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“We acquire the strength of what we have overcome.” - Ralph Waldo Emerson
So many women you know may have had breast cancer — friends and neighbors, coworkers, relatives. It seems as if every time you turn around, breast cancer is being talked about in the newspaper or on TV. You may be fearful of developing breast cancer for the first time or of receiving a diagnosis after a mammogram or other testing. If you’ve had breast cancer, you may be fearful of a possible recurrence or even of the possibility that breast cancer could take your life. Breast cancer is an uncontrolled growth of breast cells. To better understand breast cancer, it helps to understand how any cancer can develop. Cancer develops when cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because of out-of-control growth of abnormal cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more rapidly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries. Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to form new abnormal cells. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all its activities. Most of the time when DNA becomes damaged the body is able to repair it. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a person’s DNA becomes damaged by exposure to something in the environment, like smoking. Cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body. The breast cancer’s stage refers to how far the cancer cells have spread beyond the original tumor, A tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous). The term “breast cancer” refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast. Breast cancer is always caused by a genetic abnormality (a ―mistake‖ in the genetic material). However, only 5-10% of cancers are due to an abnormality inherited from your mother
or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the ―wear and tear‖ of life in general. Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 35(about 3%). In 2008, about 40,480 women will die from breast cancer in the United States. Death rates from breast cancer have been declining since about 1990, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier detection through screening and increased awareness, as well as improved treatment. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years. We have chosen the case because we want to broaden our knowledge about Breast Cancer regarding to the nursing interventions and medical management. Cancer is the second leading cause of death and is a common case in the Surgical Ward of Baguio General Hospital and medical Center (BGHMC) that also prompted the group to research on the disease. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years.
P A T I E N T S
P R O F I L E
Patient X is 53 y/o, female, currently residing at Urdaneta City, Pangasinan was born on May 28, 1956 at Dagupan City, Benguet. She is married and was blessed with four children. She is currently living with her sister and her daughter here in Baguio due to her chemotherapy sessions at Baguio General Hospital and Medical Center. She is currently a housewife, managing the family and her only daughter. At present, source of income comes from her husband working as a Computer Technician on a company. She was admitted last September 2008 at Baguio General Hospital and Medical Center (BGHMC) form MRM (modified Radical Mastectomy) with complaints of having pain in her right breast last December 2007. She attained a High school degree having the knowledge and ability to read and write. As for hobbies and interests, she certainly entertains herself by reading, cleaning and doing household chores and taking care of her family. She verbalized that the greatest gift from her is her only children.
2 months noted a mass There was Consultation admission.
Prior to Admission, patient complained, patient before the incision area of the right breast. associated tenderness but no discharged. was sought and surgery was scheduled, hence
Patient X has no previous history of allergies. She had stated that she had previous records of hospitalization and operations. Last Operations were performed on September 2008. She underwent MRM (Modified Radical Mastectomy) and Status post a 6 cycle of Chemotherapy because of presence of tumor on her right breast. She has also a history of Hypertension.
Patient X verbalized that she is the only one in the family that had cancer. She has stated that there were Family Medical Diseases known in their neither family nor hereditary sickness such as hypertension and most commonly in cancer. She declared that she had cancer due to an unhealthy lifestyle established during her younger years. Her aunt had breast cancer and survived and her cousin died due to cancer.
Patient X is married and with four children. They are living in a bungalow type of house made of cement and wood just. Purchase of mineral water is their source of drinking water in the area. She also Garbage is collected on their area daily. She is fond of eating vegetables and fruits, less meat, and fish, and very selective on food. She dislikes and avoids eating salty foods; she is not very fond of eating sweets. She also stated that promotes drinking water, hydrating herself by drinking lots of water approximately 810 glasses a day, as she knows that it would be a benefit to her health. She also stated that she is a non-alcoholic and non-smoker.
The patient was pregnant four times and delivered a four healthy children via Normal Spontaneous Delivery. During her pregnancy, she has a regular pre-natal check-up every month. She has a normal menstrual cycle (ranging from 3 to 4 days every month). She has not undergone any abortion. She has no history of reproductive abnormalities.
place. She answers questions and follow instructions appropriately. the patient is under the stage of Generativity Versus Stagnation. she is currently a housewife. Psychosocial Status Patient X is 53 y/o. source of income comes from her husband working as a Computer Technician on a company. As for hobbies and interests. female. there were no observed mood swings and emotional changes. Under Erik Erikson’s psychosocial development theory. She seems to have a good outlook in life. C. B. she certainly entertains herself by reading. There are clean blankets and pillows for the patient’s use. She attained a High school degree having the knowledge and ability to read and write. As for now. cleaning and doing household chores and taking care of her family. The ward has adequate lighting. There was a regular garbage collection in the hospital where in there is proper regulation. The garbage bins are placed on 5 . Mental Status and Status Emotional The patient was conversant and was slightly oriented to date time. good ventilation and warm temperature. She verbalized that the greatest gift from her is her only children. She was attentive in conversing with the health team members. They seem to have good relationship. 1956 at Baguio City. She deals well with her watcher and visitors. At present. The bed has no side rails.P H Y S I C A L 13 AREAS A S S E S S M E N T OF ASSESSMENT A. Staff Nurses and Watchers of each patient. Pangasinan was born on March 18. During the duty. and people and to her present condition. She was cooperative to the nursing and medical interventions. Benguet. currently residing at Urdaneta City. Her positive attitude was consistent all throughout. managing the family and her only daughter. Environmental Status The patient was admitted to Baguio General Hospital and Medical Center in Surgery East Ward of the Female Division on Bed 16. It was maintained clean at all times by the cooperation of the Hospital Janitor.
