Professional Documents
Culture Documents
COLLEGE OF NURSING
Lucinda Campus
Brgy. Ungot, Tarlac City
Presented to:
Presented by:
BSN IV - D
Santos, Marivic C.
Santos, Willa Milafrosa M.
Sotelo, Jeffrey R.
Suarez, Christine Karen A.
Sumang, Jerico B.
Date Submitted:
October 11, 2010
Acknowledgment
Our group would like to extend our deepest gratitude to the following:
We would like to extend our heartfelt gratitude to our Clinical Instructor, Mrs. Gienelle
M. Sabado, we would like to broaden our appreciation for your time and magnanimous
knowledge to teach us nursing skills and develop attitude to each and every one of us to become
better nurses someday.
To our Dear Parents, we are very grateful for always being there to support us. For giving
us the sole opportunity to experience studying BSN and for their financial help.
To our patient and his husband, thank you for imparting your knowledge and the essential
information needed for our Case Study.
And above all, we would like to express our earnest and sincerest homage and love to our
Lord God, who constantly guides us in this course of our life. We thank him for his
unconditional love for each and every one of us.
I. INTRODUCTION
Breast cancer (malignant breast neoplasm) is cancer originating from breast tissue, most
commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk.
Cancers originating from ducts are known as ductal carcinomas; those originating from lobules
are known as lobular carcinomas. Prognosis and survival rate varies greatly depending on cancer
type and staging. Some breast cancers are sensitive to hormones such as estrogen and/or
progesterone which make it possible to treat them by blocking the effects of this hormone in the
target tissues. These have better prognosis and require less aggressive treatment than hormone
negative cancers.
Worldwide, breast cancer comprises 10.4% of all cancer incidences among women,
making it the most common type of non-skin cancer in women and the fifth most common cause
of cancer death. In 2010, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths;
almost 1% of all deaths). Breast cancer is about 100 times more common in women than in men,
The Department of Health says that breast cancer is now the most common cancer in the
Philippines, accounting for 16 percent of the 50,000 cases of the dreaded disease in the country.
Computerized models are available to predict survival. With best treatment and dependent on
staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes surgery,
Nurse – centered
General:
This study is aim to gain or broaden the knowledge and skills with regards to the disease
condition Beast Cancer.
Specific:
To gain more knowledge about Breast Cancer, its epidemiology, contributing factors,
pathophysiology, clinical manifestations, and the treatment required.
To enhance the student skills by performing various nursing interventions to solve or
alleviate the patient’s needs as implementations of the formulated plans of care.
To promote the student’s wellness of social health by conducting a healthy social
interaction with the patient.
The nurse should be able to impart knowledge to the patient and significant others
regarding the patient’s condition.
To gain fulfillment during and after rendering care to the patient, thus uplifting their
emotional health.
Patient – centered
General:
To be able to know his/her existing condition and to be able to participate well with
procedures and things he/she needs to comply for the success of his/her disease treatment.
Specific:
To increase the client’s knowledge about her disease, which is Breast Cancer, by means
of giving health teachings in the contributing factors, disease course, manifestations and
treatments involved.
To address the patient’s needs and problems that accompany the disease by performing
appropriate nursing interventions based on health care plans.
To promote her emotional well-being by encouraging her to speak of whatever she feels
about her disease condition.
The client should be able to gain knowledge about her condition and the different ways
on how to understand and accept her state of being.
To gain cooperation with the health care provider in implementing the nursing
intervention as well as compliance to medical management.
Reasons in choosing the Case Study
We chose the case of breast cancer with Modified Radical Mastectomy because of the
following reasons:
a. Breast cancer is the most common cause of mortality and morbidity among women in the
Philippines and all over the world;
b. To know the Etiology, Pathophysiology, Clinical Manifestations of the Disease,
Prognosis, and treatment for such disease and be able to know what nursing
managements are appropriate.
c. To amalgamate health promotion and health maintenance into the case of post surgical
phase.
d. Knowledge and understanding about breast cancer and its surgery can develop us to be
better health care providers.
