Ateneo de Davao University

College of Nursing

A Case Presentation
On
Breast Cancer

In Partial Fulfillment of the Requirements in Related Learning Experience

Submitted to:
Ms. Kristina Concepcion, RN
Clinical Instructor

Submitted By:
Jonna Lisa M. Lagdameo
BSN- 4E

Date Submitted:
January 27, 2010
 Acknowledgement

This case study has provided me new knowledge and ideas to understand the
condition that most women have and suffer.
With the following people, this case study has been successfully completed and
was made possible:
First, my co-worker, Jesus Christ for guiding me through and enlightening my
path by giving me enough patience and persistence to do this case study with optimism
and confidence.
Second, I would like to thank my family, for making me take up nursing and get
through this individual case presentation, for having served as my reason to strive harder
to be a successful person and for making my life complete and my journey worth beyond
a lifetime.
Third, I would like to extend my gratitude to my clinical instructors for guiding
me and correcting all my mistakes which served as lessons and for being a part of the
challenges of my basic foundation in this world of health care.
Fourth, I am grateful to the hundreds of authors of my references for about 3 years
of making a case study, whose works served as my substance and inspiration from which
I derived my answers and rationales.
Lastly, to the DMSF staff for guiding me in copying and carrying out the Doctor’s
Orders and for teaching us to become a good nurse that practice ideal nursing skills and
to my group mates from group 3 of sections F and E, you made my life happy on my
entire nursing life.
DAGHANG SALAMAT!
 Introduction

“Women agonize... over cancer; we take as a personal threat the lump in every
friend's breast. “ ~Martha Weinman Lear, Heartsounds

All women are at risk, approximately 70% of breast cancers occur in women with
none of the known risk factors. Only about 5% of breast cancers are inherited, about 80%
of women diagnosed with breast cancer will be the first to be victims in their families. It
is the leading killer of women ages 35 to 54 worldwide, more than a million women
develop breast cancer without knowing it and almost 500,000 die from it every year. One
out of 4 who are diagnosed with breast cancer die within the first 5 years. No less than
40% die within 10 years. The incidence of breast cancer has been rising for the past 30
years, and the supposed authorities and experts that should know, do not know why.
The grim fact” for every 2 new cancer cases diagnosed annually, one will die
within the year”.
In the UK 30,000 new cases of breast cancer are diagnosed each year making this the
commonest malignancy in women and causing nearly 15,000 deaths per year. Randomized
studies of prevention strategies particularly with the anti-oestrogens Tamoxifen and more
recently raloxifene, and retinoids have either been completed or are on-going. The final
analysis is awaited but it is likely that effective preventive measures will be available in the
not too distant future.
In Asia, the Philippines has the highest reported incidence rate of breast cancer.
From 43.2 in 1993-1995, the age- standardized incidence rate (ASR) is now 47.7 per
100,000 females, and this figure exceeds the rate reported for several Western countries,
including Spain, Italy and moset European countries.
Many breast cancers are diagnosed among 35 to 50-year-old Filipino women. In
terms of breast cancer detection, a local study revealed that the use of breast self-
examination (BSE) and aspiration biopsy/open biopsy are the most cost-effective
strategies in the Philippine setting, incurring savings for the government by almost 3
million Philippine Pesos or US $60,000 (1989 value) per year per 100,000 women.
Mammography is neither readily available nor affordable especially in the rural areas.

Cancer site 1980–82 1983–87 1988–92 1993–95

BS M F BS M F BS M F BS M F
Lung 25.8 42.3 11.5 31 46.7 14.9 40 64.7 18.8 40 64.7 18.8

Breast 0.7 40.5 0.7 44.4 0.8 43.2 0.8 43.2

Liver 13.4 20.4 7.3 14.7 20.4 8 16.8 25.6 9 16.8 25.6 9

Cervix uteri 20.5 – 20.5 22.5 – 22.5 26.4 – 26.4 26.4 – 26.4

Stomach 9.6 11.9 7.6 9.6 11.4 7.7 9.6 12.1 7.6 9.6 12.1 7.6

Colon 6.5 7.3 5.7 8 8 7.7 10.7 11.8 9.8 10.7 11.8 9.8

Oral cavity 5.9 5.4 6.3 6.9 6.4 7.3 8.6 8.5 8.3 8.6 8.5 8.3

Prostate 12.5 12.5 – 14.6 14.6 – 19.3 19.3 – 19.3 19.3 –

Rectum 5.5 6.5 2.8 6.6 7.4 5.6 7 8.1 6.2 7 8.1 6.2

Leukemia 5.2 5.7 2.9 5.7 5.6 5.5 6.6 7.2 6.2 6.6 7.2 6.2

Nasopharynx 2.5 6 1.6 5.2 6.7 3.1 6.2 8.6 4 6.2 8.6 4

Larynx 1.4 4.3 0.4 2.8 4.4 1.1 3.4 6.2 1 3.4 6.2 1

Ovary 8 – 8 9.2 – 9.2 10.8 – 10.8 10.8 – 10.8

Thyroid 2.7 1.3 6.6 5.6 2.7 8 6.6 3.1 9.8 6.6 3.1 9.8

Corpus uteri 6.1 – 6.1 5.8 – 5.8 5.2 – 5.2 5.2 – 5.2

Non-Hodgkin’s lymphoma 2 2.1 1.6 3.3 3.8 2.6 4.6 5.8 3.6 4.6 5.8 3.6

Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4)
 Objectives

General:

The researcher formulated a general objective to guide her throughout the case
study:

This study aims to present facts about breast cancer, details of how this may affect
every woman in the society and to protect them from further advancement of breast
cancer. And also for the researcher to explore, investigate, analyze and present a
comprehensive case study regarding the case of Patient Star.

Specific:

a) To establish a good rapport and therapeutic relationship with the patient to gather
much information about her personal data and her present condition through
interview
b) To gather pertinent data found in the patient’s medical chart
c) To conduct a thorough physical assessment as a part of the baseline data gathering
d) To study the anatomy and physiology of the affected system of the patient’s
current condition
e) To trace the pathophysiology of the disease process
f) To determine and interpret the medical management employed, including
laboratory and diagnostic procedures
g) To identify and study the drugs prescribed to the patient which affects her present
condition
h) To formulate nursing care plans and health teachings that are appropriate for the
patient’s problem
i) To formulate prognosis based on the gathered information
j) Enumerate the discharge planning using the M.E.T.H.O.D. system.
k) List down all the references used in the study
 Patient’s Data

Personal Data

Code Name: Patient Star

Age/ Sex: 58/ Female

Address: Blk. 4 Lot 12 Stella Maris Village, Garcia Heights, Davao City

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Birth date: March 13, 1951

Birth place: Dagupan, Pangasinan

Occupation: Housewife

Clinical Data

Hospital Number: 01-80-**

Room / Bed Number: 424-2

Date of admission: December 14, 2009

Time of admission: 11:00 am

Chief Complaint: Left Breast Wound

Admitting Physician: Meliza Carla T. Agoilo, M.D

Attending Physician: Ferdinand Malubay, M.D

Vital signs upon admission:

T P R BP .

37.4◦ 128bpm 27cpm 120/70mmHg

 Family Background and Health History

Patient Star, 58 years old, she lived in a simple lifestyle at Dagupan, Pangasinan. Her
paternal side was pure Ilocano, her father has 5 siblings wherein hypertension was manifested by
the three of them. Her father has Bronhcial Asthma and was already deceased. Meanwhile, her
mother side hailed from Malasiqui, Pangasinan. Her grandmother died from Diabetes which was
also caused the death of her one aunt. Hypertension was also manifested by her uncles, her
mother’s siblings. Star transferred here in Davao because of her job which was part of her Rural
Training as a nurse. Patient Star has five four siblings, one of her sister has hypertension and
died from it, while her other sister was diagnosed with colon cancer.
At present, star and her family lived at Garcia Heights his husband continued to work at
his uncle’s business. They have two children, her daughter who is already 26 years old finished
International Technology at John Paul College and is already working at Victoria Plaza Mall
while his son, 24 years of age is a personal driver of a known family in the city.

Lifestyle, Diet and Activities of Daily Living (ADL)

Patient Star wakes up early at about 4:30 am to cook breakfast for her family and clean
their house and backyard. Her daughter also testified that her mother is really hardworking, she
added that her mother feels weak if she does not work or do anything and just sit and rest the
entire day. Star shared that when she was still not feeling the pain on her breast she really wants
to do everything on their house just to make it clean and beautiful, she also makes it sure that her
family is in good condition and health. She cooks food for her family everyday and sees to it that
these foods are healthy and well- balanced. She admits that before, she really eats rice and foods
rich in carbohydrates without limit but now, she learned from it already and minimizes her intake
of those restricted foods. They sleep at around 10pm in the evening.
She is not active on her subdivision’s activities because she easily gets tired on it. Their
family is not that active on parish activities but they go to church if they have time, it is not their
routine to have a mass every Sunday.

10
 Patient Star is a smoker, she consumes four sticks of cigarette everyday but she does not
drink any alcoholic beverages frequently, just occasionally. Her husband does not earn that much
of money and it brought them financial problem since they had their family life.

Client’s Past Health History

Patient Star does not have any allergic reaction towards foods, drugs and environment.
Patient stated that she had measles, mumps and chicken pox when she was young.
On year 2006, she experienced minimal amount of bleeding on her left nipple for 3 days
and after a week, she felt pain on it. She went for check-up at Davao Doctors Hospital and was
diagnosed with Mastitis and the doctor advised her to take Augmentin and to stop all her vices
mainly her smoking issue. After being diagnosed she seek help to the so called albolaryos and
quack doctors. She took Alive capsule and Green power which are herbal supplements.
She is a known Diabetic since 2006 and takes Metformin 500mg BID as her maintenance
drug.
She takes Mefenamic Acid whenever she experience headache and Paracetamol for her
fever.

Client’s Present Illness

One year prior to admission, Patient Star noted again a blood on her left nipple consulted
the physician that she had on 2006 and was given unrecalled drugs. Three months prior to
admission, patient noted crusting on the affected area, a consultation was done by the physician
and advised her for surgery but the patient failed to comply due to financial constraints, she
opted to use guava leaves and amoxicillin capsule powder instead.
Due to the pain that she felt on December 10 up to the 14 th of 2009 she was advised to be
admitted at Davao Medical School Foundation Hospital.

11
Effects and Expectations of Illness to Self and Family

Patient Star understands the fact that she must be in the hospital for her to be at ease
while fighting her disease. She was just anxious and worried because of the financial aspect that
needs to be sufficient enough for her treatment. She optimistically shared that illness is just a part
of our body to respond and act against the virus and cells that spreads inside our system~ may it
be that deadly or not. She knows that her immune system is at risk during this time of her life
that is why she needs to eat nutritious foods and lessen her intake of those restricted foods that
may compromise her health.
Patient Star and her family were open about the risks of having cancer. Even though God
has given her these diseases she remained alive and kicking just like other normal persons.

12
 Developmental Data

Development is an increase in the complexity of function and skill progression. It is the

capacity and the skill of a person to adapt to the environment and it implies a progressive and
continuous process of change leading to a state of organized and specialized functional capacity.
Development is the behavioural aspect of growth, such as a person’s ability to walk, talk, and
run. It proceeds from simple to complex or from single acts to integrated acts. Any interpretation
of this process by a disease or a disorder is called developmental delay. These changes can be
measured quantitatively but more distinctly measured in qualitative changes.

Theory Stages Justification

Erik Erikson’s Our patient belongs to Our patient is in the stage

Psychosocial Theory the stage of Generativity of Generativity because she
versus stagnation (25 years is creative and productive.
Erik H. Erikson believes to 65) because she is already Our patient does not only
that people continue to 58 years old. Generativity is think about herself but she is
develop throughout life. He when an individual is also a very good mother and
envisions life as a sequence creative, productive and wife. She does her job as a
of levels of achievement. shows concern for others. mother and wife by taking
The resolution of each task While stagnation is when an good care of her family. She
can be complete, partial, or individual is to self-indulge, provides for the needs of her
unsuccessful. He believes self-concern and shows lack family and also takes good
that the greater the tasks of interests and care of their health and
achieved the healthier will commitments. welfare. She makes sure that
the personality of the person she gives her family the love
be; failure to achieve a task and care they needed.
affects the person’s ability
to achieve the next task.
Erikson’s eight stages

13
reflect both positive and
negative aspects of the
critical life periods. The
resolution of the conflicts at
each stage enables the
person to function
effectively in the society.
Developmental tasks can be
viewed as a series of crises,
and successful resolution of
these crises is supportive to
the person’s ego

14
 Robert Havighurst’s Our patient is 58 years Patient Star has not
Developmental Task old and belongs to the achieved the first
Theory Middle Age (40 – 65 years developmental task because
old) and the following are she didn’t join in any
Robert Havighurst the task that the person must organizations in her
believed that learning is achieve during this stage. community.
basic to life and that people
continue to learn throughout Developmental task Our patient has achieved
life. He described growth the second task because she
and development as 1. Achieving adult strives so hard to support her
occurring in six different civic and social family’s needs emotionally
stages which is associated responsibility. and physiologically by
with different tasks. A preparing foods and
developmental task arises in 2. Establishing and √ providing comfortable home
a certain period of an maintaining an to sleep and rest.
individual’s life and leads to economic standard Our patient had achieved
unhappiness and success if of living. the third task because she
is achieved and leads to has 2 children and she was
3. Assisting teenage √
unhappiness if tasks is the one who assisted them
children to become
failed. Through this theory it while growing up. In the
responsible and
can help provide a present, some of her
happy adults.
framework in evaluating a children have their own
person’s accomplishment. 4. Developing adult √ family and all of them are

leisure – time already successful in life.

activities.
Our patient has achieved
5. Relating oneself √ the fourth task because
to one’s spouse as a Whenever our patient is not
person. busy she would really rest

15
 and spend time watching
6. Accepting and √ television. Also when she is
adjusting to the not doing anything, she
physiologic change would spend quality time
of middle age. with her husband.