smooth and moist pink upon inspection. 6 . Nasal mucosa is intact. Gustatory Status She is able to determine between different tastes such as sour. Tactile Status She was able to perceive hotness. Visual Status Status The patient’s pupils are equally rounded. There are no reduced accommodation to light changes when the penlight was directed to the eyes. sweet. and does wear corrective devices such as eye glasses if needed. She was able to determine from what direction the sound of the voices were coming from as observed when she turned her head towards the direction of the person she was talking to. Auditory Status She has no difficulties in hearing soft voices upon seeing her conversing with her watcher in a whispering manner. She was also able to perceive cold as noted when she asked the student nurse why the thermometer is cold. She has the capability to read due to good visual acuity. bitter. Pain was noted when she grimaced upon the administration of intravenous medications.the hallway of the ward which is managed by the Hospital Janitor. The ears are symmetrical and in lined with the outer cantus of the eyes. D. There was no impacted cerumen upon inspection. and salty. 5. she has diminished visual acuity nor reduction in visual field. Olfactory Status Air is felt in the nose when she exhaled. She could also taste any flavor or dish served to her. Based on her age. 3. She was able to discriminate foul odor as noted when she complained about the bad smell of the comfort room. Sensory 1. She does not have difficulties in seeing far away objects and recognizing people. 2. 4.
Fluid and Electrolyte status Before the hospitalization. H. She could ambulate around the ward and walks to the comfort room to refresh herself without no assistance. Tagalog and English language but fairly understandsother dialects. During her hospitalization. She described her stool as brownish and depending on the foods colors that she intake in. G. 7 . She drinks water every after meal. Tagalog and in English. She verbalizes her needs. her urination ranges from 3-4 times per day only. She has a good appetite. She has no limited movement from her bed and can barely stand on her own. she had not defecated during our 3-11 shift. F. On the days that we handled her. there is no abdominal tenderness. she did drink much water. Nutritional Status During her hospitalization. as she knows that it would be a benefit to her health. Language Perception and Formation The patient is fluent in Ilocano. E. X drinks large amounts of water just about 8-10 glasses of water a day. eating a balanced meal composing largely on fruits and vegetables and small amount of meat.6. The doctor advised her to take in foods that would boost her immune system. She can understand Ilocano. Mrs. Motor Status Patient can move all her extremities very well. Elimination Status During hospitalization. Upon palpation. There was insertion of IV administration of D5LRS 1000 Liters regulated at 21 drops per minute (gtts/min). This must have been because she takes water at all.
I. Her capillary refill is about 2-3 seconds which is normal. she was comfortable in sleeping but there are episodes where she cannot sleep due to ward setting.130/70 which also her normal BP. Circulatory Status Her pulse rate ranges from 62-95 beats per minute which is within the normal limits. The lights are on and the Noise surrounding the ward could irritate her disturbance of sleeping.9 – 37. 8 . Lips and buccal mucosa were not dry. However. K. Respiratory Status Her respiration ranges from 16-22 breaths per minutes. M. L. She has no episodes of difficulty in breathing. she has no fever. Temperature Status During her first day of hospitalization. There is normal Skin turgor which goes back normally. Comfort and Rest Status During our shift. Her temperature ranges from 36.2 degrees centigrade which is within normal range. Integumentary Status Skin was moist. J. There were noted incision on the left breast due to her mastectomy operation last 2008 at Cagayan de Oro. She has a history of hypertension. her blood pressure ranges from 100/60.
1 5 0 .1 6 0 .0 . 0 Eosinophil 0 .0 . 4 8 1 0 g / l g / L l / l x M a r k e d l y i n c r e a s e d 9 . 1 0 2 F 1 2 Hemoglobin 0 . 3 7 x 1 0 0 0 9 7 7 5 5 . 0 4 Red Cell Count 1 2 / L 1 0 1 5 0 . 0 0 . 1 0 . 0 Band T O T A L 1 . 0 0 H e m a t o l o g y N a m e : x W a r d : s u r g A g e : 3 6 / f T i m e : 9 : 1 R E F . 2 0 . 0 0 . 0 . 7 Neutrophils 0 . 4 7 5 . 0 1 1 . 8 4 0 . 5 0 .0 . 0 Monocyte 0 .0 . 4 Lymphocytes 0 . 2 3 2 1 . 0 3 .0 .L A B O R A T O R Y F I N D I N G S A N D I M P L I C A T I O N S F o r m H o s p : 3 9 1 0 5 3 L a b # : W H 1 2 2 R E S U L T 7 8 0 . 0 Midcell 0 . 0 0 . 0 0 F 4 . 0 WBC Count D I F F E R E N T I A L C O U N T 0 .4 0 0 x Platelet Count R e s u l t 5 a m R A N G E 0 . 3 0 F 0 Hematocrit l / l 0 .0 .1 0 .
5 N T I M E e c o n d s . 6 ( P T T ) N T A T I O N R A T E / H r . c 0 M 1 8 o m i n m i n m i E ( 4 s . t t u T c 8 e e t ) o s s e s n d s R . c E u 5 O 3 6 o D 2 l - M 6 n I 0 t 1 B I s 3 7 d s M E m m 0 .1 0 m m / H r % 10 . Retailocyte Count 5 6 1 I .LE Cell Prep.T P R O T H R O M B I N T 1 0 Patient 1 0 Control s e INR % Activity P A R T I A L P R O T H 2 6 Patient 2 9 Control s e E R Y T H R O C Y T E S F 0 Wintrobe Method A d Westergren Method 0 . Malarial Smear 1 Bleeding Time 2 Clotting Time 5 Lee & white C.1 3 n d s u u n P e .
if your white blood cells are low. eosinophils. Normally white blood cells help fight off infection. blast and other precursor. you are more likely to get infections. This can be really hard to deal with and make you wonder if you really want to go on with your treatment. basophils. Some people also say they feel depressed. they'll go down again after each treatment. Any infection can also worsen more quickly – a trivial infection could become life threatening within hours if it isn’t treated. as your blood counts rise. When your white blood cell count is at its lowest you can feel very tired (fatigued). Things should improve and you will start to feel better again before your next treatment. 11 . Try to hang in there. After chemotherapy. Blood Type: ―O‖ Rh: ―Positive‖ I M P L I C A T I O N : Chemotherapy affects production of white blood cells in the bone marrow. But once your treatment is finished your blood cell counts will remain at normal levels.R E M A R K S : Midcells may include less frequently occurring and rare correlating to monotype. Unfortunately.