Our case study gives us a comprehensive stepwise in terms of skills and knowledge on
applying the nursing process namely assessment, planning, implementation, evaluation, and
including health teachings. In the context assessment, different skills are applied such as
inspection, palpation, percussion and auscultation to fully obtain an accurate and objective
finding. Nurse – patient interaction (NPI) is also essential in determining the different problems
of a patient which leads to giving a Nursing Diagnosis. The North American Nursing Diagnosis
Association (NANDA) helped us in formulating this diagnosis. Planning gives us a goal and
formulates certain objectives to alleviate problems seen in the patient.
Using the SMART (Specific, Measurable, Attainable, Realistic, and Time Bounded)
technique is crucial in attaining goals. Several Nursing Intervention are implemented and
rationales behind are given to determine the purpose on how and why we do certain
interventions. Lastly would be the evaluation in which it weighs or rates if the goal was attained
partially attained or not met. Having an evaluation is a prerequisite to know if further nursing
process is needed. A case study such as this allows us to develop critical thinking and use our
nursing judgment among different problems and situations to fully develop our Nursing Skills.
III. NURSING PROCESS
1. Personal Data
A. Demographic Data
Name: Mrs. V
Sex: Female
Age: 66 years old
Civil Status: Widow
Birth date: January 4, 1944
Place of Birth: Gerona, Tarlac
Chief Complaint: Breast Mass
Admitting Diagnosis: Breast Mass, Right, t/c Malignancy
Nationality: Filipino
Role in the Family: Mother
Religion: Roman Catholic
Health Care Financing: Philhealth
Usual Source of Medical Care: RHU/Gov. Hospital
B. Environmental Status
Mrs. V’s house is made up of cement and wood. It composes of two bedrooms, a small
kitchen, living room and a comfort room. Their source of water is coming from NAWASA.
Their house is located along the Highway and their neighbouring company is the Jayson’s Pancit
Bihon wherein they usually inhaled the smoke coming from it.
C. Lifestyle
According to Mrs. V, before she had this condition, she is socially active; she used to
attend fiestas in their Gerona, Tarlac. Still she can sweep their yard, cook their foods and wash.
She sits for quite sometimes to mingle with her co-barrio people about what’s new and to relax
for the day. Since almost all their neighbours are family and relatives she maintain a good
relationship to them. According to the patient, she occasionally drinks alcoholic beverages. She
Mrs. V said that she worked as cook for almost 20 years. 9 years to a Chinese family and
11 years to the workers of a Buying Palay Station.So aside from the hot workplace, she used to
lift heavy kitchen wares containing foods. But at the age of 45 years old, she stopped cooking
She did not remember anything that contributes to the mass on her breast. She said that
she never bumped on any things, fall down, or any object that may hurt the site. Mrs. V has 6
children with her husband (deceased due to Asthma 15 years ago), who are 2 boys and 4 girls.
She said she had a Normal Spontaneous Delivery to all of them at home. All breastfed, but she
confessed that it may be one of the contributing factor that time because while she was asleep,
she carry and breastfeed each baby and they accidentally kicked her breast.
At year 2007, she noticed that a thumb - like mass located below the right armpit. With
minimal pain she felt. She did not tell to anybody about it for almost 3 years because she did not
want her children to be bothered. But as days passing by for this 3 years, this 2010, the lump or
mass becomes bigger and its shape according to her is like her closed fist comparing as ball. So
she begins to worry and tell to her children about it. They decided to consult at Tarlac
Provincial hospital last November 2009 and the doctor said that it’s a Breast Cyst and as soon
as possible she must be operated. But the family refused to have the operation since the
expenses for the operation was expensive and they decided to delay it then save for the amount
needed.
After the diagnosis, in order to cope and keep from worrying, they seek advices from
albularyos and drunk different boiled leaves of plants like Aroma, Bugnay , Tanglad and many
more herbal medicines for 4 months. But the situation seems become worst. 1 month prior to
admission ,she noticed that the lump’s color becomes like a purple star apple with lesion beside
the armpit and has blood secretions thus as days goes by, the breast skin becomes thinner and
looks like a cellophane and transparent, and it seems like to burst. They rushed to TPH to have it
check up last September 17, 2010, admitted and scheduled for operation last September 23, 2010
OA OA OA OA
HTN UC
6
6
AST HTN UC BCA UC
LEGEND:
A. Social Status
According to Mrs. V, as a mother she cannot deny whatever her children request on her.