7. Adjusting to √ Our patient has achieved

aging parents. the fifth task because our
patient does not only think
of herself but also for the
needs of her husband.
Whenever her husband is
having some problems she
will really give her full
support and try to console
and understand him.

Our patient has achieved

the sixth task because she is
already quite adjusted to the
changes she is having
because she is aware that as
she grows old, many
changes would really
happen to her physically and
psychologically because she
knows that is life’s reality.

Our patient already

adjusted herself to her
husband’s father who is

16
 already very old and many
things change. As her father
grew older and older, he
became to irritating,
annoying and kept on
nagging. Still, she possesses
her value of being patient
with him and tries to adjust
to it.

Moral Developmental Our patient belongs to Our patient belongs to this

Theory by Lawrence the Post conventional stage because she does not
Kohlberg (Social Contract Legalistic base her decisions and
Orientation) in which this behaviors on the social roles

This theory addresses person lives autonomously but she believes a higher
moral development in and defines moral values moral principle such as
children and adults. This and principles that are equality, justice or due
theory focuses on the distinct from personal process.
reasons an individual makes identification with group
a decision. According to values. A person lives
Kohlberg, this theory according to principles that
progresses through three are universally agreed on
levels and six stages, which and that the person consider
do not always linked to a appropriate for life.
certain developmental stage (universal focus)
due to the fact that some
people progresses in a
higher level compared to

17
others.

Definiton of Complete Diagnosis

Breast cancers are malignant tumors that typically begin in the ductal-lobular epithelial
cells of the breast and spread via the lymphatic system to the axillary lymph nodes. The tumor
may then metastasize to distant regions of the body, including lungs, liver, bone, and brain. The
finding of breast cancer in the axillary lymph nodes is an indicator of the tumor’s ability for
potential distant spread and is not merely contagious growth into adjacent region of the breast.
Most primary breast cancers are adenocarcinomas located in the upper outer quadrant of the
breast.

Bibliography:
Black, J. et. al. (2002).MEDICAL-SURGICAL NURSING: Clinical Management for Positive
Outcomes. Vol. 1. Philadelphia, USA: W.B. Saunders Company. pages 1011 – 1040.

18
 Breast cancer is a cancer that starts in the cells of the breast in men
and women. Worldwide, breast cancer is the second most common type of
cancer after lung cancer (10.4% of all cancer incidence, both sexes counted)
and the fifth most common cause of cancer death. Worldwide, breast cancer
is by far the most common cancer amongst women, with an incidence rate
more than twice that of colorectal cancer and cervical cancer and about
three times that of lung cancer. However breast cancer mortality worldwide
is just 25% greater than that of lung cancer in women. In 2005, breast
cancer caused 502,000 deaths worldwide (7% of cancer deaths; almost 1%
of all deaths). The number of cases worldwide has significantly increased
since the 1970s, a phenomenon partly blamed on modern lifestyles in the
Western world.

Malignant tumors within the breast are called “breast cancer”.

Theoretically, any of the types of tissue in the breast can form a cancer,
cancer cells are most likely to develop from either the ducts or the glands.
These tumors may be referred to as “invasive ductal carcinoma” (cancer
cells developing from ducts), or “invasive lobular carcinoma” (cancer cells
developing from lobes). Sometimes, precancerous cells may be found within
breast tissue, and are referred to as ductal carcinoma in-situ (DCIS) or
lobular carcinoma in-situ (LCIS). DCIS and LCIS are diseases in which
cancerous cells are present within breast tissue, but are not able to spread
or invade other tissues. DCIS represents about 20% of all breast cancers.
Because DCIS cells may become capable of invading breast tissue, treatment
for DCIS is usually recommended. In contrast, treatment is usually not
needed for LCIS.

Bibliography:
The internet: http://health.yahoo.com/breastcancer-overview/breast-
cancer-topic-overview/healthwise--tv3617.html

19
 Stage III breast cancer is divided into two categories, which are the stage IIIA and the
stage IIIB. In stage IIIA, the breast cancer will now be larger than 5 centimeters in diameter and
will already have spread to the lymph nodes located under the arm. The survival rate for stage
IIIA breast cancer is from 56% to 67% depending on how the patient responded with the
treatments.

Stage IIIB breast cancer is when the cancer has spread to the other tissues near the breast.
In this stage, the survival rate will be from 49% to 54% depending on how the patient responded
to the treatments and medications. Always remember that the key to surviving breast cancer is
through early detection. By going through breast cancer diagnoses at least once or twice a year,
you will be able to detect the cancer early on if you have it and increase your chances in getting
rid of it.

Bibliography:
The internet: http://www.breastcanceranswers.net/articles/What-should-you-know-about-
stage-3-breast-cancer.html

PHYSICAL ASSESSMENT

Date of Assessment: December 15, 2009

Time of Assessment: 6:00pm

I. VITAL SIGNS

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 Temperature Pulse Rate Respiratory Blood
Rate Pressure
37.3ºc 92 bpm 21 cpm 120/80
mmHg

Clinical Measurement:

Height Weight

4 ft.9” 44kg.

II. GENERAL SURVEY

. She is awake, conscious, coherent and oriented. Responsive when asked and well-
conversant during interview. Her emotions were visible and vary in every situation. She does
not show any signs of respiratory distress. She is a well developed mesomorph and looks
according to age. She is very calm during the assessment, wearing white shirt and pajama.

III. SKIN

Skin was senile, fair in color, warm to touch, slightly moist and smooth. Returns quickly
to its original shape after being pinched. No evidence of bruising or edema on upper and lower
extremities. Nails were well- trimmed. Hair was fairly distributed all over the body.

IV. HEAD

21
 Face and skull were symmetrical, with fair distribution of hair in the head. Hair was
black, curly with shades of dark brown and white hairs were noticed and it was also short and
dry. Scalp was flesh in color without any signs of dandruff and lice manifestation. No tenderness
and swelling were observed. Skull’s contour and size was normal. Involuntary movements and
spasmodic contractions were absent. Has an oblong- shaped face without skin pigmentations.
Forehead was furrowed with wrinkles.

V. EYES

Both eyebrows had an equal quantity of hair with no flakes and scars noted. Eyelids were
symmetrical. The lacrimal duct openings were evident at the nasal side of the upper and lower
lids. No presence of edema or hematoma. Has short eyelashes on both eyes. Blinking reflex was
present. Sclerae were anicteric, clear and white in color. Iris were dark brown in color. Pupils
briskly constrict with light and when looking at near objects; dilate when looking at far objects.
Palpebral conjuctiva were pinkish. Periorbital sections were not edematous or sunken. No
secretions observed on her eyes.
Patient verbalized that she is not using any corrective glasses or any supportive devices
on her eyes.

VI. EARS

Ears were symmetrical. No lesions, masses and swelling observed in both pinna. External
canals were clear with perhaps minimal cerumen. Inflammation and impacted cerumen were
absent.
Sense of hearing was normal. Whispered voice tones were heard.

VII. NOSE

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 Nose was symmetrical, having the same color with her face. No unusualities noted like
discharges, lesions and abnormal growth in the nasal cavity. Air moves freely through the nares
as she breathes. Nasal septum was intact and in the midline.
Sense of smell is good and she was able to distinguish different kind of scents.

VIII. MOUTH

Lips were pinkish and dry but not cracked. A red birthmark of about 1.5cm in length was
found below her lower lips. Pinkish gums were observed. Bleeding, ulceration and lacerations
were absent in the mouth. Hard and soft palates were normal with no defects or inflammation.
Tonsils were pinkish and not inflamed. A grayish discoloration was noted on the tip of her
tongue. Left molar tooth was missing. Halitosis was noted. Patient was able to masticate and
swallow.

IX. NECK

No signs of swelling, masses and lacerations noticed in the anterior and posterior of the
neck upon inspection and palpation. Range of motion was normal which includes right and left
lateral, right and left rotation, flexion, extension and hyperextension and able to move freely
without discomfort. A birthmark which was brown in color, 8cm in length and 4cm in width was
noted.

X. BREAST

Nipple on the right breast was dark brown in color. No discharges, scars or lesions seen.
No lumps palpated. Left breast was covered with a bandage and properly dressed. It was intact
and not soaked. No rashes or infection in the axillae noted.
A foul smell was noticeable coming from her breast wound.

XI. CHEST AND LUNGS

23
 Thorax was symmetrical, it moved easily without impairment upon respiration. There
were neither bulges nor retraction of the intercostal spaces. The breathing pattern was regular.
No presence of dyspnea, cough or hiccup noted. Spinal deformities and chest tubes or drainage
were absent. Breath sounds were clear upon auscultation.

XII. HEART

Her pericardial area is flat. Her heart sounds are distinct and regular upon auscultation.

XIII. ABDOMEN

The general contour of the abdomen was soft and flabby. No foul odor or discharges
observed in the umbilical area. Has a normal bowel sound of 12 per minute with a gurgling
sound.

XIV. GENITO-URINARY

No catheter attached. Patient verbalized that she urinates about 12 times daily without
any discomfort after the day of her admission. Her urine is yellow in color.
Patient added that she is already meopaused.

XV. UPPER EXTREMITIES

Peripheral pulses are present and symmetrical when palpated. Shoulder and arms were
symmetrical. Swelling and deformities were absent. No nodules and abnormal growth in the
elbows. Forearms can be flexed, supinated, pronated and extended with no pain. No missing,
deformities and tremors in the hands and fingers. Both palms were not calloused, without palmar

24
pallor. Has a capillary refill of less than 2 seconds. The range of motion in the upper extremities
was good.

XVI. LOWER EXTREMITIES

Absence of pain tenderness and has a good range of motion in the hips and joints. A scar
of 6 cm was found at the right lower leg due to an accident when she was still 14 years old. No
deformities, edema, rashes and amputation in both legs and knees. No missing toes in both feet.
Slightly calloused soles. Nails in the toes were not trimmed. Has a good range of motion in the
lower extremities.

ANATOMY AND PHYSIOLOGY

Reproductive System

The breasts, or mammary tissues, are located between the third and the seventh ribs of the

anterior chest wall and are supported by the pectoral muscles and superficial fascia. They are

specialized glandular structures that have an abundant shared nervous, vascular, and lymphatic

25
supply. The contiguous nature of breast tissue is important in health and illness. Men and women

alike are born with rudimentary breast tissue, with the ducts lines with epithelium. In women, the

pituitary released of FSH, LH, and prolactin at puberty stimulates the ovary to produce and

released estrogen. This estrogen stimulates the growth and development of ductile system. With

the onset of ovulatory cycles, progesterone release stimulates the growth and development of

ductile and alveolar secretory epithelium.

Structure

Structurally, the breasts consist of fat, fibrous connective tissue, and glandular tissue. The

superficial fibrous connective tissue is attached to the skin, a fact that is important in the visual

observation of skin movement over the breast during breast self-examination. The breast mass is

supported by the fascia of the pectoralis major and minor muscles and by the fibrous connective

26
tissue of the breast. Fibrous tissue ligaments, called Cooper's ligaments, extend from the outer

boundaries of the breast to the nipple area in radial manner.

These ligaments support the breast and form septa that divide the breast into 15 to 25

lobes. Each lobe consists of grape like clusters, alveoli or glands, which are interconnected by

ducts. The alveoli are lined with secretory cells capable of producing milk or fluid. The route of

descent of milk and other breast secretions is from alveoli to duct, to intra lobar duct, to

lactiferous duct and reservoir, to nipple. Breast milk is produced secondary to complex hormonal

changes associated with pregnancy. Fluid is produced and reabsorbed during the menstrual cycle.

The breasts respond to the cyclic changes in the menstrual cycle with fullness and discomfort.

The nipple is made up of epithelial, glandular, erectile, and nervous tissue. Areolar tissue

surrounds the nipple and is recognized as the darker, smooth skin between the nipple and the

breast. The small bumps or projections on the areolar surface known as Montgomery's tubercles

are sebaceous glands that keep the nipple area soft and elastic. At puberty and during pregnancy,

increased levels of estrogen and progesterone cause the areola and nipple to become darker and

more prominent and at the same time cause the Montgomery's glands to become more active.

