenteral fluid
Electrolyte
Nutrient
replenisher
Hypertonic
solutions are
those that have
an effective
osmolarity
greater than the
body fluids. This
pulls the fluid
into the vascular
by osmosis
resulting in an
increase
vascular volume.
It raises
intravascular
osmotic
pressure and
provides fluid,
electrolytes and
calories for
energy.
The Dextrose 5%
in Lactated
Ringers Solution
(D5LRS) is useful
for daily
maintenance of
body fluids and
nutrition, and
for rehydration.
Hypersensitivity
to any of the
components.
Redness or pain
at the injection
site may occur.
Fever
trouble
breathing
swelling

1. Do not administer
unless solution is
clear and container
is undamaged.
2. Caution must be
exercised in the
administration of
parenteral fluids,
especially those
containing sodium
ions to patients
receiving
corticosteroids or
corticotrophin.
3. Solution containing
acetate should be
used with caution
as excess
administration may
result in metabolic
alkalosis.
4. Solution containing
dextrose should be
used with caution in
patients with
known subclinical or
overt diabetes
mellitus.
5. Discard unused
portion.
6. In very low birth
weight infants,
excessive or rapid
administration of
dextrose injection
may result in
increased serum
osmolality and
possible
intracerebral
hemorrhage.
7. Properly label the IV
Fluid
8. Observe aseptic
technique when
changing IV fluid
Name of Drug Classification Mechanism of
Action
Indication Contraindication Side Effects Nursing
Responsibility
PNSS x KVO Isotonic Table salt
(sodium chloride)
Normal saline
solution has an
osmolality of
308mOsm/L.
Because the
osmolality is
entirely
contributed by
electrolytes, the
solution remains
within the ECF,
does not cause
red blood cells to
shrink or swell
.Isotonic fluids
expand the ECF
volume.
Used to give
intravenous fluids
to the patients
suffering from
salt and water
deprivation
Used in blood
transfusions,
hyponatremia,
and burn victims
Used for irrigation
during surgery, to
dilute
medications, and
to clean wounds
out
Used because it
has little to no
effect on the
tissues and make
the person feel
hydrated
preventing
hypovolemic
shock or
hypotension
None Reactions which
may occur
because of the
solution or the
technique of
administration
include febrile
response,
infection at the
site of injection,
venous
thrombosis or
phlebitis
extending from
the site of
injection,
extravasation,
and
hypervolemia.

1. Monitor pt.
frequently for:
a. Signs of
infiltration /
sluggish flow
b. Signs of
phlebitis
/infection
c. Dwell time of
catheter and
need to be
replaced
d. Condition of
catheter
dressing
2. Check the level of
the IVF.
3. Correct solution,
medication and
volume.
4. Check and regulate
the drop rate.
5. Change the IVF
solution if needed
6. If an adverse
reaction does occur,
discontinue the
infusion, evaluate
the patient, institute
appropriate
therapeutic
countermeasures
and save the
remainder of the
fluid for
examination if
deemed necessary.
REFERENCE:http://www.rxlist.com/normal-saline-drug/side-effects-interactions.htm

Name of
Drug
Classification Mechanism of Action Indication Contraindication Side effects Nursing Responsibility
Isoflurane Anesthetics It potentiates glycine
receptor activity,
which decreases
motor function.
It inhibits receptor
activity in the NMDA
glutamate receptor
subtype.
Isoflurane inhibits
conduction in
activated potassium
channels.
Isoflurane also
affects intracellular
molecules.
It activates calcium
ATPase by increasing
membrane fluidity.
It binds to the D
subunit of ATP
synthase and NADH
dehydrogenase.
Isoflurane, USP
may be used for
induction and
maintenance of
general
anesthesia.
Adequate data
have not been
developed to
establish its
application in
obstetrical
anesthesia
Known
sensitivity to
Isoflurane, USP
or to other
halogenated
agents. Known
or suspected
genetic
susceptibility to
malignant
hyperthermia.
1) increase in the
white blood cell
count (even in
the absence of
surgical stress)
and also
shivering
2) Nausea and
vomiting
(during the
postoperative
period).
3) Increase in
heart rate Rare
cases of
bronchospasm
4) Rare reports of
mild, moderate
and severe
(some fatal)
post-operative
hepatic
dysfunction.

