TABLE OF CONTENTS

S.N Contents Page No.

1. Background 1
2. Reason for selection of case study 2
3. Objectives 3
4. History taking 4-6
5. Family Tree 7
6. Physical Examination 8-13
7. Developmental Task 14
8. Disease Profile 15-34
8.1 Anatomy of Breast 15-17
8.2 Introduction of Breast Cancer 18-19
8.3 Stages of Breast Cancer 19-20
8.4 Types of Breast Cancer 20-21
8.5 Risk factors 21
8.6 Causes (According to book and patient) 22
8.7 Pathophysiology 22
8.8 Sign and symptoms(According to book and patient) 23
8.9 Diagnosis (According to book and patient) 23
8.10 Investigations 24-27
8.11 Management (According to book and patient) 27-29
8.12 Medical management 27
8.13 Surgical management 28
8.14 Nursing management 28-29
8.15 Drugs 29-33
8.16 Complication 33
9. Prognosis 33
10. Application of Nursing theory 34-36
11. Nursing Diagnosis 36
12. Nursing Care Plan 37-41
13. Daily Progress Reports 42-43
14. Diversional Therapy 44
15. Health teaching 45
16. Discharge teaching 46
17. Lesson learnt 47
18. Summary 48
19. Conclusion 49
20. Reference 50

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 BACKGROUND
Breast cancer is a disease characterized by the growth of malignant cells in the mammary
glands. Breast cancer arises in the lining cells (epithelium) of the ducts (85%) or lobules
(15%) in the glandular tissue of the breast. Initially, the cancerous growth is confined to the
duct or lobule (“in situ”) where it generally causes no symptoms and has minimal potential
for spread (metastasis).

Over time, these in situ (stage 0) cancers may progress and invade the surrounding breast
tissue (invasive breast cancer) then spread to the nearby lymph nodes (regional metastasis) or
to other organs in the body (distant metastasis). If a woman dies from breast cancer, it is
because of widespread metastasis.

Breast cancer treatment can be highly effective, especially when the disease is identified
early. Treatment of breast cancer often consists of a combination of surgical removal,
radiation therapy and medication (hormonal therapy, chemotherapy and/or targeted biological
therapy) to treat the microscopic cancer that has spread from the breast tumor through the
blood. Such treatment, which can prevent cancer growth and spread, thereby saves lives.

Breast cancer became the most common cancer globally as of 2021, accounting for 12% of
all new annual cancer cases worldwide, according to the World Health Organization.

In 2020, there were 2.3 million women diagnosed with breast cancer and 685,000 deaths
globally. As of the end of 2020, there were 7.8 million women alive who were diagnosed
with breast cancer in the past 5 years, making it the world’s most prevalent cancer.

In women under 45, breast cancer is more common in Black women than white women.
Overall, Black women are more likely to die of breast cancer. For Asian, Hispanic, and
Native-American women, the risk of developing and dying from breast cancer is lower.
Ashkenazi Jewish women have a higher risk of breast cancer because of a higher rate of
BRCA mutations.

-Breastcancer.org.

In this case study I have included the detail patient’s history consisting patient’s demographic
data, chief complaints, history of present illness, history of past illness, personal history,
dietary history, family history and developmental history. I have included the physical
examination of the patient which helped me to find out any abnormalities other than the
disease condition. Apart from this, my case study also includes the laboratory findings, drugs
used for the treatment.

In order to prevent further complication, I have to provide competent nursing care to the
patient according to his need. I also apply the nursing process in providing nursing care
respecting the patient’s physical and psychological aspect regarding her socio-economic
background, cultural aspect, his support system in order to promote health after recovery, to
cure the disease and rehabilitate the patient. Thus, I have tried to apply my best knowledge
and skills in developing positive attitude in the holistic care of the patient and family.

1
 REASON FOR SELECTION OF CASE STUDY

According to the curriculum of the Purbanchal University, on the course of BSc. Nursing 4 th
Year, we have got 2 weeks of Advanced Nursing clinical practicum in Bhaktapur Cancer
Hospital. During this period, I selected the case of “Breast Cancer” in Surgical ward.

I have selected the case of Breast Cancer because it is the most common cancer among
females worldwide and the second most common in Nepal, after cervical cancer. About 1 in
every 10 female cancers in the country is breast cancer, and that proportion is increasing.
Cancer is the second leading cause of death and is a common case in different wards of
Bhaktapur Cancer Hospital that also prompted me to select it as my case study.
Similarly, I selected this case so that I could broaden my knowledge about breast cancer
regarding its etiology, pathophysiology, complication, medical, surgical nursing management
as well as to provide a holistic care to the patient and apply my skills as well as nursing
theories in the betterment of the case.

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 OBJECTIVES
General Objective:
The general objective of case study is to gain comprehensive knowledge on Breast Cancer.

Specific Objectives:
1. To identify the physical and psychological problems of the client.
2. To provide holistic nursing care to the patient with physical and psychological
problem with application of nursing process.
3. To demonstrate skills which provide comfort and recovery of the patient.
4. To help patient and family in promotion of health with available resources.
5. To observe the impact of illness on the patients and family and their socio-
cultural influence.
6. To identify developmental task according to the age of the patient and compare
with what of natural age group.
7. To provide health teaching according to the need of the patient.
8. To upgrade knowledge about the disease, its diagnosis, treatment and
management including nursing management.
9. To develop interpersonal relationship with the patient and visitors.
10. To compare the causes, clinical features, diagnostic investigation and treatment
of breast cancer between the patient and book.
11. To identify the causes, pathophysiology, clinical features and diagnostic
investigation of breast cancer.
12. To know about the different therapies used to treat the cancer.
13. To know different types of chemo therapy used in hospitals.
14. To obtain detail history and perform physical examination of my patient.
15. To prevent the patient from further complication of diseases.
16. To minimize the stress of the patient and her family by using appropriate
diversional therapy.
17. To involve the patient, her family members and health team workers in discharge
planning and follow up.
18. To precede information and knowledge about breast cancer through case
presentation.

3
 HISTORY TAKING

Demographic Data

Name : Til Kumari Shrestha

Age/Sex : 51 years/Female

Religion : Hinduism

Address : Nepalgunj 5- Banke

Education : Illiterate

Occupation : House wife

Marital status : Married

Date of Admission : 2079/01/18

Inpatient no. : 79000387

Ward : Surgical ward

Bed no. : 218

Diagnoisis : CA Lt. Breast (Mammary Paget’s Disease)

Consultant : Dr. Utsab Man Shrestha

Chief Complain

 Burning sensation in left breast

 Itching in left breast
 Redness around nipple
 Light scaling and flaking of skin on nipple

History Of Present Illness

Patient had redness, light scaling and flaking of skin on nipple area. According to the patient
it was due to friction with clothes. She noticed this 2 years ago and went to nearby medical
for checkup and did normal dressing. It didn,t get cured for long time and patient decided to
go to Dermatologist. So, she went to DI Skin Health and Referral Centre and was suggested

4
to do biopsy on which she was diagnosed with Paget’s disease with underlying ductal
carcinoma insitu. She was then referred to Bhaktapur Cancer Hospital. She visited on
2079/01/09 and consulted Dr. Utsab Man Shrestha. She underwent different diagnostic
investigation such as Mammography and CT scan of Chest and Abdomen.

