OBJECTIVES  To ensure the safety of the patient within the duration of hospital stay

of the student nurse.

GENERRAL OBJECTIVES:
Student-centered objectives:
I, Paul Jerome Caburian, student of Don Mariano Marcos Memorial State
University affiliated at Ilocos Training and Regional Medical Center Surgical Ward
at 7-3 AM shift aim to develop my knowledge and skills to provide effective and
efficient nursing care that will lead us in the promotion of health and prevention of
the disease during the researchers’ duration of stay in the hospital.
Family-centered objectives:
The case presentation will aid as a guideline of the student nurses in
assessing and rendering proper nursing care to patients with the same problem or
disease.
Furthermore, this study allows the students to learn the nature of the
disease as well as the management that would be helpful and therapeutic to the
patient.
 To organize and rank the identified and prioritized problems
according to any mode of prioritization used.
 To provide a set of Nursing Care Plan which is the blueprint or book
guide in providing effective and efficient nursing care that is
applicable until the time of discharge.
 To educate significant others in providing nursing interventions within
and after time of discharge upon client and watchers reaches home.
 To provide a set of Nursing Care Plan which the blueprint or book
guide for the significant others in providing effective and efficient
nursing care that is applicable in the time of discharge and after.

SPECIFIC OBJECTIVES:
Client-centered objectives:

 To be able to establish rapport with the patient through interactions

and conversations during their stay in the hospital.
 To be able to provide the needed nursing managements appropriate
for her condition in
 collaboration with other health care professionals.
 To be able to conduct patient health education the patient about her
condition in a manner that the client understands or in line with the
patient’s learning capacity.
 To identify, secure and provide the needs of the patient.
Introduction of the Case/Disease
Breast cancer is the most common site-specific cancer in women and is
the leading cause of death from cancer for women aged 20 to 59 years. It accounts
for 29% of all newly diagnosed cancers in females and is responsible for 14% of
the cancer-related deaths in women (Siegel R, Naishadham D, Jemal A. Cancer
statistics, 2013)
It is estimated that worldwide over 508 000 women died in 2011 due to
breast cancer (Global Health Estimates, WHO 2013). Although breast cancer is
thought to be a disease of the developed world, almost 50% of breast cancer cases
and 58% of deaths occur in less developed countries (GLOBOCAN 2008).
In the Philippines cancer is the 4th leading cause of mortality (DOH, 2015).
Breast cancer is the leading site for both sexes combined (19%) in 2015 and ranks
1st among women (33%). An estimated 20,267 new cases is estimated to occur
among women.
The incidence rate starts rising steeply at age 30. The incidence rate has
been steadily rising sine 1980, with an average annual percentage change of
1.2%. In 2015, there is an estimated 7,384 deaths from breast cancer, the 3rd
leading cause of cancer deaths among both sexes (11%), and the highest among
women (23%) (Philippine Cancer Facts and Estimates, 2015).
Breast cancer can begin in different areas of the breast — the ducts, the
lobules, or in some cases, the tissue in between. In this section, you can learn
about the different types of breast cancer, including non-invasive, invasive, and
metastatic breast cancers, as well as the intrinsic or molecular subtypes of breast
cancer.
Carcinoma In Situ
Cancer cells are in situ or invasive depending on whether or not they invade
through the basement membrane. Broders’s original description of in situ breast
cancer stressed the absence of invasion of cells into the surrounding stroma and
their confinement within natural ductal and alveolar boundaries (Broder’s, 2014).
Because areas of invasion may be minute, the accurate diagnosis of in situ cancer
necessitates the analysis of multiple microscopic sections to exclude invasion. In
1941, Foote and Stewart published a landmark description of LCIS (Lobular
Carcinoma In Situ), which distinguished it from DCIS (Ductal Carcinoma In Situ).
In the late 1960s, Gallagher and Martin published their study of whole-breast
sections and described a stepwise progression from benign breast tissue to in situ
cancer and subsequently to invasive cancer.
Lobular Carcinoma In Situ
LCIS (Lobular Carcinoma In Situ) originates from the terminal duct lobular
units and develops only in the female breast. It is characterized by distention and
distortion of the terminal duct lobular units by cells which are large but maintain a
normal nuclear: cytoplasmic ratio. Cytoplasmic mucoid globules are a distinctive
cellular feature. LCIS may be observed in breast tissues that contain
microcalcifications, but the calcifications associated with LCIS typically occur in
adjacent tissues. This neighborhood calcification is a feature that is unique to LCIS
and contributes to its diagnosis. The frequency of LCIS in the general population
cannot be reliably determined because it usually presents as an incidental finding.
The average age at diagnosis is 45 years, which is approximately 15 to 25 years
younger than the age at diagnosis for invasive breast cancer. LCIS has a distinct
racial predilection, occurring 12 times more frequently in white women than in
African American women.
Ductal Carcinoma In Situ
DCIS is predominantly seen in the female breast, it accounts for 5% of male
breast cancers. Published series suggest a detection frequency of 7% in all biopsy
tissue specimens. The term intraductal carcinoma is frequently applied to DCIS,
which carries a high risk for progression to an invasive cancer. Histologically, DCIS
is characterized by a proliferation of the epithelium that lines the minor ducts, 2. Invasive ductal carcinoma—Adenocarcinoma with productive fibrosis
resulting in papillary growths within the duct lumina. Early in their development, the (scirrhous, simplex, NST), 80%
cancer cells do not show pleomorphism, mitoses, or atypia, which leads to difficulty
3. Medullary carcinoma, 4%
in distinguishing early DCIS from benign hyperplasia. The papillary growths
(papillary growth pattern) eventually coalesce and fill the duct lumina so that only 4. Mucinous (colloid) carcinoma, 2%
scattered, rounded spaces remain between the clumps of atypical cancer cells,
which show hyperchromasia and loss of polarity (cribriform growth pattern). 5. Papillary carcinoma, 2%
Eventually pleomorphic cancer cells with frequent mitotic figures obliterate the 6. Tubular carcinoma, 2%
lumina and distend the ducts (solid growth pattern). With continued growth, these
cells outstrip their blood supply and become necrotic (comedo growth pattern). 7. Invasive lobular carcinoma, 10%
Calcium deposition occurs in the areas of necrosis and is a common feature seen
8. Rare cancers (adenoid cystic, squamous cell, apocrine)
on mammography. DCIS is now frequently classified based on nuclear grade and
the presence of necrosis. Based on multiple consensus meetings, grading of DCIS
has been recommended. Although there is no universal agreement on
classification, most systems endorse the use of cytologic grade and presence or Paget’s Disease of the Nipple
absence of necrosis. Paget’s disease of the nipple was described in 1874. It frequently presents
as a chronic, eczematous eruption of the nipple, which may be subtle but may
progress to an ulcerated, weeping lesion. Paget’s disease usually is associated
Invasive Breast Carcinoma with extensive DCIS and may be associated with an invasive cancer. A palpable
mass may or may not be present. A nipple biopsy specimen will show a population
Invasive breast cancers have been described as lobular or ductal in origin
of cells that are identical to the underlying DCIS cells (pagetoid features or
(Devitt and Barr, 2011). Early classifications used the term lobular to describe
pagetoid change). Pathognomonic of this cancer is the presence of large, pale,
invasive cancers that were associated with LCIS, whereas all other invasive
vacuolated cells (Paget cells) in the rete pegs of the epithelium. Paget’s disease
cancers were referred to as ductal. Current histologic classifications recognize
may be confused with superficial spreading melanoma. Differentiation from
special types of breast cancers (10% of total cases), which are defined by specific
pagetoid intraepithelial melanoma is based on the presence of S-100 antigen
histologic features. To qualify as a special-type cancer, at least 90% of the cancer
immunostaining in melanoma and carcinoembryonic antigen immunostaining in
must contain the defining histologic features. About 80% of invasive breast cancers
Paget’s disease. Surgical therapy for Paget’s disease may involve lumpectomy or
are described as invasive ductal carcinoma of no special type (NST). These
mastectomy, depending on the extent of involvement of the nipple-areolar complex
cancers generally have a worse prognosis than special-type cancers (Footer and
and the presence of DCIS or invasive cancer in the underlying breast parenchyma.
Stewart, 2010).
Invasive ductal carcinoma
Foote and Stewart originally proposed the following classification for
invasive breast cancer: Invasive Ductal Carcinoma of the breast with productive fibrosis (scirrhous,
simplex, NST) accounts for 80% of breast cancers and presents with macroscopic
1. Paget’s disease of the nipple
or microscopic axillary lymph node metastases in up to 25% of screen-detected
cases and up to 60% of symptomatic cases. This cancer occurs most frequently in
perimenopausal or postmenopausal women in the fifth to sixth decades of life as
a solitary, firm mass. It has poorly defined margins and its cut surfaces show a
central stellate configuration with chalky white or yellow streaks extending into
surrounding breast tissues. The cancer cells often are arranged in small clusters,
and there is a broad spectrum of histologic types with variable cellular and nuclear
grades (Dunnwald, Rossing and Li, 2007)
Medullary carcinoma
Medullary carcinoma is a special-type breast cancer; it accounts for 4% of
all invasive breast cancers and is a frequent phenotype of BRCA1 hereditary
breast cancer. Grossly, the cancer is soft and hemorrhagic. A rapid increase in
size may occur secondary to necrosis and hemorrhage. On physical examination,
it is bulky and often positioned deep within the breast. Bilaterality is reported in
20% of cases. Medullary carcinoma is characterized microscopically by: (a) a
dense lymphoreticular infiltrate composed predominantly of lymphocytes and
plasma cells; (b) large pleomorphic nuclei that are poorly differentiated and show
active mitosis; and (c) a sheet-like growth pattern with minimal or absent ductal or
alveolar differentiation. Approximately 50% of these cancers are associated with
DCIS, which characteristically is present at the periphery of the cancer, and <10%
demonstrate hormone receptors. In rare circumstances, mesenchymal metaplasia
or anaplasia is noted. Because of the intense lymphocyte response associated
with the cancer, benign or hyperplastic enlargement of the lymph nodes of the
axilla may contribute to erroneous clinical staging. Women with this cancer have a
better 5-year survival rate than those with NST or invasive lobular carcinoma.
Mucinous carcinoma
Mucinous Carcinoma (colloid carcinoma), another special-type breast
cancer, accounts for 2% of all invasive breast cancers and typically presents in the
elderly population as a bulky tumor. This cancer is defined by extracellular pools
of mucin, which surround aggregates of low-grade cancer cells. The cut surface of
this cancer is glistening and gelatinous in quality. Fibrosis is variable, and when
abundant it imparts a firm consis-tency to the cancer. Over 90% of mucinous
carcinomas display hormone receptors (Dunnwald, Rossing, and Li, 2007). Lymph
node metastases occur in 33% of cases, and 5- and 10-year survival rates are
73% and 59%, respectively. Because of the mucinous component, cancer cells
may not be evident in all microscopic sections, and analysis of multiple sections is
essential to confirm the diagnosis of a mucinous carcinoma.
Papillary carcinoma
Papillary carcinoma is a special-type cancer of the breast that accounts for
2% of all invasive breast cancers. It generally presents in the seventh decade of
life and occurs in a disproportionate number of nonwhite women. Typically,
papillary carcinomas are small and rarely attain a size of 3 cm in diameter. These
cancers are defined by papillae with fibrovascular stalks and multilayered
epithelium. In a large series from the SEER database 87% of papillary cancers
have been reported to express estrogen receptor (Dunnwald, Rossing, and Li,
2007). McDivitt and colleagues noted that these tumors showed a low frequency
of axillary lymph node metastases and had 5- and 10-year survival rates similar to
those for mucinous and tubular carcinoma (McDivitt, Boyce, and Gersell, 2012).
Tubular carcinoma
Tubular carcinoma is another special-type breast cancer and accounts for
2% of all invasive breast cancers. It is reported in as many as 20% of women
whose cancers are diagnosed by mammographic screening and usually is
diagnosed in the perimenopausal or early menopausal periods. Under low-power
magnification, a haphazard array of small, randomly arranged tubular elements is
seen. In a large SEER database 94% of tubular cancers were reported to express
estrogen receptor (Dunnwald, Rossing, and Li, 2007). Approximately 10% of
women with tubular carcinoma or with invasive cribriform carcinoma, a special-
type cancer closely related to tubular carcinoma, will develop axillary lymph node
metastases. However, the presence of metastatic disease in one or two axillary
lymph nodes does not adversely affect survival. Distant metastases are rare in
tubular carcinoma and invasive cribriform carcinoma.
Invasive lobular carcinoma
Invasive lobular carcinoma accounts for 10% of breast cancers. The
histopathologic features of this cancer include small cells with rounded nuclei,
inconspicuous nucleoli, and scant cytoplasm. Special stains may confirm the
presence of intracytoplasmic mucin, which may displace the nucleus (signet-ring
cell carcinoma). At presentation, invasive lobular carcinoma varies from clinically
inapparent carcinomas to those that replace the entire breast with a poorly defined
mass. It is frequently multifocal, multicentric, and bilateral. Because of its insidious
growth pattern and subtle mammographic features, invasive lobular carcinoma
may be difficult to detect. Over 90% of lobular cancers express estrogen receptor
(Dunnwald, Rossing, and Li, 2007).
Disease Entity
Invasive ductal carcinoma, is cancer that began growing in a milk duct and
has in vade the fibrous or fatty tissue of the breast outside of the duct.
IDC is the most common form of breast cancer, representing 80 percent of
all invasive breast cancers in women and 90 percent in men.
Signs and symptoms:
As with any breast ca, there may be no signs or symptoms. A mammogram
may reveal a suspicious mass, which will lead to further testing. A person may also
find a lump or mass during a breast self examination.
The following are possible signs of breast cancer and should immediately
be reported to the physician for further evaluation:
 Lump in the breast
 Thickening of the breast skin
 Rash or redness of the breast
 Swelling in one breast
 New pain in one particular location of a breast
 Dimpling around the nipple or on the breast skin
 Nipple pain or the nipple turning inward
 Nipple discharge
 Lump in the underarm area
 Changes in the appearance of the nipple or breast that are different from
the normal monthly changes a woman experiences
Etiology
There is no single, specific cause of breast cancer. A combination of genetic,
hormonal, and possibly environmental factors may increase the risk of its
development. More than 80% of all cases of breast cancer are sporadic, meaning
that patients have no known family history of the disease. The remaining cases
are either familial (there is a family history of breast cancer but it is not passed on
genetically) or genetically acquired. There is no evidence that smoking, silicone
breast implants, use of antiperspirants, underwire bras, or abortion (induced or
spontaneous) increases the risk of the disease.
Breast cancer can be genetically inherited, resulting in significant risk.
Approximately 5% to 10% of breast cancer cases develop as a result of genetic
mutations. Factors that may indicate a genetic link include multiple first-degree
relatives with early-onset breast cancer, breast and ovarian cancer in the same
family, male breast cancer, and Ashkenazi Jewish background.
BRCA1 and BRCA2 are tumor suppressor genes that normally function to
identify damaged DNA and thereby restrain abnormal cell growth. Mutations in
these genes are responsible for the majority of hereditary breast cancer in the
United States. BRCA1 mutations have been associated with a 65% to 87%
estimated lifetime risk, and BRCA2 mutations have been associated with a 45% to
84% risk. Carriers also have a significantly increased risk for ovarian cancer,
approaching 30% (Turnbull & Rahman, 2008). Men with BRCA mutations,
particularly the BRCA2 mutation, also have an increased risk of breast cancer. A
recent study reported that there is a broad variation in breast cancer risk among
carriers of BRCA1 and BRCA2 when different variables are considered. A gene
carrier was found to be at significantly higher risk if a relative was diagnosed with
breast cancer at an early age (Begg, Haile & Borg, 2008).
Diagnostic Tests
Invasive Ductal Carcinoma is usually found ad the result of an unusual
mammogram. To diagnose cancer, a person will get a biopsy to collect cells for
analysis.
If the biopsy confirms that it is cancer, a person will likely have more
tests to see how large the tumor is and if it has spread:
 CT Scan - it's a powerful x-ray that makes detailed pictures inside
the body.
 PET Scan – the doctor injects a radioactive substance called a tracer
into the arm. It travels through the body and gets absorbed into the
cancer cells. Together with a CT scan, this test can help find cancer
in lymph nodes and other areas.
 MRI – uses strong magnets and radio waves to make pictures of the
breast and other structures inside the body.
 Bone Scan – the doctor injects a tracer into the arm. Pictures will be
taken to find out if cancer has travelled to the bones.
 Chest X-ray – it uses low doses of radiation to make pictures of the
inside of the chest cavity.
 Mammography – is a low dose x-ray based modality used to image
the breast.
 Breast Self Examination – Breast self-exam (BSE) is a step-by-step
approach a woman can use to look at and feel her breasts to check
for anything abnormal.
 Galactography – is a diagnostic procedure that involves injection of
less than 1 mL of radiopaque material through a cannula inserted
into a ductal opening on the areola, which is followed by a
mammogram.
 Tissue analysis:
 Percutaneous biopsy is performed on an outpatient basis to
sample palpable and nonpalpable lesions.
 Fine-needle aspiration (FNA) is a noninvasive biopsy
technique that is generally well tolerated by most women.
 Core needle biopsy is similar to FNA, except that a larger
gauge needle is used (usually 14-gauge).
 Stereotactic core biopsy is performed on nonpalpable
lesions detected by mammography.
 ultrasound-guided core biopsy are similar to those of
stereotactic core biopsy, but by using ultrasound guidance,
computer coordination and mammographic compression are
not necessary.
 Surgical biopsy – on a surgical biopsy an incision is made, the
lesion is excised and sent to a laboratory for pathologic examination.
 Excisional Biopsy – is the standard procedure for complete
pathological assessment of a palpable breast mass. The
entire mass, plus a margin of surrounding tissue, is removed.
 Incisional biopsy – surgically removes a portion of a mass. This is
performed to confirm a diagnosis and to conduct special studies.
  Wire needle localization – is a technique used to locate
nonpalpable masses or suspicious calcium deposits detected on a
mammogram, ultrasound, or MRI that require an excisional biopsy.
Management (Nursing, Medical, and Surgical)
Medical and Surgical:
Most women with IDC have surgery to remove the cancer. Treatment options are usually:
 Lumpectomy – surgeon only removes the tumor and a bit of the tissue
around it to help make sure the cancer cells have been removed. It is also
called breast conserving surgery.
 Mastectomy – surgeon removes the entire breast.
In addition to surgery, other treatments include:
 Radiation – used to decrease the chance of a local recurrence in the breast
by eradicating residual microscopic cancer cells.
 Hormone therapy – if cancer is hormone receptor-positive (estrogen helps
it grow), these drugs block or lower the amount of estrogen in the body.
 Chemotherapy – these medications target cancer cells throughout the
body. Doctors also use it before surgery to shrink tumors and after to kill
any cancer cells left behind.
 Targeted therapy – these medications block cancer cell growth.
 Sentinel Lymph Node Biopsy – In SLNB, the surgeon uses a hand-held
probe to locate the sentinel lymph node, excises it, and sends it for
pathologic analysis, which is often performed immediately during the
surgery using frozen section analysis.
 Breast reconstruction – can provide a significant psychological benefit for
women who are already struggling with the emotional distress of losing a
breast.
 Tissue expander followed by a permanent implant is the simplest and
most common method used today.
 Autologous reconstruction – is the use of the patient’s own tissue to
create a breast mound.
 Nipple–Areola Reconstruction - The most common method of creating a
nipple is with the use of local flaps (skin and fat from the center of the new
breast mound), which are wrapped around each other to create a projecting
nipple.
Nursing Management:
 Providing education and preparation about surrgical treatments.
 Reducing fear and anxiety and improving coping ability.
 Promoting decision-making ability.
 Relieving pain and discomfort.
 Managing postoperative sensations.
 Promoting positive body image.
 Promoting positive adjustment and coping.
 Improving sexual function.
 Monitoring and managing potential complications.
 Promoting home and community-based care.
II. Patient’s Profile: Date and time of assessment:
February 14 2019 @ 9:00am to 12:00pm
Name: Patient N (Physical assessment and interview)