Adverse Reaction
1) Hypotension
2) Respiratory
1. Used with caution
in patients with
coronary artery
disease
2. Monitor blood
pressure and
temperature to
detect residual
hypotension and
the possibility of
malignant
hyperthermia.
3. Must be given
with a licensed
anesthesiologist
4. Emergency kit
must be made
available
depression
3) arrhythmias

REFERENCE:http://www.drugs.com/sfx/isoflurane-side-effects.html










IV. NURSING PROCESS


A. LONGTERM OBJECTIVE

The nursing plan aims to return the patient to its normal body feeling. It also aims to restore the healthy
body of the patient. And to ensure the physiological well-being of the patient by providing patient and family
teachings through addressing emotional and psychosocial needs.

B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM RANKING JUSTIFICATION
Acute Pain related to
tissue trauma from
Surgical Incision
1 Acute pain should be the first
because if pain is not present or
will be diminish, for it wont be
totally removed because of
presence of surgical incision, the
patient will be comfortable and
other problem will be somehow
light.
Ineffective
thermoregulation
related to trauma of
breast tissue
2 This should be second because if
the patient has fever, the activity
will be limited, also this indicate
that she has infection.
Disturbed body image
related to loss of body
part secondary to
Modified Radical
Mastectomy
3 This should be third because the
patient needs to have a good
ambulation or movement of her
body parts. If she will be limited,
other problem such as impaired
skin integrity will follow.
Impaired skin integrity
related to post operative
incision secondary to
surgery
4 This should be fourth because it is
just present because of
complimentary situations just like
disturbed body image which should
be managed first.
Risk for injury 5 Tchis risk should be less prioritized
because it is just foreseeing the
possibility that may occur.
Risk for edema 6 Impaired skin integrity related to
post operative incision secondary to
surgery.
Decrease hemoglobin
secondary to anemia
7 This should be the last because the
management of increasing
hemoglobin takes a long term.



ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Mababa daw ang pula
ngdugokosabeng doctor
as verbalized by the
patient.

OBJECTIVE:
Pale in
appearance
Weak
Fatigue
Hemoglobin
result of 7.4
gm/dL
Decrease
hemoglobin
secondary to
Anemia
After one hour of nursing
intervention the client
will be able to:

Verbalizes
understanding
about the causes
and effects of
iron deficiency.

Long term:

Report in
increase
hemoglobin in
CBC result.
Explain about the
signs and
symptoms of
anemia.


Instructed about
increase intake of
iron rich food and
iron supplement.


Note changes in
balance/ gait
disturbance,
muscle weakness.






Plan activity
progression with
patient, including
activities that the
patient reviews
essential. Increase
levels of activities
as tolerated

Recommended
quiet
atmosphere, bed
rest if indicated.
For the patient
to know about
the possible
Causes of
anemia.

Iron is needed
for formation of
RBC



May indicate
neurological
changes
associated with
vitamin B12
deficiency,
affecting
patients safety
or risk for injury.

Promotes
gradual return to
normal activity
level and
improved muscle
tone or stamina
without undue
fatigue.

Enhances rest to
lower bodys
oxygen
requirements,
and reduces
After one hour
of nursing
intervention the
client was able
to verbalize
understanding
about the
causes and
effects of iron
deficiency.

The nursing
intervention
was not met.
strain on the
heart and lungs.


ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Kumportable ako pag
inilalagay ko itong bag sa
tabi ko. As verbalized by
the patient.

OBJECTIVE:

Seen placing
shoulder bag on
the operative
site.
Hemoglobin
level of
7.4gm/dL
Absence of
Significant other
for assistance.
Risk for Injury After 1-2 hours of
nursing intervention
the client will
demonstrate behaviors
to reduce risk factors
and to protect self from
injury.
Instructed to
ask for
assistance in
performing
ADLs.

Encourage
patient to
prevent doing
things beyond
what her body
can perform.



Assess mood,
coping
capabilities
and
personality
styles like
aggression and
impulsive
behaviour.

Encourage use
of techniques
to reduce
stress and vent
emotions such
as anger.


Provide
adequate rest.
To promote
safe physical
environment
and individual
safety.

Impulsive
behaviors may
contribute and
increase risk of
the patient to
injury.



These may
result in
carelessness or
increased risk
taking without
consideration
of
consequence


To reduce the
occurrences of
injury





Adequate rest
can strengthen
the patient.
After 1-2 hours of
nursing intervention
the client was able to
demonstrate behaviors
to reduce risk factors
and to protect self from
injury.


ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Hindi ko maitaas ang kaliwang
braso ko kasi masakit. As
verbalized by the patient.

OBJECTIVE:

Unable to raise left arm

Presence of suture on left
breast adjacent to armpit.