She was unknown about her condition but her family knows. She was planned to do surgery
on 2079/01/19 but due to her high blood sugar level it got postponed to 2079/01/21. She was
informed about her disease condition before surgery due to which she had high blood
pressure so, it got postponed as well.

History Of Past Illness

 Medical History: No any medical history.
 Surgical History: Cesarean Section during delivery
Personal History

a. NUTRITION: - Dieting habit before illness was normal as two regular

meal and snacks on afternoon.
b. SLEEPING HABIT: - She used to sleep 7-8 hrs. at night.
c. BOWEL & BLADDER HABIT: - Her bowel and bladder habit is normal.
d. DRINKING & SMOKING HABIT: - Never smoke and but drinks
ocassionally.
e. ALLERGIES: - She has no allergy of food, drugs, environment & other
things.

Menstrual History

a) She has menarche at the age of 13.

b) She usually experiences oligomenorrhea.
c) Amount of blood flow: normal

Environmental History
 Number of room
 Latrine
 Ventilation
 Type of fuel used in cooking
 Source of drinking water
 Method of Water Purication
: 4 with separate kitchen
: Water seal
: Well ventilated
: LP Gas
: Tap water
: Filtration, Boiling

Health Beliefs And Practices

 She believes that health and illness of a human being are due to their food
habits and lifestyle.

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  She takes medicine as per doctors ordered and also she believes in traditional
healers like “dhami and jhakri”.

Socio- Cultural Background

 She has good interaction with society and participates in social activities. She
is co-operative and gentle.
 She believes in God and worships God according to Hindu culture.

Psychological History

 She is an extroverted type of person.

 She was unknown about her disease condition but after knowing all of a sudden
she was anxious and sad.

Family History

a. She lives in joint family.

b. She has 4 members in her family and head of her family is herself.
c. Her spouse died 1 month ago.
d. She belongs to Hindu family.
e. She has good relationships with her family and peer groups.
f. Has good socioeconomic status.
g. Her family’s source of income is her son and daughter-in-law.
h. No family history of Cancer.

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Family Tree

7
 Physical Examination

Vital Signs
 Blood pressure: 110/70 mm of Hg
 Pulse: 92/min
 Respiration: 20min
 Temperature: 98ºF
 SPO2: 98% in RA

General Measurement
 Height: 5 feet 1 inch
 Weight: 69 kg
 BMI: 29.5 kg/m2

1. General appearance:
 Gait: Patient gait is normal
 Alertness and consciousness: Patient was alert and conscious
 Drowsiness: Absent
 Irritability: Patient was irritated.
 Skin color: Skin color was brown.
 Hygiene: Hygiene was well maintained.
 Nutritional status: Patient seems to be well nourished.
2. Systematic examination :
a. Skin
Inspection:
 The skin color of the patient is uniform all over the body.
 No pallor, cyanosis, redness or yellowness present.
 Absence of edema.
Palpation:
 Patient has warm skin and even temperature.
 Patient has rough skin

b. Lymph node:
Inspection:
 Absence of enlargement of lymph node.
Palpation:
 Lymph nodes were not palpable at any reason

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  No tenderness present in the lymph nodes

c. Head :
Inspection:
 Presence of dandruff on the head.
 Evenly distributed hair.
 Absence of lumps or other lesions.
 Uniform movement on the face.
Palpation:
 No any swelling or tenderness present.
d. Sinuses :
Inspection:
 Absence of redness in the frontal and maxillary sinuses.
Palpation:
 Absence of tenderness in the frontal and maxillary sinuses.
e. Eyes :
Inspection:
 Equal distribution of eyebrows in both eyes.
 No sign of infection present in the eyes.
 Both eyes are symmetrical.
 There is no swelling, redness and lesions on eye lid.
 There is no bulging of eye and no discharge present.
 Sclera was whitish with few blood vessels.
 Conjunctiva was normal in color.
 Patient cornea was transparent and pupils were normal and round.
 Pupil constricted when torch approached the eye and pupil dilated
when removed.
 There was normal parallel movement of eye in each direction.
 No any color vision present.
Palpation:
 Absence of tenderness in the area of eyes.
f. Ears :
Inspection:
 Outer canthus of the eye cross the tip of pinna.
 There was no lumps and lesion.
 Cerumen was present.
Palpation:
 There was no tenderness present on pinna.
 There was absence of tenderness on mastoid bone.

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 Weber test:
 Patient heard sound normally and equally in both ears.

Rinne test:
 Patient heart sound longer through air conduction than through bone
conduction i.e.
 Air conduction = 12 seconds
 Bone conduction = 7 seconds
g. Nose
Inspection

 Patient’s nose is centrally located.

 No any polyp and deviation.

h. Mouth and throat

Inspection

 Lips were dry and cracked lips.

 No any inflammation and bleeding present in gums.
 Tongue was symmetrical.
 No any tenderness and inflammation present on palate.
 Uvula was centrally located.
 Absence of enlarged tonsils.
Palpation

 No swelling and tenderness was present in gums.

 No any loose tooth present.
 Absence of foul odor.

i. Neck
Inspection

 Absence of tilting of neck.

 Absence of masses and scars of neck.
 Patient’s thyroid gland was not visible and enlarged.
 Patient’s neck motion was smooth.
 Absence of swelling and lump at back.
Palpation

 No tightness of neck muscles.

 Absence of tenderness along spine.
 Absence of tenderness bilaterally on neck.

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j. Chest and lungs
Inspection

 Patient’s chest was symmetrical.

 Sternum is located in midline.
 There was even expansion of chest during breathing.
Palpation

 There was no tenderness and lumps along the ribs.

 There was even expansion of chest on both sides.

Percussion

 Patient had deep resonant sound over lungs

Auscultation

 Bronchial sound when heard; expiration was greater than inspiration. It was
high pitched.
 Broncho vesicular sound when heard; expiration was equal to inspiration. It
was moderate.
 Vesicular sound when heard; inspiration was greater than expiration. The
sound heard is soft.

k. Heart
Inspection

 No enlargement of jugular vein.

 No clubbing of fingers and cyanosis present.
 Auscultation
 Clear and fast lub dub sound was present.
 Apical heart beat was 100 beats/ minute.
l. Breast
Inspection

 Veins were visible.

 Breast looks asymmetrical.
 Absence of nipples.
 Redness around nipple area.
Palpation

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  resence of tenderness in breast.
 Presence of lumps in lt. Breast.
 Absence of any abnormal discharge from the nipple.

m. Abdomen
Inspection

 Dome shaped abdomen.

