ࡱ> |uvwxyz{[ bjbj tΐΐ|+/4777h4 7L'('(((dddFe^dee((6EhEhEhe ((EheEhEhkLu (,7fZ0Lg|  d"dEhe'edddEhdddLeeeeddddddddd : ooTABLE OF CONTENTS INTRODUCTION_________________________________________________ 2 OBJECTIVES____________________________________________________ 5 NURSING ASSESMENT___________________________________________ 7 Family and Individual information and health history________________ 7 Level of Growth and Development______________________________ 9 Normal Development at Particular Stage________________________ 9 The Ill Person at Particular Stage_______________________________ 12 DIAGNOSTIC RESULT___________________________________________ 14 PRESENT PROFILE OF FUNCTIONAL PATTERNS___________________ 23 PATHOPHYSIOLOGY AND RATIONALE___________________________ 27 Schematic drawing__________________________________________ 29 Disease Process_____________________________________________ 30 Comparative Results_________________________________________ 36 NURSING INTERVENTION_______________________________________ 39 BLM_____________________________________________________ 43 NCP______________________________________________________ 44 DTR______________________________________________________ 47 SOAPIE___________________________________________________ 53 HTP______________________________________________________ 55 EVALUATION AND RECOMMENDATION__________________________ 58 EVALUATION AND IMPLICATION OF THE CASE STUDY____________ 60 BIBLIOGRAPHY_________________________________________________ 61 Introduction The student-nurse chose this for her case study out of curiosity of why most 40 years old and up women and men acquire breast cancer, as to how closely the patient should be monitored from time to tome to prevent the spread of the cancer cells throughout the body and on how to provide care for post mastectomy patients. It also serves as knowledge experience for her to utilize if she encounter patients with similar conditions. We all know that a breast disorder, whether benign or malignant can cause great anxiety and fear of potential disfigurement, loss of sexual attractiveness and even death. Therefore, it is important that the student nurse knows exactly on how much care and attention is to be rendered for such patients. And that student nurses must have expertise in assessment and management not only the physical symptoms but also the psychosocial symptoms of breast disorders. Breast cancer is an uncontrolled growth of breast cells. Cancer occurs as a result of mutations or abnormal changes, in the genes responsible for regulating the growth of cells and keeping them healthy. Normally the cells replace themselves through an orderly process of cell growth. But overtime, mutations can turn on certain genes and turn off others in a cell. That changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumor. Invasive ductal carcinoma refers to cancer that has been broken through the wall of the milk duct and begun to invade the tissues of the breast. Overtime, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body. Breast cancer can be treated through several ways. It can be through radiation therapy wherein the cancer cells are bombarded with x-rays, or with rays or particles from such radioactive substances. Second is chemotherapythe use of drugs to destroy the cancer cells with as little injury to normal cells as possible. Third, multimodality therapyit involves the use of 2 or 3 methods to treat individual cancer patients. Fourth is through surgery. In breast cancer, mastectomy is the best treatment. Mastectomy is the surgical removal of the breast. In some cases, the tissues surrounding the breast are also taken out. Mastectomies are usually performed to remove cancerous tumours and to prevent the cancer from spreading. There are three types of mastectomies: radical, simple and partial. A radical mastectomy is performed if the surgeon suspects that the cancer may have spread beyond the breast to the lymph nodes of the underarm area. In a radical mastectomy, the surgeon removes the breast, the underarm lymph nodes, and the pectoral muscles, which connect the breast to the ribs. A modified radical mastectomy involves the removal of the breast and most of the underarm lymph nodes, but leaves the pectoral muscle. A simple mastectomy consists of removing only the breast. This procedure is sometimes used in cases where the cancer appears to be confined to a single site. In a partial mastectomy, also called a lumpectomy, the surgeon removes only the tumour and breast tissue immediately surrounding it. This operation causes the least disfigurement. Here the student nurse expects more information and knowledge that she can achieve to learn more comprehensive plan of care for patients who have breast cancers and for patients who have undergone mastectomies, and to provide holistic nursing care, management and to prevent the recurrence of breast cancer. Objectives Nurse Centered General Objectives: After 3 days of student nurse patient interaction, the student nurse will be able to provide holistic nursing care and improve her attitude, skulls, and knowledge in the care of a breast cancer patient who has undergone a modified radical mastectomy. Specific Objectives: After 3 days of rendering holistic nursing care, the student nurse will be able to: establish rapport with the client and family members, perform thorough nursing assessment, obtain family and individual information, social health history, review the anatomy and physiology of the affected part, discuss the: 5.1 normal growth of the breast, 5.2 disease process of the disease, 5.3 stages of the breast cancer, 5.4 treatments for breast cancer patients, identify the present nursing problems, make a comprehensive nursing care plan, implement the formulated nursing care plan, impart health teachings to the patient and significant others, evaluate the effectiveness of nursing care rendered to the patient. Patient Centered General Objectives: After 3 days of student nurse patient interaction, the patient and family will be able to gain knowledge, attitude and skills in the care of a post-mastectomy patient. Specific Objectives: After 3 days of student nurse patient interaction, the patient and the family will be able to: establish and gain communication with the student nurse, participate proactively in the assessment process, identify the problems which is potential for a post mastectomy patient, verbalize understandings on: 4.1 normal growth of the breast 4.2 disease process of the disease 4.3 stages of the breast cancer 4.4 treatment for breast cancer patients experience relief of signs and symptoms during the student nurse care apply learned nursing care or measures. Nursing Assessment Personal History Patients Profile NAME: Mrs. Virginia Portrias Peserla AGE: 48 years old SEX: female CIVIL STATUS: married RELIGION: Roman Catholic DATE OF ADMISSION: September 7, 2009 COMPLAINTS: breast enlargement with needle prick pain IMPRESSION/DIAGNOSIS: invasive ductal carcinoma on left breast PHYSICIAN: Dr. Romero, Dr. Caminero, Dr. L. Seora Family and Individual Information, Social and Health History A case of Mrs. Peserla, Virginia, 48 years old, female, married, lives at lower Panadtaran, San Fernando Cebu. The client was admitted due to breast mass enlargement associated with needle prick pain. Four months prior to admission, patient noted onset of gradually increasing needle prick pain on the left upper quadrant of the left breast associated with green yellowish nipple discharges. Unusual breast mass enlargement on the left breast was also noted, so the patient decided to seek consult. The patient was admitted last September 7, 2009, 9:30 a.m., ambulatory with the following vital signs: temperature 36.7 degrees Celsius, RR 24 breath cycles per minute, PR 82 beats per minute, BP 180/90 mmHg. During this time the patient is undergoing several laboratory exams such as CBC, ultrasound, chest and lungs X rays, and needle aspiration biopsy. On September 12, 2009, with full consent, the client had undergone breast mass excision. The operation was successful giving her with two Jackson Pratt drainage bottle which is placed medially and laterally. Unfortunately the patient has to stay longer in the recovery room for a long period of time because of her changing blood pressure. When the patients blood pressure became stable, she was returned back to her room and is being strictly monitored every hour. The patient has been hospitalized for the first time due to typhoid fever at Cebu South general Hospital, and for the second time now for having breast cancer at the same hospital. The patient has no hypertension, diabetes mellitus, heart disease and allergies history. She doesnt smoke but is an alcoholic beverage drinker. Level of Growth and Development Middle Aged Adult 40-60 years old Middle adulthood usually refers to those years between 40 and 65 and is often described as that period when one has both grown children and older adult parents. Most have experienced personal and career achievements, along with socioeconomic stability. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactorily, will enable middle adults to prepare for retirement. Normal Development at Particular Stage Physical Changes Accepting and adjusting to the physiological changes of middle age is one of the major developmental tasks of this age period. Because middle adulthood spans 25 years, many of the physical changes described usually do not occur until later in the developmental period. Middle-aged adults use much energy to adapt self-concept and body image to physiological realities and changes in physical appearance. Climactic is a term used to describe the decline of reproductive capacity and accompanying changes brought about by the decrease in sexual hormones. This affects men and women differently. Men begin to experience decreased fertility, but they are able to continue to father children. Menopause, when the woman stops ovulating and menstruating, occurs only when 12 months have passed since the least menstrual flow. The womens ability to bear children comes to an end. Cognitive Changes Changes in the cognitive function of middle adults are few except during illness or trauma. Performance on intelligence tests indicates increases in some areas, particularly verbal abilities and tasks involving stored knowledge. Although middle aged adults sometimes perform more slowly and are not as adept at saving new or unusual problems, the ability to solve practical problems based on experience peaks at midlife because of the ability of integrative thinking. Psychosocial Development Generativity vs. Stagnation According to Erikson, the primary development task of the middle adult years is to achieve generativity, which is the willingness to establish and guide the next generation and care for others. Many find particular joy in assisting their children and other young people to become productive and responsible adults. During this period adult children often begin to help older adult parents. Individuals have the time and interest to become more involved in their church, charitable activities, politics, fund-raising and other voluntary activities that bring them satisfaction. The opposing developmental trait, stagnation, occurs when people become preoccupied with themselves or self indulgent or through inactivity become bored, withdrawn, and isolated. Short stagnant periods allow one to gather energy for the next project, but prolonged stagnation results in destructive behavior toward children and the community. Moral Development According to Kohlbergs moral development, conventional level of moral reasoning is typical for adolescent and adults. Those who reason in a conventional way, judge the morality of actions by comparing them to societys view and expectations. The conventional level consists of the third and fourth stages of moral development. In stage three (interpersonal accord and conformity driven), the self enters society by filling social roles. Individuals are receptive to approval or disapproval from others as it reflects societys accordance with the perceived role. They try to be a good boy or a good girl to live up to these expectations, having learned that there is inherent value in doing so. In stage four (authority and social order obedience driven), it is important to obey laws, dictums and social conventions because of their importance in maintaining a functional society. Moral reasoning stage four is thus beyond the need for individual approval exhibited in stage three; society must learn to transcend individual needs. The Ill Person at Particular Stage A case of Mrs. Peserla, Virginia P., a 48 years old breast cancer patient who have undergone mastectomy on her left breast, manifested cooperative behavior toward the student nurse and all other health care providers. Mrs. Peserla presented a good attitude towards making herself better. She is complying with all the treatments she has to attend without any complaints. Even though the patient has episodes of vertigo, anxiety, and depression due to her loss, still she presented an optimistic approach in getting healthy for the time of her hospitalization. The patients breast is mass less and is experiencing hematoma. Hematoma formation (collection of blood inside the cavity) may occur after either mastectomy or breast conservation and usually develops within the first 12 hours after surgery. With this formation, the surgeon placed 2 Jackson Pratt drains. When those drains, presented a white fluid/clear discharges, the drains can be removed. With patients knowledge of these, she is eager and kept in looking at the color of the discharges. Facial grimaces are also seen on the patient when she moves suddenly. For breast cancer patients feelings of anxiety, sadness, and fear of looking at the incision are normal. Mastectomy means abrupt change in body image. It is normal to mourn the loss of a breast and to fear the loss of ones life after a cancer diagnosis. Sexual intimacy can also be affected by mastectomy. Diagnostic Results Complete Blood Count Date of Diagnostic Examination: 09/15/09 Diagnostic TestsNormal ValuesPatients ResultSignificanceHemoglobin12 169.3 g/dLDecreased due to prolonged hemorrhage.Hematocrit36 4627.7%Decreased due to acute massive blood loss during surgery.RBC4.0 5.23.0 x 10^12/LDecreased due to blood loss.Mean Corpuscular Volume [MCV]80 10092 flWithin the normal rangeMean Corpuscular Hemoglobin[MCH]21 -3331 pgWithin the normal rangeRed Cell Distribution Width [RDW]11.6 14.812.3 %Within the normal rangePlatelet Count140 440 75 x 10^g/dLDecreased due to possible metastatic carcinoma and severe hemorrhage.WBC5.0 10.019.1 x 10^g/LIncreased due to stress. Neutrophil47 8086%Increased due to mastectomy procedure.Lymphocyte13 - 408%Decreased due to blood loss.Monocyte2 116%Within the normal rangeEosinophil0 5 0%Within the normal rangeBasophil0 20%Within normal range SOURCE: Daviss Comprehensive Handbook of Lab and Diagnostic Test with Nursing Implications 2nd Ed. By Leeuwen, et.al. Fluid Serum Date of Diagnostic Examination: 09/07/09 Diagnostic TestsNormal ValuesPatients ResultSignificanceCreatinine0.7 1.50.7 mg/dlWithin normal rangePotassium3.6 5.03.5 mmol/LDecreased due to hypertension and stress. SOURCE: Daviss Comprehensive Handbook of Lab and Diagnostic Test with Nursing Implications 2nd Ed. By Leeuwen, et.al. Prothrombin Time Date of Diagnostic Examination: 09/11/09 Diagnostic TestsNormal ValuesPatients ResultSignificanceProthrombin Time12 1510.7 secDecreased due to breast cancer. SOURCE: Daviss Comprehensive Handbook of Lab and Diagnostic Test with Nursing Implications 2nd Ed. By Leeuwen, et.al. Albumin Date of Diagnostic Examination: 09/11/09 Diagnostic TestsNormal ValuesPatients ResultSignificanceAlbumin3.3 5.53.1 g/dlDecreased due to neoplasm and alcoholism. SOURCE: Daviss Comprehensive Handbook of Lab and Diagnostic Test with Nursing Implications 2nd Ed. By Leeuwen, et.al. Ultrasound Date of Diagnostic Examination: 09/11/09 Diagnostic TestsNormal ValuesPatients ResultSignificanceRight BreastNormal subcutaneous mammary layers of tissue, no cyst, no tumorAxillary tail: unremarkable no focal lesion, no axillary lymphadenopathy Normal findingsLeft BreastNormal subcutaneous mammary layers of tissue, no cyst, no tumorAxillary tail: unremarkable, 3oclock: solid irregular hypoechoic nodule without posterior shadowing (3.87 x 3.35 cm), no ductal dilation seen, no axillary lymphadenopathyIrregular solid masssuggestive of invasive ductal carcinoma. SOURCE: Daviss Comprehensive Handbook of Lab and Diagnostic Test with Nursing Implications 2nd Ed. By Leeuwen, et.al.  