Cva Case Study

Manuel S.
Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
COLLEGE OF NURSING ALLIED HEALTH SCIENCES
In partial fulfillment of the requirements for

Related Learning Experience at
NCM 104A Medicine Ward
NURSING CASE STUDY
Diagnosis: Cerebrovascular Accident
Submitted by:
Balino, Iris Joy F.

Cabriga, Lady Diane M
Submitted to:
Esteve Adrian Z. Esiva PhD, RN
Clinical Instructor
Date Submitted:
12/02/2019
Cerebrovascular Accident
Manuel S. Enverga University Foundation
Lucena City
GENERAL OBJECTIVES
The purpose of this study is to enhance and gain knowledge, to develop communication
and nursing skills, to provide privacy and maintain confidentiality of the patient and to apply the
right attitudes of the student nurses in rendering and giving care to the patient with
cerebrovascular accident.
SPECIFIC OBJECTIVES
 Understand condition of cerebrovascular accident and associate it with the patient

through the introduction of the case.
 To illustrate the Anatomy and Physiology of the affected organ or the part of the body.
 To discuss the pathophysiology of the disease.
 To be clinically aware of the clinical manifestation and its complication.
 To develop an effective skill on how to plan and manage proper care in patient with,
cerebrovascular accident.
 To formulate a drug study with regards to the patient’s condition.
 To correlate the laboratory result to its normal value.
 To provide the client nursing care plan and discharge plan to assure client’s total wellness
during his hospitalization up to the time of his hospital discharge.
 To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.
I. INTRODUCTION
a. Background
Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-detector CT

(MDCT); there's no need for an additional neck MDCT angiography examination according to a
recent study conducted by researchers at the University of Maryland Medical Center and R. Adams
Cowley Shock Trauma Center, both in Baltimore, MD. The study showed that whole body MDCT
is just as accurate as neck MDCTA. Blunt cerebrovascular injuries are uncommon but potentially
devastating injuries that can lead to stroke and death. These include dissections, pseudoaneurysms,
and arteriovenous fistulae.
For the study, the researchers identified 108 blunt trauma patients that were examined with
either whole-body MDCT or neck MDCTA followed by angiography over a 23-month period.
From this group, 77 whole body MDCT and 48 neck MDCTA examinations were compared with
the results that were pulled from the reports of correlative angiography.
i. Incidence, race, gender, age, ration and proportion

According to the study, angiography confirmed blunt cerebrovascular injuries in 83 patients with
25 of those showing injury to more than one of the four major arteries (carotid or vertebral). In the
neck, where injuries were most common, each technique showed low sensitivity for blunt carotid
(69% for whole-body MDCT and 64% for MDCTA) and blunt vertebral artery injuries (74% for
whole-body MDCT and 68% for MDCTA), but specificities were high for both carotid (82% for
whole-body MDCT and 94% for MDCTA) and vertebral artery injuries (91% for whole-body
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MDCT and 100% for MDCTA). The two techniques diagnosed blunt cerebrovascular injuries with
statistically comparable accuracy. Routine use of whole-body MDCT would facilitate diagnosis
and treatment of asymptomatic blunt cerebrovascular injuries in patients without typical risk
factors for injuries. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-
wbm032808.php)
ii. Rationale for choosing the case

The group decided to choose the case of cerebrovascular accidents because it was one of the
causes of death in the Philippines. The group also consider the relative of the patient because
they are cooperative and gives accurate information to be used in correlating the actual case to
the case of the patient.
iii. Significance of the study

The significance of this study is to enhance/gain knowledge, to develop skills and apply the
right attitudes of the student nurses in rendering and giving care to the patient with
cerebrovascular accident its importance and implication. This study will serve as guidelines in
assessing and providing proper nursing care to patient with the same problem or disease.
iv. Scope of limitation of study

The study would only focus on cerebrovascular accident which is indicative to the client’s
health condition and its underlying nursing care relevant for the client within the two- week duty
at Peter Paul Medical Center at Candelaria, Quezon.
v. Conceptual Theoretical Theory
vi. Related Literature

II. CLINICAL SUMMARY
a. General Data Profile

NAME: Spongebob
ADDRESS: Candelaria, Quezon
BIRTHDAY: February 09, 1946
BIRTHPLACE: Sariaya, Quezon
SPOUSE NAME: Hello Kitty
NATIONALITY: Filipino
RELIGION: Roman Catholic
OCCUPATIONS: Jeepney Driver
DATE OF ADMISSION: September 03,2019 (6:15 AM)
ADMITTING DIAGNOSIS: Cerebrovascular accident
ADMITTING PHYSICIAN: Dr. Joel P. Janolino
Lucena City
b. Chief Complaint
Patient has chief complaints of left sided body weakness, conscious, alert, (+) facial
asymmetry, normal rate and regular rhythm, clear breath sounds, normoactive bowel
sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16
c. Nursing theory
1. History of Present Illness

As narrated by Tinky winky at the PPMC hospital 2-3 days prior to Spongebob’s
admission he is already complaining of headache, and they regarded it as the usual
headache associated with high blood pressure. They have just managed it with her
medicines for hypertension. The symptoms persisted for another day and managed it the
same way.
September 01, 2019 1:30 am, Spongebob woke them up with complains of numbness
on her body and blurry vision, he doesn’t want anybody to touch his as he can feel that
his conditions aggravates every time someone will touch his. According also to Tinky
winky upon seeing his father, she have noticed that there is an obvious asymmetry on his
father’s face and slurring of speech, she then had an idea that it may be a stroke.
They planned to bring Spongebob to a private hospital. Upon consult, he was advised
to stay at the hospital on September 03, 2019 with admitting diagnosis of CVA with
accompanying illnesses hypertension and diabetes mellitus.
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d. Family History {genogram}
e. Social History – Include theories of grown and development
f. Environment/Living Condition
g. Physical Assessment
PHYSICAL NORMAL ACTUAL INTERPRETATION

ASSESMENT FINDINGS FINDINGS
GENERAL -clear in appearance -clear in appearance
APPEARANCE and well groomed and well groomed
-cooperative - conscious and
coherent
- cooperative at times
-weakness appearance
SKIN -with good skin turgor - good and slightly Due to old age skin
dry skin. elasticity is
diminishing
HAIR -evenly distributed -symmetrical skull
hair -no presence of
-thick hair nodules and lesions
-with hair properly
distributed
NAILS -with good capillary - Capillary refill 3 - Risk for fluid and
refill of 1-2 seconds seconds electrolyte imbalance
-with pinkish nail - With pallor nail
beds beds
-with clean and short
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nails - With slightly dirty
and short nails at
normal angle
curvature
- Surrounding tissue
were intact and no
lesions noted
SKULL AND FACE -mouth uniform -mouth uniform
consistency absence consistency absence
of nodules and masses of nodules and masses
-rounded and smooth -rounded and smooth
skull contour skull contour
-symmetrical facial
movement
EYES -no eye discharges -no eye discharges
-with anicteric sclera -with anicteric sclera
-eyebrows hair evenly -eyebrows hair evenly
distributed/skin intact distributed/skin intact
-symmetrical facial -asymmetrical facial -lower facial muscles
movement movement are affected than the
upper; signifies stroke
EARS -Auricle color same -Auricle color same
as facial skin as facial skin
-Auricle are mobile -Auricle are mobile
firm and not tender firm and not tender
-Able to hear both -Able to hear both
ears ears
-no edema and -no edema and
discharges discharges
MOUTH -pinkish lips -pale lips
-without missing teeth -no teeth upper and
-with pink gums lower
-no foul odor -with pink gums
-with symmetrical -with slightly foul
contour odor
-with symmetrical
contour
MUSCULOSKETAL -symmetrical -symmetrical
(UPPER AND -no athrophy - with dystrophy
LOWER -with full range of -limited range of -relatively weak
EXTREMETIES) motion motion o left upper unable to perform
and lower extremities ADL
- Symmetrical - With rales and - With excessive
- With normal crackles upon respiratory fluids
sound auscultation - With DOB
CHEST - Normal chest - Abnormal chest
expansion expansion
- Use intercostal
muscles during
breathing
- Left Mastectomy
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-No abdominal - With soft and non
distension tender abdomen
-Flat rounded - with surgical scar on
ABDOMEN abdomen the abdomen above
-Symmetrical contour umbilicus.
-No surgical incision
h. Patterns of functioning
FUNCTIONAL HEALTH BEFORE DURING INTERPRETATION
PATTERN HOSPITALIZATION HOSPITALIZATION
Health management pattern  Third time hospital  3rd time hospital
admission. admission
 Self-medication
Nutritional / Metabolic
 Number of meals  3x a day  3x a day The patient was
per day placed to sitting
 Appetite  Poor appetite  Poor appetite upright position to
avoid
 Glass of water per aspiration.
day  3x a day
 7x a day
 Height and weight  Approximately  Approximately

65kgs and 5’2 ft 65kgs and 5’2 ft
Elimination
 Frequency of  5 x a day  With foley catheter Due to decreased
urination connected to urine intake, output also
 Amount of urine  1200 per day bag decreased.
per day  800ml /day
 Frequency of bowel  Every other day  Every other day
movement
Activity and exercise  Walking  Walking , The patient gets easily
 Easily fatigue ambulatory fatigue before and
 Exercise  Walking / cleaning  Easily fatigue during confinement.
 Fatigability the house  None
 Activities of Daily
Living
Cognitive/ Perceptual  Oriented to time  Oriented  The patient is

 Orientation place and person oriented and
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 Responsiveness Responds  Responds responds
appropriately to appropriately appropriately.
verbal and physical
stimuli
Roles/ Relationship  A good mother
 Kind
 As a mother  Caring
 Became aloof to  Due to her
 As a grandmother his daughter and sickness the
 Kind to her grand children patient became
grandchildren aloof maybe
because of the
financial burden
she have caused.
Values/Beliefs  Patient believes in  Same as before  Patient is

god and always religious and
pray. worships
god.
Self Perception / Self  Have a high self  Have a high self  Patient still
Concept worth / worth / importance has high self
importance worth in
spite of his
incident he
still think
that life is
important
that should
be lived
purposely.
Coping / stress  She seek for some  Patient is always  He has good
advice to her talking to her coping
family and friends family to lessen techniques.
the stress
III. CLINICAL DISCUSSION OF THE DISEASE