Age: 55 years old February 15 2019 @ 10:00 am to 12:00pm

(Continuation of the interview)
Sex: female
III. History of present Illness
Address: Dalangallan, City of San Fernando, La Union
Patient N stated that 3 month prior to admission, she experienced pain on
Civil status: single the left breast accompanied by a note of breast mass at 1-2 o'clock position, near
the areola with a size of one peso coin. Associated with weight loss and poor
Race: Asian appetite. No nipple discharge, dimpling and changes in skin surrounding the breast
were noted. No consultation done and no medications taken.
Nationality: Filipino
Internal history Revealed persistence of enlrging breast mass that
Culture: Ilocano prompted patient N to consult on a private clinic; where in breast ultrasound was
done but patient N could not recall the result. Patient N was referred to Dr. EA
Religious Affiliation: Roman Catholic Biteng. Still no medications were taken.

Education Attainment: Diploma in Secretariats A month prior to admission, patient N sought consultation at Lorma and
biopsy of the left breast mass was done. Result was unrecalled, however she was
Birth day: August 24, 1963 advised for surgery.

Birthplace: San Fernando, La Union Internal reveals that she is still contemplating for surgical intervention.
Patient was then scheduled for surgery hence admission.
Chief complaint: For elective surgery

Admitting Physician: Dr. Cheryl Joy Biado IV. Past medical history

Date and time of admission: February 12, 2019 @7:00 AM
Medical diagnosis:
Admitting: Breast Cancer, Left
Final: Invasive Ductal Carcinoma, Left
Patient N stated that she received complete immunization. She verbalized
that she used to experience gastritis but for the past 5 years she never had one.
She also suffers rhinitis in the months of December to February. She only have a
daughter. She also had a miscarriage in 1998. She had her first menstrual period
when she was 16 years old. It was regular and was able to moderately soaked 5
pads during the first 2 days of her menstrual period. She menopause when she
turned 51 years old. Her OB score was G2P1 (1011). She doesn’t have  V/s every 4 hours.
hypertension.  Diagnostic
 CBC typing
V. Family history
 Serum Sodium- Potassium
Patient N verbalized that her mother have a history of cardiovascular  BUN Crea
diseases. Her mother has hypertension and her father died last 2011 due to old  Chest-PA
age. Two of her siblings have hypertension and one of her brothers have throat  R lead ECG
cancer.  Therapeutic
 IVF D5LRS 1L x 8 hours
VI. Social History  Cefuroxime 1.5 g 1 hour prior to OR
 Scheduled for MRM, Left Breast tomorrow @ 8 AM
Patient N shared that she worked as a domestic helper in Singapore for 20  Secure consent
years. She never smoked and she doesn’t drink alcohol beverages. Year of 2016  Inform OR
when she decided to go back here in the Philippines, for good. She opened a sari-  Refer to Dr. Estandian for CP clearance
sari store to keep her busy and as a source of income. She also takes care of her
two granddaughters. 3:00 pm - 11:00 pm:

VIII. Course of confinement
Patient N arrived at the Emergency Room for scheduled operation. Her
initial vital signs were follows: BP: 120/80mmHg, RR: 20 bpm, PR: 81 bpm ,
temperature of 37.5℃. The patient weighs 41 kgs. She was seen and examined
by Dr. Cuyao, orders were made and carried out for admission. ER nurse on duty
hooked an IVF of D5LRS 1L x 8 hours on her left metacarpal vein. Consent was
secured for admission and informed surgery ward regarding admission, and the
patient was forwarded to the surgery ward.
February 12, 2019 9:10 am
Patient A was admitted at Female Medicare of surgery ward. Secured consent
for admission and management. The patient was initially diagnosed with breast
cancer, left. The initial vital signs are as follows: blood pressure: 120/80 mmHg,
respiratory rate: 20bpm and temperature of 37.5 C. The following orders were
given by Dr. Cuyao.
 DAT then NPO post midnight
The patient has a patent intravenous (IV) line of D5LRS 1L x 8 hours at left
metacarpal vein. The patient’s vital signs and output were monitored and
recorded. Ensured her safety, rest and comfort promoted. NPO was instructed as
ordered. She was scheduled for Modified Radical Mastectomy on February 13,
2019 @ 8 in the morning.
11:00 PM – 7:00 AM Nurses’ Notes
The nurse on duty focused on preoperative care. She was received with an
ongoing IVF of D5LRS of 1L x 8 hrs, not in distress, afebrile, alert and coherent.
Instructed to NPO post midnight. Her vital signs were monitored and recorded, the
nurse ensured safety, her needs was anticipated and attended. She was endorsed
for 7-3 shift.
February 13, 2019 7:00 – 11:00 AM Nurses’ Notes
 The nurse on duty focused on preoperative care. She was prepared for her
Modified Radical Mastectomy operation. Secured consent. IVF regulated
accordingly. Transferred to OR.
11:45 AM Nurses’ Notes
OR nurse focused on intraoperative care. She was received per stretcher
with IVF of D5LRS infusing well, for MRM Left Breast, informed consent attached
to chart. She was hooked on cardiac monitor, O2 inhalation via face mask.
Generator Endotracheal anesthesia inducted by Dr. Basnet. Skin prep done,
draped aseptically. Initial sponge, instruments and needle count done. Operation
started by Dr. Biteng assisted by Dr. Agub, Dr. Garcia and Dr. Lobangco.
Specimen out. Hemovac inserted. Final sponge, instrument and needle count
done, correct and complete. Operation ended. Forwarded to pacu for post
operative care.
1:15 PM Nurses' Notes
Into PACU a 55 year old female per stretcher, Status post MRM Left Breast.
Flat on bed for 1 hour then moderate high back rest. On O2 inhalation via face
mask 2-3 LPM til fully awake. Regulated IVF to 20 gtts/min. Started ketorolac 30
mg IV. Incorporated butorphanol 2mg in D5LRS 1L x 20gtts/min. Ondansetron 4
mg IV given. Encouraged deep breathing exercises. Seen by Dr. Aycon, ordered
Fentanyl 50 mg IV, given @ 2:17 PM.
Seen by Dr. Dela Cruz and ordered transfer to room. Informed surgery ward and
transout meds endorsed.
3:30 PM Nurses’ Notes
Nurse on duty focused on post operative care. Got back to ward with intact
wound dressing. Monitored V/S, regulated IVF accordingly. Needs attended and
ensured safety. Nurse on duty promoted rest and comfort.
3:00 Pm – 11:00 PM shift Nurses’ Notes
The nurse again focused on post operative care. She was received on bed
awake with ongoing IVF of D5LRS at 20 gtts/min. Infusing well. Not in distress and
breathing normally. Patient’s needs were attended. The NOD ensured safety,
regulated IVF accordingly. Rest and comfort promoted and seen at intervals to
avoid disturbing the patient. Endorsed on the next shift for further care.
11:00 PM – 7:00 AM shift Nurses’ Notes
Post operative care. Patient is asleep with intact wound dressing and a
hemovac drain. Patient switched to DAT with SAP and IVF was regulated to KVO
as ordered. Vital signs monitored and recorded. Needs attended. Seen at intervals
and promoted rest and comfort.
February 14, 2019 7:00 AM – 3:00 PM Nurses’ Notes
Nurse on duty focused on Risk for infection. Received patient on bed
awake with patent IV line infusing well. Vital signs monitored. Needs attended.
Ensured safety. Provided rest and comfort. Maintained drain at negative pressure.
Aseptically cleaned wound and dressed. Started celecoxib 200 mg 1 cap 2x daily
for pain. Endorsed for further care.
3:00 PM – 11:00 PM shift Nurses’ Notes
Nurse on duty focused on Risk for infection. Received patient awake on
DAT with SAP, with drain on negative pressure, with patent IVF. Patient verbalized
can now tolerate post operative pain. Vital signs monitored and recorded,
maintained drain on negative pressure, ensured safety, needs attended, seen at
intervals, rest and comfort promoted, due meds given. Afebrile. Endorsed.
11:00 PM – 7:00 AM shift Nurses’ Notes
Received patient on bed asleep on DAT with SAP, with patent IVF,
afebrile. Vital signs monitored and recorded, watched out signs of infection, needs
attended, rest and comfort promoted. Afebrile. Endorsed.
February 15, 2019 7:00 AM – 3:00 PM Nurses’ Notes