Body PartIPPAHEAD Hair Patient has short, black hair, presence of split ends, no dandruff and no lice Smooth, thin textureScalpAbsence of dandruff and parasitesNo lumps, movable and softFaceSymmetrical facial features and movementsSmooth and softEYES Eyebrows Asymmetrical and equal movement, thin, evenly distributed No pain upon palpation No pain upon percussionEyelashesShort, turned outwardLidsBrown in color, closes symmetricallyConjunctivaPinkish, moistScleraWhite and clearIrisRound and brownPupilsPupils are equally round and reactive to light and accommodation, equal reaction of both sidesVisual AcuityWears eyeglasses when readingPeripheral VisionCan see the objects at peripheryMuscle FunctionEyes were able to follow direction of objectMuscle BalanceEyes didnt wander6 Cardinal GazesAble to follow the penlightNoseSame color as the face, centrally located, nasal septum is intactSymmetrical, firm and not painful and not tenderFrontal and Maxillary SinusesNo occlusions when transillumination is doneNot No pain feltMOUTH Lips Wet from saliva, moist and light pink Slightly smoothGumsPinkish and moistTendernessTeeth No dentures used, 28 ivory colored teethHard Hard PalateWhitish Tenderness Soft PalateWhitish TendernessUvula Midline Frenulum Normal Tonsils Not inflamed, pinkTonguePinkish Not tenderEARS External Aligned with eyes Free of lumpsInternal No lesions, presence of cerumenNECK Lymph Nodes Not enlargedTrachea Central placement in the midline of the neckMovable Thyroid glandNot enlarged, not visibleGoes up and down when patient swallowsTRUNK Chest Rises and falls during inhalation and exhalation, 20 breath cycles per minute, equal chest expansion No masses Resonant sound heard upon percussion Bronchovesicular sound heardHeartRegular and normal rate and rhythm of 60 beats per minute, no murmursLungsEqual lung expansionEqual chest excursionResonant sound heardNormal breath sounds of 20 breath cycles per minute, no crackles and no wheezesBreastLeft: broken skin integrity with sutured breast with bandage and 2 Jackson Pratt Drains, hematoma formation on the axilla side Right: round with regular mass, presence of nipplePain upon movementAbdomenHas flat abdomen, no irregularities in bowel soundsSoft, smooth, warm to touch, kidney and spleen not palpable, no lesions and no edemaTympanic soundRegular bowel sound of 20 bowel sounds per minuteEXTREMITIES Upper Brown in color and right arm is able to move, left arm is flexed Pulse rate of 60 beats per minute, temperature of 37.5 degrees Celsius, warm, no lesions Arms reacted when hit by percussion hammer BP = 110/70 mmHg LowerBrown in color, able to walk, but feels dizzy when walking and movingTibial and dorsalis pedis pulse are palpableLegs reactive to percussion hammerBP = 110/70 mmHgSKINBrown in color, dry, absence of lesionsSmooth, warm, slightly senile turgor. Present Profile of Functional Health Patterns 3.1 Health Perception/Health Management Pattern The patient perceives her health as fair. It is not that bad anymore unlike before when she havent had the operation. It is also not that good because of the post-operative pain shes feeling and the feeling of nausea and vomiting. She keeps her health as healthy as possible by maintaining her health with vitamins and complying with the prescribed medications of the physician. She was prescribed to take vitamin C and lecithin-E daily for her cancer. She was also told to keep her left arm flexed and keep her right arm adducted. The patient doesnt usually wear eyeglasses but when she is reading she wears it. Mrs. Peserla has immobility orders in her arms and cannot stand up because of being nauseous. As for the moment she is most concerned of being able to move accordingly and go home and be with her family. 3.2 Nutritional Metabolic Pattern She eats meals three times a day and at the right time. Her usual fluid intake was around 7 9 glasses of water a day, and sometimes prefers orange juice. After her surgery, she has lost her appetite. She mostly eats fruits, like bananas and apples. She eats a little bit of rice and some pork. The patient is currently taking Areola-C (Vitamin C) chewable daily. She does not have any eating disorders or disability and doesnt have any allergies to any food or even medications. In addition, she doesnt smoke cigars but drinks alcoholic beverages. 3.3 Elimination Pattern The patient has normal bowel movement before the operation, she defecates everyday with dry formed stools. When the operation started, she hasnt defecated yet. She has no problems in urinating, but she is wearing diapers because she is unable to go to the comfort room because of nausea. 3.4 Activity / Exercise Pattern Doing household chores and taking care of her family is her job. She also has a part time job, wherein she sells ukay-ukay to her neighbors to earn extra money. During leisure time she usually sleeps or watches television. 3.5 Cognitive / Perceptual Pattern Mrs. Peserla wears eyeglasses when reading, other than that, the patient doesnt have deficits in sensory perception before and after the operation. The patient is oriented with the time, place and of the persons in the hospital. She is also aware of her current condition. She can also read and write. 3.6 Sleep / Rest Pattern The patient experiences disturbance in her sleep before and after the operation. She usually sleeps at 11:00 pm and wakes at 6:00 am which usually ranges 7-8 hours but it has changed. After the operation, she has to be monitored every hour making her sleep disturbed. And now her sleep last for 4-5 hours and sometimes she wakes up in between sleep. 3.7 Self - Perception Pattern Before the knowledge of her having a breast cancer, she is most concerned of her getting pregnant. That is why she takes contraceptive pills. Due to taking of pills, she acquired a stage II breast cancer. After the operation, she is most concerned about getting well, taking off the 2 drains that is attached to her and go home. 3.8 Role - Relationship Pattern The patient speaks Visayan and a little bit of Filipino and English. Her speech is clear and relevant and could express self and understand others accordingly. The patient has 3 children; the eldest no longer live with them. All in all, there are four members in the house. In time of need, she usually goes to her husband and expresses her needs. As for the decision-making and financing, it is her husband that decides. There are no complaints with regards to any abuse or other relatives. 3.9 Sexual Reproductive Pattern Because of the generation, they anticipate sexual relations changes. For now, they are more concerned of getting well and in preventing the reoccurrence of the cancer. 3.10 Coping Stress Management Pattern As for the moment, the patient is experiencing a loss and changes to her sexual relations. But with the help of her family, especially her husband, and also her friends that come to visit her, makes her feel relieved and accepted her present state. When the patient is stressed, she usually takes a rest, watches T.V., or sometimes shares her feelings with someone. 3.11 Value Belief System Patient is a Roman Catholic. Her husband is a member of Jehovahs Witness. They have different beliefs but still they come up with the same decisions. As for her children, they followed their father. The patient finds her strength from God. Praying and going to Church alone is her religious practices and thats how important God is to her. Pathophysiology and Rationale 4.1 Anatomy and Physiology Male and female breasts mature comparably until puberty, when in females estrogen and other hormones initiate breast development. This development usually occurs from 10 to 16 years of age, although the range can vary from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5. Stage 1 describes a prepubertal breast Stage 2 is breast budding, the first sign of puberty in a female. Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the nipple). Stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue. Stage 5 the continued development of a larger breast with a single contour. The breasts are located between the second and sixth ribs over the pectoralis muscle from the sternum to the mid-axillary line. An area of breast tissue, called the Tail of Spence, extends into the axilla. Fascial bands, called Coopers Ligaments, support the breast on the chest wall. The Inframammary Fold (or crease) is a ridge of fat at the bottom of the breast. Each breast contains 12-20 cone-shaped lobes, which are made up of glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together. Within each lobe are smaller chambers called lobules, which contain clusters of Alveolar Glands that produce the milk when a woman is lactating (producing milk). The alveolar glands of each lobule pass the milk into the lactiferous ducts, which open to the outside at the nipple.  