The erectile tissue of the nipple is responsive to psychological and tactile stimuli, which

contributes to the sexual function of the breast. There are many individual variations in breast

size and shape. The shape and texture vary with hormonal, genetic, nutritional, and endocrine

factors and with muscle tone, age, and pregnancy. A well-developed set of pectoralis muscles

supports the breast mass higher on the chest wall. Poor posture, significant weight loss, and lack

of support may cause the breast to droop.

The Lymphatic System

27
 The lymphatic system consists of organs, ducts, and nodes. It transports a watery clear

fluid called lymph. This fluid distributes immune cells and other factors throughout the body. It

also interacts with the blood circulatory system to drain fluid from cells and tissues. The

lymphatic system contains immune cells called lymphocytes, which protect the body against

antigens (viruses, bacteria, etc.) that invade the body.

Functions:

a.) to collect and return interstitial fluid, including plasma protein to the blood,

28
 and thus help maintain fluid balance

b.) to defend the body against disease by producing lymphocytes

c.) to absorb lipids from the intestine and transport them to the blood.

Lymph organs include the bone marrow, lymph nodes, spleen, and

thymus. Precursor cells in the bone marrow produce lymphocytes. B-

lymphocytes (B-cells) mature in the bone marrow. T-lymphocytes (T-

cells) mature in the thymus gland. Besides providing a home for

lymphocytes (B-cells and T-cells), the ducts of the lymphatic system

provide transportation for proteins, fats, and other substances in a medium

called lymph.

Lymph nodes:

Structure:

Human lymph nodes are bean-shaped and range in size from a few millimeters to about

1-2 cm in their normal state and there are about 500-700 lymph nodes spread throughout the

body. Lymph nodes are body organs (not glands) spread throughout your body.

The lymph node is surrounded by a fibrous capsule, and inside the lymph node the

fibrous capsule extends to form trabeculae. The substance of the lymph node is divided into the

29
outer cortex and the inner medulla surrounded by the former all around except for at the hilum,

where the medulla comes in direct contact with the surface. Thin reticular fibers, fibroblasts and

elastin fibers form a supporting meshwork called reticulum inside the node, within which the

white blood cells (WBCs), most prominently, lymphocytes are tightly packed as follicles in the

cortex. Elsewhere, there are only occasional WBCs.

30
 The number and

composition of follicles can

change especially when

challenged by an antigen,

when they develop a

germinal center. A lymph

sinus is a region within the

lymph that is less densely

packed with WBCs and

offers less resistance to the

flow of lymph. It is lined by

highly branched reticular cells

and macrophages. Thus,

subcapsular sinus is a region

immediately deep to the

capsule, and contains very

sparse lymphocytes. It is

continuous with similar

sinuses flanking the

trabeculae. Multiple afferent

lymph vessels that branch and

network extensively within

the capsule, bring lymph into

31
 the lymph node. This lymph

enters the subcapsular sinus.

The innermost lining of the

afferent lymph vessels is

continuous with the cells

lining the lymph sinuses. The

lymph gets slowly filtered

through the substance of the

lymph node and ultimately

reaches the medulla. In its

course it encounters the

lymphocytes and may lead to

their activation as a part of

adaptive immune response.

The concave side of the

lymph node is called the

hilum. The efferent attaches to

the hilum by a relatively

dense reticulum present there,

and carries the lymph out of

the lymph node.

Function

Nodes act as filters, with an internal honeycomb of reticular connective tissue filled with

32
lymphocytes that collect and destroy bacteria and viruses. When the body is fighting an

infection, they begin producing large numbers of lymphocytes which causes them to swell.

Lymphatic fluid in the tissues, before it has gone into a lymph node, is called interstitial fluid.

Etiology and Symptomatology

BREAST CANCER

PREDISPOSING FACTORS

FACTORS RATIONALE PRESENT JUSTIFICATION

/
ABSENT
SEX Simply being a woman is the This is present, since
main risk factor for developing our patient is a
breast cancer. Although women FEMALE.
have many more breast cells
than men, the main reason they
develop more breast cancer is
because their breast cells are
constantly exposed to the
growth-promoting effects of the
female hormones estrogen and
progesterone. Men can develop
breast cancer, but this disease is
about 100 times more common

33
 among women than men.
www.cancer.org
AGE Breast cancer can affect women This is present since
of any age. The disease is more our patient is 58
common in post-menopausal years old and is
women, but 25 percent of already menopaused.
women with breast cancer are According to experts
younger than 50. post- menopausal
www.cancer.med.umich.edu women are more
Your risk of developing breast predisposed to have
cancer increases as you get breast cancer.
older. About 1 out of 8 invasive
breast cancers are found in
women younger than 45, while
about 2 out of 3 invasive breast
cancers are found in women
age 55 or older
www.cancer.org
GENETIC RISK About 5% to 10% of breast There is no test that
FACTORS cancer cases are thought to be would support that
hereditary, resulting directly the patient has
from gene changes (called genetic mutation that
mutations) inherited from a would make here
X
parent. predispose to breast
BRCA1 and BRCA2: The cancer. Patient also
most common inherited stated that she does
mutations are those of the not have any
BRCA1 and BRCA2 genes. In relatives or even
normal cells, these genes help family member with
to prevent cancer by making breast cancer.
proteins that help keep the cells

34
 from growing abnormally. If
you have inherited a mutated
copy of either gene from a
parent, you are at increased risk
for breast cancer.
Women with an inherited
BRCA1 or BRCA2 mutation
have up to an 80% chance of
developing breast cancer during
their lifetime, and when they do
it is often at a younger age than
in women who are not born
with one of these gene
mutations. Women with these
inherited mutations also have
an increased risk for developing
ovarian cancer.

www.cancer.org
RACE White women are slightly more This is absent since
likely to develop breast cancer our patient is of
than are African-American Asian race.
women. African-American
X
women are more likely to die of
this cancer. At least part of this
seems to be because African-
American women tend to have
more aggressive tumors,
although why this is the case is
not known. Asian women has
the least number of breast

35
 cancer cases compared to that
of the Americans, Europeans
www.cancer.org
EARLY MENARCHE, Women who have had more The patient reported
LATE MENOPAUSAL menstrual cycles because they that her menarche
AGE started menstruating at an early was at 11 years old.
age (before age 12) and/or went
through menopause at a later
age (after age 55) have a
slightly higher risk of breast
cancer. This may be related to a
higher lifetime exposure to the
hormones estrogen and
progesterone.
-www.cancer.org
-Hawks and Black , Medical-
Surgical Nursing, 7th Edition,
2005
NULLIPARITY Women who have had no This is absent in my
AND children or who had their first patient because she
NON-BREASTFEEDING child after age 30 have a has undergone
WOMEN slightly higher breast cancer pregnancy for her 2
risk. Having many pregnancies children and has
and becoming pregnant at an experienced
early age reduces breast cancer breastfeeding.
risk. Pregnancy reduces a
woman's total number of
lifetime menstrual cycles,
which may be the reason for
this effect.
Some studies suggest that
breast-feeding may slightly

36
lower breast cancer risk,
especially if breast-feeding is
continued for 1½ to 2 years.
The explanation for this
possible effect may be that
breast-feeding reduces a
woman's total number of
lifetime menstrual cycles
(similar to starting menstrual
periods at a later age or going
through early menopause).

37
BREAST CANCER PRECIPITATING FACTORS
FACTORS RATIONALE PRESENT/ JUSTIFICATION
ABSENT
HIGH FAT DIET Most studies have found that breast This is absent since
cancer is less common in countries where patient eats a wide
the typical diet is low in total fat, low in variety of food.
polyunsaturated fat, and low in saturated
fat. X
High-fat diets can lead to being
overweight or obese, which is a breast
cancer risk factor.
OBESITY Being overweight or obese has been This is absent since
found to increase breast cancer risk, our patient’s BMI
especially for women after menopause. X is 18.9, which is
Before menopause your ovaries produce interpreted as a
most of your estrogen, and fat tissue healthy weight
produces a small amount of estrogen. since BMI less
After menopause (when the ovaries stop than 18.5 are
making estrogen), most of a woman's classified as
estrogen comes from fat tissue. Having underweight and
more fat tissue after menopause can more than 22.9 are
increase your estrogen levels and thereby overweight.
increase your likelihood of developing
breast cancer.
The connection between weight and
breast cancer risk is complex, however.
For example, the risk appears to be
increased for women who gained weight
as an adult but may not be increased
among those who have been overweight
since childhood. Also, excess fat in the

38
 waist area may affect risk more than the
same amount of fat in the hips and
thighs. Researchers believe that fat cells
in various parts of the body have subtle
differences that may explain this.
-www.cancer.org
-Hawks and Black , Medical-Surgical
Nursing, 7th Edition, 2005
LONG TERM Post-menopausal hormone therapy This is absent since
ESTROGEN (PHT), also known as hormone Patient Star is not
THERAPY replacement therapy (HRT), has been X having this
used for many years to help relieve therapy.
symptoms of menopause and to help
prevent osteoporosis (thinning of the
bones).
-www.cancer.org
-Hawks and Black , Medical-Surgical
Nursing, 7th Edition, 2005
ALCOHOL Alcohol use are associated with increased This is absent since
levels of circulating estrogen, and this is patient Star does
thought to be the primary means through X not consume nor
which they confer an increased risk of drink regularly.
breast cancer, since estrogen can fuel
breast cancer growth
-Fred Hutchinson Cancer Research
Center
www.sciencedaily.com
LACK OF Physical activity may prevent tumor This is absent since
PHYSICAL development by lowering hormone Patient Star does
MOBILITY levels, particularly in premenopausal X all the house
women; lowering levels of insulin and chores.
insulin-like growth factor I (IGF-I),

39
 improving the immune response; and
assisting with weight maintenance to
avoid a high body mass and excess body
fat
-McTiernan A, editor. Cancer
Prevention and Management Through
Exercise and Weight Control. Boca
Raton: Taylor & Francis Group, LLC,
2006.
CIGARETTE Carcinogens found in tobacco smoke This is present
SMOKING pass through the alveolar membrane and because Patient
into the blood stream, by means of which Star is a smoker
they may be transported to the breast via that consumes four
plasma lipoproteins. That potential breast sticks of cigarette
carcinogens in tobacco smoke can be per day.
taken up and metabolized in humans is
suggested by studies showing that
urinary excretion levels of such
compounds vary among individuals
according to their smoking habits. Due to
the fact that they are lipophilic, tobacco-
related carcinogens can be stored in
breast adipose tissue and then
metabolized and activated by human
mammary epithelial cells. Experimental
studies have indicated that tobacco
smoke contains potential human breast
carcinogens [including PAHs, aromatic
amines, and N-nitrosamines, and the
higher prevalence of smoking-specific
DNA adducts and p53 gene mutations

40
 found in the breast tissue of smokers
compared with that in nonsmokers
supports the biological plausibility of a
positive association between cigarette
smoking and breast cancer risk.
-Cigarette Smoking and the Risk of
Breast Cancer in Women
Paul D. Terry and
Thomas E. Rohan,
http://cebp.aacrjournals.org
RADIATION Women who, as children or young This is absent since
THERAPY adults, had radiation therapy to the chest patient is not on a
area as treatment for another cancer X radiation therapy.
(such as Hodgkin disease or non-
Hodgkin lymphoma) are at significantly
increased risk for breast cancer. This
varies with the patient's age when they
had radiation. If chemotherapy was also
given, the risk may be lowered if the
chemotherapy stopped ovarian hormone
production. The risk of developing breast
cancer appears to be highest if the
radiation was given during adolescence,
when the breasts were still developing.
www.cancer.org
RECENT Studies have found that women using This is absent since
X
CONTRACEPTIVE oral contraceptives (birth control pills) patient is not using
USE have a slightly greater risk of breast any contraceptive
cancer than women who have never used as reported.
them, but this risk seems to decline once
their use is stopped. Women who stopped
using oral contraceptives more than 10

41
 years ago do not appear to have any
increased breast cancer risk. When
thinking about using oral contraceptives.
-www.cancer.org
ANTIPERSPIRANT Many experts have suggested that This is present
USE chemicals in underarm antiperspirants since patient
are absorbed through the skin, interfere reported use of
with lymph circulation, cause toxins to antiperspirant since
build up in the breast, and eventually adolescent age.
lead to breast cancer.
One small study has found trace levels of
parabens (used as preservatives in
antiperspirants and other products),
which have weak estrogen-like
properties, in a small sample of breast
cancer tumors.
-www.cancer.org

42
 SYMPTOMATOLOGY
BREAST CANCER

FACTORS RATIONALE PRESENT/ JUSTIFICATION

ABSENT
Thickening/Lump in or A woman's breasts can feel This is present since
near the underarm area lumpier just before her patient noted
menstrual period. At this time thickening or lump in
of the month, she experiences an area of her breast.
a surge in female hormones—
estrogen, progesterone and
prolactin. These hormones
stimulate fibrous breast tissue
to grow and retain fluid.
Breast cancer first announces
itself in the form of a lump.
http://www.mothernature.com/
Asymmetry Prior to each menstrual period, This is present since
the surge in estrogen and patient reported very
progesterone stimulates fluid noticeable
retention and growth in breast asymmetry of her
tissue. breast due to
http://www.mothernature.com swelling and
tenderness.
Bleeding and Discharge Excess fluids seeps out into This is present since
from the nipples the duct which causes patient reported that
discharge from the nipples. she had discharges or
http://www.mothernature.com bleeding during the
course of her illness.