Received awake and coherent, IVF infusing well, with hemovac drain
negative pressure, intact wound dressing. Not in distress. Needs attended, vital
signs taken and monitored, rest and comfort promoted, due meds given. Seen and
examined by Dr Biteng. Possible MGH, for removal of drain. Afebrile. Endorsed

3:00 PM – 11:00 PM shift Nurses’ Notes

Received patient on bed awake on DAT with patent IVF, not in distress.
Vital signs monitored and recorded, safety ensured, needs attended, maintained
hemovac on negative pressure. Due meds given. Endorsed

11:00 PM – 7:00 AM shift Nurses’ Notes

Received patient asleep with patent IVF and hemovac drain on negative
pressure. Vital signs monitored and recorded, safety ensured, promoted rest and
comfort. Terminated hemovac drain, IVf consumed then switched to heplock. Due
meds given. Follow up bill.

FEBRUARY 16, 2019 7:00 AM – 3:00 PM Nurses’ Notes

Nursed on duty focused on coping mechanism. Received patient on bed,

on her lock, with intact wound dressing, on Dat, on MGH status. Educated patient
on home medications, such as CoAmoxiclav 625 mg 1 tablet BID and Celecoxib
200 mg for pain. Instructed patient about follow up on next Friday (February 22,
2019) with Dr. Biteng at 1:00 PM.
13 AREAS OF ASSESSMENT
I. Psychosocial Status
Patient N is a 55 year old female born on August 24, 1963 in City of San
Fernaando, La Union. She is single with 1 daughter. The family lives together in
Dalangallan, City of San Fernando, La Union in a concrete bungalow type of
house. She used to worked as an OFW in Singapore for 20 years. Now that she's
home, she opened a store that she tends as a source of income and to keep her
busy. She was and still the bread winner of their family. She helps her daughter in
taking good care of her two granddaughters and her mother. She believes that old
age is not an excuse for her to stop providing for her family. She described herself
as a strong and independent woman. She stated that as much as possible she will
try not to be a burden for her family. She bragged about her sacrifices and how
she was able to raise her daughter and send her to a private nursing school all by
herself. Her family belongs to an extended type of family, religiously practicing
Catholicism and has no belief or practices that might affect in providing health care.
She was very open to talk about her failed relationships with her daughter’s father
and other ex-lovers.
II. Mental Status
The patient was seen awake. She is coherent, conversant and responds
appropriately to verbal and non-verbal stimuli. She is well oriented to her current
illness, time, date, and people around her. During the interview, she was able to
express her feelings and uses clear words. She speaks with confidence. The
patient converses with eyes open and maintains eye contact. The patient is calm,
alert, and expressive. Facial expressions are congruent with subjects. Speech is
audible with moderate loudness. Speech is fluent. There is usually a flow of
conversation with pauses. Thought is organized and congruent with behavior and
nonverbal cues. She can also remember her past and present experiences that
happened. She was able to repeat the three words I asked her to remember after
taking her vital signs. Short and long term memory is intact. She had a diploma in
Secretariat and based on my assessment she’s a well read kind of person.
III. Environmental Status
Patient and her family lives along the main road and 5 to 7 minutes away
from the town proper. They have a quiet and safe neighborhood. As being used to
doing chores, patient N, is quite particular with cleanliness. She makes sure that
their house and yard are clean. She also practices proper waste segregation. One
of her hobbies is gardening, she even showed me her collection of kalachuchi and
orchids. Patient is completely thankful that even if they are in the city, their place
is away from factories. During the assessment, the patient verbalized that she
wants to go home soon because she misses her granddaughters and worried that
her plants are not getting enough care. She uses fertilizers and pesticides for her
plants.
IV. Sensory Status.
Visual Acuity
Patient is using corrective device such as reading glasses. Her specs
specs are 200 on the right eye and 175 on the left eye. She was able to distinguish
and name the objects (ballpen, cellphone, and syringe) that was shown to her. She
was able to read the words (Wilkin's, Apple, and Chandelier) at a distance of
approximately 2 meters.
Auditory
Ears are symmetrical, equal size and fully formed. Both ears has cerumen.
Ears are firm without lumps, nontender and no pain is elicited with palpation of the
auricle or mastoid process. She was able to repeat the phrase “cooking time” on
the whisper test. Also, she was able to hear the beep of the thermometer at a without assistance. She stated that she's busy tending her sari-sari store and
distance of approximately 2 meters. taking care of her plants.
Olfactory
It is symmetrical, midline, and proportional to face. No lesions noted and VI. Nutritional Status
color is consistent with facial complexion. Patient did not feel pain upon palpation,
no tenderness noted or break in contour. Patient was able to distinguish the smell
of vinegar on Cracklings and alcohol on an unlabeled bottle. Patient is on DAT with SAP. Patient verbalized that she eats poorly
because she always has no appetite. Before she was even hospitalized patient
Gustatory claimed that her eating habits has changed. She no longer enjoys the food she
used to savor. She used to eat three times daily with snacks in between. She even
Lips are dark in color and moist with no lesions. Patient’s teeth is not
mentioned that she loves vegetables. She prefer it more than meat dishes. Patient
complete, she only have 21 teeth left. 7 teeth on the upper and 14 on the lower
claimed that she lose weight during the occurrence of her disease. She used to be
part. Remaining teeth are yellowish in color with tar. She has no and not using
67 kg but upon admission she weighs 41 kg. According to her BMI (16.60) she is
dentures. Halitosis noted. She was able to discriminate the tastes of the three food
underweight. She showed me some of her photos that was taken a year ago and
we introduced to her. Sweet (Max red), sour and salty (Cracklings), and bitter (dark
I can tell that the disease got a good chunk of her. She used to look well fleshed
chocolate).
but now she’s skinny. After discharge Patient N stated she changed her diet. She
Tactile started growing vegetables on her backyard and uses organic fertilizers. Also, she
started eating organic vegetables and fruits. Patient N verbalized that she's having
Patient correctly identified light touch. Pain sensation is intact. Temperature
organic barley, and claimed that it helps her gained back her appetite and make
sensation is intact. Point localization is intact. Also, patient correctly named the
her more energetic.
objects(coin, bandage scissor, key) she held while closing her eyes.