Lymph nodes are small. Lymphatic vessels are like small veins. Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). it helps to have some basic knowledge about the normal structure of the breasts. ducts (tiny tubes that carry the milk from the lobules to the nipple). Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes. Lymph contains tissue fluid and waste products. while a small number start in other tissues. Most breast cancers begin in the cells that line the ducts (ductal cancers). Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular nodes). bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Some begin in the cells that line the lobules (lobular cancers). This system has several parts. and stroma (fatty tissue and connective tissue surrounding the ducts and lobules. T h e L y m p h a t i c s y s t e m The lymph system is important to understand because it is one of the ways in which breast cancers can spread. and lymphatic vessels). 12 . blood vessels. The female breast is made up mainly of lobules (milk-producing glands). except that they carry a clear fluid called lymph (instead of blood) away from the breast. as well as immune system cells.A N A T O M Y T h e A N D P H Y S I O L O G Y B r e a s t s In order to understand breast cancer.
the more likely it is that the cancer may be found in other organs as well. Fibrocystic changes can cause breast swelling and pain. B e n i g n B r e a s t L u m p s Benign breast tumors such as fibroadenomas or intraductal papillomas are abnormal growths. This is important to know because it could affect your treatment plan. Fibrosis is the formation of fibrous (scar-like) tissue. Still. F i b r o c y s t i c c h a n g e s Most lumps turn out to be fibrocystic changes. some benign breast conditions are important because women with these conditions have a higher risk of developing breast cancer.Knowing if the cancer cells have spread to lymph nodes is important because if it has. 13 . she may notice a clear or slightly cloudy nipple discharge. The more lymph nodes that have breast cancer.They are not life threatening. and cysts are fluidfilled sacs. and in some cases a woman can have negative lymph nodes and later develop metastases. The term "fibrocystic" refers to fibrosis and cysts. This often happens just before a woman's menstrual period is about to begin. there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. Still. not all women with cancer cells in their lymph nodes develop metastases. Her breasts may feel lumpy and. sometimes. but they are not cancerous and do not spread outside of the breast to other organs.
P A T H O P H Y S I O L O G Y Predisposing Factors: Age Gender Race Family HIstory ETIOLOGY: Unknown O F T H E D I S E A S E Precipitating Factors: exposure to radiation and certain chemicals having a sibling with leukemia HTLV-1 virus genetic abnormalities chromosomal translocations Somatic mutations in the DNA U Activate oncogene/ deactivate tumorsupppresor gene Malignant transformation of lymphoid stem cells s/sx: bone pain joint pain Diagnostic Test: BM aspiration BM biopsy Decreased production of normal blood cells Lymphoblast replace the normal marrow elements Treatment: Remission Induction Therapy Consolidation and Maintenance Therapy BM Transplantation CNS prophylaxis Uncontrolled proliferation of lymphoblast in the bone marrow Treatment: Analgesic 14 .
are called tumor suppressor genes. Others that slow down cell division. it is not yet known exactly how some of these risk factors cause cells to become cancerous. a very aggressive tumor. Women have already begun to benefit from advances in understanding the genetic basis of breast cancer.P A T H O P H Y S I O L O G Y D I S E A S E O F T H E Breast cancer may be classified pathologically as noninvasive (in situ) or invasive (infiltrating). The incidence of mucinous (colloid) carcinoma. increases with age. The noninvasive carcinomas are generally thought to be antecedents of invasive carcinoma. Inherited gene mutations Certain inherited DNA changes can increase the risk for developing cancer and are responsible for the cancers that run in some families. Paget's disease of the nipple represents spread of a ductal carcinoma to the skin of the nipple. The incidence of medullary carcinoma. We usually resemble our parents because they are the source of our DNA. Hormones seem to play a role in many cases of breast cancer. Cancers can be caused by DNA mutations (changes) that "turn on" oncogenes or "turn off" tumor suppressor genes. Although many risk factors may increase your chance of developing breast cancer. Some genes contain instructions for controlling when our cells grow. When they are mutated. often multicentric and involving both breasts. DNA affects more than how we look. is equally prevalent among premenopausal and postmenopausal women. Mutations in these genes can be inherited from parents. It is generally multicentric. is rare after menopause. However. Axillary lymph nodes are involved in < 2% of cases. Of the invasive carcinomas. and cancer is more likely to develop. and die. decreases with age. divide. but just how this happens is not fully understood. These women can then take steps to reduce their risk of developing breast cancers 15 . comprising about 70% of all cases. Lobular carcinoma in situ. which is often bilateral.the instructions for how our cells function. or cause cells to die at the right time. they no longer suppress abnormal growth. invasive ductal carcinoma is the most common among women of all ages. Certain genes that speed up cell division are called oncogenes. Certain changes in DNA can cause normal breast cells to become cancerous. Inflammatory carcinoma of the breast. A palpable breast lump is present in 50% of cases. it is usually associated with intraductal carcinoma and less so with invasive carcinoma. and <= 20% recur locally after partial mastectomy. DNA is the chemical in each of our cells that makes up our genes -. a slow-growing tumor in elderly women. Intraductal carcinoma (ductal carcinoma in situ) is the most common noninvasive carcinoma among elderly women.