a. Anatomy and Physiology
b. Pathophysiology
i. Book Based
ii. Client Based
c. Drug Study
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IV. NURSING PROCESS
a. Long Term Objective
b. Prioritized List Nursing Problem
c. Nursing Care Plan
d. Discharge Plan (METHOD)
General Objective:
The purpose of this study is to enhance and gain knowledge, to develop communication
and nursing skills, to provide privacy and maintain confidentiality of the patient and to apply the
right attitudes of the student nurses in rendering and giving care to the patient with Breast
Cancer, Pneumonia its importance and implication.
Specific Objectives:
 Understand condition of Breast Cancer, Pneumonia and associate it with the patient
 To illustrate the Anatomy and Physiology of the affected organ or the part of the body.
 To discuss the pathophysiology of the disease.
 To be clinically aware of the clinical manifestation and its complication.
 To develop an effective skill on how to plan and manage proper care in patient with,
Breast Cancer, Pneumonia.
 To formulate a drug study with regards to the patient’s condition.
 To correlate the laboratory result to its normal value.
 To provide the client nursing care plan and discharge plan to assure client’s total wellness
during his hospitalization up to the time of his hospital discharge.
 To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.
I. INTRODUCTION
A. Background of the study
a. Incidence, rate, gender, age, ratio and proportion
Breast cancer remains the most common and leading cause of death among women in the
Philippines, accounting for nearby 27.7 percent of deaths in 2014 alone. That same year, more
than 18,000 women were also diagnosed with breast cancer.
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According to the Philippine Council for Health Research and Development, one out of 13
Filipino women is expected to develop breast cancer in her lifetime.
“The greatest risk of getting breast cancer is simply by being a female,” said Dr. Maria
Luisa Abesamis Tiambeng, consultant for medical oncology at Cardinal Santos Medical Center.
While pneumonia remains in the list of the leading causes of morbidity and mortality in
the Philippines. It ranked third among the causes of morbidity and fourth among the causes of
death in 2000. There was an increase in the morbidity trend for pneumonia from 1990 to 1996.
This may be due to improved case finding and reporting with the intensification of the program
to control acute respiratory infections during this period. The morbidity trend decreased slightly
from 1997 to 2000 but the number of cases remained high at 829 cases per 100,000 population in
2000. On the other hand, there is a decreasing trend of mortality from pneumonia in the general
population from 1990 to 2000 despite the high number of cases per year. The mortality rate from
pneumonia decreased from 64.7 deaths per 100,000 population in 1990 to 42.7 deaths per
100,000 in 2000 (PHS). This reflects improvement in the diagnosis and treatment of cases.
Pneumonia risk has been found to be higher in patients undergoing breast cancer
treatment. There has been a consensus among the medical community that pneumonia in cancer
patients was a result of a weakened immune system and exposure to multiresistant bacteria – also
known as superbacteria – causing the lung infection. Cancer patients, in particular, are at a higher
risk of contracting pneumonia as they frequently visit hospitals.
When breast cancer has reached stage four – metastatic cancer – it has spread to different
organs. Removing the cancer in this case is often difficult if not impossible. Developing
pneumonia in stage 4 breast cancer can be highly problematic.Stage 4 breast cancer patients are
at a higher risk for pneumonia due to surgeries they may have to undergo to remove the cancer.
Not only do these surgeries put extra stress on an already fragile body, but as a result, the
patients are exposed to other bacteria that can lead to pneumonia. Radiation therapy, too, can
increase the risk of pneumonia, as it further weakens the immune system, making it difficult to
fight off any infections. Treatment for pneumonia is stage 4 breast cancer includes antibiotics,
antiviral medications, cough medications, and over-the-counter medications to relieve pain and
discomfort.
b. Rationale for choosing the case

The group decided to choose the case of Pneumonia, Breast Cancer because it was one of
the causes of death in the Philippines. The group also consider the relative of the patient because
they are cooperative and gives accurate information to be used in correlating the actual case to
the case of the patient.
Significance of the studies

The significance of this study is to enhance/gain knowledge, to develop skills and apply
the right attitudes of the student nurses in rendering and giving care to the patient with Breast
Cancer, Pneumonia its importance and implication. This study will serve as guidelines in
assessing and providing proper nursing care to patient with the same problem or disease.
These are other significance of the study that would support the above statement:
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1. Understand condition of Breast Cancer, Pneumonia and associate it with the patient
2. To know the Nursing history: the Personal data, Health history and Physical
assessment of the patient.
3. Illustrate the anatomy and physiology and pathophysiology of the affected organ or
part of the body.
4. Discuss and determine manifestation and complications.
5. Develop of an effective skill on how to manage a proper care in patient with Breast
Cancer, Pneumonia.
6. Formulate a drug study with regards to the patient’s condition.
7. Correlate the lab result to its normal value.
8. To provide the client nursing care plan and Discharge plan to assure for client’s total
wellness during his hospitalization up to the time of his hospital discharge
d. Scope of limitation of the study

The study would only focus on Breast Cancer, Pneumonia which is indicative to the
client’s health condition and its underlying nursing care relevant for the client within the two-
week duty at Quezon Memorial Center Lucena, City.
THEORETICAL FRAMEWORKS
Self-Care Deficit Nursing Theory of Dorothea Orem

Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three
interrelated theories: (1) the theory of Self-Care, (2) the theory of Self-Care Deficit, and (3) the
theory of Nursing System.
Theory of Self-Care
Self-care is the performance or practice of activities that individuals initiate and perform
on their own behalf to maintain life, health, and well-being.
Self-care agency is a human ability which is “the ability for engaging in self-care.”
Therapeutic self-care demand “totality of self-care actions to be performed for some

duration in order to meet self-care requisites by using various methods and related sets of
operations and actions.”
Three Categories of Self-Care Requisites

Universal self-care requisites- are associated with life processes, maintenance of the
integrity of human structure and functioning, and with general being.
Developmental self-care requisites- are associated with the developmental processes;

derived from a condition or associated with an event (e.g. adjusting to a new job).
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Health Deviation self-care requisites- Required in conditions of illness, injury, or
disease; includes seeking medical assistance, learning to live with effects of condition, etc.
Theory of Self-Care Deficit

Self-care deficit is the basic element of Orem’s general theory of nursing because it
delineates when nursing is needed. Nursing is required when adults are incapable of or limited in
their ability to provide continuous effective self-care.
Five methods of helping

1. Acting for or doing for another
2. Guiding and directing
3. Providing physical or psychological support
4. Providing and maintaining an environment that supports personal
development
5. Teaching
Theory of Nursing System

1. Wholly Compensatory Nursing System
2. Partly Compensatory Nursing System
3. Supportive-Educative System
The wholly compensatory nursing system is selected when the patient cannot or should
not perform any self-care actions. The partly compensatory nursing system is selected when the
patient can perform some, but not all, self-care actions. The supportive-educative nursing system
is selected when the patient can and should perform all self-care actions.
Lucena City
Since the diagnosis of our patient is Breast Cancer, Pneumonia we relate Orem’s theory
because, the internal and external surroundings or conditioning factors that affect the middle
adults which is the people in the physical environment such as families, friends and significant
others to prevent them in aggravating the disease.
As a nurse our goal is to give comfort, care and maintain optimal health that can aid the client in
their fast recovery.
f. Related literature of the study

PNEUMONIA
Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs
may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills,
and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause
pneumonia.
Pneumonia can range in seriousness from mild to life-threatening. It is most serious for
infants and young children, people older than age 65, and people with health problems or
weakened immune systems.
Symptoms
The signs and symptoms of pneumonia vary from mild to severe, depending on factors
such as the type of germ causing the infection, and your age and overall health. Mild signs and
symptoms often are similar to those of a cold or flu, but they last longer.
Signs and symptoms of pneumonia may include:

 Chest pain when you breathe or cough
 Confusion or changes in mental awareness (in adults age 65 and older)
 Cough, which may produce phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults older than age 65 and people with
weak immune systems)
 Nausea, vomiting or diarrhea
 Shortness of breath
Treatment
Lucena City
Treatment for pneumonia involves curing the infection and preventing complications.
People who have community-acquired pneumonia usually can be treated at home with
medication. Although most symptoms ease in few days or weeks, the feeding of tiredness can
persist for a month or more.
Specific treatments depend on the type and severity of your pneumonia, your age and
your overall health. The options include:
 Antibiotics - these medicines are used to treat bacterial pneumonia. It may take time to
identify the type to identify the type of bacteria causing your pneumonia and to choose
the best antibiotic to treat it. If your symptoms don’t improve, your doctor may
recommend a different antibiotic.
 Cough medicine - this medicine may used to calm your cough so that you can rest.
Because coughing helps loosen and move fluid from your lungs, it’s a good idea not to
eliminate your cough completely. In addition, you should know that very few studies
have looked at whether over the counter cough medicines lessen coughing caused by
pneumonia. If you want to try a cough suppressant, use the lowest dose that helps you
rest.
 Fever reducers/pain relievers - you may take these as needed for fever and discomfort.
Diagnosis
 Blood test - are used to confirm an infection and to try to identify the type of organism
causing the infection. However, precise identification isn’t always possible.
 Chest x-ray - this help to diagnose pneumonia and determine the extent and location of
the infection.
 Pulse oximetry - his measures the oxygen level in your blood. Pneumonia can prevent
your lungs from moving enough oxygen into your bloodstream.
 Sputum test - a sample of fluid from your lungs (sputum) is taken after a deep cough
and analyzed to help pinpoint the cause of the infection
METASTATIC BREAST CANCER
Metastatic breast cancer is also classified as stage 4 breast cancer. The cancer has spread
to other parts of the body. This usually includes the lungs, liver bones or brain.
The spread of cancer usually happens through one or more of the following steps:
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 Cancer cells invade nearby healthy cells

- when the healthy cell is taken over, it too can replicate more abnormal cells.
 Cancer cells penetrate into the circulatory or lymph system

- cancer cells travel through the walls of nearby lymph vessels or blood vessels.
 Migration through circulation

- cancer cells are carried by the lymph system and the bloodstream to other parts of the
body
 Cancer cells lodge in capillaries

- cancer cells stop moving as they lodged in capillaries at a distant location and divide
and migrate into surrounding tissue
 New small tumors grow

- cancer cells form small tumors at the new location (called micromatastases)
Symptoms
The symptoms may vary, depending on how far your breast cancer has spread and what
type of tissue the new cancer growth has invaded.
Metastasis to the lungs may cause:

 Chronic cough or inability to get a full breath
 Abnormal chest x-ray
 Other nonspecific systemic symptoms of metastatic breast cancer can include fatigue,
weight loss, and poor appetite, but it’s important to remember these can also be caused
by medication or depression.
Treatment
Breast cancer surgery

Operations used to treat breast cancer include:
 Removing the breast cancer (lumpectomy)

During a lumpectomy, which may be referred to as breast-conserving surgery or wide
local excision , the surgeon removes the tumor and a small margin of surrounding healthy tissue.
A lumpectomy may be recommended for removing smaller tumors. Some people with
larger tumors may undergo chemotherapy before surgery to shrink a tumor and make it possible
to remove completely with a lumpectomy procedure.
 Removing the entire breast (mastectomy)

A mastectomy is an operation to remove all of your breast tissue. Most mastectomy
procedures remove all of the breast tissue the lobules, ducts, fatty tissue and some skin, including
the nipple and areola (total or simple mastectomy)
Newer surgical techniques may be an option in selected cases in order to improve the
appearance of the breast. Skin-sparing mastectomy and nipple-sparing mastectomy are
increasingly common operations for breast cancer
Lucena City
 Removing a limited number of lymph nodes (sentinel node biopsy)

To determine whether cancer has spread to your lymph nodes, your surgeon will discuss
with you the role of removing the lymph nodes that are first to receive the lymph drainage from
your tumor
If no cancer is found in those lymph nodes, the changes of finding cancer in any of the
remaining lymph nodes is small and no other nodes need to be removed.
 Removing several lymph nodes (axillary lymph node dissection)

If cancer is found in the sentinel lymph nodes, your surgeon will discuss with you the
role of removing additional lymph nodes in your armpit
 Removing both breasts

Some when with cancer in one breast may choose to have their other (healthy) breast
removed (contralateral prophylactic mastectomy) if they have a very increased risk of cancer in
the other breast because of a genetic predisposition or strong family history
Diagnosis
Tests and procedures used to diagnose breast cancer include:
 Breast exam
Your doctor will check both of your breast and lymph nodes in your armpit, feeling for
any lumps or other abnormalities.
 Mammogram
A mammograms are commonly used to screen for breast cancer. If no abnormality is
detected on a screening mammogram, your doctor may recommended a diagnostic mammogram
to further evaluate the abnormality
 Breast ultrasound
Ultrasound uses sound waves to produce images of structures deep within the body.
Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled
cyst.
 Removing a sample of breast cells for testing (biopsy)