 Absence of any scar, incision and lesions.
 Absence of abdominal distension.
 Patient had good bowel habit as verbalized by her.
Auscultation

 Gargling sound was heard during auscultation.

Percussion
 Dull sound was heard on upper quadrants and tympanic sound was heard
on lower quadrants.
Palpation

 During palpation mild tenderness was present.

 Liver, spleen and kidneys were not palpable.

n. Female Genitals:
 No any abnormalities and no unusual discharge from the vagina.
o. Emotional Status
 Patient was anxious about the disease condition.
 Patient had good interaction with family members

p. Musculoskeletal System
Inspection

 Absence of bone or joint deformity, redness, swelling of joints.

 Patient is able to move joints.
 Correct number of fingers and toes
Palpation

 Absence of joint swelling and tenderness.

 Presence of normal temperature over a joint.

q. Reflexes
 Knee reflex: Presence of extension of knee.

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  Plantar reflex: Patient’s foot moved inward when external stimuli given.
 Triceps reflex: Extension of triceps was present.
 Bicep reflex: Flexion of bicep was present.

r. Neurological Examination

Cranial Nerves

 The cranial nerves were intact.

Glasgow Coma Scale
Glasgow coma score was 15/15.
Sensory Nerves
 Patient has intact smelling, hearing, vision, sensation and touch.
Muscle strength
 Patient has equal muscle strength on both hands and feet.

Abnormal Findings:

1. BMI: 29.5 kg/m2

2. Pt. looks confused and anxious.
3. Presence of dandruff.
4. Cerumen was present.
5. Lips were dry and cracked lips.
6. Breast looks asymmetrical.
7. Absence of nipples.
8. Redness around nipple area.
9. Presence of tenderness in breast.
10. Presence of lumps in lt. Breast.

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 DEVELOPMENTAL TASK
As my patient is of age 51 years, she falls under age group middle adulthood. Middle
adulthood starts at the age 45-65 of years. This is a period of physiological changes. Robert
Havighurst lists major developmental task of later maturity as follows:

Comparison of developmental task according to book and in my patient:

According To Book According To My Patient

1. Accepting and adjusting to She accepts the physiological changes of

physiological changes. middle age such as wrinkling of the skin.

2. Reaching and maintaining satisfaction She was satisfied being a house wife before her
in one’s occupation. illness but now she is not involved in any
activities due to her disease condition.

3. Adjusting to and possibly caring for
aging parents.
4. Helping teenage children to become
responsible adults.
She use to help, take care and supports her
elder parents before they died.
She helped her children, guide, support and
motivate them in daily activities. She also help
them to take decision before her illness. And
still she helps them in some activities of their
life.

5. Achieving adult social and civic
responsibility.
6. Relating to one’s spouse as a person
She participated in activities for social
development.
She relates her husband by supporting and
takes a important role in life but recently one
month ago her husband died.

7. Developing leisure – time activities During her leisure time she spends her time by
talking with other people and watching T.V.

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 DISEASE PROFILE
Anatomy And Physiology Of Breast
 The breasts are the most prominent superficial structures in the anterior thoracic wall
consisting of glandular tissue and a supporting fibrous and fatty matrix.
 This glandular tissue, or mammary glands, are found in the subcutaneous
tissue overlying the pectoralis major and minor muscles.
 The amount of fat surrounding this glandular tissue will determine the size of the
breasts.
 Breasts have a circular body and a nipple in the center, surrounded by a pigmented
area of skin called the areola.
 Each breast has the following boundaries:
 transversally from the lateral border of the sternum to the midaxillary line and
vertically from the second through the sixth ribs.
 Two thirds of the underlying tissue of the breast is formed by the pectoral
fascia covering the pectoralis major and the other third is formed by the fascia that
covers the serratus anterior muscle.
 A small part of the breast might extend along the inferolateral edge of the pectoralis
major, going towards the axillary fossa or the armpit. Here it forms an axillary
process or tail, called the tail of Spence.
 The sagittal section of the female breast consists of fine space between the breast and
the pectoral fascia. This is called the retromammary space or bursa, which is a loose
subcutaneous tissue plane. This plane contains a small amount of fat which allows
the breast to move a bit on the pectoral fascia.
 Breasts contain the mammary glands responsible for lactation in females. Mammary
glands are made up of 12 to 20 lobes, each of them containing many smaller lobules.
 These smaller lobules have grape-like clusters of alveoli that
contain mammary secretory epithelial cells, the milk producing cells of lactation.
 These alveoli, lobules and lobes are connected through a network of ducts called the
lactiferous ducts, and eventually form a unique lactiferous duct for each lobe which
opens independently to the areola to drain the milk produced during lactation.
 Each lactiferous duct has a dilated portion deep to the areola called the lactiferous
sinus in which there’s a small drop of milk that accumulates or remains in a nursing
mother, which becomes expelled from the areola when compressed during feeding.
 Next, the stroma of the breast is composed of adipose tissue and fibrous connective
tissue.
 In a non-lactating state, the adipose tissue is situated between the lobes and makes up
most of the breast volume.
 The fibrous connective tissue of the stroma goes on to form fibrous condensations,
called the suspensory ligaments of Cooper, which firmly attach the mammary glands
to the dermis of the overlying skin.
 These fibrous connective tissue attachments help support the lobes and lobules of the
mammary glands.

15
 The areola surround the nipples, which are typically located around the
4th intercostal space lateral to the mid clavicular line; but this varies depending on
the size of the breast.
 Each areola contains a large number of sebaceous glands, which get bigger during
pregnancy and secrete an oily substance that acts as a lubricant for the areola and
nipple.
 The nipples are conical or cylindrical prominences in the centers of the areola.
 Keep in mind that nipples have no fat, hair, or sweat glands.
 The lactiferous ducts open into the tips of the nipples.

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 A Lateral view of lactating breast. B Lobule of a mammary gland.
Blood Supply & Lymph Nodes
The blood supply from the breast comes primarily from the internal mammary artery, which
runs underneath the main breast tissue. The blood supply provides nutrients, such as oxygen,
to the breast tissue. The lymphatic vessels of the breast flow in the opposite direction of the
blood supply and drain into lymph nodes. It is through these lymphatic vessels that breast
cancers metastasize or spread to lymph nodes. Most lymphatic vessels flow to the axillary
(underarm) lymph nodes, while a smaller number of lymphatic vessels flow to internal
mammary lymph nodes located deep to the breast. Knowledge of this lymphatic drainage is
important, because when a breast cancer metastasizes, it usually involves the first lymph
node in the chain of lymph nodes. This is called the "sentinel lymph node,” and a surgeon
may remove this lymph node to check for metastases in a patient with breast cancer.
Many additional changes are seen in the breast tissue during pregnancy and lactation due to
the changes in hormones during those times.