and to monitor changes in their breasts carefully to find cancer at an earlier. Acquired gene mutations Most DNA mutations related to breast cancer. the causes of most acquired mutations that could lead to breast cancer remain unknown. such as radiation or cancer(22 of 121) causing chemicals. more treatable stage. 16 . however. But so far. occur in single breast cells during a woman's life rather than having been inherited. Most breast cancers have several gene mutations that are acquired. These acquired mutations of oncogenes and/or tumor suppressor genes may result from other factors.
easy bruising or bleeding (due to low blood platelet counts) 3. however. Fatigue is not the same as drowsiness. one of the hardest terms to define. medicines used for gout. tiredness. This type of hair loss improves when you stop taking the medicine. or lethargy. Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. nausea and vomiting 2. 2. vitamin A (if too much is taken). exhaustion. Apathy is a feeling of indifference that may accompany fatigue or exist independently. but the desire to sleep may accompany fatigue. hair loss leading to disturbed body image 2. Fatigue (due to low red blood cell counts and other reasons) Fatigue is a common health complaint. Fatigue. and a symptom of many different conditions. It is. Hair Loss Leading Disturbed Body Image Some medicines can cause hair loss. is generally defined as a feeling of lack of energy. fatigue (due to low red blood cell counts and other reasons) 4. medicines used in chemotherapy to treat cancer. Medicines that can cause hair loss include blood thinners (also called anticoagulants).N U R S I N G C A R E A N D M A N A G E M E N T LIST OF IDENTIFIED PROBLEMS ACTUAL PROBLEMS 1. also known as weariness. birth control pills and antidepressants. mouth sores PRIORITIZED PROBLEMS 1. loss of appetite POTENTIAL PROBLEMS 1. increased chance of infections (due to low white blood cell counts) 3. This attitude is dynamic and is altered through interaction with other persons and situations 17 .
loss of appetite A decreased appetite is when you have a reduced desire to eat. Any illness can affect a previously hearty appetite.and influenced by age and developmental level. body image disturbance can have profound impact on how individuals view their overall selves. the appetite should return when the condition is cured. 3. This occurs despite the body's basic caloric (energy) needs. If the illness is treatable. Depression in the elderly is a common cause of weight loss that is not explained by other factors. 18 . As an important part of one’s self-concept. Loss of appetite can cause unintentional weight loss.
how much it shrinks. To determine activity intolerance To determine circulatory problems. IMPLEMENATION DX> Monitor Vital Signs and Record Assess Ability to ambulate Assess capillary Refill Assess skin turgor. To determine hydration.gradual increase in activity level as tolerated . TX> Promote Adequate Rest RATIONALE For baseline data.N U R S I N G C A R E P L A N S ACTUAL ASSESSMENT S> ―Medyo nanghihina pa ako‖ O> Appears weak Slow Movements noted Good Skin Turgor Coherent and Conversant Needs assistance in performing ADL’s A> Activity Intolerance Related to Weakness EXPLANATION OF THE PROBLEM The length of Chemotherapy treatment depends on whether the cancer shrinks. Some of the most common possible side effect is fatigue (due to low red blood cell counts and other reasons) PLANNING STO> After 8 hours of Nursing Intervention the patient will be able to identify techniques to enhance activity tolerance such as: . Assist with activities Anticipate Needs EDX> Encourage expression of 19 .rest in between activities LTO> Goal is met if the patient will be able to report an increase in activity intolerance.rest in between activities LTO> After 8 days of Nursing Intervention. and how a woman tolerates length of treatment. the patient will be able to report an increase in activity intolerance. To enhance ability to participate with activities To protect client from injury To promote wellness To determine contributing EVALUATION STO> Goal is met if the patient will be able to identify techniques to enhance activity tolerance such as: .gradual increase in activity level as tolerated .
factors To Enhance Ability to participate in activities 20 .feelings Suggest Use of Relaxation Techniques such as visualization and guided imagery.
ASSESSMENT S> ―Nakakahiya makakalbo ako‖ O> Coherent and Conversant Submits self to Nursing Procedure and Care done A> Disturbed Body Image realted to illness treatment. LTO> Goal is met if patient will be able to verbalize acceptance of self in situation in the effects of therapeutic regimen. and how a woman tolerates length of treatment. PLANNING STO> After 8 hours of Nursing Intervention the patient will be able to verbalize understanding of body changes LTO> After 1 day of Nursing Intervention. TX> Ask for patient for verbal feedback. Some of the most common possible side effect is hair loss. the patient will be able to verbalize acceptance of self in situation in the effects of therapeutic regimen. Promotes EVALUATION STO> Goal is met if patient will be able to verbalize understanding of body changes. EXPLANATION OF THE PROBLEM The length of Chemotherapy treatment depends on whether the cancer shrinks. how much it shrinks. helps clarify the expected routine. . and correct misconception about individual’s type of cancer and treatment. IMPLEMENATION DX> Monitor vital signs and record Determine patient’s perception of cancer and cancer treatments. Provide anticipatory guidance with patient regarding treatment Protocol. length of therapy and possible side effects EDX> Refer to 21 RATIONALE For baseline data Aids in identification of ideas. misconception Misconceptions about cancer may be more disturbing than facts and can interfere with treatments/ delay healing. attitudes and fears. Accurate and concise information helps dispel fears and anxiety.
Review specific medication regimen and use of OTC drugs. 22 . competent selfcare and optimal independence. Enhances ability to manage selfcare and avoid potential complications.community resources as indicated. drug reactions.