So at her age, she can manage on house hold chores aside from baby sit on her grandchildren.
Her sons and daughters with their spouses and grandchildren are very supportive to her. She can
sweep their yard, cook their foods and wash. When her grandchild fall into sleep, she said she
watched afternoon variety shows on T.V. She is also active to church activities. If they run out of
budget and kitchen needs, there is a little store nearby their house and here is where they usually
buy what are lacking for households. She sits for quite sometimes to mingle with her co-barrio
people about what’s new and to relax for the day. Since almost all their neighbours are their
family and relatives, she maintains a good relationship to them. And her children help together
when there are problems arises, especially concerning to health on each every member.
Norms: The patient and his family have respect to other people, believing that
relationships with other people are based on mutual trust (Westershoff) and putting their faith
in action and standing up for their beliefs (Kohlberg), (Med.& Surg. Nursing Lemone and Burk
2004)
Analysis: The patient developed interpersonal relationship within the family and their
neighbors with a certain degree of satisfaction. She developed a good coping ability as evidenced
by being hopeful to regain her normal functioning or health condition. Preferences and interest
exposed of her age were rather normal. Her activities were mostly dynamic in nature.
Facial expression Her expressions were appropriate according to the content of her dialogue
and showed a smile during the entire interview.
Consciousness She was well oriented with the time and date, although she wasn’t able to
recall some of her past memories.
Communication She has a good eye contact during the interview. She was conversant, and
she could understand and speak Ilocano as well as Tagalog language.
Attention She was attentive during the interview and had a good communication
process. She was cooperative and answers the question appropriately.
Memory The patient wasn’t able to remember some of her past memories due to her
age.
Norms: The patient should appear relaxed with appropriate amount concern of
the assessment; should be clean and well groomed; expressions should be appropriate to the
content of the conversations; should be able to produce spontaneous, coherent speech; and
should respond to questions properly. (Health assessment and physical assessment, Mary
Elen zator Estes).
Analysis: The patient was oriented and conscious. She was cooperative during the interview
and was confident in expressing herself. The patient was also unable to recall some past events
that happened in her life due to her age.
C. Emotional Status
Mrs. V stated that despite all the problems in life, it should not affect her stability in life.
She tried to cover up before about her condition in order to make her sons and daughter not to
worry about her, but later, she confesses it. Since she has the fear too of what she expects to
happen in the future. She tried to manage her condition alone for almost 3 years.
Norms: A person’s emotional status depends much on is ability to cope up with the
happenings in his life. He may or may not be emotionally stable of unfortunate incidents
happened. (Nursing CEU.com: The process of human development)
Analysis: The client has a positive outlook in life and can handle her emotions well.
D. Sensory Perception
Sense of Sight
Color of Sclera Both scleras are whitish in color but the conjunctivas are pinkish in
color.
Norms: The patient should have a visual acuity of 20/20; the eyes must
be symmetrical during the six cardinal gazes; sclera should be white with some small blood
vessels. (Health Assessment and physical assessment, Mary Elen Zator Estes).
Analysis: The patient’s visual aciuty was normal. Her eyes were symmetrical in shape, the
sclera is whitish in color, and he has pale conjunctiva.
Sense of Taste
Norms: A person has no problem about his sense of taste if he can identify the
sweet, sour, salty, and bitter taste of foods he eats. (Estes, Third edition, Copyright 2006)
Analysis: Revealed normal condition of the sense of taste based from the standards.
Sense of Smell
External inspection Nose is in the midline of the face, symmetrical, without lesions or
pain.
Patency There was no obstruction upon breathing. The student nurse asked her to
smell the objects we held near her nose through blindfold. The patient responded and
verbalized what she smelled and stated that she smelled alcohol and perfume.
Norms: Nose must be symmetrical and along the midline of the face. Each nostril must be
patent. (Health assessment and Physical Assessment, Mary Elen Zator Estes)
Analysis: Revealed normal findings upon assessment based on standards. There were no
deviations observed.