A biopsy is the only definitive way to make a diagnosis of breast cancer. During a biopsy,
your doctor uses a specialized needle device guided by X-ray or another imaging test to extract a
core of tissue from the suspicious area. Often, a small metal marker is left at the site within your
breast so the area can be easily identified on future imaging tests.
Biopsy samples are sent to a laboratory for analysis where experts determine whether the
cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved in
the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have
hormone receptors or other receptors that may influence your treatment options.
 Breast magnetic resonance imaging (MRI)

An MRI machine uses a magnet and radio waves to create pictures of the interior of your
breast. Before a breast MRI, you receive an injection of dye. Unlike other types of imaging tests,
an MRI doesn’t use radiation to create the images.
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 Positron emission tomography (PET) scan
Not all women will need all of these tests and procedures. Your doctor selects the appropriate
tests based on you specific circumstances and taking into account new symptoms you may be
experiencing.
Breast cancer stages range from 0 to IV with 0 indicating cancer that is noninvasive or contained
within the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates
cancer that has spread to other areas of the body.
Breast cancer staging also takes into account your cancer’s grade; the presence of tumor markers,
such as receptors for estrogen, progesterone and HER2; and proliferation factors.
II. CLINICAL SUMMARY

A. GENERAL DATA PROFILE
NAME: PATIENT MC
ADDRESS: GUMACA,QUEZON
BIRTHDAY: APRIL 29, 1970
BIRTH PLACE: MANILA CITY
SPOUSE NAME: JUDITO CRUEL
NATIONALITY: FILIPINO
RELIGION: ROMAN CATHOLIC
OCCUPATIONS: HOUSE WIFE
DATE OF ADMISSION: MARCH 9,2019
ADMITTING DIAGNOSIS: BREAST MASS LEFT
ADMITTING PHYSICIAN: DR. KRYS MERCADO TOLEDO
B. CHIEF COMPLAINT:
CHIEF COMPLAINT:
Six months prior to admission the patient notice 2cm mass on her left breast, painful,
hard
NURSING HISTORY:
HISTORY OF PRESENT ILLNESS:
Prior to admission the patient experienced productive cough for about one month and
experienced difficulty of breathing on her home at Sta. Catalina Sur Candelaria Quezon . semi
consciously she brought to Peter Paul Medical Center accompanied by her relatives. The doctor
in charge ordered to have an Chest X-ray and other laboratory test to find the possible cause of
her present illness.
Physical assessment, chest x-ray and other laboratory test was done. She was diagnosed
to have a Pneumonia, high risk in immunocompromised host, Breast Cancer Stage 4
a. Childhood Illness:
Fever, cough and common colds
b. Immunizations:
-
c. Allergies:
No known allergies to food and drugs
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d. Incidents:
She experienced mastitis 1 year ago
e. Hospitalizations:
Quezon Medical Center at Lucena City. Due to Mastectomy 1 year ago
f. Medications used or currently taking:
Tamoxifen, Vit. B+,Fluimucil, vegocid
g. Domestic travel:
The usual route of travel is within Candelaria Quezon and Lucena City.
D. FAMILY HISTORY:
(Refer to the Genogram)
E. SOCIAL HISTORY
ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL INDICATORS INDICATORS
TASK OF NEGATIVE
POSITIVE OF
RESOLUTION RESOLUTION
MIDDLE 40-65 YEARS GENERATIVITY To have and An individual must
ADULTHOOD OLD VS nurture children deal with issues
STAGNATION and/or become they are concerned
involved with with or it can lead
future to stagnation in
generations later life.
According to this theory, the middle adulthood stage correlates to the patient’s age
because the patient established good relationship to her family and she developed a sense of
being a part of the bigger picture for her children futures.
Middle adulthood is the longest period of a human's life. It is the stage in which people
are usually working and contributing to society in some way and perhaps raising their children. If
a person does not find proper ways to be productive during this period, they will probably
develop feelings of stagnation.
F. ENVIRONMENT/ LIVING CONDITION
Patient CPA is currently living in Sta. Catlina Sur Candelaria Quezon, together with her
family they are living in small house and lot near in the main road which is made out of light
materials. The patient claimed that there is no difficulty in seeking healthcare. Patient CPA no
problems with going to church and to the market which is near to their house. Patient CPA is
inactive due low immunity to sickness before her hospitalization.
G. PHYSICAL ASSESMENT
PHYSICAL NORMAL ACTUAL INTERPRETATION

ASSESMENT FINDINGS FINDINGS
Lucena City
GENERAL -clear in appearance -clear in appearance - Patient loss weight
APPEARANCE and well groomed and well groomed due to decrease
-cooperative - uncooperative appetite
- irritable - Approximately 47
- in distressed kg
- with DOB
- Weak in appearance
SKIN -with good skin turgor - Old age Due to old age skin
elasticity is
diminishing
HAIR -evenly distributed
-evenly distributed
hair hair
-thick hair -thick hair
NAILS -with good capillary
- Capillary refill 3 - Risk for fluid and
refill of 1-2 seconds
seconds electrolyte imbalance
-with pinkish nail- With pallor nail
beds beds
-with clean and short
- With clean and
nails short nails at normal
angle curvature
- Surrounding tissue
were intact and no
lesions noted
SKULL AND FACE -mouth uniform -mouth uniform
consistency absence consistency absence
of nodules and masses of nodules and masses
-rounded and smooth -rounded and smooth
skull contour skull contour
-symmetrical facial
movement
EYES -no eye discharges -no eye discharges
-with anicteric sclera -with anicteric sclera
-eyebrows hair evenly -eyebrows hair evenly
distributed/skin intact distributed/skin intact
-symmetrical facial -asymmetrical facial -lower facial muscles
movement movement are affected than the
upper; signifies stroke
EARS -Auricle color same -Auricle color same
as facial skin as facial skin
-Auricle are mobile -Auricle are mobile
firm and not tender firm and not tender
-Able to hear both -Able to hear both
ears ears
-no edema and -no edema and
discharges discharges
MOUTH -pinkish lips -pinkish lips
-without missing teeth -with false teeth -risk for aspiration
-with pink gums (upper and lower) - sign of respiratory
-no foul odor -with pink gums infection
-with symmetrical -with slightly foul
contour odor
-with symmetrical
contour
MUSCULOSKETAL -symmetrical -symmetrical
-no athrophy - with dystrophy
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(UPPER AND -with full range of -limited range of -relatively weak
LOWER motion motion o upper and unable to perform
EXTREMETIES) lower extremities ADL
- Symmetrical - With rales and - With excessive
- With normal crackles upon respiratory fluids
sound auscultation - With DOB
CHEST - Normal chest - Abnormal chest
expansion expansion
- Use intercostal
muscles during
breathing
- Left Mastectomy
-No abdominal - With soft and non
distension tender abdomen
-Flat rounded
ABDOMEN abdomen
-Symmetrical contour
-No surgical incision
H. PATTERNS OF FUNCTIONING
FUNCTIONAL HEALTH BEFORE DURING INTERPRETATION

PATTERN HOSPITALIZATION HOSPITALIZATION
Health management pattern  Second time hospital  2nd time The patient and the
admission. hospital family was aware about
 Self medication admission the condition of the
 Has patient due to the first
maintenance time admission because
of mastectomy. (1 yr
ago)
Nutritional / Metabolic
 Number of meals  3x a day  3x a day The patient was placed
per day  Poor appetite  No appetite to sitting upright
 Appetite  7x a day  3x a day position to avoid
 Glass of water per aspiration.
day
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 Height and weight
Elimination
 Frequency of  5 x a day  3x a day Due to decreased intake,
urination  1200 per day  800ml /day output also decreased.
 Amount of urine  Every other day  Every other day
per day
 Frequency of
bowel movement
Activity and exercise Walking  Walking , The patient gets easily
 Easily fatigue ambulatory fatigue before and
 Exercise  Walking /  Easily fatigue during confinement.
 Fatigability cleaning the  None
 Activities of Daily house
Living
Cognitive/ Perceptual  Oriented to time  Oriented  The patient is

 Orientation place and person  Responds oriented and
 Responsiveness  Responds appropriately responds
appropriately to appropriately.
verbal and
physical stimuli
Roles/ Relationship  A good mother
 Kind
 As a mother  Caring
 Became aloof to  Due to her sickness
 As a grandmother his daughter and the patient became
 Kind to her grand children aloof maybe because
grandchildren of the financial
burden she have
caused.
Values/Beliefs  Patient believes  Same as before  Patient is

in god and religious and
always pray. worships god.
Self Perception / Self  Have a high  Have a high self  Patient still has
Concept self worth / worth / high self worth
importance importance in spite of his
incident he still
think that life is
important that
should be lived
purposely.
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Coping / stress  She seek for  Patient is always  He has good
some advice to talking to her coping
her family and family to lessen techniques.
friends the stress
I. LABORATORY DIAGNOSTIC EXAM

Clinical Chemistry
Component Result Normal Range Interpretation Implication Nursing Responsibilities

RBS 84 mg/DL 80-120 mg/dl Normal Results
Uric Acid 10.5 MG/DL 3.4-7.0 mg/dl High Uric Acid Hyperuricemia  Promote measures to
Level prevent exacerbations
 Urge the client to
drink 2 to 3 L of fluid
daily and to report
any decrease in urine
output.
 Teach the client
about dietary
modifications to limit
foods high in purine
(e.g. organ meats,
anchovies, sardines,
shellfish, chocolate,
meat extracts).
 Provide measure to
promote comfort and
reduce pain.
 Maintain strict bed
rest for 24 hours after
an attack.
 Provide a bed cradle
to keep bed linen off
affected joints to help
reduce pain.
 Administer
prescribed
medications, which
may include
nonsteroidal anti-
inflammatory drugs,
uric acid synthesis
inhibitors, and
uricosuric agents.
 Colchicine may be
prescribed for acute
attack and used in
small doses for
prevention.
 Nausea, vomiting,
and diarrhea are toxic
effects of colchicines
and should be
reported to the health
care provider.
Creatinine 0.4 MG/DL 0.6-1.3 Low Creatinine Muscular  The patient was
Level Dystrophy instructed in
muscular dystrophy
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in locating correct
devices like aids for
ambulation and self
care activities.
 The patient was
advised to recognize
variations in the
home location like
bed trapezes,
handrails, railed toilet
seats, and ramps for
wheelchairs.
 The patient was
taught in the good
skin care and placing
using a bed or a
wheelchair.
 The patient was
reviewed in pain
controlling methods
to deal with chronic
pain.
SGPT 9.9 U/L 0-31 U/L (F) Normal Results
Potassium 4.1 3.6-5.5 MMOL/L Normal Results
MMOL/L
Sodium 136 135-155 MMOL/L Normal Results .
MMOL/L
FBS 93 mg/DL 75-115 mg/dl Normal Results
Total 148 Up to 200 mgs/dl Normal Results
Cholesterol MGS/DL
Triglycerides 170 Up to 150 mgs/dl Elevated Hypertension  Assess and monitor
MGS/DL Triglycerides BP
level  Fluid restriction (if
clinically
appropriate)
 Perform a
comprehensive
cardiac assessment:
auscultate lung
sounds, note edema
 Administer BP
lowering agents at
appropriate time
 Assess BP and HR
before and after BP
lowering meds are
administered.
HDL 34 MGS/DL Up to 55 mgs/dl Normal Results

LDL 80 MGS/DL Up to 150 mgs/dl Normal Results
VLDL 34 MGS/DL
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Hematology