TX> Assess all systems for signs and symptoms of infection on a continual basis. EXPLANATION OF THE PROBLEM This can often have a major effect on the immune system and may reduce the body's defenses against infection for some months. LTO> After 1 day of Nursing Intervention. when the level of white blood cells will be at its lowest (this time PLANNING STO> After 8 hours of Nursing Intervention the patient will be able to verbalize understanding of Having cancer or treatment for cancer can weaken your immune system. yet encourages sufficient movement to prevent stasis complications Reduces risk EVALUATION STO> Goal is met if patient will be able to verbalize understanding of Having cancer or treatment for cancer can weaken your immune system. People having chemotherapy are particularly at risk of picking up infections between 7–14 days after the chemotherapy. both during and after treatment. Monitor Temperature RATIONALE For baseline Data. IMPLEMENATION DX> Monitor Vital Signs and record.ASSESSMENT S> O> Coherent and Conversant Submits self to Nursing Procedure and Care done A> Risk for Infection related to inadequate secondary defenses and immunosuppress ion secondary to doselimiting side effect of chemotherapy. This makes it more likely that you will pick up an infection and develop a fever. the patient will be able to demonstrate proper aseptic techniques preventing further infection such as proper hand washing. Limits fatigue. Promote adequate rest/ exercise periods LTO> Goal is met if patient will be able to demonstrate proper aseptic techniques preventing further infection such as proper hand washing. This is because chemotherapy reduces the production of white blood cells by the bone marrow. Avoid/ limit 23 . Early recognition and intervention may prevent progression to more serious situation. This makes it more likely that you will pick up an infection and develop a fever. Temperature elevation may occur because of various factors such as chemotherapy side effects.
EDX> Promote good handwashing procedures by staff and visitors. Limits potential sources of infection and/ or secondary overgrowth.is known as the nadir). invasive procedures. This time can vary slightly depending upon the chemotherapy drug. Adhere to aseptic techniques. Development of stomatitis increases risk of infection/ secondary overgrowth. Stress importance of good oral hygiene 24 . Protects patients from sources of infection. Emphasize personal hygiene of contamination . limits portal of entry for infectious agents. used. or combination of drugs.
Indications Adjunct with cytotoxic chemotherapy following radical or modified radical mastectomy to delay recurrence of surgically curable breast cancer in postmenopausal women or women >50 y with positive axillary nodes Treatment of advanced. This drug can cause serious . headache.D R U G Generic name/brand name/ classification Action and Indication S T U D Y Route/Dosage/Date prescribe Nursing consideration Dosage tamoxifen citrate (ta mox' i fen) Apo-Tamox (CAN). menstrual irregularities. nausea. Tamone (CAN) Therapeutic actions Potent antiestrogenic effects: competes with estrogen for binding sites in target tissues. The following side effects may occur: bone pain. such as the breast. Pharmacokinetics Route Onset Oral Peak Pregnancy Category D Drug class Antiestrogen Varies 4---7 h Metabolism: Hepatic. hot flashes (staying in cool temperatures may help). in the morning and evening. frequent meals may help). vomiting (small. enters breast Take the drug twice a day. 20 mg Adult Breast cancer: 20---40 mg/d PO for 5 y. lightheadedness (use caution if driving or performing tasks that require alertness). Novo-Tamoxifen (CAN). dizziness. alternative to oophorectomy or ovarian radiation in premenopausal 25 Available Forms: Tablets--10. Tamofen (CAN). Nolvadex. Reduction in breast cancer incidence: 20 mg/d PO for 5 y. T1/2: 7---14 d Distribution: Crosses placenta. weight gain. metastatic breast cancer in women and men.
pain or swelling of the legs. shortness of breath. Report marked weakness. useful for decreasing size and pain of gynecomastia. sleepiness. Contraceptive measures should be used. 26 . If you become pregnant or decide that you would like to become pregnant. treatment of pancreatic.women Preventative therapy for women at high risk for breast cancer Unlabeled uses: treatment of mastalgia. mental confusion. blurred vision. endometrial. consult with your health care provider immediately. and hepatocellular carcinoma milk Excretion: Feces fetal harm and must not be taken during pregnancy.
Safety was ensured with the close monitoring on the patient. Medications were prepared to the patient Treatment for these symptoms are a standard fluid rehydration therapy in order to maintain blood pressure. The significant others was endorsed to increase fluid intake. If circulatory failure is not reversed.S U M M A R Y O F F I N D I N G S Vital Signs were assessed and properly documented. The significant others was encouraged to converse with the patient and instructed to maintain bed rest. death may follow. 27 . The patient was on IVF of D5NSS 1L. it was regulated and monitored. The diet as tolerated was encouraged promoting vegetables and fruits in giving vitamins and minerals that could support the body’s defenses. Rapport was established and integrated with the significant others. IVF flow rate and patency on site were checked.
treatment needs to be modified for life expectancy. when appropriate. the physician should clarify the goals of care through frequent. What may be effective for prostate cancer. For patients with metastatic disease for which cure is not attainable. All cancers are different. and require different treatment. clear discussions with the patient and. however very few people understand the disease and how it develops. Cancer can affect just about every organ in the human body. Diagnosing cancer will vary as well. which provides physical. pamidronate. and strontium 89 rather than with opioids if possible. and voice an opinion about certain treatment options. and spiritual relief. explain the consequences of. Cancer is a complex group of over 100 different types of cancer. End-of-Life Issues Palliative care. depending on the organ affected. 28 . because some patients with impaired cognition are able to understand.C O N C L U S I O N If a newly diagnosed Breast cancer patient asked you to define cancer. could you tell her that she has still hope? We all have heard the word "cancer" many times. the family. All should recognize that cognitive impairment alone does not exclude the patient from participating in decision making. emotional. Pain from bony metastases should be treated as described above with nonsteroidal anti-inflammatory drugs. must be provided with attempts for curative therapy and becomes the exclusive goal when cure cannot be expected at all stages of breast cancer. probably will not be for bladder cancer. Palliative chemotherapy may be useful when the tumor invades vital organs. local radiation.
d. In addition.R E C O M M E N D A T I O N Health care providers should: a. The evaluation and diagnosis of Breast Cancer is based on the presenting symptoms and history combined with a focused physical assessment. 29 . c. Promote safety of the patient. and possibly a functional study of the breast. Cooperate with the health care providers in the implementation of her Health Care programs. Educate patient and significant others about the disease. and e. Observe the patient to avoid development of complications. every effort is made to retrieve and analyze breast has passed spontaneously or retrieved through aggressive interventions. Explain the procedure done to the patient. d. c. Should continuously monitor the vital signs of the patient. Significant others should: a. Be sensitive to the needs. b. imaging studies. Actively cooperate in the rendering of care for the patient. b.
