General Santos Doctors’ Medical School Foundation, Inc.

Bulaong, West, General Santos City, Philippines

Tel. Nos. (083)552 7877; 302 3507 Telefax No. (083)552 9793

NCM 101 HEALTH ASSESSMENT LECTURE

Name: ________________________________________ Year/Section: ____________
Professor: Dr. Clyde Cyril L. Baculio, RN Score: _________________

Case Study No. 1

Assessment of the Breast and Lymphatic System

Situation: You are caring for a 37-year-old married and multiparous woman diagnosed with right breast
cancer a few months ago. She was advised to undergo mastectomy of the right breast anytime soon and
start chemotherapy. Prior to her consultation, she explained that a self-exam revealed a lump, and after
mammography and biopsy, this surgery was the next step in cancer treatment. She was very anxious and
worried that her husband will neglect her. She verbalized, “I cannot continue with life anymore, I am so
worried, tired, and hopeless.”

Maria, the patient after series of consultation with her husband and family decided for mastectomy of the
right breast. The surgical procedure was scheduled immediately. After procedure in the Operating Room;
screening and assessment of the patient was performed by Nurse John and Nadine and find Maria awake,
alert and oriented to date, place, person and situation. The Operating Room and Post Anesthesia Care Unit
staff gave her ice due to dry mouth which she self-administers and tolerates well. She has an IV in her right
hand. She states her pain is 2 on a scale of 1-10 with 10 being the highest. Her husband asks when the
patient can eat and about visiting hours of the hospital. Maria also asks about a bedside commode for
urination and asked the nurse where she can defecate.

Other assessment findings for Maria include:

Post operative incision at right breast,
Plain Lactated Ringers 125 mL/hr IV infusion, continuous x 3 liters
Naloxone 0.4-2 mg IV/IM/SC; may repeat q2-3min PRN respiratory rate less than
6 bpm; not to exceed 10 mg
BP 120/80 SpO2 98% on Room Air, HR 68bpm and regular
RR 14 bpm, Temp 36.°5C

Tasks:
1. Identify one priority nursing problem. Explain and justify. (portrait, handwritten)
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong, West, General Santos City, Philippines
Tel. Nos. (083)552 7877; 302 3507 Telefax No. (083)552 9793

2. Create a comprehensive Nursing Care Plan for Maria (landscape, handwritten)

Assessment Nursing Plan Interventions Evaluation
Diagnosis (Goals and
Objectives)