TARLAC STATE UNIVERSITY

COLLEGE OF NURSING
Lucinda Campus
Brgy. Ungot, Tarlac City

A Case Study on Breast Cancer

In Partial Fulfillment of the Requirements of the Subject

Nursing Care Management 104

Presented to:

Gienelle M. Sabado, R.N., M.A.N.

(Clinical Instructor)

Presented by:

BSN IV - D
Santos, Marivic C.
Santos, Willa Milafrosa M.
Sotelo, Jeffrey R.
Suarez, Christine Karen A.
Sumang, Jerico B.

Date Submitted:
October 11, 2010
 Acknowledgment

Our group would like to extend our deepest gratitude to the following:

We would like to extend our heartfelt gratitude to our Clinical Instructor, Mrs. Gienelle
M. Sabado, we would like to broaden our appreciation for your time and magnanimous
knowledge to teach us nursing skills and develop attitude to each and every one of us to become
better nurses someday.

To the members: Marivic C. Santos, Willa Milafrosa M. Santos, Jeffrey R. Sotelo,

Christine Karen A. Suarez, and Jerico B. Sumang, for their efforts, and cooperation in finishing
this Case Study.

To our Dear Parents, we are very grateful for always being there to support us. For giving
us the sole opportunity to experience studying BSN and for their financial help.

To our patient and his husband, thank you for imparting your knowledge and the essential
information needed for our Case Study.

And above all, we would like to express our earnest and sincerest homage and love to our
Lord God, who constantly guides us in this course of our life. We thank him for his
unconditional love for each and every one of us.
 I. INTRODUCTION

Breast cancer (malignant breast neoplasm) is cancer originating from breast tissue, most

commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk.

Cancers originating from ducts are known as ductal carcinomas; those originating from lobules

are known as lobular carcinomas. Prognosis and survival rate varies greatly depending on cancer

type and staging. Some breast cancers are sensitive to hormones such as estrogen and/or

progesterone which make it possible to treat them by blocking the effects of this hormone in the

target tissues. These have better prognosis and require less aggressive treatment than hormone

negative cancers.

Worldwide, breast cancer comprises 10.4% of all cancer incidences among women,

making it the most common type of non-skin cancer in women and the fifth most common cause

of cancer death. In 2010, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths;

almost 1% of all deaths). Breast cancer is about 100 times more common in women than in men,

although males tend to have poorer outcomes due to delays in diagnosis.

The Department of Health says that breast cancer is now the most common cancer in the

Philippines, accounting for 16 percent of the 50,000 cases of the dreaded disease in the country.

Computerized models are available to predict survival. With best treatment and dependent on

staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes surgery,

drugs (hormonal therapy and chemotherapy), and radiation.

 II. Objectives

Nurse – centered

General:

This study is aim to gain or broaden the knowledge and skills with regards to the disease
condition Beast Cancer.

Specific:
 To gain more knowledge about Breast Cancer, its epidemiology, contributing factors,
pathophysiology, clinical manifestations, and the treatment required.
 To enhance the student skills by performing various nursing interventions to solve or
alleviate the patient’s needs as implementations of the formulated plans of care.
 To promote the student’s wellness of social health by conducting a healthy social
interaction with the patient.
 The nurse should be able to impart knowledge to the patient and significant others
regarding the patient’s condition.
 To gain fulfillment during and after rendering care to the patient, thus uplifting their
emotional health.

Patient – centered

General:

To be able to know his/her existing condition and to be able to participate well with
procedures and things he/she needs to comply for the success of his/her disease treatment.

Specific:
 To increase the client’s knowledge about her disease, which is Breast Cancer, by means
of giving health teachings in the contributing factors, disease course, manifestations and
treatments involved.
 To address the patient’s needs and problems that accompany the disease by performing
appropriate nursing interventions based on health care plans.
 To promote her emotional well-being by encouraging her to speak of whatever she feels
about her disease condition.
 The client should be able to gain knowledge about her condition and the different ways
on how to understand and accept her state of being.
 To gain cooperation with the health care provider in implementing the nursing
intervention as well as compliance to medical management.
Reasons in choosing the Case Study

We chose the case of breast cancer with Modified Radical Mastectomy because of the
following reasons:

a. Breast cancer is the most common cause of mortality and morbidity among women in the
Philippines and all over the world;
b. To know the Etiology, Pathophysiology, Clinical Manifestations of the Disease,
Prognosis, and treatment for such disease and be able to know what nursing
managements are appropriate.
c. To amalgamate health promotion and health maintenance into the case of post surgical
phase.
d. Knowledge and understanding about breast cancer and its surgery can develop us to be
better health care providers.

Importance of the case study

Our case study gives us a comprehensive stepwise in terms of skills and knowledge on
applying the nursing process namely assessment, planning, implementation, evaluation, and
including health teachings. In the context assessment, different skills are applied such as
inspection, palpation, percussion and auscultation to fully obtain an accurate and objective
finding. Nurse – patient interaction (NPI) is also essential in determining the different problems
of a patient which leads to giving a Nursing Diagnosis. The North American Nursing Diagnosis
Association (NANDA) helped us in formulating this diagnosis. Planning gives us a goal and
formulates certain objectives to alleviate problems seen in the patient.

Using the SMART (Specific, Measurable, Attainable, Realistic, and Time Bounded)
technique is crucial in attaining goals. Several Nursing Intervention are implemented and
rationales behind are given to determine the purpose on how and why we do certain
interventions. Lastly would be the evaluation in which it weighs or rates if the goal was attained
partially attained or not met. Having an evaluation is a prerequisite to know if further nursing
process is needed. A case study such as this allows us to develop critical thinking and use our
nursing judgment among different problems and situations to fully develop our Nursing Skills.
 III. NURSING PROCESS
1. Personal Data

A. Demographic Data
Name: Mrs. V
Sex: Female
Age: 66 years old
Civil Status: Widow
Birth date: January 4, 1944
Place of Birth: Gerona, Tarlac
Chief Complaint: Breast Mass
Admitting Diagnosis: Breast Mass, Right, t/c Malignancy
Nationality: Filipino
Role in the Family: Mother
Religion: Roman Catholic
Health Care Financing: Philhealth
Usual Source of Medical Care: RHU/Gov. Hospital

B. Environmental Status

Mrs. V’s house is made up of cement and wood. It composes of two bedrooms, a small

kitchen, living room and a comfort room. Their source of water is coming from NAWASA.