Inability to have exercise
of the operative site.
Risk for edema After one hour of
nursing
intervention the
client will able to
demonstrate the
instruction to
prevent risk for
edema.
Instructed to
raise the left
arm

Encourage
minimal
exercise on the
affected area
Instructed to
wear loose
clothing
Do not carry
purse or
anything heavy
on the
affected site
Avoid
exposure to
hot object that
may cause
burns
Avoid the use
of blood
pressure cuffs
to the affected
area.

Raising the left arm or
the operative site to
promote drainage and
prevent edema.
Exercise can promote
proper circulation


Tight clothing can
increase the pressure
in the operative site
To avoid pressure and
swelling on the
operative site


Hot objects can
further increase the
risk for edema


Blood pressure cuffs
can increase pressure
in the operative site
After one hour of nursing
intervention the client was
able to demonstrate the
instructions to prevent risk
for edema.




ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION
S: Ang nararamdaman
ko lang talaga dito sa
suso ko ay yung sakit,
pero di naman siya
makati,as verbalized by
the patient.

Objective:
Presence of surgical
wound on the left
breast where
incision was made
Pain rated as 10 out
of 10 as 10 as the
highest.

Impaired skin
integrity related
to post operative
incision
secondary to
surgery
After 1-2 hours of
nursing interventions,
the patient will
participate in prevention
measures and treatment
program.
Assess incision
site taking note
of size, color,
location,
temperature,
texture,
consistency of
wound/ lesion
if possible.
inspect
surrounding
skin for
erythema,
induration,
maceration
assess for odors
and drains
coming out
from the skin/
area of injury


inspect skin on
a daily basis,
describing
lesions and
changes
observed
keep the area
clean/dry,
carefully dress
wounds,
support
incision, and
prevent
infection
use appropriate
to provide
comparative
baseline data




to assess extent
of involvement



to assess early
progression of
wound healing,
development of
hemorrhage or
infection
to promote
timely
intervention/rev
ision of plan of
care
to assist bodys
natural process
of repair




protect the
After 1-2 hours of
nursing
intervention, the
client was able to
participate on the
preventive
measures and
treatment
program for her
condition.
wound
coverings


encourage
adequate rest
and sleep
encourage early
ambulation and
mobilization


provide
position
changes
practice aseptic
technique in
cleansing/dressi
ng and
medicating
lesions
instruct proper
disposal of
soiled dressing

wound and/or
surrounding
tissue
to prevent
fatigue

to promote
circulation and
reduce risks
associated with
immobility
to prevent bed
ulcers from
occuring
to reduce risk of
cross-
contamination


to prevent
spread of
infectious agent







ASSESSMENT NSG.
DIAGNOSIS
PLANNING INTERVENTION RATIONALES EVALUATION
S:Masakit yung parte na
may tahi, hindi ko nga
maigalaw ng maayos
yung katawan ko, as
verbalized by the patient.

Objective:
Facial grimace
Guarding
behavior
Pain scale of 10
out of 10 as 10
as the highest.
Autonomic
alteration of
muscle tone
Acute pain
related to tissue
trauma from
surgical incision
After 1-3 hours
of nursing
intervention,
clients pain
scale will be
reduced.
Monitor vital signs
Assess verbal/non-
verbal reports of
pain, noting
location, intensity
(0-10 scale), and
duration
Place in Semi-
Fowlers position
and support
head/neck in
neutral position
with small pillows as
required in
immediate
postoperative phase
Instruct client to use
hands to support
neck during
movement and to
avoid
hyperextension of
neck





Encourage client to
use relaxation
techniques e.g.,
guided imagery, soft
For baseline
data
Useful in evaluating
pain, choice of
interventions,
effectiveness of
therapy

Prevents
hyperextension of
the neck and
protects integrity of
the suture line



Movement
restriction is imposed
for only a few hours
postoperatively to
prevent stress on the
suture line and
reduce muscle
tension. Gentle
flexing and stretching
is then permitted
according to pain
tolerance to help
prevent neck
soreness
Helps refocus
attention and assist
client to manage pain
S:Masakit pa rin siya
pero di na naman
masyado tulad kanina
kasi may tinuturok nman
sila para sa kirot,as
verbalized by the
patient.

Objective:
Pain scale of 8
out of 10
music, progressive
relaxation
Administer
analgesics as
ordered.

more effectively

Reduces pain and
discomfort.
ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION
S:Iba na ngayon
yung
pakiramdam ko
nung nawala
yung kaliwa kong
suso, ang sama
ng tingnan sana
hindi na
mangyari dun sa
kabila,as
verbalized by the
patient.