Hemoglobin 12.7 12.5 gms/dl Normal Results 
GMS/DL
Hematocrit 38% 37.0-58.0 (F) Normal Results
WBC 20.10 X 4.15- 10.0 X 109/L Increased Level Can be sign  Provide positive
109/L of infection reinforcement
or stress when the client
seeks out others.
 Assess physical
and mental status
 Provide safe and
conducive
environment
Segmenters 89% 60-70% High Segmenters With  Monitor VS every 2
level Respiratory hrs.
Tract  Encourage patient to
Infection position in high-
Fowler’s or semi-
Fowler’s position.
 Turn patient every 2
hrs. and prn.
 Teach client to
maintain adequate
hydration by drinking
at least 8-10 glasses
of fluid/day ( if not
contraindicated).
 Teach and supervise
effective coughing
techniques.
 Perform Chest
Physical therapy.
Lymphocytes 11% 25-30% Decreased level Can be sign  Provide positive
of infection reinforcement when
the client seeks out
others.
 Assess physical and
mental status
 Provide safe and
conducive
environment
Platelet Count 429,000/CU. 200,000- Normal Results
MM 450,000/cu.mm
ABG ( ARTERIAL BLOOD GAS)
PH 7.51 7.35-7.35 High Ph level Pulmonary  Raise the head of

Alkalosis Disease the bed
 Oxygen therapy
and equipment
 Assess need for
bronchodilators
 Devices to
enhance secretion
clearance
 Provide adequate
pain relief.
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pCO2 30 MMHG 35-45 MMHG Low pcO2 level Hypoxia  Raise the head of
the bed
 Oxygen therapy
and equipment
 Assess need for
bronchodilators
 Devices to
enhance secretion
clearance
pain relief.
pO2 65 MMHG 80-100 MMHG Low pO2 level Decreased  Raise the head of
oxygen levels the bed
 Oxygen therapy
and equipment
 Assess need for
bronchodilators
 Devices to
enhance secretion
clearance
pain relief.
HCO3 23.9 MMOL/L 22-25 Normal Results
MMOL/L
TCO2 24.8 MMOL/L 23-27 Normal Results
MMOL/L
BE(B)-+2 1.6 (-+)2
S02C 94%
J. IMPRESSION / DIAGNOSIS
Chest X-Ray
Impression:
BILATERAL MULTIPLE PULMONARY NODULES.
CONSIDER METASTATIC LESION.
CT SCAN CORRELATION IS SUGGESTED.
CONSIDER COSOLIDATION RIGHT UPPER LOBE.
S/P MASTECTOMY LEFT.
PLEASE CORRELATE CLINCALLY.
ABG Results:
Interpretation
ACUTE RESPIRATORY ALKALOSIS UNCOMPENSATED WITH INADEQUATE OXYGENATION.
III. CLINICAL DISCUSION OF THE DISEASE
A. ANATOMY AND PHYSIOLOGY
GROSS ANATOMY OF THE LUNGS

The lungs are pyramid-shaped, paired organs that are connected to the trachea by
the right and left bronchi; on the inferior surface, the lungs are bordered by the
diaphragm. The diaphragm is the flat, dome-shaped muscle located at the base of the
lungs and thoracic cavity. The lungs are enclosed by the pleurae, which are attached to
the mediastinum. The right lung is shorter and wider than the left lung, and the left lung
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occupies a smaller volume than the right. The cardiac notch is an indentation on the
surface of the left lung, and it allows space for the heart (Figure 1). The apex of the lung
is the superior region, whereas the base is the opposite region near the diaphragm. The
costal surface of the lung borders the ribs. The mediastinal surface faces the midline.
Figure 1. Gross Anatomy of the Lungs.
Each lung is composed of smaller units called lobes. Fissures separate these lobes
from each other. The right lung consists of three lobes: the superior, middle, and inferior
lobes. The left lung consists of two lobes: the superior and inferior lobes. A
bronchopulmonary segment is a division of a lobe, and each lobe houses multiple
bronchopulmonary segments. Each segment receives air from its own tertiary bronchus
and is supplied with blood by its own artery. Some diseases of the lungs typically affect
one or more bronchopulmonary segments, and in some cases, the diseased segments can
be surgically removed with little influence on neighboring segments. A pulmonary lobule
is a subdivision formed as the bronchi branch into bronchioles. Each lobule receives its
own large bronchiole that has multiple branches. An interlobular septum is a wall,
composed of connective tissue, which separates lobules from one another.
Blood Supply and Nervous Innervation of the Lungs
The blood supply of the lungs plays an important role in gas exchange and serves
as a transport system for gases throughout the body. In addition, innervation by the both
the parasympathetic and sympathetic nervous systems provides an important level of
control through dilation and constriction of the airway.
Blood Supply
The major function of the lungs is to perform gas exchange, which requires blood
from the pulmonary circulation. This blood supply contains deoxygenated blood and
travels to the lungs where erythrocytes, also known as red blood cells, pick up oxygen to
be transported to tissues throughout the body. The pulmonary artery is an artery that
arises from the pulmonary trunk and carries deoxygenated, arterial blood to the alveoli.
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The pulmonary artery branches multiple times as it follows the bronchi, and each branch
becomes progressively smaller in diameter. One arteriole and an accompanying venule
supply and drain one pulmonary lobule. As they near the alveoli, the pulmonary arteries
become the pulmonary capillary network. The pulmonary capillary network consists of
tiny vessels with very thin walls that lack smooth muscle fibers. The capillaries branch
and follow the bronchioles and structure of the alveoli. It is at this point that the capillary
wall meets the alveolar wall, creating the respiratory membrane. Once the blood is
oxygenated, it drains from the alveoli by way of multiple pulmonary veins, which exit the
lungs through the hilum.
Nervous Innervation
Dilation and constriction of the airway are achieved through nervous control by
the parasympathetic and sympathetic nervous systems. The parasympathetic system
causes bronchoconstriction, whereas the sympathetic nervous system
stimulates bronchodilation. Reflexes such as coughing, and the ability of the lungs to
regulate oxygen and carbon dioxide levels, also result from this autonomic nervous
system control. Sensory nerve fibers arise from the vagus nerve, and from the second to
fifth thoracic ganglia. The pulmonary plexus is a region on the lung root formed by the
entrance of the nerves at the hilum. The nerves then follow the bronchi in the lungs and
branch to innervate muscle fibers, glands, and blood vessels.
Pleura of the Lungs
Each lung is enclosed within a cavity that is surrounded by the pleura. The pleura
(plural = pleurae) is a serous membrane that surrounds the lung. The right and left
pleurae, which enclose the right and left lungs, respectively, are separated by the
mediastinum. The pleurae consist of two layers. The visceral pleura is the layer that is
superficial to the lungs, and extends into and lines the lung fissures (Figure 2). In
contrast, the parietal pleura is the outer layer that connects to the thoracic wall, the
mediastinum, and the diaphragm. The visceral and parietal pleurae connect to each other
at the hilum. The pleural cavity is the space between the visceral and parietal layers.
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Figure 2. Parietal and Visceral Pleurae of the Lungs.
The pleurae perform two major functions: They produce pleural fluid and create
cavities that separate the major organs. Pleural fluid is secreted by mesothelial cells from
both pleural layers and acts to lubricate their surfaces. This lubrication reduces friction
between the two layers to prevent trauma during breathing, and creates surface tension
that helps maintain the position of the lungs against the thoracic wall. This adhesive
characteristic of the pleural fluid causes the lungs to enlarge when the thoracic wall
expands during ventilation, allowing the lungs to fill with air. The pleurae also create a
division between major organs that prevents interference due to the movement of the
organs, while preventing the spread of infection.
THE IMMUNE SYSTEM
The immune system is the complex collection of cells and organs that destroys or
neutralizes pathogens that would otherwise cause disease or death. The lymphatic system,
for most people, is associated with the immune system to such a degree that the two
systems are virtually indistinguishable. The lymphatic system is the system of vessels,
cells, and organs that carries excess fluids to the bloodstream and filters pathogens from
the blood. The swelling of lymph nodes during an infection and the transport of
lymphocytes via the lymphatic vessels are but two examples of the many connections
between these critical organ systems.
Functions of the Lymphatic System
A major function of the lymphatic system is to drain body fluids and return them
to the bloodstream. Blood pressure causes leakage of fluid from the capillaries, resulting
in the accumulation of fluid in the interstitial space—that is, spaces between individual
cells in the tissues. In humans, 20 liters of plasma is released into the interstitial space of
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the tissues each day due to capillary filtration. Once this filtrate is out of the bloodstream
and in the tissue spaces, it is referred to as interstitial fluid. Of this, 17 liters is reabsorbed
directly by the blood vessels. But what happens to the remaining three liters? This is
where the lymphatic system comes into play. It drains the excess fluid and empties it
back into the bloodstream via a series of vessels, trunks, and ducts. Lymph is the term
used to describe interstitial fluid once it has entered the lymphatic system. When the
lymphatic system is damaged in some way, such as by being blocked by cancer cells or
destroyed by injury, protein-rich interstitial fluid accumulates (sometimes “backs up”
from the lymph vessels) in the tissue spaces. This inappropriate accumulation of fluid
referred to as lymphedema may lead to serious medical consequences.
As the vertebrate immune system evolved, the network of lymphatic vessels

became convenient avenues for transporting the cells of the immune system.
Additionally, the transport of dietary lipids and fat-soluble vitamins absorbed in the gut
uses this system.
Cells of the immune system not only use lymphatic vessels to make their way
from interstitial spaces back into the circulation, but they also use lymph nodes as major
staging areas for the development of critical immune responses. A lymph node is one of
the small, bean-shaped organs located throughout the lymphatic system.
Structure of the Lymphatic System
The lymphatic vessels begin as open-ended capillaries, which feed into larger and
larger lymphatic vessels, and eventually empty into the bloodstream by a series of ducts.
Along the way, the lymph travels through the lymph nodes, which are commonly found
near the groin, armpits, neck, chest, and abdomen. Humans have about 500–600 lymph
nodes throughout the body.
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Figure 3. Lymphatic vessels in the arms and legs convey lymph to the larger
lymphatic vessels in the torso.
A major distinction between the lymphatic and cardiovascular systems in humans
is that lymph is not actively pumped by the heart, but is forced through the vessels by the
movements of the body, the contraction of skeletal muscles during body movements, and
breathing. One-way valves (semi-lunar valves) in lymphatic vessels keep the lymph
moving toward the heart. Lymph flows from the lymphatic capillaries, through lymphatic
vessels, and then is dumped into the circulatory system via the lymphatic ducts located at
the junction of the jugular and subclavian veins in the neck.
Lymphatic Capillaries
Lymphatic capillaries, also called the terminal lymphatics, are vessels where
interstitial fluid enters the lymphatic system to become lymph fluid. Located in almost
every tissue in the body, these vessels are interlaced among the arterioles and venules of
the circulatory system in the soft connective tissues of the body. Exceptions are the
central nervous system, bone marrow, bones, teeth, and the cornea of the eye, which do
not contain lymph vessels.
Figure 4. Lymphatic capillaries are interlaced with the arterioles and venules of
the cardiovascular system. Collagen fibers anchor a lymphatic capillary in the tissue
(inset). Interstitial fluid slips through spaces between the overlapping endothelial cells
that compose the lymphatic capillary.
Lymphatic capillaries are formed by a one cell-thick layer of endothelial cells and
represent the open end of the system, allowing interstitial fluid to flow into them via
overlapping cells. When interstitial pressure is low, the endothelial flaps close to prevent
“backflow.” As interstitial pressure increases, the spaces between the cells open up,
allowing the fluid to enter. Entry of fluid into lymphatic capillaries is also enabled by the
collagen filaments that anchor the capillaries to surrounding structures. As interstitial
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pressure increases, the filaments pull on the endothelial cell flaps, opening up them even
further to allow easy entry of fluid.
In the small intestine, lymphatic capillaries called lacteals are critical for the
transport of dietary lipids and lipid-soluble vitamins to the bloodstream. In the small
intestine, dietary triglycerides combine with other lipids and proteins, and enter the
lacteals to form a milky fluid called chyle. The chyle then travels through the lymphatic
system, eventually entering the liver and then the bloodstream.
PNEUMONIA IN AN IMMUNE-COMPROMISED HOST
Pneumonia is a respiratory condition. Pneumonia is triggered when the lungs