4.2 Schematic Diagram   Somatic mutations in the DNA Activate oncogenes/deactivate tumor suppressor gene Malignant transformation of lymphoid stem cell Uncontrolled proliferation of lymphoblast in the breast  Breast cancer  Nipple discharges Hypertension Anxiety, Fear Breast mass thickening Depression, Pricking sensation Fatigue Nausea and vomiting Post-operative pain  Med Mgt.: Nursing Mgt.: Surgical Mgt.: Medications - monitor vital signs hourly - modified Alprazolam, Losartan, - monitor output of drainage tubes radical Ketorolac, Mefenamic Acid - deep breathing exercises mastectomy and Tramadol - provide incisional site care Diet for Age - provide emotional support Bed Rest 4.3 Disease Process Cancer of the breast begins as a single transformed cell and is hormone dependent. Cancers of the breast are classified as non-invasive (in situ) or invasive, depending on the penetration of the tumor into surrounding tissue. Breast cancer may remain a non-invasive disease, or an invasive disease without metastasis, for long periods of time. Two atypical types of breast cancer are inflammatory carcinoma and Pagets disease. Breast cancer may be categorized as carcinoma of the mammary ducts, carcinoma of mammary tubules, or sarcoma of the breast. Most breast cancers are adenocarcinomas and appear to arise in the terminal section of the breast ductal tissue. There are many histologic types of breast cancer, and only examples are described. The most common type is infiltrating ductal carcinoma, accounting for approximately 70% of cases. Infiltrating ductal carcinoma refers to the cancer that has been broken through the wall of the milk duct and began to invade the tissue of the breast. Over time, this can spread to the lymph nodes and possibly to other areas of the body. Breast cancer is an uncontrolled growth of breast cells. Cancer occurs as a result of mutations or abnormal changes, in the genes responsible for regulating the growth of cells and keeping them healthy. Normally, the cells replace themselves through an orderly process of cell growth. But over time, mutations can turn on certain genes and turn off others in a cell. That changed cell gains the ability to keep dividing without control or order, producing more cells just like it and forming a tumor. Cancer of the breast is usually diagnosed in the upper outer quadrant of the breast, probably because of the large amount of tissue in this quadrant. Breast cancer begins locally within the duct or lobules. It then locally invades structures outside the duct or lobules through direct extension into the pectoral fascia, skin, or both. During the process of direct extension, breast cancer invades lymphatic channels within the breast. This may be demonstrated through a multicentric presentation of the disease. If the lesion is located in the lateral quadrants of the breast, regional invasion of the axillary lymph nodes is more likely. Medial lesions usually affect the internal mammary node chain. It is possible for distant metastasis to occur in breast cancer without prior involvement of the regional lymph nodes. This suggests a less orderly progression of the disease with possible early spread through direct extension into the blood circulation. This is the basis of another theory that breast cancer is systematic at diagnosis. Support for this theory is not universal because many patients are cured of breast cancer without ever developing distant disease. Sites of breast cancer metastasis are the bone, liver, lung, pleura, brain, and adrenal glands. The cause of breast carcinoma is not known; however, several factors appear to influence its occurrence. The strongest factor is genetic; women of succeeding generations are not only predisposed to develop breast cancer, but they develop it 10-12 years earlier than women without breast cancer, whereas, women with more children have a lower incidence. Obviously, bearing children reduces the number of menstrual periods. Breast feeding also appears to protect against breast cancer. The question continues regarding the effect of estrogens in promoting breast cancer. This uncertainty has a bearing on the use of the pill for contraceptive purposes. Although the long-range effects of using the pill are incomplete, there is reason to suggest that other means of contraception should be used by women who have a family history of breast cancer or by those who have gross cystic disease, multiple breast papillomas, or cancer in one breast. Dietary patterns are also significant; there is a positive correlation between fat consumption and rates of breast cancer. Staging involves classifying the cancer by the extent of disease. Clinical staging involves the physicians estimate of the size of the breast tumor and the extent of axillary lymph node involvement. Such staging is determined by physical examination and imaging studies. Staging of Breast Cancer StagingTumorNodeMetastasis0Tis carcinoma in Situ or Pagets disease of the nippleN0 no regional lymph nodeM0 no evidence of distant metastasisIT1 tumor no longer than 2cm T0 no evidence of primary tumorN0 N1 metastasis to movable ipsilateral axillary nodesM0 M0IIAT1 T2 tumor no larger than 5cm N0 M0IIBT2 T3 tumor larger than 5cmN1 N0M0 M0IIIAT0 T1 T2 T3N2 metastasis to ipsilateral fixed axillary nodes N1 N2M0 M0 M0IIIBT4 tumor or any size with direct extension to chest wall or skin Any TAny N N3 metastasis to ipsilateral internal mammary lymph nodesM0 M0IVAny TN0 and N1M1 distant metastasis SOURCE: Brunner and Suddarths Medical Surgical Nursing 6th Edition 4.3.1 Effects on Different Organs Breast cancer is a condition in which cells of the breast begin to divide more rapidly than they should. This is the result of genetic mutations and alterations that cause these cells to grow and develop the ability to spread to other organs. Breast cancer can affect not only the breast itself but other organs throughout the body. Interior Breast Changes Some of the earliest effects of breast cancer involve the structure of the breast itself. Breast cancer can cause a thickening of the breast tissue, sometimes in the form of a lump. This lump will feel different than the rest of the tissue and may, when pressed, not be as mobile as the surrounding breast tissue. These abnormal lumps may also cause visible changes in the size and shape of the affected breast. Exterior Changes Some of the effects of breast cancer will be apparent on the exterior of the breast. Portions of the breast may be red and warm to touch. The nipple may also become inverted. Other symptoms include nipple discharge (sometimes bloody) and peeling or flaking of the nipple skin. Breast cancer can also cause dimpling of the skin of the breast or pitting. Lymph Nodes The lymph system is the way that the body is able to drain excess fluid from tissue. Because the lymph system is an easily accessible network, it is one of the first places that breast cancer spreads. Consequently, swelling of the lymph nodes can occur before the tumor can be felt in the breast itself. These swollen lymph nodes will most commonly be in the armpit and will cause these nodes to be hard, easily palpable by the hands, and sometimes painful. Effects on Organs When cancer spreads, it can cause problems in the organs where it has metastasized. For example, if breast spreads to the bones, it can cause severe bone gain and easy breaking. If it spreads to the brain, it can cause problems with vision, changes in personality, confusion, loss of balance, and weakness in the arms or legs. Metastasis to the lungs can cause a persistent cough, chest pain and difficulty breathing. Breast cancer can also spread to the liver, where it can cause abdominal pain, a constant feeling of fullness and jaundice. 4.4 Comparative Chart Classical SymptomsClinical SymptomsRationaleBreast Mass or ThickeningManifested Patient has breast mass enlargement on her left breastDue to fibrocystic breast changes and presence of infection. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeUnusual lump in the underarm or above the collar boneNot Manifested Sign of infection in the lymph nodes. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkePersistent skin rash near the nipple areaNot Manifested There is an infection. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeNipple dischargeManifested Upon biopsy, the physician aspirated a greenish yellow fluidThere is presence of cyst / fluid filled sacs on the breast. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeBurning, stinging, or pricking sensationManifested Patient complained of a needle prick pain on her left breastDue to presence of tumors. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeHypertensionManifested On admission, patient has a blood pressure of 200/100 mmHgDue to the presence of tumors, the blood flow is slightly obstructed making the blood vessels constrict. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeNausea and VomitingManifested After the operation, patient feels nauseated and tends to vomitDue to hormonal changes. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkeFatigueManifested Patient is exhaustedA woman is tired from sleep disturbance. Source: Medical Surgical Nursing 3rd Edition b Lemone and BurkePost operative painManifested Patient feels pain upon movingWhen the anesthetics wear off from surgery, sensations return and pain from incision site is felt. Source: Medical Surgical Nursing 3rd Edition b Lemone and Burke Nursing Interventions 1. Care Guide of Patient with Disease Condition A. Provide Pain Relief. After the patient has recovered from the anesthesia, analgesia is given for the relief of pain. The nurse will frequently assess for manifestations of discomfort and initiative comfort measures by keeping the involved upper extremity elevated on pillows (about 30 degrees when the patient is in bed or sitting in a chair). This is done to reduce tension on the arm and to decrease the amount of fluid accumulation. B. Maintain Proper Measurement of Drainage of JP drains. Blood and lymphatic fluids are accumulated on the axilla after surgery. Proper and accurate measurement of these drains can be a basis of a Doctors order to remove the tubing. C. Positioning Patient Positioning of the patient depends on the dressing; a semi-Fowlers position is usually desirable. If free, the arm should be elevated with each joint positioned higher than the more proximal joint. Thus, gravity helps to remove the fluid via the lymphatic and venous pathways. Whether the arm is flexed or extended depends on the preference of the physician. Elevation of the arm helps to prevent lymph edema, which may occur after surgery because of interference with the circulatory and lymphatic systems. D. Give Incisional Site Care. When dressings are changed, the nature of the incision, the way it looks and feels, and how it will gradually change are explained. The patient needs to know that sensation in the newly healed area may have decreased because nerves have been severed; however, the area should be bathed gently and blotted dry to avoid injury. The arm on the affected side may be supported in a sling for a time to prevent tension on the wound. Gentle massage of the heated incision with cocoa butter or other lotions helps to increase the elasticity of the skin and encourages circulation. E. Encourage ambulation and Post-operative Exercises Ambulation is encouraged on the first day following surgery when the effects of the anesthetic have worn off and the patient is free from nausea and has been able to take fluids and nutrients. Assistance given when needed; the nurse supports the patient from the unoperated side. After the physicians assessment postoperatively and the removal of drainage tubes, passive range of motion of the affected arm is initiated to increase circulation and muscle strength and to prevent stiffness of the shoulder. F. Provide psychological support. A real problem may arise if the patient is reluctant to look at the incision site. Although the presence of the scar must eventually be face, the patient should not be forced at this time to look at her chest area. Her psychological defenses may require that she be spared this added shock at this time. It is sometimes helpful to direct the patient to acceptance by first drawing a picture of the incision line on a piece of paper. Then at a later time, when the dressing is being changed, the patient may show signs of being willing to look at her chest. However, he nurse must explore this area in a very gentle manner. Any resistance on the part of the patient must be sensed and respected. G. Improve sexual functions. Once discharged from the hospital, most patients are physically allowed to engage in sexual activity. However, any change in the patients body image, self-esteem, or the response of her partner may increase her anxiety level and affect sexual function. Some partners may have difficulty looking at the incision, whereas others may be completely unaffected. Encouraging the patient to openly discuss how she feels about herself and about possible reasons for a decrease in libido (e.g. fatigue, anxiety) may help clarify issues for her. Helpful suggestions for the patient may include varying the time of day for sexual activity (when the patient is less tired), assuming positions that are more comfortable, and expressing affection using alternative measures (e.g. hugging, kissing, manual stimulation).    2.2 NURSING CARE PLAN      Drug, Dose, Frequency, RouteClassification/ Mechanism of ActionIndications. C/I, AEPrinciples of CareTreatmentEvaluationTramadol 30mg IVTT q 6 hours RTC x 4 doses 8pm 2amCLASSIFICATION: Analgesics MOA: Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids. Thought to bind to opioid receptors of norepinephrine and serotonin. IND: Patients with moderate to severe pain especially post operative due to trauma, ischemia, colic or cancer C/I: Acute intoxication of alcohol, hypnotics, centrally acting analgesics, breastfeeding women AE: Dizziness, nausea, dry mouth, sweating, constipation, anxiety, flatulence, urinary frequencyWarn patient not to stop drug abruptly Tell patient to take drug as prescribed and not ton increase dose/dosage intervals unless prescribed by the doctor Reassess patients level of pain at least 20 minutes after Monitor vital signs Monitor bowel and bladder functionPatient verbalized decrease in pain sensationMefenamic Acid 50mg icap every 8 hours for pain 8am 4pm 12amCLASSIFICATION: Non-Steroidal Anti-Inflammatory Drug MOA: May inhibit prostaglandin synthesis, to produce anti inflammatory, analgesic and antipyretic effects.IND: Treatment of mild to moderate pain, osteoarthritis, and rheumatoid arthritis C/I: Allergies, MI, CVA, coronary artery bypass, uncontrolled HPN, asthma. GI bleeding, urticaria AE: Post-operative anemia, hypokalemia, agitation, insomnia, HPN, pharyngitis, pruritus, back painUse liquid form for children Tell patient not to use for marked fever (>39.5 degrees Celsius), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber Not for any adverse reactionsMonitor vital signs especially for temperature Perform tepid sponge bath when fever is present Encourage patient to increase fluid intakeThe patient verbalized a decrease in pain sensationKetorolac 30mg IVTT q 8 hours x 3 doses 8am 4pm 12 amCLASSIFICATION: Non-Steroidal Anti-Inflammatory Drug MOA: May inhibit prostaglandin synthesis, to produce anti inflammatory, analgesic and antipyretic effects.IND: Treatment of mild to moderate pain, osteoarthritis, and rheumatoid arthritis C/I: Allergies, MI, CVA, coronary artery bypass, uncontrolled HPN, asthma. GI bleeding, urticaria AE: Post-operative anemia, hypokalemia, agitation, insomnia, HPN, pharyngitis, pruritus, back painAdminister with meals to prevent GI upset Caution patient not to take aspirin, alcohol, other NSAIDs Drink a full glass of water after each dose Correct hypovolemia before givingMonitor vital signs Reassess patients level of pain Be with the patientThe patient increased in comfortParacetamol 500mg/tab 4 hours T  QUOTE  38 degrees Celsius 8am 12nn 4pm 8pm 12am 4amCLASSIFICATION: Non Opioid Analgesics/Antipyretics MOA: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulating centerIND: Mild pain or fever C/I: Patients hypersensitive to drug, use cautiously in patients with long term alcohol use because of therapeutic doses cause hepatotoxicity in patients. AE: Hematologic hemolytic anemia, leucopenia,neutropenia, pancytopenia Hepatic jaundice Metabolic hypoglycemia Skin rash, urticariaUse liquid form for children Tell