43
Skin Dimpling/Orange A dimpling of the breast skin This is present since
peeling or or nipple could be from the patient reported that
Pitting of the breast loss of elasticity in the there skin dimpling
supporting ligaments as you or pitting of the
age. But dimpling may also be breast noted during
a sign that a tumor buried in the duration of her
the tissues is pulling on the illness. Added by the
skin or nipples. In the case of patient, there is also
a tumor, dimpling might show crusting around the
up long before a lump pitting area.
becomes large enough to feel.
http://www.mothernature.com
Warmth Warmth, redness and swelling This is present since
are due to the inflammation patient noted
Redness process. It is due to the warmth, redness,
invasion and obstruction of the swelling of her left
Swelling dermal lymphatics by the breast
tumor
Medical-Surgical Nursing
Black and Hawks, 2004

Narrative Pathophysiology

44
 The etiology of breast cancer and even on any type of cancer is still unknown.
Predisposing factors that are present on the case of my patient are the following, sex, age, early
menarche and her late pregnancy, while her precipitating factor is her usage of antiperspirant for
a long period of time, since she was on adolescent stage. Under the predisposing factors, these
leads to an over expressed estrogen receptor and an increase in the estrogen level with thses it is
now expose to estrogen when it is increased, also its metabolism goes up or it also increases,
which leads to an increase in cell proliferation. On the otherhand, under the precipitating factor,
there is now an absorption of chemicals particularly that of Parabens chemical which is a weak
estrogen-like substance that enters in our breast tissues and that toxins also interferes the
circulation in our lymphatic system. Toxins being impacted and stored on our breast, builds up.
When these two factors meet, Initiations phase then starts. Wherein carcinogens bind to cell’s
DNA resulting into an alteration of functions. Genotoxic waste in estrogen metabolism takes
place and there is already an error in cellular duplication. Resulting into a damaged genes of
Tumor Suppressor Cells and modifies functioning of the proto-oncogenes. When there is already
a damage and interruption on the cell proliferation, the repair and elimination process that
supposed to be is going to happen in a certain cell, is now inhibited. Oncogenes now, make it
possible for cell transformations as dividing excessively and uncontrollably/ until it proceeds to
the next phase which is the Promotion phase where a continuous duplication of mutated DNA
happens. A single cell begins to divide abnormally and a formation of new tissue or tumor
follows. Which is now the STAGE 1 of cancer, wherein if not treated, Malignant Conversion
happens, an accumulation of cancer cells in the breast, center of tumor necrotizes and begins to
chip of malignant cells to seek new blood supply and cells eventually break out of the tumor and
invades the surrounding nodes and blood vessels. Before proceeding into the next stage the
cancer cells spreads in two ways, it is either the Lymphatic or Hematologic. When Stage 2
occurs, cells penetrate the lymphatic vessles by invasion process and cells lodge in the lymph
nodes and grow. Surrounding lymph nodes and vessles around the breast become obstructed and
are a malignant one. Cancer cells continue to stream in lymph fluid and may undergo metastasis
destroying epithelial wall until there is already an impairment in the lymph flow and

45
accumulation of fluid in the chest cavity until new sites of tumor develop. In Stage 3 before it is
going to be diagnosed in that stage, diagnostic exams are being conducted first, like excisional
biopsy, blood test, mammogram and chest x-ray. Once a patient has symptoms suggestive of a
breast cancer or an abnormal screening mammogram, she will usually be referred for a
diagnostic mammogram. A diagnostic mammogram is another set of x-rays with additional
angles and close-up views. Often, and ultrasound will be performed during the same session. An
ultrasound uses high-frequency sound waves to outline the suspicious areas of the breast. It is
painless and can often distinguish between benign and malignant lesions.

Depending on the results of the mammograms and/or ultrasounds, your doctors may
recommend that you get a biopsy. A biopsy is the only way to know for sure if you have cancer,
because it allows your doctors to get cells that can be examined under a microscope. There are
different types of biopsies; they differ on how much tissue is removed. Some biopsies use a very
fine needle, while others use thicker needles or even require a small surgical procedure to
remove more tissue. Your team of doctors will decide which type of biopsy you need depending
on your particular breast mass.

Once the tissue is removed, a doctor known as a pathologist will review the specimen.
The pathologist can tell if is the cells are cancerous or not, If the tumor does represent cancer, the
pathologist will characterize it by what type of tissue it arose from, how abnormal it looks
(known as the grade), whether or not it is invading surrounding tissues, and whether or not the
entire lump was removed during surgery. The pathologist will also test the cancer cells for the
presence of estrogen and progesterone receptors as well as a receptor known as HER-2/neu. The
presence of estrogen and progesterone receptors is important because cancers that have those
receptors can be treated with hormonal therapies. HER-2/neu expression may also help predict
outcome. There are also some therapies directed specifically at tumors dependent on the presence
of HER-2/nue. On STAGE 3B if its not treated, the patient will have poor prognosis which
means that the cancer cells that are able to sutvive the environment and pressure still continue to
venous blood flow and metastize which leads to STAGE 4wherein an impairment in liver and
lungs functioning happen that results to organ failure and arrest that may lead to death.

46
47
 PATHOPHYSIOLOGY

PREDISPOSING FACTOR PRECIPITATING FACTOR

-SEX -LONG TERM
-AGE ANTIPERSPIRANT USE
-EARLY MENARCHE
-NULLIPARITY and NON-BREAST

Over Increased Absorption of chemicals

expressed estrogen in antiperspirant through
estrogen level

Increased Parabens, weak

estrogen estrogen-like Toxins interfere
chemicals in with lymph
antiperspirant circulations
INCREASED ESTROGEN
METABOLSIM

Increased cell Toxins build up in

proliferation the breast

Initiation:
Carcinogens bind to cell’s
DNA results to alteration of
functions.

48
 Genotoxic waste Spontaneous
in estrogen error of cell
metabolism duplication

Modified functioning of
Damage to the genes
proto-oncogenes.
of Tumor Suppressor
Cells

Proto-oncogene Impaired
Repair or elimination of
becomes program cell
cells with damaged
oncogene due to death
DNA is inhibited.

Oncogenes make it possible

for cell transformations such
as dividing excessively and
uncontrollably.

Promotion:
Continuous duplication
of mutated DNA

A single cell begins

to divide abnormally

Thickening/Lump in 49
or near the underarm Formation of new tissue or STAGE
area tumor
 If not treated

Malignant Conversion:
Accumulation of cancer cells in the

Center of Tumor Necrotizes and begins to

chip of malignant cells to seek new blood

Cells break out of the tumor and

Invades to surrounding lymph nodes
and/or Blood vessels.

LYMPHATIC SPREAD: HEMATOLOGIC

Dissemination of Cancer cells to STAGE 2 SPREAD:
the lymph channels in a process Dissemination of
called embolization. Cancer cells through

Cells penetrate Cancer move to extracellular

lymphatic Cells lodge in matrix by secreting enzymes
vessels by the lymph
invasion nodes and
process grow. Endothelium cracks open then causes
surrounding tissue to be damaged
Surrounding lymph nodes and vessels
around the breast become obstructed by
Entry to blood vessels

Inflammation
of breast and Blood vessels including arteries and
Unblocked Lymph nodes Blockage of Lymph veins carries cancer cells to organs:
swelling of
drain towards the venous vessel draining the
lymph nodes
blood flow. fluids from the
50
 Cancer cells continue to
stream in the lymph fluid
Cancer cells spread into
the membrane linings

May undergo invasive

Increase in
metastasis destroying epithelial
capillary
wall.
Impaired Lymph flow and erosion of Irritation and build up of
tumor accumulates fluid in the chest fluid on adjacent tissues
cavity.

New sites of tumor STAGE

DIAGNOSTIC
EXAMS

Chest x-ray:
Excisional - Chest films acquired in the lateral
Biopsy: Blood test: Mammogram: decubitus position (with the patient
-a section of tissue -A test done to -A mammogram is a low- lying on his side) are more sensitive,
is removed under check for a dose x-ray of the breast and can pick up as little as 50 ml of
general or local specific tumor tissue. Mammograms can fluid. At least 300 ml of fluid must be
anesthesia and marker, CA 15-3 detect changes in the breast present before upright chest films can
sent for for breast cancer. tissue before they develop pick up signs of pleural effusion. A
mammographic into a lump large enough to be chest with >500ml of fluid is positive
and histological for pleural effusion.

51
 Breast Cancer Stage IIIB T4N2M0

If

Surgical Treatment: Medical Treatment:

Modified Radical Mastectomy with Split
Thickness Skin Graft-
-is an en bloc removal of the breast,
axillary lymph nodes, and overlying skin, with
the muscles left intact
Bilateral Chest Tube Thoracostomy-
-it is done to drain excess fluid from the
pleural space.
Pharmacologic Intervention-
1. Chemotheraphy is also used as primary treatment in inflammatory
breast cancer and as palliative treatment in metastatic disease or
recurrence.
2. Anti-estrogens, such as tamoxifen, are used as adjuvant systemic
therapy after surgery.
3. Hormonal agents may be used in advanced disease to induce
remissions that last for months to several years.

Nursing Interventions:
1. Monitor for adverse effects of radiation therapy such as fatigue, sore throat, dry cough, nausea, anorexia.
2. Monitor for adverse effects of chemotherapy; bone marrow suppression, nausea and vomiting, alopecia, weight gain
or loss, fatigue, stomatitis, anxiety, and depression.
3. Realize that a diagnosis of breast cancer is a devastating emotional shock to the woman. Provide psychological
support to the patient throughout the diagnostic and treatment process.
4. Involve the patient in planning and treatment.
5. Describe surgical procedures to alleviate fear.
6. Prepare the patient for the effects of chemotherapy, and plan ahead for alopecia, fatigue.
7. Administer antiemetics prophylactically, as directed, for patients receiving chemotherapy.
8. Administer I.V. fluids and hyperalimentation as indicated.
9. Help patient identify and use support persons or family or community.
10. Suggest to the patient the psychological interventions may be necessary for anxiety, depression, or sexual problems.
11. Teach all women the recommended cancer-screening procedure
52
 Fair Prognosis
If not

Prolonged or delayed development of

Poor Prognosis

Cancer cells that are able to

survive the environment and
pressure still continue to
venous blood flow

Metastasis:
New tumors metastasize in STAGE 4
the liver, lungs and lymph.

Impaired functioning of the liver and

lungs.

Failure of the liver and lungs. lymphedema

Organ Failure

Cardiac Arrest

DEATH
53
 DOCTOR’S ORDER

Date Ordered Doctor’s Order Rationale Remarks

December 14,2009  Please admit Hospital admission is

11:00 am under the service advised for observation
of Dr. Malubay
Wt: 44kg (PC) and managementer of the DONE
BP: 120/70
client.
PR: 128bpm
RR: 27 cpm
T: 37.3 ◦c
Hgt: 219mg/dl

 Diabetic Diet Diabetic Diet is being DONE

given to patients with
history of Diabetes and
high blood glucose level.
Patient Star’s Hgt value
which is 219mg/dl
revealed that she needs to
control the glucose intake
in her body.

 Monitor VSq4 and To obtain baseline data DONE

record please and check for
unusualities or deviations
from normal.

54
 To evaluate the
 Labs: DONE
> CBC,PC composition and
> Bld. Typing
concentration of the
> CXR- PA view
> ECG cellular components
> HGT now
of blood which
> UA
> S. Na, K+ measures the
following:

• the number of
red blood cells
(RBCs)
• the number of
white blood
cells (WBCs)
• the total
amount of
hemoglobin in
the blood
• the fraction of
the blood
composed of
red blood cells
(hematocrit)
• the mean
corpuscular
volume (MCV)
 Start venoclysis DONE
— the size of
with PNSS 1L at
the red blood
120cc/ ◦ # 1

55
 cells

To supply water and

electrolytes (e.g.,
 Meds: calcium, potassium,
>Metformin sodium, chloride), either
DONE
500g tab 1 tab with or without calories
BID P. O (dextrose), to the body.
(Maintenance)

>Metformin is used to
minimize glucose level.
>Ketorolac 30g DONE
It is the patient’s
IVTT q 6◦; Give maintenance drug for her
st
1 dose now Diabetes.

>Ketorolac is given for

short term management
> Cefuroxime of pain in her left breast. DONE
750g IVTT q 8◦ Also used to prevent
ANST fever and inflammation.