Objective:
Evident
removed left
breast


Disturbed body image
related to loss of body part
secondary to modified
radical mastectomy
After 1-3 hours
of nursing
intervention the
client will
verbalize
understanding of
body changes
and acceptance
of self in
situation.
Assess
perception of
change in
structure or
function of
body part.


Assess
perceived
impact of
change on
activities of
daily living
(ADLs), social
behavior,
personal
relationships,
and
occupational
activities
.Encourage
verbalization
of positive or
negative
feelings about
actual or
perceived
change
.Maintain
therapeutic
communicatio
n and
demonstrate
positive caring
To identify
existing
problem and
plan certain
therapeutic
actions


To help the
client sustain
his physical
and social
needs while
she is unable





To allow the
client to
express herself
and release
tension on
feelings.


To facilitate
good nurse-
patient
interaction and
also gain
clients trust to
S:Hindi naman
ako masyadong
pinanghihinaan
ng loob dahil
lang dito, yun
lang talaga sana
hindi na siya
mangyari dun sa
kabila kung
suso, as
verbalized by the
patient.

Goal still on
progress.
in routine
activities

Teach patient
adaptive
behavior like
using
of adaptive
equipment
that conceals
altered body
part breast
pad
Help patient
identify ways
of coping and
divertional
activities

cooperate.

To help the
client gain back
her confidence
by concealing
altered body
part.



To make the
client focus on
activities shes
interested and
happy instead
of her altered
body part











ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION
S:Nilalamig na
naman ako kasi
nilagnat ako simula
nung maopera ako,
as verbalized by the
patient.

Objective:
Flushed skin
Warm to
touch
Temp:
38.9C
Ineffective
Thermoregulation
related to trauma of
breast tissue
After 1-2 hours of
nursing
intervention the
client will maintain
core temperature
within normal range
Administer
fluids,
electrolytes
and
medications,
as ordered.
Monitor body
temperature
Promote client
safety


Maintain
bedrest




Discuss
importance of
adequate
fluid intake

To treat
underlying
cause



To asses
baseline data
To assist with
measures to
reduce body
temperature
To reduce
metabolic
demands and
oxygen
consumption

To prevent
dehydration.
After 1-2
hours of
nursing
intervention
the clients
body
temperature
reduced from
38.9 to
38.6C

Goal
partially
met.

D. Discharge Plan
Medications
a.) Advised the patient to take the medications prescribed by the physician for her to take continuously at
home:
a. Cefuroxime 500mg 1tab/three times a day (8am-1pm-6pm)
b. Celecoxib 200mg 1cap/two times a day (8am-6pm)
b.) Instructed to always check the expiration date before taking the medication.
Environment
a.) Provided safety measures to promote a safe environment.
b.) Maintain quiet, well ventilated and cal environment for fast and good recovery of the patient.
Treatment
a.) Treatment for all types of IDC is determined by the exact type of cancer and staging. Depending on the
size and spread of the tumor(s), most women will undergo a combination of any of the following treatments:
Lumpectomy
Mastectomy
Sentinel node biopsy
Axillary node dissection
Breast reconstruction
Radiation
Chemotherapy
Hormonal therapy
Biologic targeted therapy

Health teaching
a.) Instructed the patient to avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are
removed.
b.) Advised the patient to elevate the arm to avoid edema on arm and hand.
c.) Reiterated the importance of coping stress through stress theraphy such as stress reduction at home.
Out Patient referral check up
a.) After discharge, advised the patient to come back for follow up check up at OPD after one week (August
23, 2013) after discharge.

Diet
a.) Instructed the patient to avoid salty food.
b.) Advised the patient to resume regular diet after recovering from anesthesia.
c.) Encourage the patient to Inceased fluid intake and avoid Caffeinated beverages.
d.) Advised to take plenty of fruits and vegetables.


Manuel S. Enverga University Foundation
College of Nursing and Allied Health Sciences
Lucena City





A Case Study of

Ductal Carcinoma


In Partial Requirement of




Nursing Care Management 103- Related Learning Experience
Surgery Department
Quezon Medical Center


Submitted by:

BSN LEVEL III- Group II

ANCHETA, GENESIS
BANTOC, ROYCE ANNE
CAPACIA, JAN MARIZ
ESCALA, EMILY
ESTRADA, RAY JUNDIE
GALLANO, MARY CONCEPTION
MACASAET, LESLIE
MENDOZA, MARGOTT
SARGENTO, TOM FRANCIS


Submitted to:

EDWIN Q. YABUT RN, MSN
Clinical Instructor