Their house is located along the Highway and their neighbouring company is the Jayson’s Pancit

Bihon wherein they usually inhaled the smoke coming from it.
 C. Lifestyle

According to Mrs. V, before she had this condition, she is socially active; she used to

attend fiestas in their Gerona, Tarlac. Still she can sweep their yard, cook their foods and wash.

She sits for quite sometimes to mingle with her co-barrio people about what’s new and to relax

for the day. Since almost all their neighbours are family and relatives she maintain a good

relationship to them. According to the patient, she occasionally drinks alcoholic beverages. She

is not an illegal drug user neither a smoker.

D. History of Past Illness

Mrs. V said that she worked as cook for almost 20 years. 9 years to a Chinese family and

11 years to the workers of a Buying Palay Station.So aside from the hot workplace, she used to

lift heavy kitchen wares containing foods. But at the age of 45 years old, she stopped cooking

and just baby sit on her grandchildren.

She did not remember anything that contributes to the mass on her breast. She said that

she never bumped on any things, fall down, or any object that may hurt the site. Mrs. V has 6

children with her husband (deceased due to Asthma 15 years ago), who are 2 boys and 4 girls.

She said she had a Normal Spontaneous Delivery to all of them at home. All breastfed, but she

confessed that it may be one of the contributing factor that time because while she was asleep,

she carry and breastfeed each baby and they accidentally kicked her breast.
 At year 2007, she noticed that a thumb - like mass located below the right armpit. With

minimal pain she felt. She did not tell to anybody about it for almost 3 years because she did not

want her children to be bothered. But as days passing by for this 3 years, this 2010, the lump or

mass becomes bigger and its shape according to her is like her closed fist comparing as ball. So

she begins to worry and tell to her children about it. They decided to consult at Tarlac

Provincial hospital last November 2009 and the doctor said that it’s a Breast Cyst and as soon

as possible she must be operated. But the family refused to have the operation since the

expenses for the operation was expensive and they decided to delay it then save for the amount

needed.

E. History of Present Illness

After the diagnosis, in order to cope and keep from worrying, they seek advices from

albularyos and drunk different boiled leaves of plants like Aroma, Bugnay , Tanglad and many

more herbal medicines for 4 months. But the situation seems become worst. 1 month prior to

admission ,she noticed that the lump’s color becomes like a purple star apple with lesion beside

the armpit and has blood secretions thus as days goes by, the breast skin becomes thinner and

looks like a cellophane and transparent, and it seems like to burst. They rushed to TPH to have it

check up last September 17, 2010, admitted and scheduled for operation last September 23, 2010

for a Breast mass to consider Malignancy.

 IV. FAMILY HISTORY OF HEALTH AND ILLNESS

Paternal Side Maternal Side

OA OA OA OA

HTN UC

6
6
AST HTN UC BCA UC

LEGEND:

LIVING MALE PATIENT AST – Asthma HTN – Hypertension

LIVING FEMALE BCA – Breast Cancer UC – Unknown Cause OA – Old Age

DECEASED MALE DECEASED FEMALE

 IV. 13 Areas of Assessment September 18, 2010

A. Social Status

According to Mrs. V, as a mother she cannot deny whatever her children request on her.
So at her age, she can manage on house hold chores aside from baby sit on her grandchildren.
Her sons and daughters with their spouses and grandchildren are very supportive to her. She can
sweep their yard, cook their foods and wash. When her grandchild fall into sleep, she said she
watched afternoon variety shows on T.V. She is also active to church activities. If they run out of
budget and kitchen needs, there is a little store nearby their house and here is where they usually
buy what are lacking for households. She sits for quite sometimes to mingle with her co-barrio
people about what’s new and to relax for the day. Since almost all their neighbours are their
family and relatives, she maintains a good relationship to them. And her children help together
when there are problems arises, especially concerning to health on each every member.

Norms: The patient and his family have respect to other people, believing that
relationships with other people are based on mutual trust (Westershoff) and putting their faith
in action and standing up for their beliefs (Kohlberg), (Med.& Surg. Nursing Lemone and Burk
2004)

Analysis: The patient developed interpersonal relationship within the family and their
neighbors with a certain degree of satisfaction. She developed a good coping ability as evidenced
by being hopeful to regain her normal functioning or health condition. Preferences and interest
exposed of her age were rather normal. Her activities were mostly dynamic in nature.

B. Mental status/Neurological Status

Facial expression Her expressions were appropriate according to the content of her dialogue
and showed a smile during the entire interview.
 Consciousness She was well oriented with the time and date, although she wasn’t able to
recall some of her past memories.

Communication She has a good eye contact during the interview. She was conversant, and
she could understand and speak Ilocano as well as Tagalog language.

Attention She was attentive during the interview and had a good communication
process. She was cooperative and answers the question appropriately.

Memory The patient wasn’t able to remember some of her past memories due to her
age.

Norms: The patient should appear relaxed with appropriate amount concern of
the assessment; should be clean and well groomed; expressions should be appropriate to the
content of the conversations; should be able to produce spontaneous, coherent speech; and
should respond to questions properly. (Health assessment and physical assessment, Mary
Elen zator Estes).

Analysis: The patient was oriented and conscious. She was cooperative during the interview
and was confident in expressing herself. The patient was also unable to recall some past events
that happened in her life due to her age.