>Cefuroxime is used to
treat skin and soft tissue

 For infections. Patient Star is DONE

dressing with having a wound at her

Daikins solution left breast due to breast

CA.
> Daikins solution is DONE

 Monitor used for dressing, to

I&O q shift prevent germ growth on DONE

wounds.

 Dr. > To maintain fluid and

56
 Malubay informed electrolyte balance.
of this admission > To let other physicians
DONE
( seen PR) know if the physician is
 Refer to already informed about
Dr. Torno for co the patient.
DONE
mgt. >To let Dr. Torno know
Signed: about the patient’s
Meliza Carla T.  Refer to admission and condition.
Agoilo, MD Dr. Lamanosa for > To manage the pain felt
Pain mgt. by the patient on her left

 Refer breast.

accordingly

December 14, 2009

DONE
12: 30pm

>Nurse noted the ordered

 MROD, Thank you DONE
referral of Dr. Agoilo
for this referral,will
inform Dr. Torno

 Suggest to shift > To treat and prevent

antibiotic and infection and

DONE
sulperazone 1gm q inflammation on the

8◦ ANST patient’s wound at left

breast.
> To monitor the patients DONE
 Monitor CBG q 6◦
blood glucose level and
(5-11-5-11)
other blood components.

>To control
 Give Humulin R, DONE
hyperglycemia. Patient is

57
 8 units SQ now then a known diabetic.
8 Units q 6 pm for
DONE
Signed: CBG ≥ 180mg/ dl >To know if the patient
 Include S. has kidney problem.
Dr. Torno
Crea >Before administering
Cefuroxime, physician
 Hold must know first the result
Cefuroxime IV of the patient’s creatinine
value to evaluate any
December 14, 2009 DONE
renal insufficiency.
3:00 pm

> To treat the patient’s

skin and soft tissue
 Ciprofloxacin infection on her breast
500g 1tab BID 1st dose wound which may cause
ASAP fever and further DONE
inflammation.

>To treat and prevent

infection on the patient’s
 Clindamycin 300g DONE
wound.
Signed:
1cap q 6◦ after meal
Dr. Torno
>To control
hyperglycemia. Patient is
 Start Humalog a known diabetic since
mix 20 units SQ at 2006.
breakfast, 12 units SQ
December 14, 2009 at dinner
DONE
8:41 pm

>To normalize

58
 hemoglobin level, for
 Please secure 2 good blood circulation
units PRBC of and to maintain amount
patient’s Bld. of blood supply at
DONE
Type properly equilibrium.
crossmatched >To normalize
hemoglobin level, for
good blood circulation
 Please transfer and to maintain amount
once bld is of blood supply at
available, repeat equilibrium.
DONE
Hct 6 hours post
BT of 2 units >Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with

 For Toilet or without distant

Mastectomy with metastases.

Signed: DONE
skin grafting
Dr. Malubay pending schedule >To let the physician
know the procedure to be
done on her patient
 Please inform Dr.
Torno of plan
December 15, 2009 DONE
 Refer accordingly
12: 30am
>Ketorolac may interrupt
the blood levels and
readings of the S.
 Please discontinue Creatinine result DONE
Ketorolac for S.
>To treat the patient’s
Creatinine in Am,
pain.
please inform me

59
 of result
 Nalbuphine 5g
IVTT q 8◦ x 4
dose then shift to
Tramadol 100g ½ DONE
tab BID ( pls
inform if pt. > To let the physician
Signed:
develops know the patient’s
Dr. Lamanosa persistent N&V) problem and to provide
DONE
 Refer for relief on it.
problems >To relieve acute pain
being felt by the patient.
December 15, 2009
DONE
1:00 am
 Etericoxib 120g > To provide patient
Signed: P.O OD with adequate amount of
Dr. Agoilo fluid and electrolytes.
 IVFTF: PNSS 1L
@ 120cc/ ◦
December 15, 2009
DONE
7:20 am
>To start the treatment
rehgimen in order to
normalize hemoglobin

 Ff. up availability level, for good blood

of blood circulation and to

maintain amount of
blood supply at
DONE
equilibrium.
>To know evaluate the
patient’s condition in her
treatment and therapeutic

60
  Refer creatinine regimen.
result please to > Daikins solution is
ROD used for dressing, to DONE
Signed:
prevent germ growth on
Dr. Agoilo wounds.

 For dressing with

December 15, 2009 Daikins solution DONE

c/o ROD/ surgical
9:00 am
clerk in-charge > To provide patient
Signed: with adequate amount of
fluid and electrolytes.
Dr. Agoilo
 IVFTF: PNSS 1L
#3 @ 120cc/ ◦
December 15, 2009 DONE

10:00 am
> To provide the patient
medications that will
Signed:
relieve the pain that she
Dr. Torno
felt and to avoid further
 Continue meds
inflammation and
infection.
December 15, 2009 DONE
11:00 am
> Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with
or without distant
 Schedule for
DONE
metastases.
Toilet mastectomy
>For anesthesia
TF 1st case
administration of the
(lapcholecystecto-
patient during the
my)

61
  Dr. Lamanosa for surgical procedure to be
DONE
anesthesia done.
> To start the therapeutic
regimen and for the
patient’s body to be
DONE
 Seen AC & ready for the procedure.
consult, start BT > To let the OR staff
Signed:
once available know about the
Dr. Malubay procedure and for it to be
DONE
 Inform OR scheduled.
>To have a smooth
process on the
physician’s part.

December 15, 2009  Refer, accordingly DONE

11:50 am
>To prevent the patient
from vomiting.
Signed:
Dr. Narisma
 Please give 1amp
Plasil now, then q
December 15, 2009
6◦ PRN for
DONE
4:30 pm vomiting
> Ciprofloxacin IV drug
is used for patients who
are immunosuppressed
 Hold Cipro and and with infection. DONE
Clinda p.o
> Patient’s glucose level
 Shift to Cipro
is already decreased into
200g IV q 12; no
normal level, holding the
Signed: skin test
Dr. Torno medicine avoids the
 Hold Metformin

62
 patient to be
hypoglycemic.
December 15, 2009 DONE

8:00 am
> To provide the patient
medications that will
relieve the pain that she
 Continue meds felt and to avoid further
inflammation and
DONE
infection.
> Toilet Mastectomy is
done for mobile ulcerated
fungating tumours with
 Schedule for or without distant
DONE
Toilet mastectomy metastases.
Signed: tom TF 1st case > To provide patient
with adequate amount of
Dr. Narisma
fluid and electrolytes.

 IVFTF: PNSS 1L
to run @ 120cc/ ◦
December 15, 2009
x 2 cycle #4, 5 DONE
9:30am  Refer accordingly
> To prevent any
complications during the
operation scheduled for
 PRE- OP Orders:
the next day
 NPO post >To have a baseline data
midnight before operation and to
know any unusualities
that may not allow the
 V/S before OR patient to be operated.
>To prepare the patient

63
 for operation.

>To provide patient with

 General / oral adequate amount of
hygiene PTOR liquid and electrolytes in
the body.
 IVF: D5NSS 1L
@ 120cc/ ◦ >To sedate the patient
while performing the
procedure.
 Meds:
1. Diazepam 5g 1tab > Ranitidine is useful in
at 6 am with sips of promoting healing of
water stomach and duodenal
ulcers, and in reducing
2. Ranitidine 15g ulcer pain.
1tab at 6am with sips >To normalize
of H20 hemoglobin level, for
good blood circulation
and to maintain amount
 Secure 1 unit of blood supply at
of bld and equilibrium.
crossmatch >To prepare and avoid
the patient from
excreting waste during
Signed:
surgery.
Dr. Lamanosa
> To let the physician
 Pls let pt. void know any problems prior
prior to giving to operation.
December 16, 2009 meds DONE
> Resuming the patient’s

64
10:30 am  Refer for diet allows the patient to
problem ingest food again for
Signed:
Dr. Malubay body’s supplement. NPO
diet for her is only for
OR preparation.

December 16, 2009  May resume DONE

diet, reschedule > To prevent infection
12:20 pm
OR tomorrow @ and inflammation on the
Signed: 7:30am affected area or her
Dr. Malubay
wound on breast.

December 16, 2009  For DONE

> To let the OR staff and
5:30 pm compliance of
residents know about the
antibiotics
procedure to be done on
the patient.
DONE
> To prevent aspiration
and for the patient to
avoid excreting waste

 Please during the procedure.

DONE
schedule tomorrow > To let the OR staff and

@ 7:30pm residents know about the

procedure to be done on

 NPO post the patient and let Dr.

midnight Lamanosa know the

changes that happened.
Signed: DONE
Dr. Malubay > To provide the patient
adequate liquid and
electrolyte intake and
 Inform OR
supplement.
and Dr. Lamanosa

65
  IVFTF:
D5NSS 1L @
120cc/ ◦

Diagnostic Exams

Blood Chemistry (12-14-09)

Date Exam Normal Rationale Result N/H/L Clinical Significance

Value of
patient

Dec. Creatinine 44.0- 80.0 Measure the level of 109 H There is an indication of
14, umol/L the waste product umol/ kidney problem.
2009 creatinine in your blood L
and urine. This test tells
how well your kidneys
are working.

Blood Chemistry (12-15-09)

66
Date Exam Normal Rationale Result N/H/L Clinical Significance
Value of
patient

Dec. Creatinine 53 - 115 Measure the level of 109 H There is an indication of

15, umol/L the waste product umol/ kidney problem
2009 creatinine in your blood L
and urine. This test tells
how well your kidneys
are working.

Potassium 3.5- 5.3 This test measures the 4.07 N There is a normal
mmol/ L amount of potassium in mmol/ regulation on how the heart
the blood. Potassium L beats.
(K+) helps nerves and
muscles communicate. It
also helps move nutrients
into cells and waste
products out of cells.

Sodium 135-148 The sodium levels are 136.06 N There is a normal sodium
mmol/ L measured to detect mmol/ level in the blood.
whether there is a right L
balance of sodium and
liquid in the blood to
carry out those functions.

Hematology

Date Exam Normal Rationale Result N/ Clinical Significance

Value of H/
patient L

Dec. Hemoglobin M: 140- 170 This is the amount 99 L A decreased result

14, g/dl used to measure the below the normal
2009 amount of range may indicate
F: 120- 150 hemoglobin per liter anemia.
g/dl of blood. It is
measured to evaluate
blood loss, anemia,
and response to
therapy.

67
Hematocrit M: 0.40- This test is used to 0.30 L There is an
0.60 measure the indication of anemia
proportion of whole and dehydration.
F: 0.38- blood volume
0.40 occupied by
erythrocytes. It is
useful in the
evaluation of blood
loss, anemia,
polycythemia, and
dehydration.

RBC Count 4.06- 6.0 Used to evaluate 3.06 L Indicates anemia.

x10^12/L any type of decrease x10^
or increase in the 12/L
number of red blood
cells as measured per
liter of blood.

WBC Count 5.0-10.0 Used to determine 17.1 There is an

x10^9/L the presence of an x10^9/ N indication of infections
infection or leukemia. L or leukemia.
It is also used to help
monitor the body’s
response to various
treatments and to
monitor bone marrow
function.

Neutrophils 45 – 65% This test measures 65% H There is indication

the amount of of immune, blood, and
neutrophils in blood. cancer disorders,
Neutrophils are a type including neutropenia.
of white blood cell
(WBC). This test is
used to evaluate and
manage immune,
blood, and cancer
disorders, including
suspected
neutropenia.
.

Lymphocyte 20 – 35% This test is done to 10% L There are low

s (P) determine the secretion antibodies

68
 lymphocyte blood which are involved in
count. the immune system
response and
regulation.

Monocytes 2 – 10% This test is done to 6% N Monocytes remove

help diagnose an debris or foreign
illness such as particles from the
infection or circulation. They also
inflammatory disease. participate in immune
response.

Eosinophils 1 – 4% This test counts 4% N No indication of

the number of allergic conditions,
eosinophil in blood. It blood and infectious
is used to evaluate diseases, as well as
and manage allergic infections.
conditions, blood and
infectious diseases, as
well as certain
infections.

Basophils 0 – 1% This test measures 0 N No indication of

the amount of allergic disorders,
basophils in blood. neoplastic disorders,
This test is used to and infections caused
help evaluate and by parasite.
manage treatments
including certain
allergic disorders,
blood disorders,
neoplastic disorders,
and infections caused
by parasites

Blood Typing

Date Result

December 14, 2009 “A” Rh Positive

69
 X- Ray Report (12-15-09)

Chest PA: Heart is within normal limits in size. There are infiltrates in the right lower
lobe. Rest of the lung fields are clear. Lateral CP sinuses are sharp.
Impression: Infiltrates may be inflammatory or neoplastic in origin. Please correlate
clinically.