patient not to use for marked fever (>39.5 degrees Celsius), fever persisting longer than 3days, or recurrent fever unless directed by prescriber Note for any adverse reactionsMonitor vital signs especially for fever Perform tepid sponge bath when fever is present Encourage patient to increase fluid intakeThe patient manifested a temperature within normal range.Alprazolam (Xanax) 250mg itab BID 8am 6pmCLASSIFICATION: Anxiolytics MOA: Unknown. A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.IND: Anxiety, panic disorder C/I: Patients hypersensitive to drug or other benzodiazepine Acute-closure glaucoma Used cautiously in patients with hepatic, renal or pulmonary disease AE: Insomnia, irritability, dizziness, hot flushes, palpitations, sore throat, rhinitis, diarrhea, dry mouth, constipation, dysmenorrheal, increased or decreased weight, arthralgia, myalgia, back pain, dyspnea, pruritus, increased sweating, dermatitis, injury, influenzaDont withdraw drug abruptly Tell patient to swallow extended release tablets whole Tell patient taking half of a scored orally disintegrating tablet to discard the unused half Encourage patient to avoid alcohol and smoke Monitor renal, hepatic, hematopoietic function periodically Be with the patientThe patient decreased anxietyRanitidine HCl 50mg IVTT q 8 hours 8am 4pm 12amCLASSIFICATION: Anti-ulcer Drug MOA: Competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion.IND: Active duodenal and gastric ulcer Maintenance therapy for active duodenal and gastric ulcer Gastroesophageal reflux disease Heart burn Patients hypersensitive to drug and those with acute porphyria Use cautiously with hepatic dysfunction CNS headache, malaise, vertigo EENT blurred vision HEPATIC jaundice OTHER anaphylaxis, angioedema, burning, itching at injection siteDrug may be added to total parenteral nutrition solutions Instruct patient to take drug once daily at bedtime for best results Can be taken without regards to mealsNotify prescriber for presence of adverse effects Monitor stool frequency and color Tell patient to avoid smokingThe patient was able to decrease the tendency and feeling of vomitingSalbutamol + Ipratropium (Combivent) ineb TID x 3 doses 8am 1pm 6pmCLASSIFICATION: Bronchodilators MOA: Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic receptors on bronchial smooth muscles.IND: Management of reversible bronchospasm associated with obstructive airway disease in patients who requires more than one single bronchodilator C/I: Hypertrophic obstruction , cardiomyopathy or tachyarrhythmias, history of hypersensitivity to soya, lecithin or related lead products AE: Fine tremor of skeletal muscles, headache, palpitations, dizziness, nervousness, dryness of mouth, throat irritation, urinary retention Of one or more inhalation is prescribed, instruct patient to wait at least 2 minutes before repeating Warn patient about risk of paradoxical bronchospasm and to stop drug immediately if it occurWash face mask regularly Auscultate lung sounds before and after nebulization Perform chest physiotherapy after nebulization Monitor fluid intake and outputThe patient was able to breathe normallyCefuroxime (Zinacef) 750mg IVTT q 8 hours 8am 4pm 12amCLASSIFICATIONS: Cephalosporins MOA: Second generation cephalosporins that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidalIND: Serious lower respiratory tract infection, UTI, skin/skin structure infection, bone/joint infection, septicemia, meningitis, gonorrhea C/I: Patients hypersensitive to drug or other cephalosporin, used cautiously in breastfeeding women and in patients with history of colitis or renal insufficiency AE: Phlebitis, thrombophlebitis, diarrhea, nausea, anorexia, vomiting, pain, temperature elevationTest for any allergy to drug Monitor patient for signs of superinfection Advise patient receiving drug IV to report discomfort at IV injection siteInstruct patient to notify prescriber about rash, loose stools or diarrhea or evidence of superinfection Monitor vital signs especially temperatureThe patient manifested timely wound healingLosartan (Anzar) 100mg/tab OD po 8amCLASSIFICATION: Anti-hypertensive Angiotensin II receptor Antagonist MOA: Inhibits vasoconstrictive and aldosterone secreting action of angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells.IND: Hypertension Nephropathy in type 2 DM Reduce risk of stroke in patients with hypertension and left ventricular hypertrophy Patients hypersensitive to drug Breast feeding women Use cautiously in patients with impaired renal/hepatic function CNS dizziness, asthenia, fatigue, headache, insomnia CV edema, chest pain EENT nasal congestion, sinusitis, pharyngitis GI abdominal pain, nausea, diarrhea, dyspepsia MS muscle cramps, myalgia, back or leg pain RESP cough, upper respiratory infection OTHER - angioedemaDrug can be used alone or with other anti hypertensive drugs If anti hypertensive effect is inadequate using once daily doses, a twice daily regimen using the same or increase daily total dose may give more satisfactory response Tell patient to avoid salt substitutes Monitor vital signs, especially blood pressure Assess patients renal functionThe patient has maintained low blood pressure within normal range. 2.3 SOAPIE Charting PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 S O A P I E # 1 sakit man gihapon iglihok day as verbalized by the patient Patient feels pain at the left excised breast, lasting for a few seconds every time, I make sudden movements. Characterized by excruciating pain, aggravated by any sudden movement. Relieved by immobilization and bed rest, and treated with Tramadol and Mefenamic Acid. Has a pain scale rate of 10, facial grimace noted altered comfort: pain related to breast mass excision to verbalize a decrease in pain sensation as evidenced by a decrease in pain scale rate of 10 to 6 and increase in comfort vital signs taken every hour, monitored JP fluid output separately, provided comfort measures such as repositioning, discouraged patient in lifting heavy objects and avoid wearing tight clothes, encouraged verbalization of feelings, encouraged deep breathing exercises, administered analgesics ad anti-inflammatory drugs nakuha kuhaan and sakit gamay kumpara gahapon, as verbalized by the patient PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 S O A P I E # 2 usahay gani day, dili ko ganahan mu tan-aw ani, as whispered by the patient Patient undergone mastectomy, some facial grimace noted, sometimes blank face, patient is on bed, cannot stand up because of pain, tears fell when patient was alone in her bed Altered body image: loss of left breast related to breast cancer to verbalize relief of anxiety and adaptation to actual body image monitored vital signs every hour, monitored JP drains and recorded output separately, encouraged patient to look at or touch the affected body part, provided comfort and emotional support, encouraged verbalization of feelings, administered anxiolytics as prescribed patient touches her breast and verbalizes cge lang day, magpabutang niya ko ug artificial na totoy. 2.4 Health Teaching Plan PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 HEALTH TEACHING PLAN OBJECTIVESCONTENTMETHODOLOGYEVALUATIONGeneral Objective: After 5 days of student nurse patient interaction, the patient and significant others will be able to acquire knowledge, attitude and skills in dealing with breast cancer. Specific Objective: After 8 hours of SN patient interaction, the patient will be able to: identify the risk factors for breast cancer risk factors for breast cancer: age personal history of breast cancer certain breast changes family history overweight/obesity after menopause breast densities drinking alcohol lack of physical activity undergone radiation therapy to the chest informal discussion the patient was able to identify the risk factors for breast cancerenumerate the procedures for the treatment of breast cancer2.procedures for the treatment of breast cancer: 2.1 surgical management 2.1.1 modified radical mastectomy 2.1.2 total mastectomy 2.1.3 breast conservation Treatment 2.1.4 sentinel lymph node biopsy 2.2radiation therapy 2.3systemic treatments 2.3.1 chemotherapy 2.3.2 hormonal therapy 2.3.3 targeted therapyinformal discussionthe patient enumerated the procedures and asked questionsdiscuss ways on how to prevent recurrence of breast cancer3.ways in preventing the recurrence of breast cancer: 3.1get to a healthier regimen 3.2increase activity level 3.3limit or avoid the use of estrogen and progesterone pills for perimenopausal / postmenopausal symptoms 3.4curb alcohol consumption 3.5quit smoking 3.6stick to a low fat diet (<33g of fat per day) 3.7reduce consumption of foods that contain hormones and pesticides 3.8comply with follow-up careinformal discussionthe patient was able to enumerate the ways in preventing the recurrence of breast cancerdemonstrate post operative exercises4.post operative exercises: 4.1 wall hand climbing with elbows slightly bent, place the palms of the hand on the wall at shoulder level. By flexing the fingers, work the hands up the wall until arms are fully extended. 