17
 BREAST CANCER

Introduction
Breast cancer is a disease in which cells in the breast grow out of control. There are different
kinds of breast cancer. The kind of breast cancer depends on which cells in the breast turn
into cancer.
Breast cancer arises in the lining cells (epithelium) of the ducts (85%) or lobules (15%) in
the glandular tissue of the breast. Initially, the cancerous growth is confined to the duct or
lobule (“in situ”) where it generally causes no symptoms and has minimal potential for
spread (metastasis).
Over time, these in situ (stage 0) cancers may progress and invade the surrounding breast
tissue (invasive breast cancer) then spread to the nearby lymph nodes (regional metastasis)
or to other organs in the body (distant metastasis). If a woman dies from breast cancer, it is
because of widespread metastasis.
Breast cancer treatment can be highly effective, especially when the disease is identified
early. Treatment of breast cancer often consists of a combination of surgical removal,
radiation therapy and medication (hormonal therapy, chemotherapy and/or targeted
biological therapy) to treat the microscopic cancer that has spread from the breast tumor
through the blood. Such treatment, which can prevent cancer growth and spread, thereby
saves lives.
Breast cancer can begin in different parts of the breast. A breast is made up of three main
parts: lobules, ducts, and connective tissue. The lobules are the glands that produce milk.
The ducts are tubes that carry milk to the nipple. The connective tissue (which consists of
fibrous and fatty tissue) surrounds and holds everything together. Most breast cancers begin
in the ducts or lobules.
Breast cancer can spread outside the breast through blood vessels and lymph vessels. When
breast cancer spreads to other parts of the body, it is said to have metastasized.
Epidemiology
Breast cancer became the most common cancer globally as of 2021, accounting for 12% of
all new annual cancer cases worldwide, according to the World Health Organization.
In 2020, there were 2.3 million women diagnosed with breast cancer and 685 000 deaths
globally. As of the end of 2020, there were 7.8 million women alive who were diagnosed
with breast cancer in the past 5 years, making it the world’s most prevalent cancer.
In women under 45, breast cancer is more common in Black women than white women.
Overall, Black women are more likely to die of breast cancer. For Asian, Hispanic, and
Native-American women, the risk of developing and dying from breast cancer is lower.
Ashkenazi Jewish women have a higher risk of breast cancer because of a higher rate
of BRCA mutations.

18
 -Breastcancer.org.
In Nepal
In the Kathmandu Valley, the PBCR registered 2,156 new cancer cases with overall age-
adjusted incidence rate for all cancers of 95.7 per 100,000 population (95.3 for males and
98.1 for females). The age-adjusted mortality rate for males was 36.3 (n = 365) and for
females 27.0 (n = 305) per 100,000 population. We found that the commonest cancers in
males were lung and stomach, whereas in females, they were breast and lung cancer.
Gallbladder cancer was among the top five common cancers in both sex.
Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in
2020. The most common in 2020 (in terms of new cases of cancer) were:
1. Breast (2.26 Million Cases);
2. Lung (2.21 Million Cases);
3. Colon And Rectum (1.93 Million Cases);
4. Prostate (1.41 Million Cases);
5. Skin (Non-Melanoma) (1.20 Million Cases); And
6. Stomach (1.09 Million Cases).
The most common causes of cancer death in 2020 were:
1. Lung (1.80 Million Deaths);
2. Colon And Rectum (916 000 Deaths);
3. Liver (830 000 Deaths);
4. Stomach (769 000 Deaths); And
5. Breast (685 000 Deaths).

Stages Of Breast Cancer

1. Early stage, stage 0, or noninvasive breast cancer: The disease is only in the breast,
with no signs that it’s spread to the lymph nodes .
2. Stage I : The cancer is 2 centimeters or less in size and hasn't spread.
3. Stage II A : The tumor is:
 Smaller than 2 centimeters across, with underarm lymph node involvement.
 Larger than 2 but less than 5 centimeters across, without lymph node involvement.
4. Stage IIB : A tumor that is:
 Larger than 5 centimeters across, without underarm lymph node involvement
 Larger than 2 but less than 5 centimeters across, with lymph node involvement.
5. Stage IIIA or locally advanced breast cancer:
 A tumor larger than 5 centimeters that has spread to the lymph nodes under the arm
or near the breastbone.
 Any size tumor with cancerous lymph nodes that stick to one another or nearby
tissue.
6. Stage IIIB : A tumor of any size that has spread to the skin or chest wall.

19
 7. Stage IIIC : A tumor of any size that has spread farther and involves more lymph
nodes.
8. Stage IV (metastatic) : A tumor, regardless of size, that has spread to places far away
from the breast, such as bones, lungs, liver, brain, or distant lymph nodes.
In my Patient: Stage 0

Types Of Breast Cancer

Some of the most common types of breast cancer include:
1. In situ cancers : These types haven't spread past the duct or lobule where they
started.

 Ductal carcinoma in situ (DCIS): This is ductal carcinoma in its earliest stage
(stage 0). In this case, the disease is still in the milk ducts. But if you don’t treat this
type, it can become invasive. It’s often curable.
 Lobular carcinoma in situ (LCIS): This is found only in the lobules, which
produce breast milk. It isn't a true cancer, but it means you’re more likely to get
breast cancer later. If you have it, get regular breast exams and mammograms.

2. Invasive cancer : These have spread or invaded the surrounding breast tissue.

a. Invasive or infiltrating ductal carcinoma (IDC): This cancer starts in the milk
ducts. It breaks through the wall of the duct and invades the fatty tissue of the breast.
It’s the most common form, accounting for 80% of invasive cases.
b. Invasive lobular carcinoma (ILC): This cancer starts in the lobules but spreads to
surrounding tissues or other body parts. It accounts for about 10% of invasive breast
cancers. Subtypes of this invasive breast cancer include:
c. Adenoid cystic (or adenocystic) carcinoma: These are similar to cells found in
your salivary glands and saliva.
d. Low-grade adenosquamous carcinoma (a type of metaplastic carcinoma): This
rare tumor is usually slow-growing and often mistaken for other types.
e. Medullary carcinoma: The tumors in this rare type are a soft, squishy mass that
looks like part of your brain called the medulla.
f. Mucinous carcinoma: Tumors in this rare type float in a pool of mucin, part of the
slippery, slimy stuff that makes up mucus.
g. Papillary carcinoma: Fingerlike projections set these tumors apart. This rare type
usually affects women who’ve been through menopause.
h. Tubular carcinoma: The tumors are slow-growing and tube-shaped.

3. Less common types include:

a. Inflammatory breast cancer: This rare type is caused by inflammatory cells in
lymph vessels in your skin.

20
 b. Paget's disease of the nipple: This type affects the areola, the thin skin around your
nipple.
c. Phyllodes tumors of the breast: These rare tumors grow in a leaflike pattern. They
grow quickly but rarely spread outside the breast.
d. Metastatic breast cancer: This is cancer that has spread to another body part, like
your brain, bones, or lungs.
According to Patient
Paget's disease of the nipple with underlying ductal carcinoma insitu

Pagets disease with underlying ductal carcinoma insitu

Pagets disease of the breast is a rare type of cancer that forms in or around your nipple. It’s
involved in 1% to 4% of all breast cancers. It may be linked with an underlying breast cancer,
either ductal carcinoma in situ or invasive breast cancer.