Drug Study

GENERIC NAME Ranitidine hydrochloride

BRAND NAME Ranitidine
CLASSIFICATION Histamine2 (H2) antagonist
ORDERED DOSAGE 50 mg q 8 hours / q 4 hors IVTT
MODE OF ACTION Competitively inhibits the action of histamine at the H2 receptors

of the parietal cells of the stomach, inhibiting basal gastric acid

secretion and gastric acid secretion that is stimulated by food,

70
 insulin, histamine, cholinergic agonists, gastrin and pentagastrin.
Intractable duodenal ulcer; pathologic hypersecretory condition;
short term therapy for patients unable to tolerate oral forms,
duodenal and gastric ulcer, maintenance therapy for duodenal
INDICATION
ulcer, gastroesophagial reflux disease, erosive esophagitis, self
medication for occasional heart burn, acid indigestion, and sour
stomach
Drug-drug: Antacids: may interfere with ranitidine absorption,
Diazepam: May decreased diazepam absorption, Gilipizide: May
increase hypoglycaemic effect, Procainamide: May decrease renal
DRUG INTERACTION clearance of procainamide, Warfarin: May interfere with warfarine
clearance
Drug-lifestyle: Smoking: may increase gastric acid secretions and
worsen disease
Contraindicated in patients hypersensitive to drugs and its
CONTRAINDICATION
components; Porphyria
Headache, malaise, dizziness, rash, constipation, nausea, vomiting,
SIDE EFFECTS
abdominal pain
ADVERSE Tachycardia, bradycardia, hepatitis, impotence or decreased libido,
REACTIONS leucopenia, granulocytopenia, thrombocytopenia
Assessment
• History – allergy to ranitidine, impaired renal or hepatic
NURSING function
RESPONSIBILITIES • Physical – skin lesions; orientation, affect; pulse, baseline
ECG, live evaluation, abdominal examination, normal
output, CBC, renal function test
Intervention
• Decrease doses in renal and liver failure
• Provide concurrent antacid therapy to relieve pain.
• Arrange for regular follow – up, including blood tests, to
evaluate effects.
Patient teaching

71
 • If you also are using antacid, take it exactly as prescribed,
being careful of the times of administration.
• Have regular follow – up care to evaluate your response.
• You may experience these side effects: constipation or
diarrhea (request aid from your health care provider),
nausea, vomiting, impotence or decreased libido, headache
• Report sore throat, fever, unusual bruising or bleeding,
tarry stools, confusions, hallucinations, dizziness, severe
headache, muscle or joint pain.
Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
BIBLIOGRAPHY Wilkins, Wolters Kluwer Company

Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)

Generic Name Ketorolac

Brand Name Toradol
Classification NSAID, nonopioid analgesic
Dosage 30mg q 8hr IVTT
Mode of Action • Inhibits prostaglandin synthesis, producing peripherally
mediated analgesia. Also has anti-pyretic and anti-
inflammatory properties
Indications • Short-term management of pain
• Ocular itching caused by seasonal allergic rhinitis
• Postoperative inflammation following cataract surgery
• Pain and burning or stinging following corneal refractive
surgery
Contraindications • Hypersensitivity to the drug or other NSAIDS

72
 • Acute peptic ulcer disease, recent GI bleeding or
perforation, history of peptic ulcer or GI bleeding
• Suspected or confirmed cerebrovascular bleeding,
hemorrhagic diathesis, or incomplete hemostasis and in
those with a high risk of bleeding
• Intrathecal or epidural administration( due to alcohol
content of product)
• Labor, delivery, or lactation
• Perioperative pain from coronary artery bypass graft
surgery
Side Effects • Drowsiness, dizziness, headache, nausea, vomiting,
epigastric pain, indigestion, flatulence, constipation,
insomnia, dry mouth, sweating
Adverse Effects • Gastric or duodenal ulcers, renal failure, peripheral edema,
dyspnea, hemoptysis, pharyngitis, bronchospasm, rhinitis,
anaphylaxis

Drug Interaction • Concurrent use with aspirin may decrease effectiveness

• With aspirin, other NSAIDS, potassium supplements,
corticosteroids, or alcohol, adverse GI effects is increased
• Chronic use with acetaminophen may increase risk of
adverse renal reactions
• May decrease effectiveness of diuretics or hypertensives
• Increases risk of toxicity with methotrexate
• Increases risk of bleeding with cefotetan, cefoperazone,
valproic acid, clopidogrel, and ticlopidine
• Increases risk of adverse heamatologic reactions with
antineoplasctic or radiation therapy
• May increase risk of nephrotoxicity from cyclosporine
• Probenecid increases ketorolac blood levels and the risk of
adverse reactions
Nursing • Assess pain ( type, location, & intensity) before and after

73
Responsibilities drug therapy.
• Assess for rhinitis, asthma, urticaria. Patients who have
asthma, aspirin-induced allergy, and nasal polyps are at
increased risk of developing hypersensitivity reactions.
• Instruct patient on how and when to ask for medication
• Tell patient to take medication exactly as directed. Take
missed doses as soon as remembered if not almost time for
next dose. Do not double dose.
• Advise patient to avoid driving or other activities requiring
alertness until response to the medication is known
because it may cause drowsiness or dizziness.
• Caution patient to avoid the concurrent use of alcohol,
aspirin, NSAIDS, acetaminophen or other OTC
medications without consulting health care professional
• Advise patient to consult health care professional if rash,
itching, visual disturbances, tinnitus, weight gain, edema,
black stools, persistent headache, influenza-like-syndrome
( chills, fever, muscle aches, pain) occurs/
Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company

Karb, V.D., Queener, D.F., Freeman, J.B., RN, PhD. (1996)

BIBLIOGRAPHY
Handbook of Drugs for Nursing Practice .2nd Ed. Mosby Year
Book, St. Louis, Missouri, U.S.A.

Foley, M, RN, BSN, et.al. (2005) Mosby’s 2005 Drug Consult for
Nurses .1st Ed. Elsevier Mosby, St. Louis Missouri, U.S.A.

74
Generic Name Tramadol
Brand Name Ultram
Classification Analgesic ( centrally acting)
Dosage 50mg q 8hr IVTT
Mode of Action • Binds to mu-opioid receptors and inhibits the reuptake of
serotonin and norepinephrine in the CNS
Indications • Moderate to moderately severe pain
Contraindications • Contraindicated with hypersensitivity or allergy to
tramadol or opioid.
• Patients who are acutely intoxicated with alcohol,
sedatives/hypnotics, centrally acting analgesics, opioid
analgesics, or psychotropic agents.
• Patients who are physically dependent on opioid
analgesics.
• Not recommended for use during pregnancy or lactation
Side Effects • Dizziness, headache, nausea, vomiting, constipation,
sweating, hypotension, dry mouth,
Adverse Effects • Seizures, anaphylactoid reactions, hypertonia, physical/
sychological dependence, tolerance, anorexia

Drug Interaction • Alcohol & general anesthetics: increases respiratory

depression
• Carbamazepine: decreases tramadol effect r/t increased
metabolism
• CNS depressants: additive CNS depression
• Cyclobenzaprine: increases risk of seizures
• Digoxin: increases risk of digoxin toxicity
• MAO inhibitors/promethazine/trycyclic antidepressants:
increases risk of seizures

75
 • Naloxone: increases risk of seizures if naloxine used for
tramadol overdose
• Quinidine: increases levels of tramadol
Nursing • Assess pain (type, location, and intensity) before and after
Responsibilities administration of the medication.
• Assess blood pressure and respiratory rate before and
periodically during administration.
• Assess bowel function. Prevention of constipation should
be instituted with increased intake of fluids and bulk and
laxatives to minimize constipating effects.
• Monitor patient for seizures. May occur within
recommended dose range.
• Explain therapeutic value of medication before
administration to enhance the analgesic effect.
• Instruct patient on how and when to ask for medication
• Advise patient to avoid driving or other activities requiring
alertness until response to the medication is known because
it may cause drowsiness or dizziness.
• Advise patient to change positions slowly to minimize
orthostatic hypotension.
• Caution patient to avoid concurrent use of alcohol or other
CNS depressants with this medication.
• Encourage patient to turn, cough, and breathe deeply for
every 2 hr to prevent atelectasis
Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug
BIBLIOGRAPHY Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company

76
GENERIC NAME Etoricoxib

77
 BRAND NAME Arcoxia
CLASSIFICATION COX-2 inhibitor
ORDERED DOSAGE 120mg cap 1 cap OD
COX-2 inhibitors reduce pain and inflammation by blocking
MODE OF ACTION COX-2, an enzyme in the body which plays a role in joint
inflammation and pain.
• acute and chronic treatment of the signs and symptoms of

osteoarthritis and rheumatoid arthritis

• management of ankylosing spondylitis
INDICATION • relief of chronic musculoskeletal pain
• relief of acute pain

• to treat acute gouty arthritis

DRUG INTERACTION
• allergy to Arcoxia or allergic reaction to aspirin or other
anti-inflammatory medicines
• if the patient has had heart failure, a heart attack, bypass
surgery, chest pain (angina), narrow or blocked arteries of
the extremities (peripheral arterial disease), a stroke or
mini stroke (TIA or transient ischemic attack).
• high blood pressure that is not well controlled on blood
CONTRAINDICATION pressure medication.
• If the patient is having major surgery and has conditions
which increases the risk of coronary artery disease or
atherosclerosis such as high blood pressure, diabetes, high
cholesterol or smoking.

• If the patient is having major surgery on his heart or

arteries.
Nausea, vomiting, headache, dizziness, heartburn, indigestion,
SIDE EFFECTS uncomfortable feeling or pain in the stomach, diarrhea, swelling of
ankles, legs or feet, increased BP
ADVERSE Allergic reactions, including rash, itching and hives; altered taste;
REACTIONS wheezing; insomnia; anxiety; drowsiness; mouth ulcers; diarrhea;

78
 confusions; hallucinations; decreased platelet count; severely
increased BP; atrial fibrillations; palpitations; stomach ulcers;
hepatotoxicity; renal toxicity
NURSING •
RESPONSIBILITIES

BIBLIOGRAPHY http://www.drugs.com/arcoxia.html

GENERIC NAME Clindamycin

BRAND NAME Cleocin, Dalacin C
CLASSIFICATION Antibiotic
ORDERED DOSAGE 300mg 1cap q8 6am-2pm-10pm
Inhibits bacterial protein synthesis by binding to 50S subunit of
MODE OF ACTION
ribosome.
INDICATION • Infections caused by sensitive staphylococci, streptococci,
pneumococci, Bacteroides, Fusobacterium, Clostridium
perfringens, and other sensitive aerobic and anaerobic
organisms
• Endocarditis prophylaxisfor dental procedures in patients

79
 allergic to penicillin
• Acne vulgaris
• Bacterial Vaginosis
• Pneumocystis jiroveci (carinii) pneumonia

• Toxoplasmosis (cerebral or ocula) in immunocompromised

patients
Drug-Drug
• Erythromycin: May block clindamycin site of action
DRUG INTERACTION
• Kaolin: May decrease absorption of oral clindamycin
Neuromuscular blockers: May potentiate neuromuscular blockade
• Contraindicated in patients hypersensitive to drug or
lincomycin

CONTRAINDICATION • Use cautiously in patient seith renal or hepatic disease,

asthma, history of GI disease, of significant allergies

• Use cautiously in neonates

CV: thrombophlebitis
EENT: pharyngitis
GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,
diarrhea, dysphagia, esophagitis, flatulence, nausea,
SIDE EFFECTS/ pseudomembranous colitis, unpleasant or bitter taste, vomiting
ADVERSE REACTIONS GU: UTI, vaginal discharge
HEMATOLOGIC: eosinophilia, thrombocytopenia, transient
leucopenia
SKIN: maculopapular rash, urticaria
OTHER: anaphylaxis; erythema
NURSING • Inform patient of the possible side/adverse effects and drug
RESPONSIBILITIES interactions
• Instruct patient to notify physician/prescriber if
side/adverse effects and drug interactions is noted
• Give with full glass of water to prevent dysphagia

80
 • Tell patient to follow proper medication regimen
• Monitor vital signs for baseline data and patient monitoring

BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company

GENERIC NAME Ciprofloxacin

BRAND NAME Cifroxin
Quinolones / Eye Anti-infectives & Antiseptics / Ear Anti-
CLASSIFICATION
infectives & Antiseptics
ORDERED DOSAGE PO Susceptible infections 250-750 mg twice daily. Acute
uncomplicated cystitis 100 mg twice daily for 3 days.
Gonorrhoea 250-500 mg as a single dose. Pseudomonal lung
infections in cystic fibrosis 20 mg/kg twice daily. Max: 750 mg
twice daily. Prophylaxis of meningococcal meningitis 500 mg as
a single dose. Surgical prophylaxis 750 mg as a single dose 60--
90 mins pre-op. Acute exacerbations of cystic fibrosis
Associated w/ P. aeruginosa infection: 20 mg/kg bid. Max: 750
mg bid. IV Susceptible infections 100-400 mg twice daily.
Pseudomonal lung infections in cystic fibrosis 400 mg twice
daily. Max: 400 mg 3 times/day. Ophth Superficial ophth
infections As 0.3% soln: Apply every 15 mins for 6 hr, followed

81
 by every 30 mins for day 1, then hrly on day 2 and 4 hrly for days
3-14. Treatment duration: ≤21 days. Otic Otitis externa; Otitis
media As 0.2 or 0.3% soln: Instill 4 drops twice daily for 7 days.