or cancer may have spread to lymph nodes near the breastbone. 30 . which are sticking together or to other structures. without invasion into normal adjacent breast tissue. or cancer may be found in lymph nodes near the breastbone OR the tumor is any size. Cancer has spread to the axillary lymph nodes. There may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast AND Stage the cancer has spread to lymph nodes either above or IIIC below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone. Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear). The tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes OR the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes. No tumor is found in the breast.A P P E N D I C E S S t a g e s Stage Stage 0 Stage I o f B r e a s t C a n c e r Stage IIA Stage IIB Stage IIIA Stage IIIB Definition Cancer cells remain inside the breast duct. Cancer is found in axillary lymph nodes that are sticking together or to other structures. or cancer may be found in lymph nodes near the breastbone. Stage The cancer has spread — or metastasized — to other IV parts of the body. but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm) OR the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes OR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes. No tumor can be found in the breast. The tumor may be any size and has spread to the chest wall and/or skin of the breast AND may have spread to axillary lymph nodes that are clumped together or sticking to other structures. Inflammatory breast cancer is considered at least stage IIIB.
Smoking is associated with a small increase in breast cancer risk. so that he or she has an accurate understanding of your level of breast cancer risk. and alcohol consumption. Risk factors you can control Weight. other growth factors. there are some risk factors you can control. Exposure to estrogen. Many of the most important risk factors for breast cancer are beyond your control. milk. Studies have shown that breast cancer risk increases with the amount of alcohol a woman drinks. including breast cancer. and your doctor can help you come up with a plan. Your doctor also needs to be aware of any other risk factors beyond your control.B r e a s t C a n c e r R i s k F a c t o r s A ―risk factor‖ is anything that increases your risk of developing breast cancer. Diet is a suspected risk factor for many types of cancer. However. especially for women after menopause. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer. which can increase breast cancer risk. Be sure to talk with your doctor about all of your possible risk factors for breast cancer. The American Cancer Society recommends engaging in 45-60 minutes of physical exercise 5 or more days a week. There may be steps you can take to lower your risk of breast cancer. visit our page on healthy eating to reduce cancer risk in the Nutrition section. family history. For more information. Having more fat tissue means having higher estrogen levels. such as weight. Because the female hormone estrogen stimulates breast cell growth. Being overweight is associated with increased risk of breast cancer. such as age. physical activity. and pesticides. Smoking. antibiotics. Diet. and ice cream). without any breaks. Alcohol consumption. It’s a good idea to restrict sources of red meat and other animal fats (including dairy fat in cheese. Fat tissue is the body’s main source of estrogen after menopause. Exercise. such as: 31 . but studies have yet to show for sure which types of foods increase risk. Some of these risk factors are under your control. This can influence recommendations about breast cancer screening — what tests to have and when to start having them. Alcohol can limit your liver’s ability to control blood levels of the hormone estrogen. when the ovaries stop producing the hormone. can increase the risk of breast cancer. I. Evidence is growing that exercise can reduce breast cancer risk. because they may contain hormones. exposure to estrogen over long periods of time. which in turn can increase risk. and studies show that eating a lot of red and/or processed meats is associated with a higher risk of breast cancer. A low-fat diet rich in fruits and vegetables is generally recommended. and medical history.
mainly due to the activity of the female hormones estrogen and progesterone. Simply growing older is the second biggest risk factor for breast cancer. you could be at higher risk of getting breast cancer. visualization exercises. but only for a limited period of time. is higher than if you never had the disease. Women who stopped using oral contraceptives more than 10 years ago do not appear to have any increased breast cancer risk. Radiation therapy to the chest. Stress and anxiety. Race. R i s k f a c t o r s c o n t r o l y o u c a n ’ t Gender. If you have already been diagnosed with breast cancer. Having radiation therapy to the chest area as a child or young adult as treatment for another cancer significantly increases breast cancer risk. joy. So-called ―mindful measures‖ (such as meditation. taking combined hormone replacement therapy (estrogen and progesterone. or you have multiple relatives affected by breast or ovarian cancer (especially before they turned age 50). Using oral contraceptives (birth control pills) appears to slightly increase a woman’s risk for breast cancer. Personal history of breast cancer. From age 30 to 39. However. There is no clear proof that stress and anxiety can increase breast cancer risk. or taking estrogen alone for more than 10 years being overweight regularly drinking alcohol Recent oral contraceptive use. White women are slightly more likely to develop breast cancer than are African American women. Hispanic. Age. I I . Being a woman is the most significant risk factor for developing breast cancer. This activity puts them at much greater risk for breast cancer. If you have a first-degree relative (mother. That jumps to 1 in 27. your risk of developing it again. either in the same breast or the other breast. Family history of breast cancer. and prayer) may be valuable additions to your daily or weekly routine. HRT) for several years or more. or . sister) who has had breast cancer. or almost 4%. 32 . women’s breast cells are constantly changing and growing. and satisfaction can have a major effect on your quality of life.43%. yoga. anything you can do to reduce your stress and to enhance your comfort. Asian. the risk is 1 in 233. daughter. too. The increase in risk seems to be highest if the radiation was given while the breasts were still developing (during the teen years). Although men can get breast cancer. and Native American women have a lower risk of developing and dying from breast cancer. Some research suggests that these practices can strengthen the immune system. by the time you are in your 60s.