Risk Factors

 Age: Chances go up as you get older. The average age at diagnosis is 57.
 Sex: Paget’s can affect men and women, but women are more likely to get it.
 Race: White women are more likely to get breast cancer than black or Hispanic
women, but black women are most likely to die from it.
 Alcohol: Drinking heavily makes it more likely.
 Dense breasts: This will show up on a scan called a mammogram.
 Extra weight: This is especially true after menopause or if you gained weight as an
adult.
 Family history: Your chances go up if your parents or siblings had breast cancer.
 Gene changes: You might hear them called mutations. BRCA1 and BRCA2 make
you more likely to get breast and ovarian cancers, but they lead to fewer than 1 out of
10 breast cancers.
 History of breast cancer: If you’ve had it in either breast, your chances are higher.
 History of unusual things in your breast (abnormalities): Having lobular
carcinoma in situ or atypical hyperplasia raises your odds.
 Hormone replacement: Taking estrogen after menopause makes cancer more likely.
 Radiation: If you got radiation to your chest as a child or young adult, you’re more
likely to get breast cancer

21
Causes

According to book According to patient

-Exact cause is unknown - Unknown
-Increasing age - She is 51 years old.
-Sex : female - Present
-Family history of breast cancer -Absent
-Radiation exposure - Menarche at the age of 14 years
-Beginning period at a younger age - Present
-Obesity - Absent
Pathophysiology

Predisposing factors

(Age, Gender, Genetics, Alcoholism, Fat intake, radiation exposure)

Neoplasm formation in the breast

Primary tumor begins in the breast

Tumor becomes invasive

Travel (metastasize ) to Progressed beyond breast

other organ in the systems to regional lymph nodes

It becomes systemic

Signs And Symptoms

22
 SN According to book According to patient
1. Tingling sensation Present
2. Itching Present
3. More sensitivity Present
4. Burning Present
5. Pain Present
6. Bloody or yellowish discharge from Yellowish discharge present
your nipple
7. Oozing or bleeding areas Absent
8. A nipple that looks flattened against Present
your breast
9. Thickened skin in the nipple area Present
10. Skin irritation and dimpling Present
3
11. Constant pain in part of breast Burning sensation and pain in left
breast.

Diagnosis

According To Book In My Patient

 History taking  Done (including past history of
-past history of illness illness and family history)
-family history.

 Physical examination  Done

 Breast examination  Done
 Mammogram  Done
 Biopsy  Punch Biopsy Done
 CT scan  Done

Diagnostic Investigation In My Patient

23
 HistoPathology Report

Referring Physician: Dr. S. Karki

Date: 2079/01/06

Biopsy Site: Skin, left areolar region

Procedure Performed: Punch biopsy
Gross Description
The specimen consists of a piece of skin tissue, measuring 0.4x0.3x0.3 cm. Entire specimen
submitted in single cassette.
Microscopic Description :

Epidermis shows nests of atypical epithelial cells replacing the squamous cells in some areas.
There are also singly dispersed cells in pagetoid fashion in the epidermis. These cells are
moderately pleomorphic with abundant eosinophilic to clear cytoplasm and centrally placed
nucleus with coarse nuclear chromatin and prominent nucleoli. The underlying dermis shows
a
few ducts with proliferation of atypical epithelial cells in cribriform and solid pattern. Mitotic
figures constitute 0-2/HPF.
Diagnosis: Skin, left areolar region: Punch biopsy:
- Paget's disease with underlying ducal carcinoma in situ.

Pathologist: Prof. Dr. Ram Chandra Adhikari, MD

24
 CT SCAN OF CHEST AND ABDOMEN
(Plain and Contrast)

Plain and contrast enhanced volume scan of the whole chest and abdomen were obtained
from the lung apices to pubic symphysis along with IV contrast.

Findings: Chest

 Ill-defined heterogeneously enhancing lesion measuring 1.7x1.6x1.1 em noted in left

areolar region conglomerating with the periareolar cutaneous thickening. Minimal
perilesional fat strandings noted. No anterior chest wall infiltration, noted.

 No significant lymph nodes noted in left axilla. Fibrocalcific changes noted in apical
segment of right upper lobe. No other abnormal nodules noted in right upper lobe.
Rest of bilateral lungs are normal in neration, bronchovascular markings and
attenuation pattern. No abnormal nodules or mass lesion noted.

 Mediastinum: Trachea is central. Carinal bifurcation is normal. Cardiac shadow and

major vessels are normal. No lymphadenopathy seen. Pleura: No effusion or
thickening noted.

Abdomen

 Liver: Normal in size, outline and attenuation. IHBDs are not dilated. No focal lesion
seen. Hepatic veins and IVC are normal. Gall Bladder: Normal in outline and wall
thickness. No calculi or focal lesion seen. CBD: Normal in course and caliber. Portal
vein: Normal in course and caliber.

 Spleen: Normal in size, outline & attenuation.

 Pancreas: Normal in size, outline & attenuation. No focal lesion seen. Both kidneys:
Normal in size, outline, & attenuation. No focal lesion seen. No calculus or
hydronephrosis seen.
 Stomach and visualized bowel loops appear normal. Urinary bladder: Normal in outline
and distensibility. Wall thickness is normal.
 Uterus: Normal in size, outline and attenuation. No focal lesion is seen.

• B/L adnexa: Normal.

No free fluid or lymphadenopathy seen in the abdomen and pelvis.

IMPRESSION: Known case of carcinoma of left breast. Current CT shows:

Heterogeneously enhancing lesion in left areolar region conglomerating with
periareolar cutaneous thickening as mentioned above carcinoma of breast
(biopsy proven).
 No axillary metastatic lymph node in current CT.
 No intrathoracic and intraabdominal metastasis.