Tactile Sensitivity
Pain tolerance The student nurse pointed the sharp and dull edges of the ballpen
to the pt.’s skin and asked her to tell the sensation. The patient responded and verbalized
what she felt and stated that she felt sharp and dull object touched her skin.
Analysis: The patient’s sensory transmission functions are within the normal as
manifested by the data presented.
Auditory Acuity
“Watch tick” test She could hear the sound of the watch 1inch away from her.
Symmetry Ears were symmetrical with each other and were aligned on the
level of his eyes. There was no pain complained felt upon inspection.
Whisper test The patient was able to hear whispered words from 1-2 inches
away and repeated the words accordingly.
Norms: The patient should be able to hear whispered words to 2 inch away. The pt.
should not complain of pain upon palpation. (Health assessment and physical assessment, Mary
Elen Zator Estes)
E. Motor Stability
Mrs. V is able to ambulate with assistance on the first and second day but on the third day
she does it alone. She moves slowly with minimal movements.
Norms: Normal motor stability includes the ability to perform the different steps in doing
range of motion. It should be firm with smooth and coordinated movements (Estes, Third edition,
Copyright 2006)
Analysis: The client’s walking gait was not normal on the 1st and 2nd day after operation.
F. Body Temperature
Norms: 36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition,
Copyright 2004)
Analysis: The body temperature of the patient was within normal range.
G. Respiratory Status
H. Circulatory Status
Norms: The average heart rate of an adult is 80 – 100 bpm, and the average blood
pressure of an adult is 120/80mmHg. (Kozier, Seventh edition, Copyright 2004).
Analysis: With regards to Mrs. V’s circulatory status, it shows that her pulse rate and blood
pressure is in the normal range.
I. Nutritional Status
In the recall of previous diet taken by the patient, the client’s diet is under control of
glucose and carbohydrate diet. Her diet according to the physician’s order is on high fiber. She
eats 3 meals per day with some snacks during the afternoon or siesta time. Her fluid intake was
less than 3 bottles of water (1.5L each) amounting to approximately 4.5L.
BMI Computation:
Given: weight = 45 kg
Height = 5 ft (4 inches)
BMI = weight in kg / height in (m) 2
= 45 / (1.6256)2
BMI = 17.01
Norms: “Normal eating pattern is on the minimum of 3 – 5 times per day, depending
upon metabolic need and demands. Fluid is on the average of 8-10 glasses” (2-3 liters) per day.
(Physical Assessment and Health Examination 4th Edition, Carolyn Jarvis) BMI is a
measurement that indicates body composition. The degree of overweight or obesity as well as
the degree of underweight can be determined by making use of BMI.(Estes, Third edition,
Copyright 2006)
Standard Body Mass Index for Adults (Estes, Third edition, Copyright 2006)
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater
Analysis: Based on the standards, her nutritional status was beyond the normal range and
she was underweight.
J. Elimination Status
She usually voids 3 – 4 times per day depending on the amount of fluid he ingests, and
his urine colour was yellow. She also stated that she usually defecates once a day; and described
her stool is brown in colour, and solid - formed.
Norms: Normal bowel movement is usually 1 – 2 times per day. It should be solid -
formed and brown in colour. Normal urine output of an adult is usually 1200-1500mL per day,
and voids 3 – 4 times a day. (Kozier Seventh edition, Copyright 2004)
Mrs. V stated that she only sleeps at 9:00 PM and wakes up at 4:00 AM. at home. She
usually sleeps 6-7 hours at night but during her hospital, confinement she has a disturbed
sleeping pattern due to her post - op condition with pain and minimal movement. So she takes
nap during the afternoon.
Norms: A normal sleep hour of an adult per day is 6-8 hours without disturbance.(Kozier,
Seventh edition, Copyright 2004)
L. Reproductive Status
The patient had her menarche at the age of 14. Her cycle usually lasts for 5 days. She
experienced headaches and pain on the pelvic area during her cycle. She became sexually active
at the age of 19. She had menopaused at the age of 45.