C. Emotional Status

Mrs. V stated that despite all the problems in life, it should not affect her stability in life.
She tried to cover up before about her condition in order to make her sons and daughter not to
worry about her, but later, she confesses it. Since she has the fear too of what she expects to
happen in the future. She tried to manage her condition alone for almost 3 years.
Norms: A person’s emotional status depends much on is ability to cope up with the
happenings in his life. He may or may not be emotionally stable of unfortunate incidents
happened. (Nursing CEU.com: The process of human development)

Analysis: The client has a positive outlook in life and can handle her emotions well.

D. Sensory Perception

Sense of Sight

Visual acuity Visual acuity has no alterations.

Symmetry Patient’s eyes are symmetrical and round in shape.

Color of Sclera Both scleras are whitish in color but the conjunctivas are pinkish in
color.

Norms: The patient should have a visual acuity of 20/20; the eyes must
be symmetrical during the six cardinal gazes; sclera should be white with some small blood
vessels. (Health Assessment and physical assessment, Mary Elen Zator Estes).

Analysis: The patient’s visual aciuty was normal. Her eyes were symmetrical in shape, the
sclera is whitish in color, and he has pale conjunctiva.

Sense of Taste

Color The tongue is pinkish in color.

Hydration It is moist and rough with a clear secretions or saliva.

 Taste She verbalized the sweet taste when she ate her food, indicating
she could determine the taste the food served to her.

Norms: A person has no problem about his sense of taste if he can identify the
sweet, sour, salty, and bitter taste of foods he eats. (Estes, Third edition, Copyright 2006)

Analysis: Revealed normal condition of the sense of taste based from the standards.

Sense of Smell

External inspection Nose is in the midline of the face, symmetrical, without lesions or
pain.

Patency There was no obstruction upon breathing. The student nurse asked her to
smell the objects we held near her nose through blindfold. The patient responded and
verbalized what she smelled and stated that she smelled alcohol and perfume.

Norms: Nose must be symmetrical and along the midline of the face. Each nostril must be
patent. (Health assessment and Physical Assessment, Mary Elen Zator Estes)

Analysis: Revealed normal findings upon assessment based on standards. There were no
deviations observed.

Tactile Sensitivity

Pain tolerance The student nurse pointed the sharp and dull edges of the ballpen
to the pt.’s skin and asked her to tell the sensation. The patient responded and verbalized
what she felt and stated that she felt sharp and dull object touched her skin.

Temperature She could feel the humid temperature in the hospital.

Norms: The skin contains receptors for pain, touch, pressure and temperature.
Sensory signals that help determine precise locations on the skin are transmitted along rapid
sensory pathways, and less distinct signals such as pressure or poorly localized touch are sent
via slower or sensory pathways. (Health Assessment and Physical Examination, Mary Ellen
Zator Estes 5th Edition)

Analysis: The patient’s sensory transmission functions are within the normal as
manifested by the data presented.

Auditory Acuity

“Watch tick” test She could hear the sound of the watch 1inch away from her.

Symmetry Ears were symmetrical with each other and were aligned on the
level of his eyes. There was no pain complained felt upon inspection.

Whisper test The patient was able to hear whispered words from 1-2 inches
away and repeated the words accordingly.

Norms: The patient should be able to hear whispered words to 2 inch away. The pt.
should not complain of pain upon palpation. (Health assessment and physical assessment, Mary
Elen Zator Estes)

Analysis: Upon assessment, there were no lesions or inflammation found.

E. Motor Stability

Mrs. V is able to ambulate with assistance on the first and second day but on the third day
she does it alone. She moves slowly with minimal movements.
Norms: Normal motor stability includes the ability to perform the different steps in doing
range of motion. It should be firm with smooth and coordinated movements (Estes, Third edition,
Copyright 2006)

Analysis: The client’s walking gait was not normal on the 1st and 2nd day after operation.

F. Body Temperature

Date Time Temperature

September 27, 2010 10:00 am 37.5 ◦C
September 28, 2010 07:00 am 37.2 ◦C
10:00 am 36.3 ◦C
02:00 pm 36.9 ◦C
September 29, 2010 07:00 am 36.8 ◦C
10:00 am 37.0 ◦C
02:00 pm 36.8 ◦C

Norms: 36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition,
Copyright 2004)

Analysis: The body temperature of the patient was within normal range.

G. Respiratory Status

Date Time Respiratory Rate

September 27, 2010 10:00 am 19 cpm
September 28, 2010 07:00 am 20 cpm
10:00 am 17 cpm
02:00 pm 16 cpm
September 29, 2010 07:00 am 20 cpm
10:00 am 18 cpm
02:00 pm 20 cpm
Norms: Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of
pattern, normal respiration must be regular and even in rhythm. The normal depth of
respirations must be effortless. (Health Assessment and Physical Examination 3rd Edition Mary
Ellen Zator Estes).

Analysis: The patient has normal respiration during the assessment.

H. Circulatory Status

Date Time Blood Pressure Pulse Rate

September 27, 2010 10:00 am 110/80 mmHg 84 bpm

September 28, 2010 07:00 am 120/70 mmHg 89 bpm

10:00 am 120/90 mmHg 92 bpm

02:00 pm 110/70 mmHg 90 bpm
September 29, 2010 07:00 am 100/70 mmHg 98 bpm
10:00 am 120/90 mmHg 94 bpm
02:00 pm 110/90 mmHg 96 bpm

Norms: The average heart rate of an adult is 80 – 100 bpm, and the average blood
pressure of an adult is 120/80mmHg. (Kozier, Seventh edition, Copyright 2004).

Analysis: With regards to Mrs. V’s circulatory status, it shows that her pulse rate and blood
pressure is in the normal range.