can increase the risk of breast cancer. DES exposure. however. For women who do have children. which produce estrogen-like substances when broken down by the body) Pregnancy and breastfeeding. and you should visit your doctor if you experience breast changes. S y m p t o m s & D i a g n o s i s Breast cancer symptoms vary widely — from lumps to swelling to skin changes — and many breast cancers have no obvious symptoms at all. Symptoms that are similar to those of breast cancer may be the result of non-cancerous conditions like infection or a cyst. 33 . and this appears to reduce future breast cancer risk. Pregnancy and breastfeeding reduce the overall number of menstrual cycles in a woman’s lifetime. Women who took a medication called diethylstilbestrol (DES). visit our Lower Your Risk section. breastfeeding for this long is neither possible nor practical. such as: starting menstruation (monthly periods) at a young age (before age 12) going through menopause (end of monthly cycles) at a late age (after 55) exposure to estrogens in the environment (such as hormones in meat or pesticides such as DDT. have an increased risk of breast cancer. without any breaks.Breast cellular changes. Unusual changes in breast cells found during a breast biopsy (removal of suspicious tissue for examination under a microscope) can be a risk factor for developing breast cancer. breastfeeding may slightly lower their breast cancer risk. or had their first full-term pregnancy after age 30. For many women. These changes include overgrowth of cells (called hyperplasia) or abnormal (atypical) appearance. used to prevent miscarriage from the 1940s through the 1960s. Women who have never had a full-term pregnancy. For more detailed information about risk factors for breast cancer. Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth. Women whose mothers took DES during pregnancy may have a higher risk of breast cancer as well. Breast self-exam should be part of your monthly health care routine. Some of these risk factors are not under your control. exposure to estrogen over long periods of time. have a slightly increased risk of breast cancer. especially if they continue breastfeeding for 1 1/2 to 2 years.
R i s k o f D e v e l o p i n g C a n c e r B r e a s t The term ―risk‖ is used to refer to a number or percentage that describes how likely a certain event is to occur. For example: From age 30 to 39. The uncertainty stinks. the better your chances of beating it. Put another way. R e l a t i v e r i s k Relative risk is a number or percentage that compares one group’s risk of developing breast cancer to another’s. Physical Exam by a doctor. If you're over 40 or at a high risk for the disease. or 0. The earlier breast cancer is found and diagnosed. From age 60 to 69. The actual process of diagnosis can take weeks and involve many different kinds of tests.Mammogram. must be provided with attempts for curative therapy and becomes the exclusive goal when cure cannot be 34 . you should also have an annual mammogram. From age 40 to 49. which often compare groups of women with different characteristics or behaviors to determine whether one group has a higher or lower risk of breast cancer than the other (either as a first-time diagnosis or recurrence).o f . or 1. Absolute risk also can be stated as a percentage. emotional.7%. This is the type of risk frequently reported by research studies. we often talk about two different types of risk: absolute risk and relative risk. the lower the risk. I I . From age 50 to 59. This means that 1 in 233 women in this age group can expect to develop breast cancer. absolute risk is 1 in 233. and spiritual relief. But once you understand your own unique ―big picture.‖ you can make better decisions. When we talk about factors that can increase or decrease the risk of developing breast cancer.4%. Waiting for results can feel like a lifetime.L i f e I s s u e s Palliative care.43%. The younger you are. or 3. You and your doctors can formulate a treatment plan tailored just for you. absolute risk is 1 in 69. It is based on the number of people who will develop breast cancer within a certain time period. I . or 2. your odds of developing breast cancer if you are in this age range are 1 in 233. absolute risk is 1 in 38. absolute risk is 1 in 27. either for the first time or as a recurrence. A b s o l u t e r i s k Absolute risk is used to describe an individual’s likelihood of developing breast cancer.6%. E n d . The absolute risk of developing breast cancer during a particular decade of life is lower than 1 in 8. which provides physical.
cancer cells may break away from the primary breast tumor and spread through the bloodstream. your doctor may try different chemotherapy drugs. the family. Treatment usually lasts for several months. Pain from bony metastases should be treated as described above with nonsteroidal anti-inflammatory drugs. The drugs travel through the bloodstream to reach cancer cells in most parts of the body. with each period of treatment followed by a recovery period. The chemotherapy is given in cycles. explain the consequences of. and voice an opinion about certain treatment options. If the tumor does not shrink. When used as adjuvant therapy after breast-conserving surgery or mastectomy.expected. But if they are allowed to grow. it's not clear that neoadjuvant chemotherapy improves survival. Adjuvant chemotherapy: Systemic therapy given to patients after surgery who have no evidence of cancer spread is called adjuvant therapy. and strontium 89 rather than with opioids if possible. Palliative chemotherapy may be useful when the tumor invades vital organs. chemotherapy reduces the risk of breast cancer coming back. when appropriate. and they can't be felt during a physical exam. local radiation. For patients with metastatic disease for which cure is not attainable. So far. At all stages of breast cancer. they don't show up on imaging tests. treatment needs to be modified for life expectancy. clear discussions with the patient and. Chemotherapy Chemotherapy is treatment with cancer-killing drugs that may be given intravenously (injected into a vein) or by mouth. because some patients with impaired cognition are able to understand. 35 . The goal of adjuvant chemotherapy is to kill undetected cells that have traveled from the breast. pamidronate. the physician should clarify the goals of care through frequent. they can establish new tumors in other places in the body. Another possible advantage of neoadjuvant chemotherapy is that doctors can see how the cancer responds to chemotherapy. All should recognize that cognitive impairment alone does not exclude the patient from participating in decision making. When is chemotherapy used? There are several situations in which chemotherapy may be recommended. These cells don't cause symptoms. The major benefit of neoadjuvant chemotherapy is that it can shrink large cancers so that they are small enough to be removed by lumpectomy instead of mastectomy. Neoadjuvant chemotherapy: Chemotherapy given before surgery is called neoadjuvant therapy. but it seems to be at least as effective as adjuvant therapy after surgery. Even in the early stages of the disease.