become infected. This happens due to the presence of bacteria, viruses, parasites, or
fungi. Fluid then lingers in the lungs(Figure 5). When a person with an already weakened
immune system gets pneumonia, it is called “pneumonia in an immune-compromised
host.”
Having a weakened immune system makes it harder for you to fight off germs.
Immediate medical intervention and careful monitoring are necessary. Without them,
patient will run the risk of serious complications.
If the patient have a compromised immune system and develop symptoms of
pneumonia, contact the doctor soon.
Figure 5. Actual patient’s Chest X-ray with result of

multiple, varisized nodular and confluent opacities are
seen in both lung fields. The right upper lobe is opacified.
The heart is not enlarged. Diaphragm, sulci and chest
bones are intact. The left breast shadow is absent (Status
Post Mastectomy)
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Risk Factors for Pneumonia
People with weakened immune systems will have more difficulty fighting off the
bacteria or the virus that is causing their pneumonia. The following medical conditions
can lead to a weaker immune system: HIV/AIDS, heart disease, diabetes, bone marrow or
organ transplants.
After any inpatient surgical procedure, your body is healing for at least a week. In
this state, your immune system can be compromised and you may have a higher risk of
pneumonia.
A major risk factor for pneumonia is chronic obstructive lung disease (COPD).
People who are treated for COPD with corticosteroid medications can be more vulnerable
to pneumonia risks. The longer this medication has been used, the higher the risk.
Even in cases during which an immune-compromised person contracts

pneumonia, the prognosis varies from person to person.
In people with a severely weakened immune system, complications are more

common. These complications can include a rapid spread of infection and high levels of
bacteria in the bloodstream. Respiratory failure and organ damage can also occur. In
cases where pneumonia lingers for a long time, the use of a device to assist with
breathing may become necessary.
In some cases, pneumonia can result in death. According to the WHO data
published in 2017 Influenza and Pneumonia Deaths in the Philippines data reached
75,970 or12.27% of total deaths. However, there is a very wide mortality range that
depends on the cause, severity, and availability of quality care to the person with
pneumonia.
ANATOMY & PHYSIOLOGY OF THE BREAST
The breast is an organ whose structure reflects its special function: the production
of milk for lactation (breast feeding). The epithelial component of the tissue consists of
lobules, where milk is made, which connect to ducts that lead out to the nipple. Most
cancers of the breast arise from the cells which form the lobules and terminal ducts.
These lobules and ducts are spread throughout the background fibrous tissue and adipose
tissue (fat) that make up the majority of the breast. The male breast structure is nearly
identical to the female breast, except that the male breast tissue lacks the specialized
lobules, since there is no physiologic need for milk production by males.
Anatomically, the adult breast sits atop the pectoralis muscle (the "pec" chest
muscle), which is atop the ribcage. The breast tissue extends horizontally (side-to-side)
from the edge of the sternum (the firm flat bone in the middle of the chest) out to the
midaxillary line (the center of the axilla, or underarm). A tail of breast tissue called the
"axillary tail of Spence” extend into the underarm area. This is important because a breast
cancer can develop in this axillary tail, even though it might not seem to be located
within the actual breast(Figure 6).
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Figure 6. Anatomy of the breast.
The breast tissue is encircled by a thin layer of connective tissue called fascia.
The deep layer of this fascia sits immediately atop the pectoralis muscle, and the
superficial layer sits just under the skin. The skin covering the breast is similar to skin
elsewhere on the body and has similar sweat glands, hair follicles, and other features. A
clinician will examine the skin in addition to the breast tissue itself when performing a
breast exam.
Blood Supply & Lymph Nodes
The blood supply from the breast comes primarily from the internal mammary
artery, which runs underneath the main breast tissue. The blood supply provides
nutrients, such as oxygen, to the breast tissue. The lymphatic vessels of the breast flow in
the opposite direction of the blood supply and drain into lymph nodes. It is through these
lymphatic vessels that breast cancers metastasize or spread to lymph nodes. Most
lymphatic vessels flow to the axillary (underarm) lymph nodes, while a smaller number
of lymphatic vessels flow to internal mammary lymph nodes located deep to the breast.
Knowledge of this lymphatic drainage is important, because when a breast cancer
metastasizes, it usually involves the first lymph node in the chain of lymph nodes. This is
called the "sentinel lymph node,” and a surgeon may remove this lymph node to check
for metastases in a patient with breast cancer (Figure 7).
Many additional changes are seen in the breast tissue during pregnancy and
lactation due to the changes in hormones during those times.
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Figure 7. Blood supply and lymph nodes.
METASTATIC BREAST CANCER
Metastatic breast cancer is breast cancer that has spread beyond the breast to
other organs in the body, most often the bones, lungs, liver or, less commonly, brain.
There are many words used, but they actually mean the same thing.
Metastatic breast cancer is also called stage IV (4) breast cancer, secondary
breast cancer and advanced breast cancer. When referring to a specific area or site of
metastatic breast cancer, the term secondary is often used — for example a secondary in
the bone. The word metastases is sometimes also used to describe these sites, e.g. bone
metastases. The original cancer in the breast is referred to as the primary.
Although metastatic breast cancer has spread to another part of the body, it is
considered and treated as breast cancer. For example, breast cancer that has spread to
the bones is still breast cancer (not bone cancer) and is treated with breast cancer drugs,
rather than treatments for a cancer that began in the bones.
Sometimes people are found to have metastatic breast cancer at their first
diagnosis of breast cancer. This is called ‘de novo’ metastatic breast cancer.
Note: Treatment for Patient CPA during the clinical exposure focuses on alleviating the
respiratory disease specifically pneumonia.
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B. PATHOPHYSIOLOGY BOOK BASED / CLIENT BASED
B.1.a. BOOK BASED (Pneumonia)
Precipitating Factors: Predisposing Factors:
 Exposure to chemical and bacterial  Lifestyle

agents  Environment
 Hospitalization because of surgical  Age
Virulent Microorganism
operation  Diet
 Sex
 Heredity
 Self-Medication
Microorganism enter the nasal passages
Passes to the larynx, pharynx, trachea
Micro organism enters and affects both airway and lung perenchyma
Airway Damage Lung Invasion
Infiltration of bronchi Flattening of epithelial cells
Infectious organism lodges

Macrophages and leukocytes
Stimulation of bronchioles Stimulation of bronchioles Mucus and phlegm production
Alveolar Collapse Narrowing of air passage
COUGHING
FEVER DIFFICULTY OF BREATHING Productive / Non productive
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B.1.b. CLIENT BASED (Pneumonia)
Precipitating Factors: Predisposing Factors:
 Exposure to chemical and bacterial  Inactive lifestyle due to Breast CA Stage4

Virulent Microorganism
agents (Immunocompromised host; High  Living in a light materialled house with
Risk) (Streptococcus Pnuemoniae) decreased protection from harsh
 Left Breast Mastectomy 1 year ago weather condition
@QMC (Metastatic Breast Cancer)  Age: 63 years old
 T/C Pulmonary Metastatic Lesions  Diet as tolerated (Poor appetite)
 Sex: Female
Microorganism enter the nasal passages  Self-Medicating prior to admission
Prior to admission Patient CPA with (Date of Admision:10/19/2018)
maintenance for Breast CA
Stage4(Tamoxifen); Discontinued during
hospitalization to prevent A/E of pulmonary
Passes to the larynx, pharynx, trachea
embolism
HAMA Medication
Predisone2g BID, Appebon OD
Micro organism enters and affects both airway and lung perenchyma
3 days incubation period

Airway Damage Lung Invasion
Infiltration of bronchi Flattening of epithelial cells
 Cefuroxime 1500mg IV Q8 (10/19/18)

Infectious organism lodges
 Vigocid 4.5gm IV Q8 (10/19-21/18) Macrophages and leukocytes
 HAMA Med Azythromycin
Stimulation of bronchioles Stimulation of bronchioles Mucus and phlegm production
 Duavent 1 neb Q6 (10/19/18)

Alveolar Collapse Narrowing of air passage
 Pulmodual 1neb Q4 (10/19-20/18)
 Salbutamol 1 neb Q6 (10/20-21/18)
COUGHING
FEVER DIFFICULTY OF BREATHING Productive / Non productive
 Oxygenation 2L/min 10/19-21,2018)  Fluimicil 200mg OD(10/19-21/018)
Lucena City
1. DRUG STUDY
DRUG ACTION INDICATION DOSE CONTRA SIDE NURSING
INDICTION EFFECT CONSIDERATION
GENERIC Second- Pharyngitis, 1500mg Contraindicate Large doses  Determine
NAME : generation tonsillitis,infecti IV q8 to d in patients can cause history
Cefuroxime cephalosporin ons of the run for hypersensitive cerebral of hypersensi
that inhibits urinary and 2hours to drug. irritation and tivity
BRAND cell-wall lower Use cautiously convulsions; reactions to
NAME : synthesis, respiratory in patients nausea, cephalosphor
Zoltax promoting tracts, and skin hypersensitive vomiting, ins,penicillin
osmotic and skin- to penicillin diarrhea, GI s and history
CLASSIFICA instability; structure because of disturbances; of allergies
TION : usually infections possibility of erythema particularly
Antibiotic bactericidal caused by cross- multiforme, to drugs
Streptococcus sensitivity with Stevens- before
pneumoniae and other beta- Johnson therapy is
S. pyogenes, lactam syndrome, initiated.
Haemophillus antibiotics. epidermal  Report on
influenzae, Use with necrolysis selt of loose
Staphylococcus caution stools
aureus, in breast- Absorption
Escherichia coli feeding of cefuroxim
women and e is enhanced
inpatients with by food.
history of  Notify
colitis or renal prescriber
sufficiency about rashes
or super
infections

Lucena City
GENERIC treatment of ob management of 1 neb hypertrophic Headache,  drugs should be
NAME : structive airway reversible q6 obstructive cardio dizziness, given only if the
Ipratropium diseases bronchospasm myopathy nausea, dry potential
salbutamol associated or tachyarrythmia mouth, benefit
obstructive shaking justifies the
BRAND airway disease (tremors), potential risk to
NAME : nervousness, the fetus.
Duavent patient with or constipatio  position patient
COPD on a n may occur on high back
CLASSIFICA regular inhaled rest position
TION : bronchospasm  do back tapping
bronchodilator and who required after you
a bronchodilator nebulizer the
patient
 do not give a
food
immediately, it
can cause
vomiting

GENERIC Antibacterial Treatment of 4.5gm History of allergic Nausea;  Report rash,
NAME : combination severe gm -ve IV q8 reactions to indigestion, itching, or
Piperacillin- product infection & to run penicillins, vomiting, other signs of
Tazobactam consisting of other for 3 cephalosporins, β- diarrhea or hypersensitiv
the susceptible hours lactamase constipation; ity
BRAND semisynthetic bacteria; inhibitors rash, itchy or immediately.
NAME : piperacillin neutropenic red skin,  Report loose
Vigocid and the beta- patients; cystic urticaria; stools or
lactamase fibrosis; otitis sleeping diarrhea as
CLASSIFICA inhibitor media; skin difficulty, these may
TION : tazobactam. infection; headache or indicate
Antiinfective; Tazobactam surgical dizziness; pseudomemb
beta-lactam component infection ranous
antibiotic; does not prophylaxis; colitis.
antipseudomon decrease the UTI; bone &  Do not breast
al penicillin activity of the joint feed while
piperacillin infections; taking this
component gynecological drug without
against infection consulting
susceptible including physician
organisms postpartum
endometritis &
pelvic
inflammatory
disease (PID);
peritonitis;
septicemia