VII. Elimination Status

V. Motor Status

Patient's usual stool is yellowish in color, hard in consistency. She

Patient was able to move all of her extremities except her left upper
defecates twice a day. She doesn’t strain herself when she defecates. During
extremity; she has limited range of motion. She can not raise her left arm because
hospitalization she only pooped once in 3 days. As to her hydration status, she
it is painful to move. She has difficulty in turning because of the pain she feels
verbalized that she drinks at least 8 glasses of water a day. She drinks soda but
whenever she move. Postural instability when performing routine ADLs. She can
not that often. Her urine is yellow to dark yellow in color she urinates 3 to 4 times
walk and able to do her usual ADLs with assistance from her daughter.
Movements are slowed because she feels pain whenever she move or do a day. She stated that she does not feel any pain when voiding. She still voids
something. She rated it 6/10. A week after her discharged at the hospital she no frequently the same before and during hospitalization. After hospitalization, patient
longer feel pain, as verbalized by the patient. She is now doing her usual ADLs
N claimed that she started making fresh juices from fresh fruits and vegetables. not using of accessory muscles. Her oygen saturation is 98%. No clubbing of
She take it twice a day, one in the morning and another one in the afternoon. finger nails. Upon auscultating her lungs, assessment showed that she had no
presence of abnormal breath sounds.

VIII. Fluid and Electrolyte Status XI. Body Temperature

Patient has an ongoing PLRS X 1000 mL regulated at KVO. She is not The patient have not experienced increased in temperature, she stated that
always thirsty, her mouth's mucous membrane is not dry, her skin turgor goes back she doesn’t feel hot. The patient’s temperature during assessment was 37.1 °C,
immediately, no presence of edema. The patient has a normal capillary refill with axillary site. She was thankful that her room has air-conditioning.
a capillary refill of less than 2 seconds. Her electrolyte results on the 12th of
February, 2019 are as follows:
XII. Integumentary Status
 Sodium Na (+): 146.5 mmol/L (NV: 135-148 mmol/L)
 Potassium K (+): 3.91 mmol/L (NV: 3.50-5.30 mmol/L)
Patient is brown in color and has a good skin turgor which goes back
immediately. Skin temperature is cool and appropriate to the environment.
IX. Circulatory Status Moisture is consistent through out, with evenly smooth skin texture. Hair is thick
and well distributed across the scalp. No lice or nits noted. Nails are smooth and
translucent, and consistent in color and thickness. Supraclavicular and posterior
Upon assessment on the circulatory status of the patient, her pulse rates
cervical lymphadenopathy noted on the left side of the body. A diagonal full-
were: radial pulse 83 beats per minute, carotid pulse 88 beats per minute, temporal
thickness wound is noted on left breast due to surgical incision. Hemovac drain is
pulse 78 beats per minute, apical pulse 85 beats per minute. Her pulse was
inserted in her chest with a negative pressure. An amount of 30 mL, bright red
characterized as bounding pulse with a grade of +4. Heart sounds was normal.
discharge, is noted during assessment. Elastic bandage is wrapped around her
Her blood pressure during the assessment was 110/80 mmHg. The client has a
chest with a dry and intact wound dressing. Patient N claimed that her wound has
brown color, pink nail beds and dark lips. No signs of pallor. Neck veins do not
healed without complications. On the healing process she noted that her wound
appear full.
appeared pink to red which is a sign of healthy healing.

X. Respiratory Status
XIII. Rest and Comfort

Patient N is a non-smoker, no one in their house smoke. She claimed that

Patient affirmed that she sleeps 7 to 8 hours before hospitalization. During
she doesn’t have asthma. During assessment her posture is upright and relaxed.
her stay in the hospital, she was able to sleep well and even when her sleep was
Facial expression is relaxed. Skin color is appropriate tone for race, no cyanosis
disturbed because of vital signs monitoring, she have no trouble going back to
or pallor noted. Respiratory rate is 20 breaths per minute with regular rhythm and
sleep. During assessment she’s feeling moderate pain on her operation site. She
rated it as 5/10. She claimed that she has high tolerance of pain. She only get to
feel pain when she’s moving. A week after she got out of the hospital, she started
doing simple chores like sweeping and watering plants. Patient has recuperated
well with her surgery. She verbalized that she’s going to take care of herself more
so that she can keep the recurrence of hear disease at bay.
GENOGRAM: father of the patient mother of the patient

Deceased Hypertension

sibling 1 patient sibling 3 sibling 4 sibling 5 sibling 6 sibling 7 sibling 8 sibling 9 sibling 10 sibling 11

HEALTHY BREAST CANCER THROAT CANCER HEALTHY HEALTHY HEALTHY HYPERTENSION HEALTHY HEALTHY HEALTHY HEALTHY

DAUGTHER OF THE PATIENT

HEALTHY

GRANDDAUGHTERS

HEALTHY HEALTHY
ANATOMY AND PHYSIOLOGY OF THE BREAST
Each breast is a hemispheric projection of variable size anterior to the
pectoralis major and serratus anterior muscles and attached to them by a layer of
fascia composed of dense irregular connective tissue.
pituitary, with contributions from progesterone and estrogens. The ejection of milk is
stimulated by oxytocin, which is released from the posterior pituitary in response to the
sucking of an infant on the mother’s nipple (suckling).

Each breast has one pigmented projection, the nipple, that has a series of
closely spaced openings of ducts called lactiferous ducts, where milk emerges. The
circular pigmented area of skin surrounding the nipple is called the areola (small
space); it appears rough because it contains modified sebaceous (oil) glands. Strands
of connective tissue called the suspensory ligaments of the breast (Cooper’s
ligaments) run between the skin and fascia and support the breast. These ligaments
become looser with age or with the excessive strain that can occur in long-term jogging
or high-impact aerobics. Wearing a supportive bra can slow this process and help
maintain the strength of the suspensory ligaments.

Within each breast is a mammary gland, a modified sudoriferous (sweat) gland

that produces milk. A mammary gland consists of 15 to 20 lobes, or compartments,
separated by a variable amount of adipose tissue. In each lobe are several smaller
compartments called lobules, composed of grapelike clusters of milk-secreting glands
termed alveoli (small cavities) embedded in connective tissue. Contraction of
myoepithelial cells surrounding the alveoli helps propel milk toward the nipples. When
milk is being produced, it passes from the alveoli into a series of secondary tubules
and then into the mammary ducts. Near the nipple, the mammary ducts expand slightly
to form sinuses called lactiferous sinuses, where some milk may be stored before
draining into a lactiferous duct. Each lactiferous duct typically carries milk from one of
the lobes to the exterior.

The functions of the mammary glands are the synthesis, secretion, and ejection
of milk; these functions, called lactation, are associated with pregnancy and childbirth.
Milk production is stimulated largely by the hormone prolactin from the anterior
 MODIFIABLE: Damage and failure in repair of NON-MODIFIABLE:
DNA.
OBESITY GENDER

EXPOSURE TO IONIZING RADIATION Genetic mutation FAMILY HISTORY OF BREAST Cancer

HIGH FAT DIET (BRCA1, BRCA2, P53) HORMONAL FACTORS

ALCOHOL INTAKE RACE

Inactivation of tumor
Suppressor genes

Activation of growth Unregulated cell Alteration in genes that

promotion oncogenes proliferation regulate apoptosis

Decreased apoptosis
Papillary growth within the
duct lumina
Tumor causes local
Colonial expansion
inflammation

Ciribriform growth pattern

Tumor progression
Damage to suspensatory
Solid growth pattern ligaments and lactiferous
duct

Comedo growth pattern

Fibrosis

Tumor necrotic factor alpha Neoplasia

production Pain
Migrate along lactiferous Cross basement membrane Malignant neoplasm Enter and blocks lymphatic Lymps builds up in interstitial
duct of lumen vessels space

INVASIVE DUCTAL Modified Radical Tumor cells spread via lymph LYMPHADENOPHATIES
CARCINOMA MAstectomy IMPAIRED PHYSICAL
MOBILITY

Skin becomes thickened and

Pooling of blood
Incision on left breast Axillary lymph nodes and dimpled
SELF-CARE DEFICIT
other breast

Malignant tumor cells PEAU D’ORANGE

inflammation Breakage on skin

Increase proinflammatory Metabolism of

Granulation of tissue cytokine production macronutrients affected
Damage of nerve endings

Decrease appetite Increased proteolysis Decreased lean body mass

inducing factor
remodelling
Post-operative pain

Decreased food intake

Healed wound WEIGHT LOSS

(SCAR) (ANOREXIA

CACHEXIA SYNDROME)
DISTURBED BODY IMAGE DECREASED SELF-ESTEEM
February 12, 2019 11:18 AM

Hematology Result – B Positive

PARAMETER RESULT UNIT REF.RANGE PARAMETER RESULT UNIT REF.RANGE

Hemoglobin 133 g/L 120-160 MCHC 339 g/L 310-370

Hematocrit 0.39 0.37-0.47 RDW-CV 0.113 % 0.110-0.160

Erythrocytes 4.6 x10^9/L 4.0-5.4 RDW-SD 39.8 fL 35.0-56.0

WBC 5.7 x10^9/L 4.0-10.0 MPV 9.6 fL 6.5-12.0

Neutrophils 71.1 % 55.0-65.0 PDW 10.0 9.0-17.0

Lymphocytes 23.1 % 25.0-35.0 PCT 1.19 mL/L 1.08-2.82

Monocytes 4.7 % 3.0-6.0 IG# 0.0 %

Eosinophils 0.9 % 2.0-4.0 NRBC# 0.0 %

Basophils 0.2 % 0.0-1.0

Platelet count 202 x10^9/L 150-450

MCV 84.7 fL 80.0-100.0

MCH 28.7 pg 27.0-34.0

February 12, 2019 12:17 PM

TEST RESULT UNIT REFERENCE RANGE

Urea/Bun Liquid 3.34 mmol/L 1.70 – 8.30

CREA Jaffe Gen2 58.92 umol/L 44 – 97

Comp

TEST REFERENCE RESULT

Sodium Adult: 135 – 148 mmol/L 146.5 mmol/L

Potassium Adult: 3.50 – 5.30 mmol/L 3.91 mmol/L

January 4, 2019

Breast Ultrasound

INTERPRETATION:

Both breast exhibit normal fibroglandural echopattern.