4.2 rope turning tie a light rope to a doorknob. Stand facing the door. Take the free hand or end of the rope in the hand on the side of surgery. Place other hand on hip. With robe-holding arm extended and held away from the body, turn the rope, making as wide swings as possible. 4.3 rod/broomstick lifting grasp a rod with both hands, held about 2 feet apart. Keeping the arms straight, raise the rod over the head. Bend elbows to lower the rod behind the head. 4.4pullet tugging toss a light rope over a shower curtain rod or doorway curtain rod. Stand as nearly under the rope as possible. Grasp an end in each hand. Extend the arms straight and away from the body. Pull the left arm up by tugging down with the right arm, then the right arm up and the left arm down in a sea-sawing motion.informal discussion, demonstration, picturesthe patient was unable to demonstrate due to present condition but acquired positive response about exercise Evaluation and Recommendation Prognosis Breast cancer is more unpredictable than most other cancers because of hormones, dependence, immune response, host resistance, and other variable factors. Generally, the smaller the tumor, the better the prognosis. Carcinoma of the breast is not a pathologic entity that develops over night. It starts with a genetic alteration in a single cell and takes time to divide and double in size. A carcinoma may double in size 30 times to become 1cm or larger, at which point it becomes clinically apparent. Based on the patients assessment, the possibility of acquiring infection is great, increased depression is also anticipated unless treatment/reconstructive treatment is initiated and the possibility of the reoccurrence of the disease. Therefore, prevention of the reoccurrence must be observed by the patient. Recommendation The most important goal for the patient who undergone mastectomy is to achieve full recovery and rule out the possible occurrence of infection. Below are listed recommendations for the patient are as follows: Compliance and maintenance of the medications being prescribed by the physician. Bed rest if the patient feels fatigue and in pain. Nutritious foods are provided for the patient to eat. Promoting good personal hygiene and stressing careful hand washing. Post operative exercises are recommended. Abstain from alcohol after recovery. Environmental sanitation. Deep breathing exercises if pain is felt. Heat and cold application and washing on the affected site. Ambulation is encouraged. Encourage adequate rest. Follow up consultation or check-up at clinics or hospitals. Evaluation and Implication of the Case Study Nursing Practice Studying the case of Mrs. Virginia Peserla, gave the student nurse an opportunity to enhance the students knowledge, attitude and skills in rendering holistic nursing care for patients who have breast cancer and patients who undergone mastectomy. It has furnished current ideas that focus on dedication to study. This case study, though not that perfect can add as reference for the never ending discovery for better interventions of students, professionals and family of the client. Nursing Evaluation This case study has been very much useful in making the students understand the scope of this condition. It facilitated the student nurse to relate theories, discoveries, and other facts written in situations, to actual situations. Through these observations, students have attained new set of concepts which will be of great remedy in caring for patients with the same conditions. Nursing Research This case study can be utilized as reference for imminent research studies. This will also furnish additional knowledge to the students for associating real life situations. Bibliography The World Book Encyclopedia volume13 page 250 Brunner and Suddarths Medical Surgical Nursing 11th Edition, Volume2 Basic Nursing by Potter and Perry 6th Edition Daviss Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing Implications 2nd Edition by Leeuwen et. al. Medical Surgical Nursing Critical Thinking in Client Care 3rd Edition by Priscilla Lemone and Burke Medical Surgical Nursing Pathophysiological Concepts volume 2 2nd Edition by Patrick, Woods, et. al. Brunner and Suddarths Medical Surgical Nursing 6th Edition HYPERLINK "http://www.breastcancer.org"www.breastcancer.org http://en.wikipedia.org/wiki/moralkohlbergs_stages_of _moral_development      PAGE \* MERGEFORMAT 1 Physical Assessment Precipitating Factors: Radiation exposure Fat intake and Obesity Alcohol use Cigarette Smoking Intake of Contraceptive Pills PREDISPOSING FACTORS: Genetics Hormonal factors Age Gender Family history ETIOLOGY: Unknown 2. Actual Patient Care 2.2 Brunswicks Lens Model Patients Name: Mrs. Virginia Peserla Age: 48 y.o. Attending Physician: Dr. Romero Complaints: mass enlargement of breast Sex: female Diagnosis: Invasive Ductal Carcinoma With needle prick pain BRUNSWICKS LENS MODEL Measures to: I. alleviate pain and increase in comfort: 1. provide comfort measures such as repositioning, touch, & quiet and calm activities, 2. clean the incision part regularly and cover with gauze, 3. discourage patient in lifting heavy objects and avoid wearing tight clothes that may rub the incision part, 4. encourage verbalization of feelings about pain, 5. promote passive and then active exercises of the hand, arm, and shoulder on the affected side, 6. administer analgesics and anti-inflammatory drugs, as prescribed by the physician, 7. evaluate patients response to analgesics and anti-inflammatory drugs I. Physiologic Overload - Pain OLDCART: Patient felt an acute, tolerable pain, felt at the left excised breast, lasting for a few seconds every time, I make sudden movements, characterized by excruciating pain, aggravated by any sudden movement, relieved by immobilization and bed rest, and treated with Tramadol 30mg and Mefenamic Acid 500mg Pain Scale: Objective Cues: Patient has a pain scale rate of -patient is restless 10 wherein 1 is the lowest -seen patient resting and 10 as the highest. -BP=100/70 mmHg -excision of left breast -facial grimace Objectives: After 8 hours of SN patient interaction, the patient will be able to: verbalize a decrease in pain sensation as evidenced by a decrease in pain scale rate from 10 6 and increase in comfort, verbalize relief of anxiety and adaptation to actual body image, manifest normal healing process of the incisional part. II. relieve feelings of anxiety: 1. establish therapeutic student nurse-client relationship, conveying attitude and developing a sense of trust, 2. assist in correcting underlying problems, 3. encourage family members to treat client normally and not as invalid, 4. encourage client to look at/touch affected body part, 5. set limits on maladaptive behavior and assist client to identify positive behaviors, 6.administer anxiolytics as prescribed by the physician, 7. reassess patient and encourage verbalization of relief of anxiety III.Risk Problem - Risk for Infection Objective Cues: - incised left breast with dressing - undergone breast mass excision - presence of 2 tubes for drainage of blood (medial and lateral) - has decreased eosinophil level at 5% - decreased blood pressure of 100/70 mmHg II. Psychologic Overload - Altered body image Objective Cues: - undergone mastectomy - some facial grimace, sometimes blank face - patient on bed - cannot stand up because of pain - tears fell when patient was alone on her bed Subjective Cues: - usahay gani day, dili ko ganahan mutan-aw ani, whispered by the patient. ALTERATION IN COMFORT: pain related to breast mass excision ALTERED BODY IMAGE: loss of left breast related to breast cancer RISK FOR INFECTION: surgical incision and JP drains attached related to breast mass excision A case of Mrs. Virginia Peserla, 48 years old female with physiologic and psychologic problem. 