Laboratory Investigation

25
Date Investigation Result Unit Normal value
HEMATOLOGY REPORT
Complete Blood Count (CBC)
Total Leukocyte Count (TLC)
7800 /cumm 4000-11000
Differential Leukocyte Count
Neutrophils 70 % 40-75
Lymphocytes 20 % 20-45
Monocytes 06 % 2-10
Eosinophills 04 % 1-6
Hemoglobin 16.1 gm% 11-16
Packed Cell Volume (PVC) 45.0 % 36-46
2079/01/0
Platelets 260,000 /cumm 150000-
8
Red Blood Cells (RBC) 4.9 Mil/cumm 450000
MCV 91.6 Fl 4.7-6.1
MCH 32.8 Pg 80-90
MCHC 35.8 % 27-32
ESR (Westergren) 55 mm/1st hr 31.5-36
Blood Grouping & Rh type “A” Positive 00-20
Prothtrombin time (PT) 17 sec
INR 1.23 13-17
Control 14 sec

BIOCHEMISTRY

Kidney Function Test 17 mg/dl 10-45

Urea 0.5 mg/dl 0.5-1.1
Creatinine 140 mEq/L 135-146
Sodium (Na+) 4.9 mEq/L 3.5-5.2
Potassium(K+)
Liver Function Test 0.6 mg/dl 00-1.1
2079/01/0
Bilirubin Total 0.2 mg/dl 00-0.3
9
Bilirubin Direct 44 IU/L 9-52
SGPT (ALT) 31 IU/L 14-36
SGOT (AST) 114 IU/L 37-137
Alkaline phosphatase (ALP) 7.5 g/dl 6.8-8.0
Total Protein 4.7 g/dl 3.5-5.0
Albumin

2079/01/2 SEROLOGY TEST

2
HIV ½ antibody (Quick) Non-reactive
HBsAg (Quick) Non-reactive
HCV antibody (Quick) Non-reactive
2079/01/0 TUMOR MARKERS REPORT
9
Free Triiodothyronine (ft3) 3.5 pg/ml 2.77-5.27
Free Thyroxine (fT4) 1.05 ng/dl 0.78-2.19

26
 TSH 0.94 mIU/L 0.46-4.68

Glucose Result Unit Normal

Value
Test 2079/10/13 2079/01/18 2079/01/19 2079/01/20
252 188 140 Mg/ 60-110
Blood Sugar fasting
dl
410 284 Mg/ 70-140
Blood Sugar PP
dl
HBA1C 10.1 % 4.0-5.7

TREATMENTS
According to Book According to Patient
 Radiation Therapy  Surgery
 Chemotherapy
 Hormonal Therapy
 Targeted Therapy
 Surgery

Management

1. MEDICAL MANAGEMENT
ACCORDING TO BOOK ACCORDING TO MY PATIENT
1. Pharmacotherapy Done
Symptomatic treatment

2. Radiation therapy

3. Chemo therapy

4. Rehabilitation care

27
 2. Surgical management:

Breast conserving surgery (BCS): It is the operation procedure, removal

of one quarter of the breast such as:

 Lumpectomy: It is surgery to remove cancer or other abnormal

tissue from the breast. It is also called breast conserving surgery.

 Quadrantectomy: It is a surgical procedure for breast cancer in

which one quarter of breast tissue is removed.

 Partial mastectomy: It is another name for a lumpectomy, a breast-

conserving surgery that only removes the part of the breast that has
cancer.

 Segmental mastectomy: It is a type of surgery that removes a lump

and leaves as much normal breast tissue as possible.

3. Nursing Management

After gaining clear vision to nursing process, I had identified the existing and potential
problems of the patient. I have mentioned below the assessment, nursing diagnosis, planning,
intervention, and evaluation respectively.

A. ASSESSMENT:
- Collect the biodemographic data, history of all present illness, past illness and family
history.
- Physical examination
- Review the past medical history, assess the level of self-esteem.
- Observe for physical changes.
- Observe for communication.
- Assess nutritional status and appetite of patient.
- Assess the knowledge for self care at the level of disease process.

28
 B. Nursing Intervention:
 Involved the patient in planning and treatment.
 Helped patient identify and use support persons or family or community.
 Provided psychological interventions necessary for anxiety.
 Administered IV fluids as indicated.
 Observe condition of patient and stability of vital signs.
 Presence of complications: pain, edema, infection, limited arm movement range.

Drugs Used In My Patient

1. Metformin 1gm PO OD
2. Glimeperide 2 mg PO BD
3. Alprazolam 0.5 mg PO HS
4. Losartan 25 mg PO OD
5. Inj. Insulin 6U SC

Metformin

Generic Name: Metformin

Trade Name: Glucophage, Fortamet
Classification: Antidiabetics, Biguanides

Dosage:
 500 mg once/ daily with meals.

Mechanism of action:
 It is primarily used in patients with type 2 diabetes mellitus, and its main mechanism
of action in this disease setting is inhibition of hepatic gluconeogenesis. Metformin
interacts with complex I in the mitochondrial electron transport chain, thereby
lowering cellular ATP levels and causing AMP accumulation.

Indication
 Type 2 Diabetes mellitus.
 Gestational diabetes mellitus
 Cardiovascular or neuroprotective effects.

Contraindication
 Known hypersensitivity to metformin.
 Renal disease
 Cardiovascular collapse
 Myocardial Infraction
 Diabetic Ketoacidosis
Nursing Consideration
 Take with meals to avoid gastrointestinal problems

29
  Notify problem like lactic acidosis symptoms, including hyperventilation, fatigue and
myalgia.
 Must be taken daily and not discontinued abruptly.

Glimepiride

Generic name: Glimeperide

Trade name: Amaryl
Classification: Sulfonylureas

Mechanism of Action
 The mechanism of action of glimepiride in lowering blood glucose appears to be
dependent on stimulating the release of insulin from functioning pancreatic beta cells,
and increasing sensitivity of peripheral tissues to insulin.

Indication
 Adjunct to diet and exercise in patients with type 2 diabetes
 May also be used in combination with insulin in type 2 diabetes.

Dosage
 Adult
 PO Start with 1-2 mg once daily with breakfast or first main meal
 May increase to usual maintenance dose of 1-4 mg once daily(max: 8mg/day)

Available forms
 Tablets- 1mg, 2mg, 4mg

Adverse effects
 CNS: Dizziness, asthenia, headache, blurred vision, changes in accomodation
 GI: Nausea, vomiting, diarrhoea, Abdominal pain
 Hematologic: Leukopenia, agranulocytosis (rare), thrombocytopenia
 Metabolic: Hypoglycemia
 Dermatologic : Rash, pruritus, erythema, urticaria, maculopapular eruptions.

Contraindication
 Hypersensitivity to glimepiride
 Diabetic ketoacidosis
 Nondiabetic patients with renal glycosuria
 Pregnancy
 Lactation

Nursing Considerations
 Give once daily in the morning with breakfast or with first main meal
 Monitor fasting and postprandial blood glucose and urinary glucose frequently
 Monitor for hypoglycemia especially with concurrent drugs which enhance
hypoglycemic effects

Patient Awareness
30
  Test fasting and postprandial blood glucose frequently.
 Take a missed dose as soon as possible unless it is almost time for next dose; never
take two doses at the same time.
 Avoid drinking alcohol.
 Use sunscreen and avoid sunlamps.
 Learn about adverse reactions and drug interactions.
 Do not breast feed while taking this drug.

Alprazolam
Generic name: Alprazolam
Trade name: Xanax, Niravam, and Xanax XR
Classification: Anxiolytics, Benzodiazepines

Mode of action

 CNS depressant. Mode of action not known, but appears to act at the limbic, thalamic,
and hypothalamic levels of the CNS. It is associated with significantly less
drowsiness.
Indication

 Management of anxiety disorders or for short-term relief of anxiety symptoms.