A lobulated solid nodule is seen within the right breast measuring 4.76x5.58x5.5 mm, 10 o'clock position.

A lobulated partially calcified solid mass measuring 34.9x37.6x22.41 mm is seen within the left breast, subareolar area.

No ductal ectasia seen.

No skin dimpling nor thickening noted.

Axillary vessels are unremarkable.

Axillary lymphadenopathies are seen bilaterally the largest measuring 7.91x4.23x6.70 mm and 7.26x6.54x6.24 mm on the right and 22.1x9.93x17.14 mm and 3.62x12.8x6.3 mm
on the left.

IMPRESSION:

SOLID NODULE, RIGHT BREAST, AS DESCRIBED.

SOLID MASS, LEFT BREAST, AS DESCRIBED.

AXILLARY LYMPHADENOPATHIES, BILATERAL.

WOULD SUGGEST FOLLOW-UP

 PRIORITIZATION AND RANKING OF NURSING PRONBLEMS:

NURSING MANIFESTATIONS A – AIRWAY ACTUAL/POTENTIAL OVERT/COVERT MASLOW’S

DIAGNOSIS B – BREATHING HEIRARCHY OF
C – CIRCULATION NEEDS
Subjective:
“medyo nasakit pay
Acute pain related to toy sugat ko, aglalo nu ACTUAL COVERT PHYSIOLOGIC
surgical procedure. agkutiak” as
verbalized by the
patient.

P – when moving
Q – stabbing pain
R – radiates at the
back
S – pain rate 6/10
T – last within minutes

Objectives:
-facial grimace (when
moving)
-guarding behavior
restlessness
-inability to
concentrate

Vital signs:
BP – 120/80 mmHg
Temp. – 37.1 °C
 SUBJECTIVE:
Imbalanced nutrition: “nagdakkel ti
less than body kinuttungak, imagine
requirements related ACTUAL OVERT PHYSIOLOGIC
anak from 67 kg to 51
to cachexia secondary kg in like less than 6
to biological factors. month”, as verbalized
by the patient.

OBJECTIVE:
-loss of weight (from
67 kg to 41 kg)
-weak looking
-BMI of 16.60,
underweight

Impaired physical SUBJCTIVE:

mobility related to ACTUAL OVERT PHYSIOLOGIC
pain/discomfort “agsakit toy sugat ko
secondary to Modified nu aggunayak” as
Radical Mastectomy verbalized by the
patient.

OBJECTIVE:
-slowed movements
 -limited range of
motion
-difficulty turning
-facial grimace
-guarding behavior

SUBJECTIVE:
Self-care deficit
related to impaired “makadigdigosakon ACTUAL OVERT PHYSIOLOGIC
mobility status ngem haan ko pay
secondary to met mabalinan nga
pain/discomfort. agdigos nga
maymaysak” as
verbalized by the
patient.
OBJECTIVE:

Self feeding deficit:

Inability to open
containers.
Hygiene deficit:
Inability to wash body
or body parts.
Get in and out of
bathroom without
assistance.
Grooming deficit:
Inability to change
clothes on her own.
 SUBJECTIVE:

Impaired skin integrity “nasakit diyay sugat

related to surgical ko”, as verbalized by ACTUAL OVERT PHYSIOLOGIC
incision secondary to the patient.
modified Radical
Mastectomy OBJECTIVE:

Surgical incision of 10
cm. on the left breast.

Inadequate primary
defenses (broken
Risk for infection skin) POTENTIAL OVERT PHYSIOLOGIC

SUBJECTIVE:
Disturbed body image “awan tay maysa nga
related to surgery susok kon, feeling ko
secondary to invasie haanak kompleton”,
Ductal carcinoma as verbalized by the
patient. ACTUAL OVERT ESTEEM

OBJECTIVE:
Evident missing body
part (left breast)
Grimacing and crying
while speaking, noted
 Risk for Low self Disturbed body image POTENTIAL OVERT ESTEEM
esteem due to loss of body
part

LIST OF PRIORITIZED PROBLEMS AND ITS RANKING:

1. Acute pain related to surgical procedure.

2. Imbalanced nutrition: less than body requirements related to cachexia secondary to invasive Ductal carcinoma.
3. Impaired skin integrity related to surgical incision secondary to modified radical mastectomy.
4. Impaired physical mobility related to pain/discomfort secondary to modified radical mastectomy.
5. Self-care deficit related to mobility status secondary to pain/discomfort.
6. Disturbed body image related to modified radical mastectomy secondary to invasive ductal carcinoma.
7. Risk for infection.
8. Risk for Low self-esteem.
 ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION
THE PROBLEM

Subjective: Modified Radical STO: Dx: STO:

Mastectomy
“medyo nasakit pay toy After 30 minutes of Perform pain To rule out worsening of After 30 minutes of
sugat ko, aglalo nu nursing education and assessment each time underlying condition/ nursing education and
agkutiak” as verbalized intervention, the patient pain occurs. Note and development of intervention, the patient
by the patient. Incision on left breast will be able to verbalize investigate changes complications. was able to verbalize
methods that provide from previous reports. methods that provide
P – when moving relief such as DBE, relief such as:
Breakage on skin positioning, splinting, hot Observe non-verbal
Q – stabbing pain Observations may/may
and cold compress, and cues (facial grimace, DBE, Positioning,
not be congruent with
R – radiates at the back diversional activities and guarding behavior). splinting, hot and cold
verbal reports indicating compress, and
S – pain rate 6/10 will feel immediate relief
Damage of nerve need for further diversional activities
or lessen the pain from evaluation.
endings
T – last within minutes 6/10 to 4/10 pain scale. And was able to feel an
Usually altered in acute immediate relief from
Monitor vital signs. pain. pain; from 6/10 to 4/10
Objectives: Post-op pain.
pain scale.
-facial grimace (when
GOAL MET
moving)

-guarding behavior

-restlessness

-inability to concentrate Tx:


Vital signs:
BP – 120/80 mmHg LTO:
Temp. – 37.1 °C
During her hospital stay
the patient will be able to
control and reduce pain
Nursing Diagnosis: to an acceptable level
Acute pain related to on her own, 4/10 to no
surgical procedure. pain at all.
Independent:
Provide comfort To promote non-
measures (hot/cold pharmacological pain
LTO
compress). management.
Demonstrate use of For pain relief. During her hospital stay
relaxation exercise the patient was not able
(focused or deep to control and reduce
pain to an acceptable
breathing exercises)
level on her own, 4/10 to
Dependent: no pain at all.
Administer analgesic GOAL PARTIALLY
For pain relief.
medication such MET
celecoxib as per doctor's
order. The patient is still feel
pain during her hospital
Ed: stay.
Encourage diversional
activities such as To distract attention and
tv/radio, socialization reduce tension.
with others.
Provide calm and
To reduce anxiety and
conducive environment.
stress.
Encourage adequate To prevent fatigue.
rest periods.
IMPAIRED PHYSICAL MOBILITY

ASSESSMENT EXPLANATION OF PLANNING NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

SUBJCTIVE: Modified Radical STO: Dx: STO:

Mastectomy
“agsakit toy sugat ko After 30 minutes of Observe movement To note any After 30 minutes of
nu aggunayak” as nursing education when client is incongruencies with nursing education
verbalized by the patient will be able to unaware of reports of abilities. patient was able to
patient. Incision on left breast demonstrate observation. demonstrate
techniques that enable techniques that
resumption of enable resumption of
OBJECTIVE: Breakage on skin activities such as: Note activities such as:
Feelings of frustration/
-slowed movements DBE, splinting, use of emotional/behavioral powerlessness may DBE, splinting, use of
adjunctive devices and responses to impede attainment of adjunctive devices
-limited range of Damage of nerve problems of
safety measures goals. and safety measures
motion endings immobility.
GOAL MET
-difficulty turning
Post-op pain Monitor vital signs. Usually altered in
-facial grimace acute pain.
LTO: LTO:
-guarding behavior
During hospital stay During hospital stay
Impaired physical Tx:
and even on and even on
mobility
discharge, patient will Independent: discharge, patient was
be able to maintain or able to maintain or
increase strength and increase strength and
Nursing Diagnosis: function of affected Instruct in use of For position changes function of affected
and/or compensatory siderails and IV stand. or transfer. and/or compensatory
Impaired physical body part. body part.
mobility related to
pain/discomfort
secondary to Modified Support affected body To maintain position of
Radical Mastectomy parts using pillows, function and reduce GOAL MET
foot supports, air risk of pressure ulcers.
mattress.