I. Nutritional Status

In the recall of previous diet taken by the patient, the client’s diet is under control of
glucose and carbohydrate diet. Her diet according to the physician’s order is on high fiber. She
eats 3 meals per day with some snacks during the afternoon or siesta time. Her fluid intake was
less than 3 bottles of water (1.5L each) amounting to approximately 4.5L.
 BMI Computation:

Given: weight = 45 kg
Height = 5 ft (4 inches)
BMI = weight in kg / height in (m) 2
= 45 / (1.6256)2
BMI = 17.01

Norms: “Normal eating pattern is on the minimum of 3 – 5 times per day, depending
upon metabolic need and demands. Fluid is on the average of 8-10 glasses” (2-3 liters) per day.
(Physical Assessment and Health Examination 4th Edition, Carolyn Jarvis) BMI is a
measurement that indicates body composition. The degree of overweight or obesity as well as
the degree of underweight can be determined by making use of BMI.(Estes, Third edition,
Copyright 2006)

Standard Body Mass Index for Adults (Estes, Third edition, Copyright 2006)
 Underweight = <18.5
 Normal weight = 18.5-24.9
 Overweight = 25-29.9
 Obesity = BMI of 30 or greater

Analysis: Based on the standards, her nutritional status was beyond the normal range and
she was underweight.

J. Elimination Status
 She usually voids 3 – 4 times per day depending on the amount of fluid he ingests, and
his urine colour was yellow. She also stated that she usually defecates once a day; and described
her stool is brown in colour, and solid - formed.

Norms: Normal bowel movement is usually 1 – 2 times per day. It should be solid -
formed and brown in colour. Normal urine output of an adult is usually 1200-1500mL per day,
and voids 3 – 4 times a day. (Kozier Seventh edition, Copyright 2004)

Analysis: The patient’s elimination status is normal. No alterations found during

assessment.

K. Rest and Sleep

Mrs. V stated that she only sleeps at 9:00 PM and wakes up at 4:00 AM. at home. She
usually sleeps 6-7 hours at night but during her hospital, confinement she has a disturbed
sleeping pattern due to her post - op condition with pain and minimal movement. So she takes
nap during the afternoon.

Norms: A normal sleep hour of an adult per day is 6-8 hours without disturbance.(Kozier,
Seventh edition, Copyright 2004)

Analysis: The patient has inadequate rest and sleep.

L. Reproductive Status

The patient had her menarche at the age of 14. Her cycle usually lasts for 5 days. She
experienced headaches and pain on the pelvic area during her cycle. She became sexually active
at the age of 19. She had menopaused at the age of 45.
Norms: “Menarche, which is the first menstruation occur at an average age of
onset between 9 to 17 years old.” (Maternal and Child Health Nursing 4th Edition by Pilliterri)

Analysis: The patient has normal reproductive status.

M. State of Skin Appendages

Mrs. V has a normal complexion. She had undergone a capillary refill test resulting 3
seconds capillary refill. Her extremities was warmth. Her hair was black with some white hairs.
She had an incision site at the Right breast with dry wound dressing.

Norms: Skin varies from light to brown from ruddy pink to light pink. Generally, the skin
has uniform color except in areas exposed to the sun, in areas of lighter pigmentation in palms,
nail beds, and lips. The hair should be evenly distributed, thick, shiny and free from infestation.
Capillary refill must be within 2 – 3 seconds and should return immediately. (Kozier, Seventh
edition, Copyright 2004)

Analysis: Revealed abnormal findings based on the standards given due to her operation at
her right breast
 V. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Date Ordered Normal Values Analysis and

Indication/s or
Laboratory and Date (units used in the Result/s interpretation of
purposes
procedures Resulted hospital) Results

Hematology September 17, WBC 4.5-11X10 /L WBC 10.6 G/L Normal

Report 2010
Complete blood count
(CBC) is a
determination of the LYM 0.23-0.35% LYM 4.5 42.1 %L Increased
number of red and
white blood cells per
cubic millimeter of MID 0.0–1.8 MID 0.7 6.3%M Normal
blood. A CBC is one of
the most routinely
performed test in a GRAN 2.0 – 7.8 GRAN 5.5 51.6%G Normal
clinical laboratory and
one of the most
valuable screening and
RBC 4.20–6.30X10 RBC 3.98 T/L Decreased
diagnostic techniques.
/L
It also helps the health
professional to check HGB 120-180 g/L
the patient’s condition, HGB 119 g/L Decreased
such as anemia,
infection and some HCT 0.370-
symptoms like fatigue. 0.5%/L HCT 0.368L/L Decreased
And weakness the
patient’s have.
 Normal
MCH 29.9pg
MCH 26.0-32.0/g

Normal
MCHC 323 g/L
MCHC 310-360
g/L

Normal
PLT 140-940 PLT 264 g/L
g/L

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure.

2. Explain the importance of the procedures to be done to the pt.
Diagnostic/ Laboratory Date Ordered and Indication/s or purposes Result/s Analysis and
procedures Date Resulted interpretation of
Results

Chest Pulmonary The ribs are intact. The heart

Radiography is a projection is not enlarged. No
radiograph of the chest used pneumothorax or pleural
Chest Pulmonary September 17, 2010 to diagnose conditions effusion is demonstrated. The Normal.
Radiography affecting the chest, its lung fields are essentially
contents, and nearby normal. The diaphragm is
structures. Chest normal.
radiographs are among the
most common films taken,
being diagnostic of many Impression: The lung fields
conditions. are essentially clear.

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure.

2. Explain the importance of the procedures to be done to the pt.

Diagnostic/ Date Ordered and Indication/s or Normal Values Result/s Analysis and
 Laboratory Date Resulted purposes (units used in the interpretation of
procedures hospital) Results

Color: clear or amber Amber Normal

Urinalysis September 17, 2010 For detection of any Appearance: straw Turbid Not normal
bacteria in the urine,
glucose, albumin, Reaction: alkaline Alkaline Normal
blood, protein Specific gravity
presence of
infection. 1.010-1.030 1.010 Normal

Albumin: (-) Negative Normal

Glucose: (-) Negative Normal

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure.