Norms: “Menarche, which is the first menstruation occur at an average age of
onset between 9 to 17 years old.” (Maternal and Child Health Nursing 4th Edition by Pilliterri)
Mrs. V has a normal complexion. She had undergone a capillary refill test resulting 3
seconds capillary refill. Her extremities was warmth. Her hair was black with some white hairs.
She had an incision site at the Right breast with dry wound dressing.
Norms: Skin varies from light to brown from ruddy pink to light pink. Generally, the skin
has uniform color except in areas exposed to the sun, in areas of lighter pigmentation in palms,
nail beds, and lips. The hair should be evenly distributed, thick, shiny and free from infestation.
Capillary refill must be within 2 – 3 seconds and should return immediately. (Kozier, Seventh
edition, Copyright 2004)
Analysis: Revealed abnormal findings based on the standards given due to her operation at
her right breast
V. DIAGNOSTIC AND LABORATORY PROCEDURES
Normal
MCHC 323 g/L
MCHC 310-360
g/L
Normal
PLT 140-940 PLT 264 g/L
g/L
NURSING RESPONSIBILITIES:
NURSING RESPONSIBILITIES:
Diagnostic/ Date Ordered and Indication/s or Normal Values Result/s Analysis and
Laboratory Date Resulted purposes (units used in the interpretation of
procedures hospital) Results
Urinalysis September 17, 2010 For detection of any Appearance: straw Turbid Not normal
bacteria in the urine,
glucose, albumin, Reaction: alkaline Alkaline Normal
blood, protein Specific gravity
presence of
infection. 1.010-1.030 1.010 Normal
NURSING RESPONSIBILITIES:
NURSING RESPONSIBILITIES:
MUCINOUS
CARCINOMA
Incisional biopsy often Not normal
yield better diagnosis for Gross: The specimen
Incisional Biopsy September 23, 2010 deep pannicular skin consists of two dark
diseases and more brown, irregular and soft
subcutanous tissue can tissue measuring 1.0x1.-
be obtained. Advantage x0.3 cm in aggregate
of the incisional biopsy dimension.
is that hemostasis can be
done more easily due to Micro: Microscopic
better visualization. sections reveal malignant
glands floating in pools of
mucin. Also noted are
scattered neoplastic cells
in a desmplastic stroma.
NURSING RESPONSIBILITIES:
The breasts are composed of fatty tissue that contains the glands responsible for milk
production in late pregnancy and after childbirth. Within each breast, there are about 15 to 25
lobes formed by groups of lobules, the milk glands. Each lobule is composed of grape-like
clusters of acini (also called alveoli), the hollow sacs that make and hold breast milk. The
lobules are arranged around ducts that funnel milk to the nipples. About 15 to 20 ducts come
together near the areola (dark, circular area around the nipple) to form ampullae - cavities
that store the milk before it reaches the nipple surface. Montgomery's glands are small oil
glands that are located around each areola. They release a lubricant that protects the nipples
during nursing.
Breast Size and Shape
The breasts are not always exactly the same size or shape. They are incompletely
developed at birth and - in men - remain small and undeveloped unless subjected to abnormal
hormonal stimulation. In general, breast formation is complete within a year or two after the
start of menstruation; however, the acini keep growing, and fibrous and fatty tissues are
continually added during adolescence. Pregnancy and nursing cause further increases in
breast size. As a woman ages, the fatty tissue of the breasts may become more prominent
than the glandular tissue, and the breasts may feel softer. The breasts gradually atrophy
Breast Position
The breasts cover a large part of the chest wall. In front, the breast tissue may extend
from the clavicle (collarbone) to the middle of the sternum (breastbone). On the side, breast
tissue may continue into the axilla (armpit) and reach as far as the latissimus dorsi (muscle
extending from the lower back to the humerus bone of the upper arm).