100% resolution of physiological and potential health problems. III. achieve timely wound healing: 1. reassess patient for any presence of abscess formation, 2.give post-operative care by changing the dressing of the wound regularly, 3. dispose drainage in a proper disposing area, 4. clean the incised part with water and soap regularly while observing good hygiene, 5. notify prescriber for any changes seen on the site such as redness, pus, swelling, warm to touch, 6. administer cephalosporins, as prescribed by the physician, 7. assess patient for any superinfection, or adverse reaction to the drug DESIRED OUTCOME NURSING INTERVENTIONS DIAGNOSIS CUES ACTUAL STATE OF PATIENTS CONDITION Goal: After 5 days of student nurse patient interaction the patient will be able to display improvement in health condition and manifest absence of any complication. PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 NURSING CARE PLAN this provide non-pharmacological pain management to prevent infection to promote proper healing of wound to assess effectiveness of treatment this will stimulate circulation, promote neurovascular competence and prevent stasis with subsequent stiffening of the shoulder girdle provides relief of discomfort when unrelieved by other measures to assess if the pain relievers worked Source: Nurses Pocket Guide by Doenges, Et.al. Measures to alleviate pain and increase in comfort: 1. provide comfort measures such as repositioning, touch, & quiet and calm activities, 2. clean the incision part regularly and cover with gauze, 3. discourage patient in lifting heavy objects and avoid wearing tight clothes that may rub the incision part, 4. encourage verbalization of feelings about pain, 5. promote passive and then active exercises of the hand, arm, and shoulder on the affected side, 6. administer analgesics and anti-inflammatory drugs, as prescribed by the physician, 7. evaluate patients response to analgesics and anti-inflammatory drugs After 8 hours of student nurse patient interaction, the patient will be able to: verbalize a decrease in pain sensation as evidenced by a decrease in pain scale rate from 10 to 6 and increase in comfort, Many patients tolerate the breast surgery quite well and have minimal pain during post-operative period. This is particularly true of the less invasive procedures. However, all patients must be carefully assessed because individual patient can have varying degrees of pain. Patient who have more invasive procedure such as modified radical mastectomy may have considerably more pain. Modified radical mastectomy is the removal of the entire breast tissue, nipple areola complexion, and a portion of axillary lymph nodes. Because nerves in the skin and axilla are often cut or injured during breast surgery, patient may experience a variety of sensation. Source: Brunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition ALTERATION IN COMFORT: pain related to breast mass excision Physiologic Overload Pain OLDCART: Patient felt an acute, tolerable pain, felt at the left excised breast, lasting for a few seconds every time, I make sudden movements, characterized by excruciating pain, aggravated by any sudden movement, relieved by immobilization and bed rest, and treated with Tramadol 30mg and Mefenamic Acid 500mg Pain Scale: Patient has a pain scale rate of 10 wherein 1 is the lowest and 10 as the highest. Objective Cues: -patient is restless -excision of left breast -seen patient resting -BP=100/70 mmHg -facial grimace RATIONALE NURSING ACTIONS OBJECTIVE OF CARE SCIENTIFIC BASIS / SIGNIFICANCE NURSING DIAGNOSIS NEEDS / PROBLEMS CUES PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 NURSING CARE PLAN 1. to gain trust 2. to promote optimal healing/adaptation 3. to aid patient in recovery and relieve anxiety 4. to begin to incorporate changes into body image 5. to aid in recovery 6. to help in decreasing anxiety 7. to assess if the treatments were effective Source: Nurses Pocket Guide by Doenges, Et.al. Measures to relieve feelings of anxiety: 1. establish therapeutic student nurse-client relationship, conveying attitude and developing a sense of trust, 2. assist in correcting underlying problems, 3. encourage family members to treat client normally and not as invalid, 4. encourage client to look at/touch affected body part, 5. set limits on maladaptive behavior and assist client to identify positive behaviors, 6.administer anxiolytics as prescribed by the physician, 7. reassess patient and encourage verbalization of relief of anxiety 2. verbalize relief of anxiety and adaptation to actual body image, The breast is considered a significant component of feminine beauty. Shapeliness is a quality much desired and is emphasized in a womans choice of clothing. Thus a womans reaction to any actual or suspected disease or injury affecting her breast tends to reflect the prevailing societal view of the female breast. So, patients who have undergone mastectomy often find it very difficult to view the surgical site for the first time. No matter how prepared the patient may think she is, the appearance of an absent breast can be very emotionally distressing. Ideally, the patient sees the incision for the first time when she is with the nurse or another health care provider who is available for support. Source: Brunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition ALTERED BODY IMAGE: loss of left breast related to breast cancer II. Psychologic Overload Altered body image Objective Cues: - undergone mastectomy - some facial grimace, sometimes blank face - patient on bed - cannot stand up because of pain - tears fell when patient was alone on her bed Subjective Cues: - usahay gani day, dili ko ganahan mutan-aw ani, whispered by the patient. RATIONALE NURSING ACTIONS OBJECTIVE OF CARE SCIENTIFIC BASIS / SIGNIFICANCE NURSING DIAGNOSIS NEEDS / PROBLEMS CUES PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 NURSING CARE PLAN 1.to verify for any signs of infection 2. to prevent infection 3. to prevent the spread of microorganisms 4. to prevent the spread of microorganism 5. to provide necessary actions for the changes 6. to prevent infection and bacterial growth 7. to assess the effectiveness of the drug Source: Nurses Pocket Guide by Doenges, Et.al. Measures to achieve timely wound healing: 1. reassess patient for any presence of abscess formation, 2.give post-operative care by changing the dressing of the wound regularly, 3. dispose drainage in a proper disposing area, 4. clean the incised part with water and soap regularly while observing good hygiene, 5. notify prescriber for any changes seen on the site such as redness, pus, swelling, warm to touch, 6. administer cephalosporins, as prescribed by the physician, 7. assess patient for any superinfection, or adverse reaction to the drug 3. manifest normal healing process of the incisional part. After a surgery, hematoma and serous formation is developed. These are the collection of serous fluid and blood inside the cavity, on the breast excision or in the axilla. So, the surgeon, makes an incision for the JP drains to drain the post-operative bloody output. The creation of surgical wound disrupts the integrity of the skin and its protective function. Exposure to deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, a potentially life-threatening complication. Source: Brunner and Suddarths Textbook of Medical Surgical Nursing 11th Edition RISK FOR INFECTION: surgical incision and JP drains attached related to breast mass excision III.Risk Problem Risk for Infection Objective Cues: - incised left breast with dressing - undergone breast mass excision - presence of 2 tubes for drainage of blood (medial and lateral) - has decreased eosinophil level at 5% - decreased blood pressure of 100/70 mmHg RATIONALE NURSING ACTIONS OBJECTIVE OF CARE SCIENTIFIC BASIS / SIGNIFICANCE NURSING DIAGNOSIS NEEDS / PROBLEMS CUES PATIENTS NAME: Mrs. Virginia Peserla SEX: Female AGE: 48 years old ROOM #: FS 7 DRUG THERAPEUTIC RECORD S O A P I E S O A P I E   [ \ g h ; < w y 3 4 s t - . 0 Ƶըo h 4Qh PCJOJQJ^JaJh Ph 4QCJOJQJh 4Qh 4QCJOJQJaJhrPCJOJQJaJhrPhrPCJOJQJ hrPhrPCJOJQJ^JaJhrPh 4QCJOJQJaJhrPCJOJQJh 4QCJOJQJh Ph PCJOJQJhPCJOJQJ(U ] = z 5 u / u d`gd P$ pda$gd 4QdgdrP d`gdrP hd^hgd Pdgd P $da$gdrP0 i m n 6 7 q s 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