2. Explain the importance of the procedures to be done to the pt.
 Diagnostic/ Date Ordered and Indication/s or Normal Values Result/s Analysis and
Laboratory Date Resulted purposes (units used in the interpretation of
procedures hospital) Results

For the FBS 3.9 – 6.1 5.34 Normal

determination of the mmol/L
Blood chemistry September 18, 2010 chemical
constituents of
blood by assay in a BUN 2.9 – 8.3
clinical laboratory mmol/L 4.78 Normal
as part of a
diagnostic protocol.

Crea 53 – 106 70.72 Normal

mmol/L

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure.

2. Explain the importance of the procedures to be done to the pt/
Diagnostic/ Laboratory Date Ordered and Indication/s or Result/s Analysis and
procedures Date Resulted purposes interpretation of
Results

Incisional Biopsy
September 23, 2010
MUCINOUS
CARCINOMA
Incisional biopsy often Not normal
yield better diagnosis for Gross: The specimen
deep pannicular skin consists of two dark
diseases and more brown, irregular and soft
subcutanous tissue can tissue measuring 1.0x1.-
be obtained. Advantage x0.3 cm in aggregate
of the incisional biopsy dimension.
is that hemostasis can be
done more easily due to Micro: Microscopic
better visualization. sections reveal malignant
glands floating in pools of
mucin. Also noted are
scattered neoplastic cells
in a desmplastic stroma.

NURSING RESPONSIBILITIES:

Before, during and after diagnostic and laboratory test/s done:

1. Inform the pt. and the family about the procedure.

2. Explain the importance of the procedures to be done to the pt.
 VI. ANATOMY AND PHYSIOLOGY

The breasts are composed of fatty tissue that contains the glands responsible for milk

production in late pregnancy and after childbirth. Within each breast, there are about 15 to 25

lobes formed by groups of lobules, the milk glands. Each lobule is composed of grape-like

clusters of acini (also called alveoli), the hollow sacs that make and hold breast milk. The

lobules are arranged around ducts that funnel milk to the nipples. About 15 to 20 ducts come

together near the areola (dark, circular area around the nipple) to form ampullae - cavities

that store the milk before it reaches the nipple surface. Montgomery's glands are small oil

glands that are located around each areola. They release a lubricant that protects the nipples

during nursing.
 Breast Size and Shape

The breasts are not always exactly the same size or shape. They are incompletely

developed at birth and - in men - remain small and undeveloped unless subjected to abnormal

hormonal stimulation. In general, breast formation is complete within a year or two after the

start of menstruation; however, the acini keep growing, and fibrous and fatty tissues are

continually added during adolescence. Pregnancy and nursing cause further increases in

breast size. As a woman ages, the fatty tissue of the breasts may become more prominent

than the glandular tissue, and the breasts may feel softer. The breasts gradually atrophy

(shrink) after menopause.

Breast Position

The breasts cover a large part of the chest wall. In front, the breast tissue may extend

from the clavicle (collarbone) to the middle of the sternum (breastbone). On the side, breast

tissue may continue into the axilla (armpit) and reach as far as the latissimus dorsi (muscle

extending from the lower back to the humerus bone of the upper arm).

In fact, the anatomic relationship between the breasts and the underlying muscle is a very

important consideration in surgical therapy. The breasts overlay vital chest wall muscles such as

the pectoralis major (the 'pecs'), the pectoralis minor (thin, triangular muscle beneath the pecs),

and the intercostals (muscles between the ribs). The breasts also may cover some of the serratus

magnus (also called the serratus anterior; a slender muscle that is attached to the ribs/ rib muscles
and connects with the shoulder blade) and the rectus abdominis (long, flat muscle that stretches

up the torso from the pubic bone to the ribs).

Lymphatic System

Lymph is a clear, tan fluid that contains lymphocytes (white blood cells that fight

disease). Lymph is drained from the breast tissues by a rich supply of vessels. Such lymphatic

vessels connect with a network of lymph nodes that are located around the breasts' edges or in

nearby tissues of the armpits and collarbone. Lymph nodes play a central role in the spread of

breast cancer. The axillary (underarm) lymph nodes are particularly important, as they are among

the first places that cancer is likely to be found if it metastasizes (spreads) from the breast. This

lymph node cluster is often referred to as the 'tail,' or level I nodes. Level II nodes are located

underneath the pectoralis minor muscle, and level III nodes are found near the center of the

collarbone.
 VII. PATHOPHYSIOLOGY

Predisposing factor: Precipitating Factor:

 Sex  High – fat diet
 Age  Obesity
 Family History of Breast Cancer  Lack of physical Mobility
 Early Menarche  Alcohol use
 Race (African – American, Asian)  Lifestyle
 Non – breastfeeding woman  Anti – perspirant use

Increased estrogen metabolism

Absorpttion of chemicals through perspirant use

Increased cell prolifertion

Toxins interfere in the lymph nodes

Toxins build up in the breast

Carcingens bind to DNA results to alteration in function

Genotoxic waste in estrogen Spontaneous error of cells

Damage to the genes of Tumor Supressor Cells Continuous duplication of mutated DNA
Repair or elimination of cells with damaged DNA is inhibited

A single cell begins to divide abnormally

Thickening of a lump Formation of new affected tissue STAGE 1

near the abdomen

If not treated:

Malignant conversion: accumulation of cells in the center of Tumor necrotized and begins to chip of malignant cells to
seek new blood

Cells break out of the tumor and invades to surrounding lumph nodes

Lymphatic spread: dissemination of cancer Hematologic spread: cancer move to

STAGE 2
cells to the lymph channels in the process the extracellular matrix by secreting
enzymes

Cells penetrates to lymph vessels by invasion

and lodges in the lymph nodes Entry to blood vessels
 Surrounding vessels and lymph nodes Blood vessels including arteries and veins
becomes obstructed carries cancer cells to other organs