Ciprofloxacin promotes breakage of double-stranded DNA in

MODE OF ACTION susceptible organisms and inhibits DNA gyrase, which is essential
in reproduction of bacterial DNA.

• Infections caused by sensitive staphylococci, streptococci,

pneumococci, Bacteroides, Fusobacterium, Clostridium
perfringens, and other sensitive aerobic and anaerobic
INDICATION
organisms

Decreased absorption with concurrent sucralfate, magnesium-

aluminum antacids, calcium, iron, zinc and multivitamins.
Increased methotrexate and caffeine levels when taken
concurrently with ciprofloxacin. Probenecid reduces renal
clearance of ciprofloxacin. Potentiates oral anticoagulants and
glibenclamide. Concurrent use with corticosteroids may increase
tendon rupture. Concurrent use with ciclosporin may cause
DRUG INTERACTION transient increases in serum creatinine. CNS excitation may occur
with concurrent admin of quinolones and NSAIDs. Serum
concentrations of theophylline are markedly elevated when co-
administered with ciprofloxacin; monitor serum levels of
theophylline.
Potentially Fatal: Concurrent use with tizanidine can cause
marked elevation in serum levels of tizanidine; avoid concurrent
usage.
CONTRAINDICATION Hypersensitivity. Not to be used concurrently with tizanidine.
Avoid exposure to strong sunlight or sun lamps during
treatment. Epilepsy, history of CNS disorders; severe renal or
hepatic dysfunction; G6PD deficiency; maintain adequate

82
 hydration; myasthaenia gravis. Caution when used in patients
with QT prolongation or risk factors e.g. bradycardia, pre-
existing cardiac disease or uncorrected electrolyte
disturbances. Discontinue treatment if patients experience
tendon pain, inflammation or rupture. Avoid usage in
methicillin-resistant staphylococcus aureus (MRSA) infections
due to high level of resistance. May impair ability to drive or
operate machinery. Safety and efficacy have not been
established in pregnant and lactating women. Not to be used in
children <18 yr; except where benefit clearly exceeds risk.
CV: thrombophlebitis
EENT: pharyngitis
GI: abdominal pain, anorexia. Bloody or tarry stools, constipation,
diarrhea, dysphagia, esophagitis, flatulence, nausea,
SIDE EFFECTS/ pseudomembranous colitis, unpleasant or bitter taste, vomiting
ADVERSE REACTIONS GU: UTI, vaginal discharge
HEMATOLOGIC: eosinophilia, thrombocytopenia, transient
leucopenia
SKIN: maculopapular rash, urticaria
OTHER: anaphylaxis; erythema
NURSING • Inform patient of the possible side/adverse effects and drug
RESPONSIBILITIES interactions
• Instruct patient to notify physician/prescriber if
side/adverse effects and drug interactions is noted
• Give with full glass of water to prevent dysphagia
• Tell patient to follow proper medication regimen
• Monitor vital signs for baseline data and patient monitoring
 Assess overall health status and alcohol usage before
administering acetaminophen. Patients who are
malnourished or chronically abuse alcohol are at higher
risk of developing hepatotoxicity with chronic use of usual

83
 doses of this drug
• Assess amount, frequency, and type of drugs taken in
patients self-medicating, especially with OTC drugs.
Prolonged use of acetaminophen increases the risk of
adverse renal effects.
Lab Test Considerations
• Evaluate hepatic, hematologic, and renal function
periodically during prolonged, high-dose therapy

BIBLIOGRAPHY Lippincott, Williams and Wilkins.(2006).Nursing2006 Drug

Handbook.(26th ed.). Maryland, USA:Lippincott, Williams and
Wilkins, Wolters Kluwer Company

84
 Nursing Theories

Nursing theory is the term given to the body of knowledge that is used to support nursing
practice. In their professional education nurses will study a range of interconnected subjects
which can be applied to the practice setting. This knowledge may be derived from experiential
learning, from formal sources such as nursing research or from non-nursing sources.

Florence Nightingale’s Environmental Theory

Nightingale's core nursing theory has an environmental focus: She believed that the
environment is an alterable medium that can be used to improve the conditions of nature and
encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and
adequate waste management are just a some of the elements she believed could be monitored and
improved when necessary. She stated that nursing is an act of utilizing the patient’s environment
to assist him in his recovery. This involves the nurse's initiative to configure environmental
settings appropriate for the gradual restoration of the patient's health, and that external factors
associated with the patient's surroundings affect life or biologic and physiologic processes, and
his development.

This theory is applicable to our patient because the institution where she stayed was
following an ideal way of treating their patients. The ward where she stayed was clean with
proper ventilation, provision of light and with controlled noise. There was also an adequate
management wherein there were separate garbage bins for biodegradable, non-biodegradable and
infectious materials. These factors follows Nightingales assumptions that helps for a faster
recovery of the patient.

Faye Glen Abdellah’s Patient- Centered Approach

85
 Faye Glenn Abdellah’s problem solving approach (twenty one nursing problems) was
created to direct the nurse. It helps the nurse have an organized approach in his or her care of the
patient. It does so by providing 21 nursing problems that serve as a guide for the patient to
pattern his or her plan of care after. It can be used for data collection, planning, and prioritizing
nursing interventions.

The client’s student nurse has the task of maintaining her health and improving her
wellbeing. Doing so entails an organized plan of care that we can get from Faye Abdella’s
theory. The nurse should gather necessary information about his condition before identifying a
therapeutic plan. The student nurse assessed her ability to maintain her proper nutrition,
elimination, fluid and electrolyte balance, the body’s response to disease, regulatory
mechanisms, and maintenance of sensory function. Last is remedial care such as identifying and
accepting feelings, maintenance of effective verbal and nonverbal communication. After
identifying the needs of the patient, nursing interventions were to be done to promote wellness of
our client. It is clear that these 21 nursing problems help organize the needs and the tasks that her
student nurse needed to accomplish.

DONE 1.. To promote good hygiene and physical comfort

DONE 2. To promote optimal activity, exercise, rest, and sleep
DONE 3. To promote safety through prevention of accidents, injury, or other
trauma and through the prevention of the spread of infection
DONE 4. To maintain good body mechanics and prevent and correct deformities
DONE 5. To facilitate the maintenance of a supply of oxygen to all body cells
DONE 6. To facilitate the maintenance of nutrition of all body cells
DONE 7. To facilitate the maintenance of elimination
DONE 8. To facilitate the maintenance of fluid and electrolyte balance
DONE 9. To recognize the physiologic responses of the body to disease
conditions
DONE 10. To facilitate the maintenance of regulatory mechanisms and functions
N/D 11. To facilitate the maintenance of sensory function

86
 DONE 12. To identify and accept positive and negative expressions, feelings, and
reactions
DONE 13. To identify and accept the interrelatedness of emotions and illness
DONE 14. To facilitate the maintenance of effective verbal and nonverbal
communication
DONE 15. To promote the development of productive interpersonal relationships
DONE 16. To facilitate progress toward achievement of personal spiritual goals
DONE 17. To create and maintain a therapeutic environment
DONE 18. To facilitate awareness of self as an individual with varying physical,
emotional, and developmental needs
DONE 19. To accept the optimum possible goals in light of physical and
emotional limitations
N/ D 20. To use community resources as an aid in resolving problems arising
from illness
N/ D 21. To understand the role of social problems as influencing factors in the
cause of illness

Lydia Hall’s Theory

Lydia Hall’s theory is visually presented by three interlocking circles. Each circle
represents a particular aspect of nursing. The three circles represent the care, core and cure. The
major aspect of care is to achieve an interpersonal relationship with the health care provider that
will much more facilitate development. This aspect provides motherly care and comfort, provide
teaching-learning activities and support the daily biological function of the patient. The
closeness of the nurse and patient promotes the sharing and exploration of feelings with the
nurse. The core aspect emphasized the therapeutic use of self and usage of reflective technique.
The patient becomes more aware of the feeling being experienced as evidenced of making
conscious decision, understand and accept feeling. In Hall’s theory health is derived as a state of
self-awareness. The cure circle is based on pathological and therapeutic sciences like giving of
prescribed medications. These three aspects function independently but they are interrelated and
the circle’s size represents the progress in each aspect.
87
 Hall’s theory is applicable in the case of our Client. The care aspect shows the
relationship between the patient and the health care provider who is, in her case, the student
nurse. The student nurse gives health teachings to the client like the prescribed diet, medications
and lifestyle for her condition. She is aware of her condition and listens to the student nurse’s
health teachings to avoid further complications and problems. Our client was able to verbalize
her willingness to be well with the student nurse. The student nurse should encourage support in
order to promote positive outlook of the client. The core aspect helped the patient reflect on her
situation today and in this manner the patient will learn to accept and understand her situation
and cope up with ways to promote her state of wellness. The client shows motivation on getting
well by taking her medications on time which is part of the cure aspect of Hall’s theory.

88
 NURSING CARE PLAN NO. 1

D CUES N NURSING GOAL OF CARE INTERVENTIONS

A E DIAGNOSIS
T E
E D
SUBJECTIVE: ACUTE PAIN Within 2-4 hours a. Provide with calm and quiet
1 “ Sakit kayo akong S related to of my care, patient environment.
2 samad sa breast,” as A Wound at left will be able to: R. For adequate rest and sleep.
- verbalized by the F breast secondary
1 patient. E to Breast cancer -verbalized that b. Provide comfort measures.
4 T pain is relieved or R. To provide nonpharmacological
- OBJECTIVE: Y controlled pain management.
0 -painscale of 7 out of R.
9 10 as 8-10 severe pain, A Unpleasant -verbalized that c. Administer analgesics/ pain reliev
5-7 moderate pain, 0-4 N sensory and pain scale of 7 out as indicated to maximal dosage.
7 mild pain D emotional of 10 will R. To alleviate pain.
: experience arising decreased within
0 -grimace face noted S from actual or 0-3 pain scale d. Encourage adequate rest periods.
0 E potential tissue R. To prevent fatigue.
p -guarded behavior C damage can due
m noted U to a disease e. Instruct/ encourage use of relaxatio
R process.. exercises.
-uncomfortable I R. Reduces skeletal muscle tension
position T which will reduce the intensity of the
Y pain.
-with dry and intact
dressing at left breast N f. Encourage diversional activities.
E R. To redirect attention and control t
-VS E pain felt.
BP= 120/70mmHg D
RR= 34cpm g. Encourage verbalization of feeling
PR= 80 bpm about the pain.

89
 T= 37.1 C R. Be able to know the degree of pai
felt.

h. Encourage deep breathing exercise

R. To assist in muscle and generalize
relaxation.

NURSING CARE PLAN NO. 2

D CUES N NURSING GOAL OF CARE INTERVENTIONS

A E DIAGNOSIS
T E
E D
SUBJECTIVE: Impaired Skin Within my 3 days 1. Assess skin, note for color, turgor
1 “Naga katol akong S Integrity related span of care and sensation.
2 samad, nagabaho pud A to left breast patient will R: establishes comparative baseline
- siya”, as verbalized by F wound secondary maintain her providing opportunity for timing
1 the patient. E to breast cancer. normal vital signs intervention.
4 T and well being and
- OBJECTIVE: Y R: no further signs of 2. Demonstrate good skin hygiene
0 -disruption of skin infection will be R: Maintaining clean dry skin provid
9 surface A A dimpling of the seen or observed barrier to infection.
-with dry, clean and N breast skin or on her.
7 intact dressing at left D nipple could be 3. Instruct family to maintain clean d
: breast. from the loss of clothes preferably cotton fabric.
0 - foul odor was noted S elasticity in the R: stiff or rough clothes causes skin
0 coming from her left E supporting friction and increases risk of infectio
p breast C ligaments as you
m U age. But dimpling 4. Emphasize the importance of prop
-Vital Signs: R may also be a nutrition and fluid intake.