In fact, the anatomic relationship between the breasts and the underlying muscle is a very
important consideration in surgical therapy. The breasts overlay vital chest wall muscles such as
the pectoralis major (the 'pecs'), the pectoralis minor (thin, triangular muscle beneath the pecs),
and the intercostals (muscles between the ribs). The breasts also may cover some of the serratus
magnus (also called the serratus anterior; a slender muscle that is attached to the ribs/ rib muscles
and connects with the shoulder blade) and the rectus abdominis (long, flat muscle that stretches
Lymphatic System
Lymph is a clear, tan fluid that contains lymphocytes (white blood cells that fight
disease). Lymph is drained from the breast tissues by a rich supply of vessels. Such lymphatic
vessels connect with a network of lymph nodes that are located around the breasts' edges or in
nearby tissues of the armpits and collarbone. Lymph nodes play a central role in the spread of
breast cancer. The axillary (underarm) lymph nodes are particularly important, as they are among
the first places that cancer is likely to be found if it metastasizes (spreads) from the breast. This
lymph node cluster is often referred to as the 'tail,' or level I nodes. Level II nodes are located
underneath the pectoralis minor muscle, and level III nodes are found near the center of the
collarbone.
VII. PATHOPHYSIOLOGY
Damage to the genes of Tumor Supressor Cells Continuous duplication of mutated DNA
Repair or elimination of cells with damaged DNA is inhibited
If not treated:
Malignant conversion: accumulation of cells in the center of Tumor necrotized and begins to chip of malignant cells to
seek new blood
Cells break out of the tumor and invades to surrounding lumph nodes
Expected
Assessment Planning Intervention Rationale
Outcome
S> “Nahihirapan akong > Within 3º of Render sponge bath to To maintain > After 3º of
matulog ng maayos kasi rendering appropriate provide better freshness. rendering
maingay dito” nursing intervention, circulation. appropriate nsg.
the pt. will able to Intervention, the
sleep and feel Change loosens
clothing. To provide pt. is able to sleep
O> frequent yawning comfortable. comfort and feel
noted. comfortable.
S>O Within 4 hours of Stress the importance To reduce the risk After 4 hours of
rendering proper of proper hand of contributory rendering proper
O> nursing interventions, washing technique factors nursing
Complaint of pain the patient will relieve intervention, the
on incision site from signs and Maintain adequate To prevent patient will relieve
Restlessness noted symptoms of infection hydration , increase dehydration and from signs and
Malaise fluid intake maintain symptoms of
Swelling and hydration status infection as
redness noted at evidenced by
the site Instruct SO in To have more temperature
techniques to prevent information SO decreases from
skin integrity and needs 37.8 C to 37.
Nursing Diagnosis: prevent spread of
infection
Risk for infection r/t
inadequate primary Encourage intake of To promote faster
defense 2◦ surgical vitamin C rich foods , wound healing
procedure (Modified CHON and protein and increase
radical mastectomy) resistance to
infection
Encourage patient
Scientific Explanation: observe proper To decrease the
hygiene risk of acquiring
An infection is the infection
detrimental colonization
of a host organism by a
foreign species. In an Provide skin care Peripheral
gently massage bony circulation may
infection, the infecting
area. Keep the skin be impaired
organism seeks to utilize dry , linens dry and placing patient at
the host's resources to wrinkle free risk for skin
multiply (usually at the irritation
expense of the host).
Administer antibiotics To reduce risk of
as prescribed spread of
infection
IX. Medical Management/Treatment
Date ordered /
Date
Medical Client’s
performed / General Indication/s or
Management / reaction to
Date changed / Description Purpose/s
Treatment treatment
Date
discontinued
NURSING RESPONSIBILITIES:
Generic Name: Ordered: Intravenous, Possess anti- > Indicated > Consider > Administer > Monitor
Oral inflammatory for the relief the rights in as part of a patient’s
Ketorolac 09/26/10 analgesic and of the s/s of drug regular intake and
antipyretic RA and administration analgesic output to
effects. They osteoarthritis schedule check for GI
Brand Name: are largely > Inform the rather that on disturbance
related to > For relief of patient about as needed
Toradol mild to the > Instructed
inhibition of basis
prostaglandin moderate pain medication patient to
synthesis. > Check for increase fiber
Dosage & > For > Administer
Classification: any unusual intake such
treatment of with food and bruising as pineapple
Frequency
Non-Steroidal primary mild if GI and/or
Anti- dysmenorrheal upset occurs bleeding > Record the
Inflammatory medication
30 mg 2 cap > For fever
Drug given.