Assist client reposition

self on a regular To maintain position of
schedule. function and reduce
risk of pressure ulcers.

Schedule activities
with adequate rest To reduce fatigue.
periods during the
day.

Dependent:
To permit maximal
Administer effort/ involvement in
medications prior to activity.
activity as needed for
pain relief.
Ed:

Involve client and SO Enhances

in care, assisting them commitment to plan,
to learn ways of optimizing outcomes.
managing problems of
immobility.

Demonstrate use of Promotes

adjunctive devices independence and
and safety measures. enhance safety.
SELF-CARE DEFICIT

ASSESSMENT EXPLANATION OF PLANNING NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

SUBJECTIVE: Modified Radical STO: Dx: STO:

Mastectomy
“makadigdigosakon After 30 minutes of Identify degree of To identify appropriate After 30 minutes of
ngem haan ko pay nursing education, individual impairment/ activity suitable to nursing education,
met mabalinan nga patient will be able to functional level. patients capability. patient was able to
agdigos nga Incision on left breast demonstrate/ verbalize demonstrate/verbalize
maymaysak” as techniques/life style techniques/life style
verbalized by the changes to meet self Assess To evaluate changes to meet self
patient. Breakage on skin care needs such as: memory/intellectual effectiveness of health care needs, such as:

Use of assistive functioning. teaching. Use of assistive

devices, and energy devices, and energy
OBJECTIVE: Damage of nerve
saving behaviors saving behaviors.
endings Determine strengths To maintain/increase
Self feeding deficit: GOAL MET
and skills of the client. level of functioning.
Inability to open
containers. Post-op pain

Hygiene deficit: Tx:

LTO: Independent: LTO:
Inability to wash body Impaired physical
or body parts. mobility By discharge, patient By discharged, patient
will be able to perform was able to perform
self-care activities self-care activities
Get in and out of Self-care deficit within level of own Assist with necessary To encourage patient within level of own
bathroom without ability. adaptations to and build on ability.
assistance. accomplish ADLs. successes.
GOAL MET
Grooming deficit:

Inability to change Assist with To enhance

clothes on her own. rehabilitation program. capabilities.

Provide for Enhances

communication among coordination and
Nursing Diagnosis: those who are continuity of care.
Self-care deficit involved in caring for/
related to impaired assisting the client.
mobility status
secondary to
pain/discomfort. Review safety Reduce risk of injury.
concerns and modify
activities/environment.

Arrange for assistive

devices as necessary. For position changes
or transfer
Dependent:

Administer To permit maximal

medications regimen effort and involvement
as perscribed such as in activity.
celecoxib.

Ed:

Promote client/SO
participation in Enhances
problem identification commitment to plan,
and decision making. optimizing outcomes.

Identify energy saving

behaviors. To reduce fatigue.

Review instructions Provides clarification,

from other members reinforcement, and
of the health care periodic review by
team and provide client/SO.
written copy.
WEIGHT LOSS

ASSESSMENT EXPLANATION OF PLANNING NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

SUBJECTIVE: Malignant tumor cells STO: Dx: STO:

“nagdakkel ti After 30 minutes of Ascertain To determine what After 30 minutes of

kinuttungak, imagine nursing education, understanding of information to provide nursing education,
anak from 67 kg to 51 Increase patient will be able individual needs. client/SO. patient was able to
kg in like less than 6 proinflammatory verbalize verbalize
month”, as verbalized cytokine production understanding of understanding of
by the patient. causative factors Computation of BMI To evaluate if the causative factors
when known and client is in normal when known and
Decrease appetite necessary weight. necessary
OBJECTIVE: intervention. intervention.
Assess weight, Establishes baseline
-loss of weight (from measure or calculate parameter. GOAL MET
Decrease food in take body fat.
67 kg to 41 kg)

-weak looking LTO: LTO:

Weight loss
-BMI of 16.60, By discharge, patient Patient was able to
underweight Or Reveals possible
will be able to Evaluate total food cause of malnutrition. partially demonstrate
demonstrate behavior intake. behavior or life style
life style changes to changes to regain
Nursing Diagnosis: Malignant tumor Cells regain appropriate appropriate weight.
weight.
Imbalanced nutrition: Metabolism of Tx: GOAL PARTIALLY
less than body macronutrients MET
requirements related affected Independent:
to cachexia secondary Not enough time for
Assist the patient in For the education of assessment.
to biological factors. demonstrating the patient for
Increase proteolysis behavior, life style appropriate recovery
inducing factor changes to regain from nutritional I’m
appropriate weight. balance.

Decrease lean body

mass Promote pleasant This promotes comfort
environment including to the patient and
socialization. encourages good
Weight loss eating habit.

Instruct patient to
choose food or have Stimulates appetite of
family to bring food the client.
that seems appealing.

Weight at regular
intervals and Monitors effectiveness
document results. of dietary plans.
Dependent:

Consult dietician and To have an accurate

nutritional support dietary intake for long
team as necessary. term needs.

Ed:

Discuss eating habits Determines

including food informational needs of
preferences, the patient. Appeals to
intolerance and client tasks, and
aversion. enhances intake.

Teach client to weight To monitor

weekly and document effectiveness of
results. dietary plan.

Emphasized of well- To know the benefits

balanced, nutritious of week balanced
intake. nutritious foods and
where to find them
amidst financial crisis.
IMPAIRED SKIN INTEGRITY

ASSESSMENT EXPLANATION OF PLANNING NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

SUBJECTIVE: Modified Radical STO: Dx: STO:

Mastectomy
“nasakit diyay sugat ko”, After 30 minutes of Assess blood supply To determine if After 30 minutes of
as verbalized by the nursing education, and sensation of circulation and nursing education,
patient. patient will be able to affected area. sensation has patient was able to
Incision on left breast participate in prevention decreased. participate in prevention
measures and treatment measures and treatment
program. To estimate the duration program.
OBJECTIVE: Determine depth of of wound healing.
Breakage on skin injury/damage to
Surgical incision of 10 integumentary system.
cm. on the left breast. GOAL MET
Impaired skin integrity
Inspect skin on a daily To determine if infection
Nursing Diagnosis: LTO: basis, describing has occurred. LTO:
Impaired skin integrity changes observed.
During hospital stay and Patient was able to
related to surgical by discharge, patient will display timely healing of
incision secondary to be able to display timely Foul odor is an wound without
modified Radical healing of wound without Note odors emitted from indication of wound complication during
Mastectomy. complication. the skin/ area of injury. infection. hospital stay.

Tx: GOAL PARTIALLY

MET
Independent: Not enough time to
assess the wound
Keep the area clean/dry, To prevent infection and healing after discharge.
carefully dress wound, stimulate circulation to
support incision, surrounding area.

Use appropriate barrier To prevent cross

dressings, wound contamination and
coverings, drainage infection.
appliances, and skin
protective agents for
open/draining wound
and stoma.

To protect wound and

Use appropriate padding surrounding tissue.
devices when indicated.

Promotes circulation
Encourage early and reduces risks
ambulation/ associated with
mobilization. immobility.
Dependent:

Expose wound to air To keep wound dry and

and light as indicated. promote faster healing.

Consult with wound To assist with

specialist as indicated. developing plan of care
for problematic or
potentially serious
wounds.

Ed:

Discuss importance of To treat infection and

prevent further
early detection of skin
changes and/or complication.
complications.

Enhances commitment
Assist the client/SO in to plan, optimizing
understanding and outcomes.
following medical
regimen and developing
program of preventive
care and daily
maintenance.
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE INTERACTIONS NURSING
REACTION IMPLEMENTATION
Generic Name: Binds to Antibiotic Hypersensitivity to Diarrhea Cefuroxime Use with caution in
Cefuroxime penicillin- prophylaxis. cephalosporin. decreases effects of patients with history of
binding proteins Decreased BCG vaccine live by penicillin allergy.
Brand Name: and inhibits BCG vaccine Live. hemoglobin or pharmacodynamic
Ceftin, Zinacef final hematocrit. antagonism. Wait Use caution in patients
transpeptidation until Abx Tx complete with history of colitis,
Class: step of Eosinophilia to administer live renal impairment, or
Cephalosporin, peptidoglycan bacterial vaccine. with a history of seizure
2nd generation synthesis, Nausea or vomiting disorders.
resulting in cell-
wall death; Vaginitis
resists
degradation by
beta-lactamase;
proper dosing
and appropriate
route of
administration
are determined
by condition of
patient, severity
of infection and
susceptibility of
microorganism.
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE REACTION INTERACTIONS NURSING
IMPLEMENTATION
Generic Name: Pain relief Pain Patient currently Headache Increases toxicity of May cause GI bleeding,
Ketorolac due to receiving aspirin. the other Stevens-Johnson
prostaglandin Somnolence pharmacodynamic syndrome, anaphylaxis,
inhibition Advanced renal synergism. drowsiness.
Brand Name: impairment. Dyspepsia
Toradol Should not exceed 5
With active peptic GI pain days of therapy.
ulcer disease.
Class: Nausea Bleeding risk increased
NSAIDs, With suspected or with garlic, ginger, and
nonopiod confirmed Diarrhea gingko
analgesics. cerebrovascular
bleeding. Dizziness May decrease
effectiveness of
Hypersensitivity to hypertensive
ketorolac. medications and
diuretics.
Breast feeding
woman.