Lucena City
GENERIC Exerts Treatment 200mg Contraindicat Bronchospas  Monitor
NAME : mucolytic of respiratory saches ed in patient m Angio effectiveness
Acetylcysteine action through affections in 20cc with severe edema of therapy
its free characterized by water hypertension; Rashes and advent
BRAND sulfhydryl thick and viscous TID severe. Pruritus of adverse/
NAME : group which hypersecretions: Coronary Nausea and allergic
Fluimucil opens up the acute bronchitis, artery Vomiting, effects.
disulfide bonds chronic bronchitis disease, Fever,  Instruct
CLASSIFICA in the and its hypersensitiv Syncope, patient
TION : mucoproteins exacerbations; ity Sweating, inappropriate
Mucolytic thus lowering Pulmonary to pseudoede Arthralgia, use and
agent mucous emphysema phrine,acriva Blurred adverse
viscosity. ,mucoviscidosis stine or any vision, effects to
and bronchiectasis component; Disturbances report
renal of
impairment liver function

Lucena City
GENERIC Ipratropium Management Neb q4 Patients who is Fine tremor  Use Cautiously
NAME : bromide is an of reversible PRN allergic to the of Skeletal to patients
Ipratropium anticholinergic bronchospasm for Drug Muscle; with known
Br,Salbutamol (parasympatholy associated with SOB Palpitations; sensitivity to
/albuterol tic) agent which, obstructive Patients with Headache, atropine,
sulfate based on animal airway Hypertropic dizziness, soybeans,
studies, appears diseases in obstructive nervousness soyalecithin,
BRAND to inhibit patients who cardiomyopathy Dryness of and peanuts.
NAME : vagally- require more the mouth,  Assess Vital
Pulmodual mediated than a single Patient shaving throat Signs Before
reflexes by bronchodilator tachyarrythmia irritation; drug
CLASSIFICA antagonizing the urinary administration
TION : action retention  Observe for
Antiasthmatic of acetylcholine, paradoxical
&COPD the transmitter bronchospasm
Preparations agent released at (Wheezing).
the If Condition
neuromuscular occurs, with
junctions in the hold
lung. Medication
Anticholinergics and notify
prevent the physician or
increases in other
intracellular healthcare
concentration of professional
Ca++ which is immediately
caused by  Instruct patient
interaction of to contact
acetylcholine health care
with the professional
muscarinic immediately if
receptors on shortness
bronchial of breath is not
smooth muscle relieved by
medication or
is
accompanied
by diaphoresis,
dizziness,
palpitations, or
chest pain

GENERIC In low doses, Relief and prevention Neb Contraindicated Nervousne  Observe 10
NAME : acts relatively of brochospasm q6 with ss, shaking rights in
Albuterol selectively at in patients with hypersensitivity (tremor), giving
beta 2 – reversible obstructive to albuterol; mouth/ medications.
adrenergic airway disease. tachyarrhythmia throat
Lucena City
BRAND receptors to s,tachycardia dryness or  Use minimal
NAME : cause Inhalation: treatment cause by irritation, doses for
salbutamol bronchodilati of acute attacks digitalis intoxica cough, minimal
on and of brochospasm. tion. dizziness,h periods; drug
CLASSIFICA vasodilation; eadache, tolerance can
TION : at higher Prevention of exercise- Use cautiously trouble occur with
Bronchodilator doses, beta 2 induced brochospasm. with diabetes sleeping, prolonged used.
selectivity is mellitus; or nausea  Maintain a
lost, and the Unlabeled use: hyperthyroidism may occur – adrenergic
drug acts at adjunct intreating , history of blocker ( cardio
beta 2 serious hyperkalemia seizure disorders selective beta –
receptors to in dialysis patients; blocker, such
cause typical seems to lower as atenolol,
Sympathomi potassium concentrati should be use
metic cardiac on when inhaled by with
effect patients on respiratory
hemodialysis distress ) on
standby
incase cardiac
arrhythmias
occur
DRUG ACTION INDICATION CONTRA SIDE NURSING

GENERIC Competes with Treatment of Contraindicat hives;  Avoid
NAME : estrogen for metastatic breast ed with difficulty prolonged
Tamoxifen binding sites in cancer in women allergy to breathing; sun exposure,
target tissues, and men; in tamoxifen, swelling of especially if
such as the premenopausal pregnancy, your face, skin is
BRAND breast women with lactation, lips, tongue, unprotected.
NAME : metastatic breast women who or throat. Apply
Nolvadex cancer, tamoxifen require sunscreen
is an alternative to concomitant lotions (SPF
CLASSIFICA oophorectomy coumarin- 12 or greater)
TION : or ovarian type to all
Antiestrogen irradiation anticoagulati exposed skin
on therapy or surfaces
in women  Report to
with a physician
history of occurrence of
DVT or PE marked
Lucena City
weakness,
sleepiness,
mental
confusion,
edema,
dyspnea,
blurred
vision
 Report onset
of tenderness
or redness in
an extremity

GENERIC The B complex To treat and Oral Sensitivity to Headache  Monitor vital
NAME : vitamins act as prevent vitamin any of the Paresthesia signs
Vitamin b coenzyme and deficiency ingredients Blurred  Give the drug
complex are essential for included in vision with meals.
metabolism of the Rashes  Warn the
BRAND protein, medication Wheezing patient that
NAME : carbohydrate Diarrhea stool may be
Surbex and fatty acids Flatulence dark or green
Nausea and  Administer
CLASSIFICA vomiting liquid
TION : Irritation preparations
Multivitamins Agitation in water or
Slightly drop juice to mask
of blood the taste and
pressure prevent
staining
of teeth.

GENERIC Blocking the Aspirin is used to 1 tab Hypersensitivity dark urine.  Avoid taking
NAME : production of a reduce fever and tid to  nausea. alcohol or
Ibuprofen + prostaglandin relieve mild to PRN acetaminophen  salicylates to
pale stools.
Paracetamol that is released moderate pain from for orphenacetin; prevent bleeding
conditions such as pain use with alcohol
Lucena City
BRAND in the body muscle aches,  stomach  Avoid using it if
NAME : during pain. toothaches, pain. allergic to
Algesic forte common cold, and  vomiting. paracetamol
Increasing the headaches. It may  Consult your
 yellowing
CLASSIFICA pain threshold also be used to doctor if you
of the skin
TION : and increases reduce pain and develop blurred
or eyes
nonsteroidal the blood flow swelling in vision, ringing or
anti- across the skin, conditions such as roaring in ears
inflammatory heat loss and arthritis. Aspirin is  Consult your
drugs sweating known as a doctor if you have
salicylate and a systemic lupus
nonsteroidal anti- erythematosus
inflammatory drug  Do not take
paracetamol if
you consume
alcoholic
beverages every
day
 Inform your
doctor if you have
bruising or
bleeding
 Take the drug
with a meal or
snack to prevent
upset stomach

BRAND Alamin Alamin-Fez (Folic 3vials This product diarrhea,  Advise
NAME : Injection is a Acid)® is a is nausea, patients of
Alamin Sn naturally prescription iron contraindicat vomiting, the risks
occurring co- supplement ed in patients headache, associated
enzyme form indicated for use in with a known dizziness, with Alamin-
of Vitamin improving the hypersensitiv hypotension, Fez (Iron
Lucena City
B12, which nutritional status of ity to any of pruritus, pain (Ferrous
circulates iron deficiency the in extremity, Fumarate))
through the ingredients. arthralgia,  Advise
blood stream. Hemochroma back pain, patients to
In addition to tosis and muscle report any
the Vitamin hemosiderosi cramp, symptoms of
B12 structure, s are injection site hypersensitiv
it has an contraindicati reactions, ity that may
additional ons to iron chest pain, develop
methyl therapy and during and
containing peripheral following
metal-alkyl edema Alamin-Fez
group. It helps (Iron
the body to (Ferrous
produce red Fumarate))
blood cells and administratio
can be used as n, such as
a dietary rash, itching,
supplement dizziness,
light-
headedness,
swelling, and
breathing
problems

GENERIC Enters target Replacement 20mg Contraindicat CNS:  Administer
NAME : cells and binds therapy in adrenal BID ed with Euphoria, once-a-day
Prednisone to intracellular cortical infections, headache, doses before
corticosteroid insufficiency· especially insomnia, 9AM to
BRAND receptors, Hypercalcemia tuberculosis, confusion, mimic
NAME : thereby fungal psychosis. normal peak
Lucena City
Apo- initiating many associated with infections, CV: CHF, corticosteroid
Prednisone complex cancer amebiasis, edema. blood levels.
reactions that vaccinia and GI: Nausea,  Increase
CLASSIFICA are responsible varicella, vomiting, dosage when
TION : for its anti- and antibiotic peptic ulcer. patient is
Corticosteroid inflammatory resistant infec Musculoskele subject to
(intermediate and immune tions; tal: Muscle stress.·
acting), suppressive lactation weakness, del  Taper doses
Glucocorticoid effects ayed wound when
Hormone healing, discontinuing
muscle high-dose or
wasting, long-term
osteoporosis, therapy.
aseptic  Do not give
necrosis of live virus
bone, spontan vaccines with
eous immune
fractures. suppressive
Endocrine: doses
Cushingoid of corticoster
features, oids
growth
suppression
in children,
carbohydratei
n tolerance,
hyperglycemi
a. Special
Senses:
Cataracts.
Hematologic:
Leukocytosis.
Metabolic:
Hypokalemia

GENERIC exerts the Appebon with Iron 1 tab Contradicted Some of the  Give the drug
NAME : synergistic acti Capsule are OD in patients side effects with meals.
Vitamin B- ons of generally used for hypersensitiv include  Monitor vital
Complex + Buclizine, B- treating poor e to any of its sleepiness signs
Iron + Lysine complex appetite, anorexia active and dulling  Administer
+ Buclizine vitamins nervosa and ingredients. of mental liquid
Hydrochloride & iron in a underweight. It attentiveness, preparations
Lucena City
nutritional also is used for Subjects headache, dry in water or
BRAND supplement to dietary support in suffering mouth, juice to mask
NAME : stimulate post operation from primary jitteriness, the taste and
Appebon with appetite. cases, metabolic hemachro nausea and prevent
iron Buclizine has problems and matosis, tiredness. staining
metabolic period of recovery prostatic These side of teeth
CLASSIFICA effects that hypertrophy effects are  Warn the
TION : have been and angle- fleeting and patient that
Appetite shown to closure pass away as stool may be
stimulant stimulate glaucoma. your body dark or green
appetite adjusted to
the active
compounds.
Inform your
physician in
case any of
these
Appebon
adverse
reactions
become
persistent and
troublesome

GENERIC exerts its treatment of the 200mg Is contra diarrhea ,  Take this
NAME : bactericidal following 1 tab indicated in nausea, antibiotic for
Cefixime effect by infections BID patients with abdominal the full
attaching to caused by known pain, course of
BRAND penicillin- susceptible allergies to the vomiting and, treatment
NAME : binding strains of the cephalosporin skin rash  Report loose
Suprax proteins (PBP) or penicillin stools or
Lucena City
and inhibiting designated antibiotics or diarrhea
CLASSIFICA peptidoglycan microorganisms to any during drug
TION : synthesis, thus ingredients in therapy and
Antibiotic causing the for several
damage to the formulation or weeks after.
bacterial cell component of Older adult
wall the container patients are
especially
susceptible to
pseudomemb
ranous colitis
 Do not miss
any doses
and take the
doses at
evenly
spaced times,
day and night
 Do not breast
feed while
taking this
drug without
consulting
physician