Unlocked lymph nodes Blockage of lymph vessels Inflammation of the

drains towards the venous draining fluids breasts and lymph nodes
blood flow

Cancer cells continues to stream in the lymph fluids

Cancer cells spread into membraane lining

May undergo invasive metastasis destroying epithelial tissues

Irritation and build up of fluids on adjacent tissues

Impaired lymph fow and erosion of tumors

accumulates in the chest

New sites of tumor STAGE 3

Cancer cells that are able to survive the
environment and presuure will continues

Metastasis STAGE 4 If untreated: DEATH

 VIII. NURSING CARE PLANS

Expected
Assessment Planning Intervention Rationale
Outcome

S> “Masakit ang sugat ko Within 30 minutes of After 30 minutes

“ rendering appropriate  Dress the wound.  To prevent of rendering
nursing interventions, occurrence of appropriate nursing
PS: 7/10 the client’s pain scale infection. interventions, the
will decrease from client’s pain scale
O> 7/10 to 3/10.  Provide comfort like  To increase will decrease from
back rubbing. relaxation of the 7/10 to 3/10.
 Grimace noted pt.
 Guarding behavior
noted
 Assist in deep
 Restlessness  Pursed-lip
breathing and pursed-
 Diaphoretic breathing and
lip breathing
deep breathing
Nursing Diagnosis: was effective in
decreasing pain
Acute pain r/t surgical
procedure (Modified  Cognitive
 Support the client’s
radical mastectomy) behavioral
use of non-
pharmacological strategies can
methods to help restore sense of
Scientific Explanation: self control,
control pain such as
distraction, imagery personal efficacy
An unpleasant sensation and active
and relaxation
caused by noxious participation for
stimulation of the sensory her own care.
nerve ending. It is a
subjective feeling and an
individual response to the  Reinforce the  Teaching client to
cause. Pain is subjective in importance of pain stay on top of
which the pt. inhibits a medication to keep their pain and
pain under control prevent it from
feeling of distress.
getting out of
Stimulating or trauma to control will
certain nerve endings as a improve the
result of surgery causes ability to
pain. accomplish the
goals of recovery.

 Administer pain  To relieve pain

medications such as
morphine sulfate and
analgesics as
prescribed
 Expected
Assessment Planning Intervention Rationale
Outcome
 Periodically  To monitor
S>O Within 1 to 2 hours of premeasured wound progress of After 1 to 2 hours
proper nursing and observe for any wound healing of proper nursing
O> intervention, the complications such intervention, the
 Disrupted skin patient will be able to infection. patient will be able
surface participate in to participate in
 Complaint of pain prevention and  Keep area clean and  To reduce prevention and
on incision site treatment program. dry, carefully dress pressure enhance treatment program.
 Restlessness noted wound , and support circulation to
 Swelling and incision compromised
redness noted at tissue
the site
 Excessive  Use appropriate  To provide
perspiration noted padding device if positive nitrogen
indicated balance and aid in
Nursing Diagnosis: healing and
maintain good
Impaired Skin r/t surgical health
procedure (Modified
radical mastectomy)
 Instruct and encourage  To achieve
Scientific Explanation: strict compliance of wellness and
medication regime prevent further
The condition defines as a complications
state in which body’s
natural skin has been
damaged either naturally
or surgically.
 RATIONALE EXPECTED
ASSESSMENT PLANNING IMPLEMENTATION
OUTCOME

S> “Nahihirapan akong > Within 3º of  Render sponge bath to  To maintain > After 3º of
matulog ng maayos kasi rendering appropriate provide better freshness. rendering
maingay dito” nursing intervention, circulation. appropriate nsg.
the pt. will able to Intervention, the
sleep and feel  Change loosens
clothing.  To provide pt. is able to sleep
O> frequent yawning comfortable. comfort and feel
noted. comfortable.

>sleepy in appearance.  Provide proper

ventilation.  To maintain a
>weak in appearance. cool environment
suitable for
>restless
sleeping.
>irritable

 Render back rubs.  To promote and

Nursing Diagnosis: give relaxation
techniques.
Disturbed sleep pattern r/t
physical discomfort
  To provide
comfortable and
 Arrange bedside clean
linens. environment.
Scientific Explanation:

Time limited disruption of

sleep (natural, periodic,
suspension of
consciousness) amount
and quality.

Assessment
S>O
O>
 Complaint of pain
on incision site
 Restlessness noted
 Malaise
 Swelling and
redness noted at
the site
Nursing Diagnosis:
Risk for infection r/t
inadequate primary
defense 2◦ surgical
procedure (Modified
radical mastectomy)
Scientific Explanation:
An infection is the
detrimental colonization
of a host organism by a
foreign species. In an
infection, the infecting
Expected
Planning Intervention Rationale
Outcome
Within 4 hours of  Stress the importance  To reduce the risk After 4 hours of
rendering proper of proper hand of contributory rendering proper
nursing interventions, washing technique factors nursing
the patient will relieve intervention, the
from signs and  Maintain adequate  To prevent patient will relieve
symptoms of infection hydration , increase dehydration and from signs and
fluid intake maintain symptoms of
hydration status infection as
evidenced by
 Instruct SO in  To have more temperature
techniques to prevent information SO decreases from
skin integrity and needs 37.8 C to 37.
prevent spread of
infection
 Encourage intake of  To promote faster
vitamin C rich foods , wound healing
CHON and protein and increase
resistance to
infection
 Encourage patient
observe proper  To decrease the
hygiene risk of acquiring
infection
 Provide skin care  Peripheral
gently massage bony circulation may
area. Keep the skin be impaired
organism seeks to utilize dry , linens dry and placing patient at
the host's resources to wrinkle free risk for skin
multiply (usually at the irritation
expense of the host).
 Administer antibiotics  To reduce risk of
as prescribed spread of
infection
 IX. Medical Management/Treatment
Date ordered /
Date
Medical Client’s
performed / General Indication/s or
Management / reaction to
Date changed / Description Purpose/s
Treatment treatment
Date
discontinued

1. D5LR 1L Date ordered: A hypertonic To increase the There were no

solution with volume of signs of
Sep. 19, 2010 greater blood following inflammation or
concentration severe loss of infiltration
of solutes blood or plasma during the
2. D5LR 1L Date ordered: than plasma and is used for infusion.
and can draw fluid and
Sep. 20, 2010
fluids out of electrolyte
the cells and replenishment
interstitial and caloric
3. D5NM Date ordered: spaces into supply.
the vascular
30gtts Sep. 21, 2010
system.