and how a woman tolerates length of treatment. or if it spreads after initial treatments. Some of the most common possible side effects include: • hair loss • mouth sores • loss of appetite • nausea and vomiting • increased chance of infections (due to low white blood cell counts) • easy bruising or bleeding (due to low blood platelet counts) • fatigue (due to low red blood cell counts and other reasons) 36 .Chemotherapy for advanced breast cancer: Chemotherapy can also be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is diagnosed. The length of treatment depends on whether the cancer shrinks. how much it shrinks.
so cancers starting in these areas are sometimes called adenocarcinomas. Most breast cancers are invasive carcinomas – either invasive ductal carcinoma or invasive lobular carcinoma. fat tissue. the tumor is treated as if it were an invasive ductal cancer. including 37 . Because the tumor cells lack these receptors. when it is confined to the layer of cells where it began. Sarcoma Sarcomas are cancers that start from connective tissues such as muscle tissue. Carcinoma This is a term used to describe a cancer that begins in the lining layer (epithelial cells) of organs such as the breast. and they tend to grow and spread more quickly than most other types of breast cancer. Medullary carcinoma This special type of infiltrating breast cancer has a rather well defined boundary between tumor tissue and normal tissue. such as invasive ductal cancer combined with invasive lobular breast cancer. They have not invaded into deeper tissues in the breast or spread to other organs in the body. in situ means that the cancer cells remain confined to ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). Invasive (infiltrating) carcinoma An invasive cancer is one that has already grown beyond the layer of cells where it started(as opposed to carcinoma in situ). Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas). or blood vessels.D E F I N I T I O N Breast cancer O F T E R M S terms general It is important to understand some of the key words used to describe breast cancer. Breast cancers with these characteristics tend to occur more often in younger women and in African-American women. Triple-negative breast cancer This term is used to describe breast cancers (usually invasive ductal carcinomas) whose cells lack estrogen receptors and progesterone receptors. and are sometimes referred to as non-invasive breast cancers. It also has some other special features. Adenocarcinoma Is a type of carcinoma that starts in glandular tissue (tissue that makes and secretes a substance). Sarcomas of the breast are rare. In breast cancer. The ducts and lobules of the breast are glandular tissue (they make breast milk). In this situation. Carcinoma in situ This term is used for the early stage of cancer. Mixed tumors Mixed tumors are those that contain a variety of cell types. neither hormone therapy nor drugs that target HER2 are effective against these cancers (although chemotherapy may be useful if needed).
although the outlook is likely to be better. These tumors are treated like invasive ductal cancer. Papillary carcinoma The cells of these cancers tend to be arranged in small. The outlook (prognosis) for this kind of breast cancer is generally better than for the more common types of invasive breast cancer. In rare cases they are invasive. Adenoid cystic carcinoma (adenocystic carcinoma) These cancers have both glandular (adenoid) and cylinder-like (cystic) features when seen under the microscope. The skin of the nipple and areola often appears crusted. It is rare. such as cells that look like skin cells (squamous cells) or cells that make bone. They are called tubular because of the way the cells are arranged when seen under the microscope. Tubular carcinomas account for about 2% of all breast cancers and tend to have a better prognosis than most other infiltrating ductal or lobular carcinomas. with infiltrating ductal carcinoma. Metaplastic carcinoma Is a very rare type of invasive ductal cancer. Most cancer specialists think that true medullary cancer is very rare. the dark circle around the nipple. and they make up no more than 1% or 2% of all breast cancers. If no lump can be felt in the breast tissue and the biopsy shows DCIS but no invasive cancer. These cancers are most often considered to be a subtype of ductal carcinoma in situ (DCIS). with areas of bleeding or oozing.the large size of the cancer cells and the presence of immune system cells at the edges of the tumor. Paget disease of the nipple This type of breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola. more often. Tubular carcinoma Tubular carcinomas are another special type of invasive ductal breast carcinoma. The prognosis for mucinous carcinoma is usually better than for the more common types of invasive breast cancer. in which case they are treated like invasive ductal carcinoma. and are treated as such. The woman may notice burning or itching. and they tend to have a very good prognosis. scaly. 38 . the prognosis is excellent. They rarely spread to the lymph nodes or distant areas. Medullary carcinoma accounts for about 3% to 5% of breast cancers. Paget disease is almost always associated with either ductal carcinoma in situ (DCIS) or. this rare type of invasive breast cancer is formed by mucus-producing cancer cells. These tumors include cells that are normally not found in the breast. Mucinous carcinoma Also known as colloid carcinoma. accounting for only about 1% of all cases of breast cancer. and red. and that cancers that are called medullary cancer should be treated as the usual invasive ductal breast cancer. finger-like projections when viewed under the microscope. They make up less than 1% of breast cancers. These cancers tend to be diagnosed in older women.
these cancers may not respond as well to the other treatments used for invasive ductal or lobular breast cancer. which develop in the ducts or lobules. A malignant phyllodes tumor is treated by removing it along with a wider margin of normal tissue. this is an extremely rare complication of breast radiation therapy. in contrast to carcinomas. It tends to develop about 5 to 10 years after radiation treatment. When it does.Phyllodes tumor This very rare breast tumor develops in the stroma (connective tissue) of the breast. These tumors are usually benign but on rare occasions may be malignant. While surgery is often all that is needed. Angiosarcoma This is a form of cancer that starts from cells that line blood vessels or lymph vessels. Benign phyllodes tumors are treated by removing the mass along with a margin of normal breast tissue. or by mastectomy. 39 . Angiosarcoma can also occur in the arm of women who develop lymphedema as a result of lymph node surgery or radiation therapy to treat breast cancer. It rarely occurs in the breasts. it is usually seen as a complication of radiation to the breast. Other names for these tumors include phylloides tumor and cystosarcoma phyllodes. Treatment is generally the same as for other sarcomas. These cancers tend to grow and spread quickly. However.
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