GENERIC Blocks Injectable form is 500mg Contraindicat Mild to  Culture site
NAME : transpeptidation used for treatment 1 tab ed with moderate of
Azithromycin by binding to50s of serious BID hypersensitiv nausea, infection bef
ribosomal infections of the ity to vomiting, ore therapy.
BRAND subunit of lower respiratory azithromycin, abdominal  Administer
NAME : susceptible tracts. erythromycin pain, on an empty
Zithromax organisms and , or any dyspepsia, stomach 1 hr
disrupting RNA- flatulence, before or
Lucena City
CLASSIFICA dependent macrolide diarrhea, 2– 3hr after
TION : protein synthesis antibiotic cramping; meals. Food
antiinfective; at the chain angioedema, affects the
macrolide elongation step cholestatic absorption of
antibiotic jaundice this drug
;dizziness,  Take the full
headache, course
vertigo, prescribed.
somnolence; Do not take
transient with
elevations of antacids.
liver enzyme Tablets
value andoralsuspe
nsion can be
taken with or
without food
 Report severe
or watery
diarrhea,
severe
nauseaor
vomiting,
rash or
itching,
mouth sores,
vaginal sore

GENERIC Protection Minor sore TID Lesions and CNS :  Instruct patient
NAME : against oral throat; halitosis, ulcerations of ageusia, not to swallow
Hexetidine bacterial and general oral oral/buccal dysgeusia the medication
fungal hygiene, mucosa  Caution the
BRAND infection to Improves Disorders patient that the
NAME : give fast relief appearance of the solution may be
Bactidol from sore respiratory too harsh to taste.
of mouth tissue,
throat and system and  Assess for any
protects too the
mouth ulcers. the thoracic lesions in the
Lucena City
CLASSIFICA surfaces a and mouth of
TION : faints formation mediastinal the patient
Oral anti septic of decay acids organs:
coughing,
wheezing
caused by a
hypersensiti
vity
reaction
GI: dry
mouth,
dysphagia,
nausea,
enlarged
salivary
glands,
vomiting
TYPE OF CLASSIF CONTENT ACTION INCATION CONTRA HOW NURSING

SOLUTION ICATIO INDICATION SUPPLIED RESPONSIBI
N LITIES
Brand name: Isotonic -It contains no Normal - Used Heart failure- 1000ml 1. Monitor patient
Plain NSS Intravenou antimicrobial Saline is a because it has Pulmonary frequently or:
Other name: s Solution agents. sterile, non little to no edema-Renal a. Signs of
0.9%Sodium -The pH is 5.0 pyrogenic effect on the impairment-
DOSE : infiltration/sluggish
Chloride (4.5 to7.0). solution for tissues and Sodium retention 19-20 flow
Solution -It contains 9 fluid and make the gtts/min b. signs of
g/L Sodium electrolyte person feel phlebitis/infection
Chloride with replenishme hydrated c. well time of
an osmolarity nt preventing catheter and need to
of hypovolemic be replaced
308mOsmol/L shock or d. Condition of
.-It contains hypotension catheter dressing.
154mEq/L
Sodium and 2. Check the level of
Chloride. the IVF.
a. Correct
solution,
medication
and volume.
Lucena City
b. Check and
regulate the
drop rate.
c. Change the
IVF solution if
needed.
d. Do not
connect
flexible plastic
IV. NURSING PROCESS

A. LONG TERM OBJECTIVES
The study aims to improve airway breathing and circulation, boost patient’s immunity and
prevent complications of the client through collaborative management with physician
therapist associate with the nutritionist.
B. PRIORITIZED LIST NURSING PROBLEM
PROBLEM RANKING JUSTIFICATION

Ineffective airway clearance Airway must be given the
related to the increased first attention as based on the
production of respiratory rule of ABC which is
secretions 1 Airway, Breathing and
Circulation. In addition,
difficulty of breathing can
cause anxiety to the client
that is why, immediate
attention must be done
Ineffective breathing pattern This demands immediate
related to decreased lung treatment/ care and
expansion subsequent medical
2 attention. This also needs
attention as based on the rule
of ABC, which is Airway,
Breathing, and Circulation.
Impaired gas exchange Lack of action in this health
related to altered oxygen care problem may cause
supply. 3 loading to hypoxia of the
lung tissue and a significant
ventilation perfusion
mismatch
Risk for infection related to It is fourth prioritized
compromised immune because based on the Types
system 4 of Nursing Diagnosis the
patient’s health is at “risk”
and may likely happen
Risk for decreased cardiac Hypertension is considered a
output related to increased health deficit because
vascular vasoconstriction without adequate knowledge
Lucena City
5 and maintenance , it could
lead premature death
secondary to stroke, heart
disease, ors kidney failure.
Disturbed body image According to Maslow’s
related to loss of body part hierarchy of needs, this is
secondary to curative 6 under self-esteem. Esteem
surgery in cancer or presents the normal human
mastectomy desire to be accepted and
valued by others.
C.NCP (based on the sequence of prioritized problem)
Pneumonia
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Short Term INDEPENDENT: After 8 hours of
“nahihirapan po akong airway Goal:  Encourage deep  Deep breathing nursing
huminga” as clearance breathing promotes intervention,
verbalized by the related to the After 8 hours of exercises oxygenation Goal Partially
patient increased nursing before controlled Met.
production of intervention, coughing The patient was
Objective: respiratory secretions will  To improve able to
 Rapid secretions be mobilized, productivity of
breathing/ airway patency  Assist patient in the cough >demonstrate
tachypnea will be coughing  Adequate fluid coughing and
 Cough with maintained free exercises intake enhances deep breathing
yellow of secretions, as  Increase fluid liquefaction of exercise every 1-
sputum evidenced intake, as pulmonary 2 hours during
production patient’s ability appropriate secretions and the day
 Diminished to effectively facilitates
and cough out expectorations of >Client’s
adventitious secretions, clear mucus respiratory rate is
breath sounds lung sounds, and  Provides a basis not within
(crackles) uncompromised for evaluating normal range
 Dyspnea respiratory rate adequacy of (RR – 27)
 V/S taken as  Monitor rate, ventilation
follows: rhythm, depth ,  To promote >Inspiratory
T: 35.4 and effort of drainage of crackles can still
P: 97 bpm respirations secretions and be heard at the
better lung right lower lobe
R:33 bpm
BP: 140/100  Assist patient expansion
>Cough
into moderate  Decreased
high back rest continues to be
airflow occurs in
positions productive
areas
consolidated with
 Auscultate lung fluid. Bronchial
fields, noting breath sounds
areas of (normal over
decreased of bronchus) can
absent airflow also occur in
and adventitious consolidated
breath sounds areas. Crackles,
rhonchi, and
wheezes are
heard on
inspiration and/or
expiration in
response to fluid
Lucena City
accumulation,
thick secretions,
and airway
spasm/obstruction
 To help loosen
and clear the
mucus from the
airways
(mucolytics);
decreased
resistance in the
respiratory
airway and
DEPENDENT: increased airflow
 Administer to the lungs
ordered (bronchodilators)
medications and to loosen and
such as clear mucus and
mucolytic phlegm from the
agents. respiratory tract
Bronchodilators, (expectorants)
expectorants  A variety of
respiratory
therapy
treatments may
be used to open
constricted
airways and
liquefy
secretions.
 Administer
nebulizations as
needed
Difficulty of Breathing