4. D5LR 1L Date ordered:

Sep. 22, 2010

NURSING RESPONSIBILITIES:

Before, during and after the treatment:

1. Explain the procedure to the patient.
2. Secure consent from patient before IV infusion.
3. Verify physician’s order indicating the type of solution, amount to be administered, and
rate of flow of the infusion.
4. Inspect IV site for signs of infiltration or inflammation.
5. Check IV flow rate and monitor fluid volume overload.
6. Monitor intake and output.
 Route of General Nursing Responsibilities
Drug Name Date Indications
Administration Action Before During After

Generic Name: Ordered: Intravenous, Possess anti- > Indicated > Consider > Administer > Monitor
Oral inflammatory for the relief the rights in as part of a patient’s
Ketorolac 09/26/10 analgesic and of the s/s of drug regular intake and
antipyretic RA and administration analgesic output to
effects. They osteoarthritis schedule check for GI
Brand Name: are largely > Inform the rather that on disturbance
related to > For relief of patient about as needed
Toradol mild to the > Instructed
inhibition of basis
prostaglandin moderate pain medication patient to
synthesis. > Check for increase fiber
Dosage & > For > Administer
Classification: any unusual intake such
treatment of with food and bruising as pineapple
Frequency
Non-Steroidal primary mild if GI and/or
Anti- dysmenorrheal upset occurs bleeding > Record the
Inflammatory medication
30 mg 2 cap > For fever
Drug given.
P.O. T.I.D. reduction
 Client’s
Date Ordered,
General Specific Foods Response and/or
Type of Diet date Started,
Description Taken Reaction to the
Date Changed
Diet

NPO Date ordered: Strictly, not NONE The patient

allowed to take any understood the
September 22, kind of food or procedure.
2010 liquids by mouth.

Full Liquid Date ordered: Full liquid diet 1 cup noodle She was glad that
Diet allows only foods soup or “Broth” finally she could
September 23, in liquid form or only, tea eat foods.
2010 those which readily
become liquid at
body temperature.

Soft Diet Date ordered: A diet that allows Lugaw She was glad that
fruits and finally she could
September 24, vegetables with eat foods.
2010 low-cellulose
content as well as
fish and meat with
no or very little
connective tissues.

NURSING RESPONSIBILITIES:
Before, during and after the administration of the diet:

1. Explain the procedure.

2. Be sure that the patient flatus before giving the diet.
3. Teach the family about the diet.
4. Check the patient’s food.
5. Observe tolerance for eating.
 6. Check the patient’s readiness for the next diet.
7. Document the procedure.

Date Ordered, Client’s response /

Type of General Indication/s or
Date Started, reaction to the
Exercise Description Purpose/s
Date Changed activity / exercise

Bed Rest Date ordered: Is a medical For fast Relaxed and

treatment refers recovery of the comfortable.
Sep. 23, 2010 to staying in patient.
bed day and
night as a
treatment for an
illness or
medical
condition.

Ambulation Date ordered: Ambulation is For progress She can tolerate

the and early walking without
Sep. 24, 2010 recommended recovery of the assistance.
for a healthy patient.
lifestyle, and
has numerous
environmental
benefits.

NURSING RESPONSIBILITIES:

1. Educate the patient about the importance of ambulation and bed rest, and the appropriate
way of doing the exercise.
2. Assisted the patient in ambulation
 X. SURGICAL MANAGEMENT

Client’s
Name of Date Brief
Indication/s or Purpose/s response to the
procedure performed Description
operation

Modified Sep. 23, A surgical The purpose for modified Client

Radical 2010 procedure radical mastectomy is the understood the
Mastectomy that removes removal of breast cancer risk and benefit
the breast, (abnormal cells in the breast of the operation.
surrounding that grow rapidly and Thus accepting
tissue, and replace normal healthy the postoperative
nearby tissue). Modified radical outcome.
lymph nodes mastectomy is the most
that are widely used surgical
affected by procedure to treat operable
cancer. breast cancer. This
procedure leaves a chest
muscle called the pectoralis
major intact. Leaving this
muscle in place will provide
a soft tissue covering over
the chest wall and a normal-
appearing junction of the
shoulder with the anterior
(front) chest wall. This
sparing of the pectoralis
major muscle will avoid a
disfiguring hollow defect
below the clavicle.
Additionally, the purpose of
modified radical
mastectomy is to allow for
the option of breast
reconstruction, a procedure
that is possible, if desired,
due to intact muscles around
the shoulder of the affected
side. The modified radical
 mastectomy procedure
involves removal of large
multiple tumor growths
located underneath the
nipple and cancer cells on
the breast margins.