90
 BP= 120/70mmHg I sign that a tumor R: improve nutrition and hydration
RR= 34cpm T buried in the will improve skin condition.
PR= 80 bpm Y tissues is pulling
T= 37.1 C on the skin or 5. provide and apply wound dressing
N nipples. In the R: wound dressing serves as barrier t
E case of a tumor, surrounding tissue.
E dimpling might
D show up long 6. encourage early ambulation
before a lump R: promotes circulation
becomes large
enough to feel. 7: assist client in understanding and
following medical regimen
R: enhances commitment to plans,
optimizing outcomes

8: encourage client to verbalize

feelings
R: to promote proper intervention to
the problem

NURSING CARE PLAN NO. 3

DATE CUES NEED NURSING GOAL NURSING

/ TIME DIAGNOSIS OF CARE INTERVENTION

Dec. Subjective: Disturbed body At the end of my 1. Establish trusting

S
15, “Unsa kaya ang image related to shift, the client relationship or rapport to
E
2009 mahimong itsura L impending surgical will begin to the patient.
F
sa akong totoy procedure on her exhibit her ® To gain trust.
-
@ paghuman sa E left breast due to perception on her 2. Ascertain whether
S
7:30pm operasyon Breast Cancer baseline body support and counseling
T
noh?”, as E image after were initiated when the
E
verbalized by the surgery , as possibility of and/or
M
91
patient evidenced by necessity of mastectomy
verbalization of was first discussed.
N
Objective: E ® Woman who positive ® This provides
E
- Patient is undergo surgery for adaptation to her information about patient’s
D
scheduled for breast cancer impending level of knowledge and
toilet experience a sense surgery, anxiety about individual
Mastectomy of loss – changes in situation.
tomorrow life routines, social 3. Encourage patient to
morning interactions, self- verbalize feelings
- dressing placed concept, and body regarding the procedure
on left breast image – and fear of done. Acknowledge
death. Recovery normality of feelings of
during the anger, depression, and grief
postoperative over loss. Discuss daily
period after “ups and downs” that can
mastectomy occur.
requires a great deal ® It helps patient realize
of energy. A that feelings are not
client’s usual unusual and that guilty
coping strategies about them is not necessary
may not be or helpful. Patient needs to
effective. Not every recognize feelings before
one perceives or they can be dealt with
handles stress in the effectively.
same way. Clients 4. Note behaviors of
who have surgically withdrawal, increased
lost a breast may dependency, manipulation,
adapt in the same or noninvolvement in care.
way as they would ® This suggests of
to any loss. problems in adjustment
that may require further

92
References: evaluation and more
Black, J. et. al. extensive therapy.
(2001). MEDICAL- 6. Provide opportunity for
SURGICAL patient to deal with
NURSING: mastectomy through
Clinical participation in self-care.
Management for ® Independence in self-
Positive Outcomes. care helps improve self-
6th ed. USA: W.B. confidence and acceptance
Saunders Company. of situation.
7. Encourage questions
about current situation and
future expectations.
Provide emotional support
when surgical dressings are
removed.
® Loss of breast causes
many reactions, including
feeling disfigured, fear of
viewing scar, and fear of
partner’s reaction to
change in body.
8. Plan or schedule care
activities with patient.
® Promotes sense of
control and give message
that patient can handle
situation, enhancing self-
concept.
9. Maintain positive
approach during care

93
 activities, avoiding
expressions of disdain or
revulsion. Do not take
angry expressions of
patient personally.
® Assists patient to accept
body changes and feel all
right about self. Anger is
most often directed at the
situation and lack of
control individual has over
what has happened
(powerlessness), not with
the individual caregiver.
10. Identify role concerns
as woman, wife, mother,
career woman, and so
forth.
® This may reveal how
patient’s self-view has
been altered.

NURSING CARE PLAN NO. 4

Date Cues Need Nursing Diagnosis Objective of Nsg.

Care Intervent

94
 Objective: Risk for infection related Within 8 hrs span 1. Monitor
to break in skin integrity of nursing care, signs.
December -wound at left S as evidenced by left breast patient will be R: an incre
16, breast A wound secondary to breast able to maintain temperature
2009 -foul smell coming F cancer an optimum level first sign of
from the wound E of wellness and no infection.
-clean and intact T progress of 2. Adminis
dressing at left Y ® A woman who has infection or spread prophylacti
breast breast cancer with of wound. antibiotics
- foul smell A draining wound is at risk ordered.
coming from her N for infection. R: to reduc
wound was noted. D prevent bac
Reference: infection
- Vital Signs: S Lemone and Burke,
BP= 120/70mmHg E Medical Surgical Nursing,
RR= 24cpm C Critical Thinking in Client
PR= 84 bpm U Care, 2004 3. Orient cl
T= 37.3 C R signs and
I symptoms o
T sepsis (syst
Y infection);
chills, diap
N altered leve
E consciousn
E positive blo
D cultures.

®Health te
are essentia
the comple
recovery of

95
 client

4.Stress pro
hand washi
techniques
between nu
patient
®kills or pr
the spread o
microorgan
5. Change
dressing as
or as indica
® to preven
growth of b
and infectio
6.Eat nutrit
food and
encourage t
vitamins
® to impro
immune sy
7.Promote
hygiene
® to promo
wellness
NURSING CARE PLAN NO. 5

96
 N
DAT NURSING
E NURSING OBJECTIVE
E/TI CUES INTERVENTION EVALUATION
E DIAGNOSIS OF CARE
ME WITH RATIONALE
D
S/O: A Ineffective Breathing After 8hours of • Assessed respiratory GOAL MET
-RR=34cpm C Pattern related to disease care, patient will rate. At the end of the shift,
Dec. -shortness T process secondary to be able to  Provides a basis for the client was able to
14, of breath I Breast cancer establish normal evaluating establish normal and
2009 -dyspneic V and effective adequacy of effective breathing
- use of I Rationale: breathing pattern ventilation pattern as evidenced
accessory T Cancer of the lung and as evidenced by: • Noted chest by:
muscles Y breast are the most -RR of 16- movement; use of
while - common cancers to cause 20cpm accessory muscles Client’s respiratory
breathing E breathlessness. The -be free from during respiration. rate is within normal
X former causes cyanosis or other  Use of accessory range: RR-20 cpm.
E breathlessness by symptoms of muscles of
R invading and obstructing hypoxia respiration may Client was free from
C airways in the lung. occur in response to cyanosis or other
I Breast cancer on the ineffective signs/symptoms of
S other hand, causes ventilation. hypoxia.
E malignant pleural • Maintained patient
effusions rather than on moderate to high
P blocking an area in the back rest.
A lungs
 Positioning helps
T
maximize lung
T Reference :
expansion.
E http://www.virtualcancer
• Encourage patient
R centre.com/symptoms.as
to have adequate
N p?sid=15
rest periods between
activity
 To prevent fatigue
• Checked for
obstructions:
accumulation of
secretions.
 To maintain 97
adequate airway
patency
 DISCHARGE PLAN

Medications Exercise Treatment Health Teachings Out- Patient

• Inform the • Inform the • Inform the • Encourage • Encourage the
patient of the patient that patient to the patient to patient to hav
importance of she can be take have regular check
compliance of ambulatory prescribed adequate ups to monito
medication but avoid medications rest and her health
especially strenuous on time and sleep. status.
maintenance of activities. with the • Advise the • Inform the
medicines. Avoid right dosage. patient to patient not to
• Inform the lifting • If any signs have proper self diagnose
patient that she heavy and hygiene. if there are
must take her things. symptoms of • Encourage cases where
medications at • Encourage recurrence the patient to signs and
the right time the patient of illness, contact symptoms are
prescribed by to do immediately health care felt.
her doctor. stretching in report to the provider
• Since the the morning doctor so once
patient is taking and at night that it can be symptoms
several as this intervened are felt.
medications, would help on. • Relaxation
advise her to in the • Do not use technique
organize circulation any herbal can be done
medications in of the blood medications to help
a container so in the body. to cure any reduce blood
that it would be • If patient sickness, pressure.
easier to access feels dizzy immediately • Lifestyle
the medications or weak, seek medical modification
on time. encourage advice. should be
• Inform the to do range • Avoid done
patient not to of motion becoming because they
skip exercise. too fatigue. are effective
medication, and • Encourage Always in
if skipped, do patient to do make sure preventing
not double the deep that she will further
next dose. breathing be having illnesses.
• Encourage the exercise. adequate
patient to avoid rest.
taking OTC • Avoid
drugs unless stressful

98
consult has environment
been done by .
the physician. • If dizzy,
advise to sit
or lie down
immediately
to avoid
casualties.

99
Prognosis

100
 CRITERIA GOOD FAIR POOR RATIONALE JUSTIFICATION
Onset of Illness As early as possible, The patient seek
the patient should seek medical help only
medical treatment when on the event when
the signs and symptoms there is already
of a certain illness are bleeding on her
manifesting. When breast and it was
medical attention is still on the year
given early to the 2006. She did not
patient, the signs and have any follow up
symptoms will not lead check up, and now,
to further it is already in stage
complications. If the 3B of the disease
illness is diagnosed in process.
the late stage, recovery
would be slow and
difficult.
http://www.med.nyu.ed
u/patientcare/library/a
rticle.html?
ChunkIID=165011
Duration of With proper treatment The patient only
Illness by therapy and/or by seeks and had a
medications, the client return check up to
should adhere to what her physician only
is being ordered by her when her cancer
physician during the progressed already.
duration of illness.
Without these, the
duration of illness will
last longer which
means the client will be
at more risk of
complications.
http://www.healthteach
ing.com/pre.html
Environment The environment The patient’s home
affects an individual’s environment is
general health. clean and
Maintaining a good comfortable to live
environment that is fit in. The hospital is
for the patient and aid’s also clean and tidy
in the recovery of the which imposes
patient. proper and ideal
http://www.environmen place for their
talhealth.ca/w90vision. patient’s health.
html
Family Support Families and friends Patient Star has
are considered to be support from
significant others for everyone in her
they are the ones who family, her children
provide a sick person visit her a lot and
strength, hope and her current husband
encouragement. With is very caring. 101
their love and support,
the patient would be
able to show
LEGEND:
1 POOR= 1.0- 1.6
2 FAIR= 1.7-2.3
3 GOOD= 2.4-3.0

General Prognosis: FAIR

The patient’s prognosis is fair because patient in general is already in Stage 3B cancer
that is already in the advance stage of the disease. Although she cooperates well on the
therapeutic regimen being advised to her by the physician, family also supports her all
throughout the disease process and the patient is optimistic enough that she will gain her strength
again and be well after the surgery, still we cannot deny the fact that all the factors that brought
her the disease are present and are helping the spread of those cancer cells in her body.

Recommendation

To the Patient:

In order for Patient Star to achieve recovery, the researcher highly encouraged her to
maintain good nutrition by eating foods with roughage such as whole grains, raw fruits and
vegetables and try to eat less food high in salt and fats. Resumption of activities should also pace
gradually to avoid any problems, strenuous activities must be avoided and exercises or ADL’s

102
should be done as tolerated. Advised the importance of follow-up examinations and treatments
for these will promote faster recovery for the patient and possible complications that may arise
will be treated immediately.

To the Significant Others:

Patient Star’s family must understand the importance of early detection of the illnesses;
the researcher would like to encourage them to have routinary check ups to avoid any further
complications that may occur if not treated early. Consult a doctor if unusualities occur to the
patient so that proper medication may be prescribed to treat underlying condition. They must
extend their support, for assistance and guidance is a good way of helping the patient and
collaborate in plans to promote faster recovery. Lastly, is to always have a healthy way of living,
by doing so, the body is more ensured to be protected and armed against any diseases.

To my fellow Student Nurses:

In line with this case study and case presentation, we had undergone Leadership and
Training courses wherein we practiced it on our Head Nursing duties, I would like to emphasize
to practice teamwork and unity among our group. Let us be arole model in our patients. Lastly,
continue to have deep faith in our God Almighty.
Bibliography

Books:
• Handbook of diseases (thirds edtion) by Sarah Y. Yuan, MD, PhD
• Nurse’s Pocket Guide, diagnoses, prioritized interventions and rationales, by Marilynn E.
Doengers, Marry Frances Moorhouse
• 2008 Lippincott’s Nursing Drugs Guide by Amy Karch
• Fundamental of Nursing, standards and practice, third edition by Sue C. Delaune and
Patricia K. Lander
• Anatomy and physiology, fifth edition by Gary A. Thibodeau and Kevin T, Patton
• Fundamentals of Nursing, concepts, process and practice by Barbara Kozier, Glenora
ERB, Audrey Berman and Shirlee Snyder
• Pathophysiology made incredibly easy 4th edition.

103
 • Pathophysiology Concepts of Altered Health States by Carol Mattson Porth
• Medical surgical Nursing, clinical management for positive Outcomes by Joyce M. black
and Jane Hokanson Hawks
• Springhouse Nurse’s Drug Guide 2008
• MIMS 110th Edition 2006

Internet sources:
• http://www.smartskincare.com/reviews/product/other_supplem_na_conzace_20040911.ht
ml
• http://www.rxlist.com/methergine-drug.htm
• http://www.umm.edu/altmed/drugs/methylergonovine-085300.htm
• http://www.drugs.com/pro/methergine.html
• http://www.answers.com/topic/scurvy
• http://www.rxlist.com/toradol-drug.htm
• www.mims.com
• http://www.patient.co.uk/showdoc/30002493/
• www.wikipedia.com
• http://www.medscape.com/viewarticle/579312
• http://emedicine.medscape.com/article/279116-overview
• http://brighamrad.harvard.edu/Cases/bwh/hcache/38/full.html
• http://www.personal.u-net.com/~njh/cgest.html
• http://www.merck.com/mmpe/sec18/ch254/ch254f.html

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