Woman in labor or
delivery
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE REACTION INTERACTIONS NURSING
IMPLEMENTATION
Generic Name: Inhibits action Duodenal Hypersensitivity to Headache It decreases effect of May cause arryhtmias,
Ranitidine of histamine ulcers ranitidine or ferrous sulfate by agranulocytosis,
in gastric components of the Abdominal pain increasing gastric pH. aplastic anemia,
Brand Name: parietal cells, GERD formulation. confusion.
Zantac decreased Agitation It increases the level
gastric acid Heart burn or effect of Assess abdominal pain.
Class: secretion. Alopecia Methylphenidate by
Histamine H2 Esophagitis increasing gastric pH. Monitor for blood in
Antagonists Confusion stool.
GI bleed
Constipation Monitor CBC.

Diarrhea

Dizziness

Nausea

Vomiting
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE INTERACTIONS NURSING
REACTION IMPLEMENTATION
Generic Name: Blocks Nausea/vomiting Hypersensitivity to Headache dronedarone and Administer slowly over
Ondanstron effects of ondansetron ondansetron both 2-5 minutes – fatal QT
serotonin on Malaise/fatigue increase QTc interval. prolongation and
Brand name: vagal nerve Coadministration with Contraindicated. VTach, respiratory
Zofran and CNS apomorphine; Constipation Avoid with congenital arrest.
combination reported long QT syndrome;
Class: to cause profound Hypoxia ECG monitoring May cause headache,
5-HT3 hypotension and loss recommended with constipation, diarrhea,
Antagonist, of consciousness. Drowsiness concomitant dry mouth.
Antiemetic medications that
Diarrhea prolong QT interval, Assess nausea and
electrolyte vomiting.
Dizziness abnormalities, CHF,
or bradyarrhythmias. Assess for
Fever extrapyramidal
symptoms.

Monitor liver function

test.
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE REACTION INTERACTIONS NURSING
IMPLEMENTATION
Generic Name: Binds to Supplement to Significant respiratory Asthenia fentanyl, butorphanol. Use caution with
Fentanyl opiate general depression Either increases increased ICP, head
receptor in anesthesia, Confusion effects of the other by trauma, adrenal
Brand Name: CNS altering continuous IV Acute or severe pharmacodynamic insufficiency
Sublimaze perception of infusion for bronchial asthma in an Constipation synergism. Avoid or
pain, purpose of unmonitored setting or Use Alternative Drug. Avoid use with MAOIs.
Class: producing analgesia. in the absence of Dry mouth Coadministration with
Opioid analgesic CNS resuscitative other CNS May cause apnea,
depression. equipment. Nausea depressants, such as laryngospasm,
skeletal muscle decreased respiration,
Hypersensitivity to Somnolence relaxants, may cause bradycardia,
drug or components of respiratory hypotension.
the formulation. Sweating depression,
hypotension, Do not sonsume
Within 2 weeks of Vomiting profound sedation, grapefruit while taking
monoamine oxidase coma, and/or death. this medication.
inhibitor use. Abdominal pain Consider dose
reduction of either or Monitor hemodynamics
Know or suspected GI Anorexia both agents to avoid during administration.
obstruction, including serious adverse
paralytic ileus. Anxiety effects. Monitor for Assess patient pain
hypotension, scale frequently.
Apnea respiratory
depression, and
profound sedation.
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE INTERACTIONS NURSING
REACTION IMPLEMENTATION
Generic Name: Amoxicillin Antibiotic Allergy to penicillins. Diarrhea amoxicillin decreases Use caution in hepatic
Coamoxiclav binds to prophylaxis effects of BCG impairment; hypatic
penicillin- Previous history of Mycosis vaccine live by dysfunction (rare) is
Brand Name: binding cholestatic pharmacodynamic more common in
Augmentin, proteins, thus jaundice/hepatic Nausea antagonism. elderly and/or males
Augmentin XR, inhibiting final dysfunction Contraindicated. Wait and prolonged therapy
Augmentin ES- transpeptidation associated with Rash until Abx Tx complete may increase risk; may
600 step of amoxicillin/clavulanate to administer live occur after completing
peptidoglycan Vomiting bacterial vaccine. therapy.
Class: synthesis in
Penicillin s, bacterial cell Loose stool amoxicillin decreases Risk of bacterial or
Amino walls; addition effects of typhoid fungal superinfections;
to clavulanate Anemia vaccine live by if suspected,
inhibits beta- pharmacodynamic discontinue drug
lactamase- Thrombocytopenia antagonism. immediately and
producing Contraindicated. Wait administer appropriate
bacteria, Leukopenia until Abx Tx complete therapy.
allowing to administer live
amoxicillin Agranulocytosis bacterial vaccine.
extended
spectrum Hepatotoxicity
action.
Flatulence
DRUG NAME ACTION INDICATIONS CONTRAINDICATION ADVERSE INTERACTIONS NURSING
REACTION IMPLEMENTATION
Generic Name: Inhibits Pain Aspirin allergy, chronic Headache Ketorolac: either Caution in asthma
Celecoxib cyclooxygenase hepatitis, perioperative Hypertension increases toxicity of (bronchial), bleeding
(COX)-2; does pain resuling from Fever the other by disorder,
Brand Name: not affect COX- coronary artery Dyspepsia pharmacodynamic bronchospasm,
Celebrex 1 (at bypass graft surgery. Arthralgia synergism. duodenal/gastric/peptic
therapeutic Cough ulcer, renal impairment
Class: concentrations), Vomiting
NSAIDs, COX2 thereby Diarrhea Anemia may occur;
Inhibitor decreasing Sinusitis monitor hemoglobin or
formation of Abdominal pain hematorcrit in long term
prostaglandin Diarrhea treatment patients
synthesis. Flatulence
Dizziness Use caution in
pediatrics with
systemic-onset juvenile
idiopathic arthritis;
serious adverse
reactions, including
disseminated
intravascular
coagulation reported

NSAIDS have the potential

to trigger HF by
prostaglandin inhibition that
leads to sodium and water
retention, increased
systemic vascular
resistance, and blunted
response to diuretics
REFERENCES:

Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA

Cancer J Clin. 2013; 63:11-30.

124. Broders AC. Carcinoma in situ contrasted with benign penetrating epithelium. 132. Dunnwald LK, Rossing MA, Li CI. Hormone receptor status, tumor
JAMA 2014;99:1670. characteristics, and prognosis: a prospective cohort of breast cancer patients. Breast
Cancer Res. 2007 9:R6.
125. Foote FW, Stewart FW. Lobular carcinoma in situ: A rare form of mammary
cancer. Am J Pathol. 1941;17:491-496. 133. McDivitt RW, Boyce W, Gersell D. Tubular carcinoma of the breast. Clinical and
pathological observations concerning 135 cases. Am J Surg Pathol. 1982;6:401-411.
126. Consensus conference on the classification of ductal carcnoma in situ. Hum
Pathol. 1997; 28:1221-1225.
127. Recht A, Rutgers EJ, Fentiman IS, et al. The fourth EORTC DCIS Consensus
meeting (Chateau Marquette, Heemskerk, The Netherlands, 23-24 January 1998)–
conference report. Eur J Cancer.1998; 34:1664-1669.
128. Devitt JE, Barr JR. The clinical recognition of cystic carcinoma of the breast.
Surg Gynecol Obstet. 1984;159:130-132.
129. Gallager HS, Martin JE. The study of mammary carcinoma by mammography
and whole organ sectioning. Early observations. Cancer. 1969;23:855-873.
130. Seth A, Kitching R, Landberg G, et al. Gene expression profiling of ductal
carcinomas in situ and invasive breast tumors. Anticancer Res. 2003; 23:2043-2051.
131. Simpson JF, Wilkinson EJ. Malignant neoplasia of the breast: Infiltrating
carcinomas. In: Bland KI, Copeland EMI, eds. The Breast: Comprehensive
Management of Benign and Malignant Diseases. Philadelphia:WB Saunders;
1998:285.