 Also used as adjunct in management of anxiety associated with depression and
agitation, and for panic disorders, such as agoraphobia
Dosage
Anxiety Disorders
 Adult: PO 0.25-0.5 mg TDS. (max: 4 mg/day)
 Geriatric: PO 0.125-0.25 mg BD

Available Forms

 Tablets- 0.25 mg, 0.5 mg, 1 mg, 2 mg

 Sustained-release tablets- 0.5 mg, 1 mg, 2 mg, 3 mg
 Oral solution- 0.5 mg/5 mL, 1 mg/mL

Adverse effects
 CNS: Drowsiness, sedation, light-headedness, dizziness, syncope, depression,
headache, confusion, insomnia, nervousness, fatigue, clumsiness, unsteadiness,
rigidity, tremor, restlessness, paradoxical excitement, hallucinations
 CVS: Tachycardia, hypotension, ECG changes
 Respiratory: Dyspnea
 Special Senses: Blurred vision

Contraindication
 Sensitivity to benzodiazepines
 Acute narrow angle glaucoma
 Pulmonary disease
 Use alone in primary depression or psychotic disorders
 Children <18 years

31
  Pregnancy
 Lactation

Nursing Considerations

 Monitor for s/s of drowsiness and sedation, especially in older adults or the
debilitated, they may require supervised ambulation and/or side rails.

Patient Awareness
 Make position changes slowly and in stages to prevent dizziness.
 Do not use alcohol, other CNS depressants, or OTC medications containing
antihistamines (e.g., sleep aids, cold, hay fever, or allergy remedies) without
consulting physician.
 Do not drive or engage in potentially hazardous activities until response to drug is
known.
 Taper dosage following continuous use; abrupt discontinuation of drug may cause
withdrawal symptoms: nausea, vomiting, abdominal and muscle cramps, sweating
confusion, tremors, convulsions.
 Do not breast feed while taking this drug.
 Do not drive or engage in potentially hazardous activities until response to drug is
known.
 Inform doctor or dentist before any kind of surgery about taking valproic acid.
 Do not breast feed while taking this drug.

Losartan potassium

Generic name: Losartan potassium

Trade name: Cozaar
Classification: angiotensin II receptor antagonists

Mechanism of Action
 It is an angiotensin Il receptor antagonist. It selectively blocks the vasoconstriction
and aldosterone-secreting effects of the angiotensin I by selectively antagonizing its
binding to AT1 receptors
Indication
 Hypertension

Dosage
Adult
 Hypertension
 PO 25-50 mg in 1-2 divided doses (max: 100 mg/day); start with 25 mg/day if volume
depleted (i.e., on diuretics)

Available forms
 Tablet- 25mg, 50 mg

32
Adverse Effects
 CNS: Dizziness, insomnia, headache.
 GI: Diarrhea, dyspepsia.
 Musculoskeletal: Muscle cramps, myalgia, back or leg pain.
 Respiratory: Nasal congestion, cough, upper respiratory infection, sinusitis.).

Contraindication
 Hypersensitivity to losartan
 Lactation

Nursing Consideration
 Monitor BP
 Inadequate response may be improved by splitting the daily dose into twice-daily
dose.
 Monitor CBC, electrolytes, liver & kidney function with long-term therapy

Patient Awareness
 Notify physician of symptoms of hypotension (e.g., dizziness, fainting).
 Notify physician immediately of pregnancy.
 Do not breast feed while taking this drug.

Complications
Cancer treatment can have side effects that last a long time or that start weeks, months, or
years after you finish treatment. These include:

 Pain and numbness (peripheral neuropathy)

 Swelling in your arms or legs (lymphedema)
 Bone loss (osteoporosis)
 Infertility
 Heart problems
 Blood clots

Prognosis

The outlook depends on:

 If you have a tumor in the affected breast

 If the tumor is ductal carcinoma in situ or invasive breast cancer
 The stage of invasive breast cancer in that breast
 If you have invasive cancer in the affected breast and it’s spread to nearby lymph
nodes

About 83% of women in the U.S. diagnosed with this condition from 1988 to 2001 lived at
least 5 more years. By comparison, about 87% of women diagnosed with any kind of breast
cancer in that period lived at least 5 more years.

33
For women with both Paget's disease of the breast and invasive cancer in the same breast, the
5-year relative survival rate went down with each stage of the cancer:

 Stage I: 95.8%
 Stage II: 77.7%
 Stage III: 46.3%
 Stage IV: 14.3%

APPLICATION OF NURSING THEORY

I had applied the Nursing theory of Virginia Henderson’s while giving care to my patient.
This theory has focused on individual and her ability to perform fourteen component of basic
nursing care unaided if she had the necessary strength will or knowledge. My patient Mrs. Til
Kumari Shrestha had some problem which is inter- related with the Henderson’s fourteen
component and she required my assistance to achieve health or recover from illness.

 Introduction to Virginia Henderson

 She was born in Kansai City, Missouri, on March 19, 1897.

 She completed diploma in nursing from the army school of nursing at
Walter Reed Hospital, Washington D.C. in 1921 A.D.
 She gave her definition of nursing which she called “concept”.
 Her definition of nursing was:
“The unique functions of the nurse is to assist the individual, sick or well,
in the performance of those activities contributing to health or its recovery
(or to peaceful death) that he would perform unaided if he has the
necessary strength, will or acknowledge.”
 She emphasized the importance of increasing the patient’s independence
so that progress after hospitalization would not be delayed.
 Died on March 19, 1996.

 14 components of basic nursing care are:

 Breathe normally
 Eat and drink adequately
 Eliminate body wastes
 Move and maintain desirable posture
 Sleep and rest
 Select suitable clothes: dress and undress
 Maintain body temperature within normal range by adjusting clothes and
modifying environment.
 Keep the body clean and well groomed and protect the integument

34
  Avoid dangers in the environment and avoid injuring others.
 Communicate with others in expressing emotions, need, fear and options.
 Worship according to one’s faith.
 Work in such a way that there is sense of accomplishment.
 Play or participate in various forms of recreation.
 Learn, discover or satisfy the curiosity that leads to normal development and
health and use of available resources.

Following table shows the comparison between Henderson`s fourteen component with patient
need.

According To Nursing Theory According To My Patient

1. Breathe normally. 1. She breathe normally.

2. Eat and drink adequately. 2. She eat and drink adequately.

3. Eliminate body waste. 3. Normal bowel and bladder habit.

4. Move and maintain desirable position. 4. She can maintain desirable position.

5. Sleep and rest 5. She couldn’t sleep well as she was anxious.

6. Select comfortable clothes dress or undress. 6. She had her own clothes which made her
feel easy and comfortable.

7. Maintain body temperature within normal 7. Temperature was normal.

limit, by adjusting, clothing and modifying the
environment.

8. Keep the body clean and well groomed and 8. She maintain her personal hygiene and keep
protect the integument. the body clean and well groomed and protect
the integument.

9. Avoid danger in environment and avoid 9. She is in hospital environment.

other injuries.