Subjective: Ineffective After 30 INDEPENDENT: Goal Met.
“nahihirapan po ako breathing minutes of  Elevated head  Elevation of the
sa paghinga ko” as pattern related nursing of the bed for bed facilities After 30 minutes
verbalized by the to decreased intervention, about 30 respiratory of nursing
patient lung the client will degrees and ask function by use intervention, the
expansion experience the client to of gravity. It also client will
Objective: lessened assume dorsal decreases experience
 Nasal difficulty of recumbent pressure on the lessened
flaring breathing as position abdomen when difficulty of
 Slight manifested by assuming the breathing as
cyanotic decreased in position manifested by
nail beds RR from 27  Promote chest decreased in RR
 Rapid bpm to 20 bpm expansion from 27 bpm to
shallow with the  Precipitators of 20 bpm with the
breathing absence of allergic type of absence of nasal
 RR: 27bpm nasal flaring respiratory flaring and
and presence of  Encouraged reactions that presence of calm
calm breathing deep breathing can trigger or breathing
exercises exacerbate onset
of acute episode
Lucena City
 Kept  Assesses the
environment condition of the
pollution to a client
minimum
 Helps in giving
adequate oxygen
to the client
 Monitored
respiratory
patterns,
including rate,
depth, and effort  Assess the
condition of the
DEPENDENT: client
 Gave
supplemental
oxygen as
ordered (2LPM
via nasal
cannula)
COLLABORATIVE:
 Obtained blood
specimen for
Arterial Blood
Gas study
Lung Cancer
Subjective: Impaired gas After 8 hours INDEPENDENT: After 8 hours of
“nakakaranas po s’ya exchange of nursing  Note respirator  Respiration may nursing
ng hingal sa paghinga related to intervention rate, depth, and be increased as intervention the
at pananakit ng dibdib” altered oxygen the patient will ease of a result of pain patient was able to
as verbalized by the supply. demonstrate respirations. or as an initial demonstrate
relative improved Observe for the compensatory improved
ventilation and use of accessory mechanism to ventilation and
Objective: adequate muscles, pursed accommodate adequate
 Restlessness oxygenation of lip breathing, for loss of lung oxygenation of
 Cyanosis tissues by changes in skin tissue. Increased tissues by ABGs
 Change in ABGs within or mucous work of within patient’s
mentation patient’s membrane breathing and normal range.
 V/S taken as normal range. colour cyanosis may
follows indicate
T: 35.4 increasing
P: 97 bpm oxygen
R: 33 pm consumption
BP: 140/100 and energy
mmHg expenditures
and reduced
respiratory
reserve
 Auscultate  Consolidation
lungs for air and lack of air
movement and movement on
abnormal breath operative side
sounds are normal in
the
Lucena City
pneumonectomy
 Investigate patient
restlessness and  May indicate
changes in increased
mentation or hypoxia or
level of complication
consciousness such as
mediastinal shift
in
pneumonectomy
patient when
accompanied by
tachypnea,
tachycardia, and
tracheal
 Maintain patent deviation
airway by  Airway
positioning, obstruction
suctioning, use impedes
of airway ventilation,
adjuncts impairing gas
exchange
 Reposition
frequently,  Maximizes lung
placing patient expansion and
in sitting drainage of
positions and secretions
supine to side
positions
 Avoid
positioning  Positioning the
patient with a patients
pneumonectomy following lung
on the operative surgery with
side. Favor the their “good lung
“good lung down”
down” position maximizes
oxygenation by
using gravity to
enhance blood
flow to the
healthy lung,
creating the best
possible match
between
ventilation and
 Encourage or perfusion
assist with deep  Promotes
breathing maximal
exercises and ventilation and
pursed-lip oxygenation and
breathing as reduces or
appropriate prevent
atelectasis
DEPENDENT:
 Administer
supplemental  Maximizes
oxygen via available
nasal cannula, oxygen,
partial especially while
rebreathing ventilation is
mask, or high reduced because
humidity face pain
mask as
indicated
Lucena City
 Monitor graph
of ABGs, pulse  Decreasing
oximetry Pao2 or
reading increasing
PaCO2 may
indicate need
for ventilator
support
Immune Compromised
Subjective: Risk for infection Short Term:  Provide  Body After 2 hours of
“medyo mahina na po s’ya related to isolation/ Substance nursing
ngayon kesa dati, parang compromised After 2 hours of monitor Isolation intervention,
ang dali n’ya pong dapuan immune system nursing visitor as (BSI) Short Term Goal
ng sakit ngayon” as intervention, indicated should be is Fully Met as
verbalized by the relative patient will: used for all evidenced by:
infections
> demonstrate patients. >Demonstration
different ways to Wound/ of different
prevent infection linen ways to prevent
isolation infection such
Long Term: and hand as:
washing  Monit
After 3 days of may be all ored
nursing that is visitor
intervention, required for s as
patient will: draining sugges
wounds. ted by
>will not acquire Patients health
infection with provid
diseases er
transmitted  Freque
through air nt
may also positio
need n
airborne change
and droplet s
precautions.  Coveri
Reverse ng of
isolation/ mouth
restriction by the
of visitors family
may be whene
needed to ver
protect the they
immune cough
suppressed
patient After 2 days of
nursing
 Wash hands  Reduces intervention,
with risk of Long Term
antibacterial cross- Goals are Fully
soap contaminati Met as
before/after on because evidenced by:
each care gloves may
activity even have >Absence of
if gloves are unnoticeabl infection
used e defects,
get torn or
damaged
during use
 Encourage/  Good
provide pulmonary
Lucena City
frequent toilet may
position reduce
changes, respiratory
deep- compromise
breathing/
coughing
exercises
 Encourage  Prevents
patient’s spread of
family to infection
cover mouth via airborne
and nose with droplets
tissue
Hypertension
Subjective: Risk for decreased Outcome INDEPENDENT: Outcome
“ang BP ko po ay palaging cardiac output Identification:  Monitor blood  Bounding Identification:
mataas at sumasakit po ulo related to pressure carotid jugular
ko minsan kapag yung increased vascular The patient will periodically. redial femoral The patient will
biglang galaw ” as vasoconstriction participate in Measure both pulses may be participate in
verbalized by the patient. activities that arms three times: observed/ activities that
reduce cardiac 3-5 minutes apart palpitated. reduce cardiac
Objective: workload while patient is at Pulses in the leg workload
 Pale in colour rest for initial may be
 Skin cool and The patient will evaluation diminished, The patient will
moist to touch maintain blood implicating maintain blood
 Jugular vein can pressure within effects of pressure within
be easily seen and acceptable range vasoconstriction acceptable range
bounding upon and
palpitation The patient will vasoconstriction The patient will
 Verbalized light demonstrate and venous demonstrate
headedness on stable cardiac congestion. stable cardiac
sudden change of rhythm and rate  Note presence of,  S3a nd S4 heart rhythm and rate
position within patient’s quality of central sounds may within patient’s
 Easy fatigability normal range and peripheral indicate atrial normal range
and occasional pulses. and venous
dyspnic hypertrophy
occurrences upon and impaired
exertion functioning
 Blood pressure  Auscultate heart  Presence of
ranging from tones and breathe adventitious
140/90-150/100 sounds breath sounds
mmHg may indicate
 Pulse rate: pulmonary
115bpm congestion
secondary to
developing
heart failure
 Observe skin  Presence of
colour, moisture, pallor; cool and
temperature and moist skin and
capillary refill delayed
time capillary refill
may be due to
peripheral
vasoconstriction
or decreased
cardiac output
 Note independent  It may indicate
or general edema heart failure,
vascular or
renal
impairment
Lucena City
 Provide a calm  Promotes
environment: relaxation
minimizing noise:
limiting visitors
and length of stay
 Maintain activity  It reduces
restrictions(bed physical stress
rest) and assist and stimuli that
patient with self affect the blood
care activities pressure
 Provide comfort  Decreases
measures i.e discomfort and
elevation of head may reduce
sympathetic
stimulation
 Encourage  It helps reduce
relaxation stressful stimuli
techniques like thereby
guided imagery decreases blood
and distractions pressure
 Monitor response  Response to
to medications to drug is
control blood dependent on
pressure both the
individual and
the synergistic
effect of the
drug. It is also
important to
check for any
untoward signs
and symptoms
of medications.
DEPENDENT:
 Administer  These
medications like medications
diuretics, alpha should be
and beta medically
antagonists, prescribed by
calcium channel the physician
blockers, and and dose and
vasodilators timing of
medications
should be
followed.
Checking BP
prior to giving
of medications
is always a
must to prevent
hypotension
COLLABORATIVE:
 Instruct and  This restrictions
implement to help manage
patient dietary fluid retention
restrictions in and decrease
sodium, fat and myocardial
cholesterol
Breast Cancer
Subjective: Disturbed body After a month of  Assess  To identify Goal Met.
image related to nursing perception of existing
Lucena City
“Nalulungkot at naaawa loss of body part intervention change in problem After a month of
ako sa sarili ko. Akala ko secondary to client’s structure or and plan nursing
simpleng rashes lang yung curative surgery psychological function of certain intervention
nakita ko, kung sana in cancer or condition will body part therapeutic client’s
naagapan yun bago lumala mastectomy improve evident actions psychological
at naging cancer baka hindi by the 4 stage of  Assess  To help the condition will
nila sana ako tinanggalan grief from perceived client improve evident
ng breast” as verbalized by bargaining and impact of sustain his by the 4 stage of
the patient depression change on physical grief from
towards activities of and social bargaining and
Objective: acceptance daily living needs while depression
 Evident missing (ADLs) , she is towards
body part of the social unable acceptance
left breast. behaviour,
 Grimace and personal Subjective:
crying while relationships, “Medyo maayos
verbalizing noted. and na pakiramdam
Poor appetite and occupational ko ngayon.
uncooperative in activities Napagtanto ko
ADL  Encourage  To allow lang na hindi
 Apathy, Social verbalization the client to naman matatapos
Isolation, and of positive or express buhay ko ditto.
concealing of the negative herself and Habang may
loss body part feelings about release buhay may pag
actual or tension on asa” as
perceived feelings verbalized by the
change  client
 Maintain  To
therapeutic facilitate
communicati good nurse-
on and patient
demonstrate interaction
positive and also
caring in gain clients
routine trust to
activities cooperate
 Teach patient  To help the
adaptive client gain
behaviour back her
like using of confidence
adaptive by
equipment concealing
that conceals altered
altered body body part
part breast
pads
 Help patient  To make
identify ways the client
of coping and focus on
divertional activities
activities she’s
interested
and happy
instead of
her altered
body part
D. Discharge Plan (M.E.T.H.O.D)

 Medication
o The patient has to continue the medications given.
Name of Drug Dosage & Route Curative Effects Side Effects

Frequency
Lucena City
Fluimucil 600 mg P.O. Mucolytic Agent Fever, Runny Nose,
Sore Throat
Prednisone 20mg P.O. Synthetic Sleep problems
Glucocorticoid Drug (insomnia), Mood
changes
Appebon 1 tab P.O. Dietary Supplement Stomach upset, pain,
constipation
Algesic 1 tab PRN for pain P.O. Pain Reliever Constipation,
drowsiness,
dizziness
Pulmodual Neb Q4 PRN for SOB Inhalant Bronchodilator Dry mouth, nausea,
constipation
Cefixime 200mg P.O. antibiotic Severe stomach or
abdominal pain,
persistent nausea or
vomiting
Azithromycin 500mg P.O. antibiotic Stomach upset,
diarrhrea/ loose
stool, nausea,
vomiting or
abdominal pain
 Fluimucil 600mg
 Prednisone 20mg
 Appebon 1 tab
 Algesic 1 tab PRN for pain
 Pulmodual Neb. Q4 PRN for SOB
 Cefexime 200mg
 Azithromycin 500mg
 Environment/Exercise
Type of Activity allowed/ to be continued:

o Deep Breathing Exercises
o Light Activities
Procedure or Steps:
1. Sit up straight as you prepare to do these exercises. Keep you backbone fully upright with
your shoulders pulled back as you get into position
2. Inhale slowly and deeply. Slowly fill your lungs with air. Think about how pure, fresh and
cleansing this “new” air is for your body
3. Focus on how your lungs feel as they fill with air. Notice how they expand. Pay attention to
how your diaphragm moves to make room for more air in your lungs
4. Exhale slowly. Release the air from your lungs until they are completely empty. Feel your
lungs contracting as your expel all of the “old” air from your body
Use of Equipment (if any): No equipment’s necessary
Restrictions: Strenuous Activities
 Therapy/Treatment
o Comply with medications
Lucena City
o Increase Fluid Intake
o Utilize Deep Breathing Exercise for at least twice a day
 Health Teaching
( ) clinic appointment schedules ( ) use of alternative medicines
( ) follow-up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications
( ) Others: Health Teaching on Deep Breathing Exercise
 Out-Patient
o Advise the patient’s family to follow-up checkup as physician’s ordered
 Diet
a. Prescribed Diet:
- Diet as Tolerated
b. Restrictions
- No restrictions

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Manuel S.

Enverga University Foundation

COLLEGE OF NURSING ALLIED HEALTH SCIENCES

In partial fulfillment of the requirements for

NURSING CASE STUDY

Diagnosis: Cerebrovascular Accident

Balino, Iris Joy F.

 Understand condition of cerebrovascular accident and associate it with the patient

Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-detector CT

i. Incidence, race, gender, age, ration and proportion

ii. Rationale for choosing the case

iii. Significance of the study

iv. Scope of limitation of study

v. Conceptual Theoretical Theory

vi. Related Literature

a. General Data Profile

1. History of Present Illness

e. Social History – Include theories of grown and development

PHYSICAL NORMAL ACTUAL INTERPRETATION

 Height and weight  Approximately  Approximately

Cognitive/ Perceptual  Oriented to time  Oriented  The patient is

Values/Beliefs  Patient believes in  Same as before  Patient is

III. CLINICAL DISCUSSION OF THE DISEASE

b. Rationale for choosing the case

Significance of the studies

d. Scope of limitation of the study

Self-Care Deficit Nursing Theory of Dorothea Orem

Therapeutic self-care demand “totality of self-care actions to be performed for some

Three Categories of Self-Care Requisites

Developmental self-care requisites- are associated with the developmental processes;

Theory of Self-Care Deficit

Five methods of helping

Theory of Nursing System

f. Related literature of the study

Signs and symptoms of pneumonia may include:

METASTATIC BREAST CANCER

 Cancer cells invade nearby healthy cells

 Cancer cells penetrate into the circulatory or lymph system

 Migration through circulation

 Cancer cells lodge in capillaries

 New small tumors grow

Metastasis to the lungs may cause:

Breast cancer surgery

 Removing the breast cancer (lumpectomy)

 Removing the entire breast (mastectomy)

 Removing a limited number of lymph nodes (sentinel node biopsy)

 Removing several lymph nodes (axillary lymph node dissection)

 Removing both breasts

Tests and procedures used to diagnose breast cancer include:

 Removing a sample of breast cells for testing (biopsy)

 Breast magnetic resonance imaging (MRI)

II. CLINICAL SUMMARY

ACCORDING TO ERIK ERIKSON

F. ENVIRONMENT/ LIVING CONDITION

PHYSICAL NORMAL ACTUAL INTERPRETATION

FUNCTIONAL HEALTH BEFORE DURING INTERPRETATION

Cognitive/ Perceptual  Oriented to time  Oriented  The patient is

Values/Beliefs  Patient believes  Same as before  Patient is

I. LABORATORY DIAGNOSTIC EXAM

Component Result Normal Range Interpretation Implication Nursing Responsibilities

HDL 34 MGS/DL Up to 55 mgs/dl Normal Results

Component Result Normal Range Interpretation Implication Nursing Responsibilities

ABG ( ARTERIAL BLOOD GAS)

Component Result Normal Range Interpretation Implication Nursing Responsibilities