P.O. T.I.D. reduction
Client’s
Date Ordered,
General Specific Foods Response and/or
Type of Diet date Started,
Description Taken Reaction to the
Date Changed
Diet
Full Liquid Date ordered: Full liquid diet 1 cup noodle She was glad that
Diet allows only foods soup or “Broth” finally she could
September 23, in liquid form or only, tea eat foods.
2010 those which readily
become liquid at
body temperature.
Soft Diet Date ordered: A diet that allows Lugaw She was glad that
fruits and finally she could
September 24, vegetables with eat foods.
2010 low-cellulose
content as well as
fish and meat with
no or very little
connective tissues.
NURSING RESPONSIBILITIES:
Before, during and after the administration of the diet:
NURSING RESPONSIBILITIES:
1. Educate the patient about the importance of ambulation and bed rest, and the appropriate
way of doing the exercise.
2. Assisted the patient in ambulation
X. SURGICAL MANAGEMENT
Client’s
Name of Date Brief
Indication/s or Purpose/s response to the
procedure performed Description
operation
NURSING RESPONSIBILITY:
SUBJECTI
DATE OBJECTIVES ASSESSMENT PLANNING INTERVENTION EVALUATION
VE CUE/S
CUE/S
September S>O O> Risk for Within 4 hours Stress the importance of After 4 hours
22, 2010 Complai infection r/t of rendering proper hand washing of rendering
nt of inadequate proper nursing technique proper nursing
pain on primary defense Maintain adequate
interventions, the intervention,
incision 2◦ surgical hydration , increase
procedure patient will the patient
site fluid intake
(Modified relieve from was relieved
Restless Instruct SO in
ness radical signs and techniques to prevent from signs and
noted mastectomy) symptoms of skin integrity and symptoms of
Malaise infection. prevent spread of infection.
Swelling infection
and Encourage patient
redness observe proper hygiene
noted at Provide skin care gently
the site massage bony area.
Keep the skin dry, linens
dry and wrinkle free
Administer antibiotics
as prescribed
DISCHARGE PLANNING
It was September 30, 2010 when the patient was discharge. She was able to do her
ADL such us dressing and going to the bathroom without any assistance.
The doctor ordered the patient for OPD fallow-up. And was also advice to have a
complete bed rest and continue Diet as Tolerated with Low Salt, Low Fat Diet.
ii. METHOD
T - Upon the day of discharge, she was advised to clean and change the
dressing of the incision site daily.
H-
Encouraged taking prescribed drugs for maintenance and early
recovery.
Instructed to report any adverse reaction of medicines
immediately.
Educated the patient to avoid activities or habits that can
precipitate fatigue/ eating large meals, drinking coffee, smoking,
exercising too extraneously.
Explained the importance of balance diet.
Encouraged brief rest period throughout the working day.
Advised patient who are anxious and nervous to consider
counselling, to the relaxation techniques may also be used.
O- Follow-up check-up on October 07, 2010 at the Out-Patient –
Department of Tarlac Provincial Hospital.
D- Diet as Tolerated
XIII. CONCLUSION
The therapeutic management for this problem the patient is placed on bed rest either in
the hospital or at home and administers medications as prescribed. All objectives were
constructed for our patient’s benefit in able for the group to have prioritized nursing action. The
group constructed and considered all the objectives that we gathered from our patient. For our
objectives, the group had evaluated it as good and successful actions because the goals were
achieved and all appropriate nursing interventions are rendered to our patient.
XIV. RECOMMENDATION
The group recommended that after the operation, the patient should be aware for the
problems that may occur in her incision site, especially for the risk of infection. The groups
also recommend that the pt. must continue her medication as prescribed by the doctor that will
help for her faster recovery. The pt. was advice to avoid her past lifestyle for the mean time,
which may cause arising of problem in her situation. The cleaning of her incision site and
changing the dressing daily was recommended to the patient. On her discharge, the pt. was
recommended to have a follow-up check up, to know if the treatment is effective, if there are
changes during her recovery and to know if there is a progress and an improvement of the
patient’s condition.
XV. BIBLIOGRAPHY