NURSING RESPONSIBILITY:

Before, during and after the surgical procedure:

1. Explain procedure to the patient.

2. Advise the patient to not eat or drink for several hours before the examination.
3. Provide patient privacy
4. Observe for patient’s response to the procedure
5. Assist patient to move from supine to sitting position
6. Follow up for the result of the procedure
 XI. SOAPIE/R

SUBJECTI
DATE OBJECTIVES ASSESSMENT PLANNING INTERVENTION EVALUATION
VE CUE/S
CUE/S

S>  Dress the wound. After 30

September “Masakit O> Acute pain r/t Within 30 minutes of
24, 2010 ang sugat surgical minutes of  Provide comfort like rendering
ko”  Grimace procedure rendering back rubbing appropriate
noted (Modified
appropriate nursing
 Guarding radical  Assist in deep
PS: 7/10 mastectomy) nursing breathing and pursed- interventions,
behavior
noted interventions, the lip breathing the client’s
 Restlessn client’s pain scale  Support the client’s use pain scale was
ess will decrease of non- decrease from
 Diaphore from 7/10 to 3/10. pharmacological 7/10 to 3/10.
tic methods to help control
pain such as
distraction, imagery
and relaxation
 Reinforce the
importance of pain
medication to keep
pain under control
 Administer pain
medications such as
morphine sulfate and
analgesics as
prescribed
 SUBJECTI
DATE OBJECTIVES ASSESSMENT PLANNING INTERVENTION EVALUATION
VE CUE/S
CUE/S

S>O O>  Periodically After 1 to 2

September  Disrupted Impaired Skin Within 1 to 2 premeasured wound hours of proper
24, 2010 skin r/t surgical hours of proper and observe for any nursing
surface procedure nursing complications such intervention,
 Complain (Modified intervention, the
infection.
the patient was
t of pain radical
mastectomy) patient will be be able to
on  Keep area clean and
able to dry, carefully dress participate in
incision
site participate in wound , and support prevention and
 Restlessn prevention and incision treatment
ess noted treatment program.
 Swelling program.
and  Use appropriate
redness padding device if
noted at indicated
the site
 Excessiv  Instruct and encourage
e strict compliance of
perspirati medication regime
on noted
 SUBJECTI
DATE OBJECTIVES ASSESSMENT PLANNING INTERVENTION EVALUATION
VE CUE/S
CUE/S

S>  Render sponge bath to After 3º of

September “Nahihirap O> frequent Disturbed sleep > Within 3º of provide better rendering
22, 2010 an akong yawning noted. pattern r/t rendering appropriate
circulation.
matulog ng physical appropriate nsg.
>sleepy in discomfort nursing  Change loosens Intervention,
maayos
appearance. intervention, the clothing.
kasi the pt. was able
maingay >weak in pt. will able to to sleep and
 Provide proper
dito” appearance. sleep and feel feel
ventilation.
comfortable. comfortable.
>restless  Render back rubs.
>irritable
 Arrange bedside linens.
 SUBJECT
EVALUATIO
DATE IVE OBJECTIVES ASSESSMENT PLANNING INTERVENTION
N
CUE/S CUE/S

September S>O O> Risk for Within 4 hours  Stress the importance of After 4 hours
22, 2010  Complai infection r/t of rendering proper hand washing of rendering
nt of inadequate proper nursing technique proper nursing
pain on primary defense  Maintain adequate
interventions, the intervention,
incision 2◦ surgical hydration , increase
procedure patient will the patient
site fluid intake
 (Modified relieve from was relieved
Restless  Instruct SO in
ness radical signs and techniques to prevent from signs and
noted mastectomy) symptoms of skin integrity and symptoms of
 Malaise infection. prevent spread of infection.
 Swelling infection
and  Encourage patient
redness observe proper hygiene
noted at  Provide skin care gently
the site massage bony area.
Keep the skin dry, linens
dry and wrinkle free
 Administer antibiotics
as prescribed
DISCHARGE PLANNING

i. General condition of the patient upon discharge.

It was September 30, 2010 when the patient was discharge. She was able to do her
ADL such us dressing and going to the bathroom without any assistance.

The doctor ordered the patient for OPD fallow-up. And was also advice to have a
complete bed rest and continue Diet as Tolerated with Low Salt, Low Fat Diet.

ii. METHOD

M- Take home medication instructed as follows:

 Cefuroxime 500mg 1 cap. P.O. once a day
 Ketorolac 10mg 1 cap three times a day
E – Complete bed rest.

T - Upon the day of discharge, she was advised to clean and change the
dressing of the incision site daily.

H-
 Encouraged taking prescribed drugs for maintenance and early
recovery.
 Instructed to report any adverse reaction of medicines
immediately.
 Educated the patient to avoid activities or habits that can
precipitate fatigue/ eating large meals, drinking coffee, smoking,
exercising too extraneously.
 Explained the importance of balance diet.
 Encouraged brief rest period throughout the working day.
  Advised patient who are anxious and nervous to consider
counselling, to the relaxation techniques may also be used.
O- Follow-up check-up on October 07, 2010 at the Out-Patient –
Department of Tarlac Provincial Hospital.

D- Diet as Tolerated

XIII. CONCLUSION

The therapeutic management for this problem the patient is placed on bed rest either in

the hospital or at home and administers medications as prescribed. All objectives were

constructed for our patient’s benefit in able for the group to have prioritized nursing action. The

group constructed and considered all the objectives that we gathered from our patient. For our

objectives, the group had evaluated it as good and successful actions because the goals were

achieved and all appropriate nursing interventions are rendered to our patient.

XIV. RECOMMENDATION

The group recommended that after the operation, the patient should be aware for the

problems that may occur in her incision site, especially for the risk of infection. The groups

also recommend that the pt. must continue her medication as prescribed by the doctor that will

help for her faster recovery. The pt. was advice to avoid her past lifestyle for the mean time,
which may cause arising of problem in her situation. The cleaning of her incision site and

changing the dressing daily was recommended to the patient. On her discharge, the pt. was

recommended to have a follow-up check up, to know if the treatment is effective, if there are

changes during her recovery and to know if there is a progress and an improvement of the

patient’s condition.

XV. BIBLIOGRAPHY

 Fundamentals of Nursing, Daniels

 Fundamentals of Nursing: Process, Concepts and Practice, 7th Edition
 Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes
 Friedman and Smith, 1998
 Nursing Diagnosis Handbook, 5th Edition 2006 by Ackley and Ludwig
 http://medical-dictionary.thefreedictionary.com/nutritional+status
 www.umm.edu/sleep/normal_sleep.html
 www.yahoo.com
 www.google.com
 www.scribd.com
 www.nursingcrib.com