10. Communicate with expressing fear and 10. Encouraged to verbalize her feeling when
opinion. she was anxious and tensed.

11. Worship according to one’s faith. 11. She followed Hinduism ; worship God
according to her religion.

12. Work in such a way that provides sense of 12. She is a housewife.
accomplishment.

13. Learn, discover or satisfy the curiosity that 13. Satisfied with hospital treatment but
leads to normal developed and health using the
35
 available health facilities. worried about disease condition.

14. Play or participate in various form of 14. She involves herself in family talk and
recreation. household work.

Findings
 She couldn’t sleep well as she was anxious.
 She was worried about disease condition.
 She looks fearful and tensed related to prognosis of disease.

Nursing Diagnosis:
Actual Nursing Diagnosis
1. Anxiety related to diagnosis of disease condition as evidenced by restlessness.
2. Disturbed sleep pattern related to anxiety as evidenced by verbal reports of difficulty
falling asleep.
3. Fear related to abnormal health status as evidenced by facial expression.
4. Deficient knowledge regarding illness, prognosis, treatment, self care and discharge
needs.

Potential Nursing Diagnosis

1. Risk for infection related to surgical incision.

36
 NURSING CARE PLAN
1. Anxiety related to diagnosis of disease condition as evidenced by
restlessness.
Assessment Nursing Nursing Planning Implementation Rational Evaluation
Diagnosis goals

Anxiety To Monitor the Patient It helps in My goals

related to reduce condition of condition was further action. were
Subjective
diagnosis of anxiety patient. monitored partially
data: Pt.
disease within through met as
frequently
condition as two interaction. patient’s
asked, “Why
evidenced days. Provided anxiety
am I here and Information was
my information Appropriate level was
what had provided related
restlessness. related to information decreased
happened to to disease
disease may help in than
me?” condition.
condition. better before
Objective understanding during
data: of prescribed hospitaliza
plan of care. tion.
Patient looks
anxious. Talk therapy
Provide talk was provided to It helps to
therapy to patient . ventilate her
patient. feelings.
Allow
patient to Close relatives
interact with were allowed to It helps to share
family. meet her. her feelings and
get
psychological
support.

Reassess the Patient’s It helps in

condition of condition was evaluation.

37
 patient. reassessed.

2. Disturbed sleep pattern related to anxiety as evidenced by verbal reports of

difficulty falling asleep.

Assessmen Nursing Nursing Planning Implementation Rationale Evaluation

t diagnosis goal

Subjective Disturbed Patient will Assess the Usual sleeping To obtain The goals
data: Patient’s sleep improve her sleeping pattern was baseline were not
said” I don’t pattern sleep pattern pattern of described by the data fully met as
feel sleepy related to within a the patient patient which help the patient
most of the anxiety as week of
in assessement. still have
time”. evidenced intervention.
by verbal disturbed
Objective reports of sleeping
data: Patient difficulty pattern.
was awake falling Advice the The patient was Helps to
till 2 am. asleep. patient not advised to involve improve
to sleep in recreation during sleep at
for long in day time to avoid night
day time. sleep.

38
 Advise to Patient was asked To ensure
maintain to maintained same the sleep at
same schedule of night
sleeping bedtime properly.
time

Reassess Patient’s sleep

the sleep pattern was
pattern reassessed.

3. Fear related to abnormal health status as evidenced by facial expression.

Assessment Nursing Nursing Planning Implementati Rationale Evaluatio
diagnosis goal on n

Subjective Fear related The patient Identify Patient’s To obtain The goals
data: to abnormal fear will be patient’s perception baseline data were not
Patient’s health status reduced perception of threat was fully met
said” is my as after my threat identified as patient
health ok? evidenced nursing represented by
through the was scared
Objective by facial intervention situation
data: “ expression .. vigilant related to
patient observation her health
looks and interaction condition.
worried and Encourage The patient Helps to
frightened”. patient to was provide
express fear encouraged to concerns and
express her deal with
feeling through anxiety
talks
Identify Previous To increase
previous coping coping attention in
strength mechanism own
were identified capabilities
increase
and evaluated
sense of
control.

Encourage use Deep breathing Helps to

of relaxation exercise reduce
technique guided feeling of
imagery helplessness.

39
 technique was
taught.
Reassess the Patient Helps to
condition of the condition was evaluate.
patient reassessed for
fear and
anxiety.

4. Deficient knowledge regarding illness, prognosis, treatment, self care and discharge
needs.

Assessment Nursing Nursing goal Planning Implementatio Rationale Evaluation

diagnosis n
Subjective Deficient Patient will Develop Created an It helps to My goals
data: Patient knowledge verbalize good environment of establish good were
asked, regarding understanding interpersonal trust by rapport & partially
“ What illness, of disease relationship. listening to respect before met as the
happens now prognosis, process, patient patient will be patient was
that I am treatment, treatment, problems. willing to take able to
diagnosed self care self care and part in learning verbalize
with and discharge process. knowledge
Cancer?” discharge needs after regarding
Objective needs. my nursing Give Made her It helps to illness,
data: intervention. information understand prevent from prognosis,
Frequent about about disease false belief treatment,
questioning disease condition and about disease self care
Negativity condition its prognosis. condition and and
towards and its provide discharge
diagnosis. prognosis. reassurance by needs than
clearing before.
queries.

Give Provided It helps to

information information prevent from
about about health
importance importance of deterioration
of surgery. surgery. and
complication.

Encourage Encouraged It helps to

family family provide
participation participation in emotional

40
 in care. care. support

Reassess the Patient’s It helps in

knowledge knowledge was evaluation.
of the reassessed
patient

1. Risk for infection related to surgical incision.

Assessment Nursing Nursing planning Implementation Rationale Evaluation

diagnosis goal
Objective Risk for Patient’s Assess the Vital signs and To obtain Goal was
data: infection risk for patient for incision site baseline data. partially
Patient will related to infection the sign of inspection was met as the
undergo surgical will be infection. done. risk for
mastectomy. incision. reduced infection
during her was
hospital decreased
stay. until her
hospital
stay.
Advice Patient was To decrease risk
patient to adviced to of infection.
maintain maintain aseptic
aseptic technique while
technique cleaning wound
while by frequent
cleaning handwashing.
wound.
Refrain from Gauze pad was To decrease risk
touching inserted on of infection as
wound wound and was microorganisms
frequently closed by cannot enter.
and keeping packing with
it open. guaze and
adhesive tape.
Perform Dressing was To decrease risk
dressing of done in of infection by

41
 wound as alternative days maintaining
suggested by following cleanliness of
physician. aseptic wound.
technique.
Reassess the The risk of To evaluate the
risk of infection in the findings.
infection in patient was
the patient. assessed

DAILY PROGRESS REPORT

2079/01/19

Patient general condition seems fair. She was kept in comfortable position. Vitals signs were
monitored and recorded. She was on NPO. Her IV line was open. Difficulty in sleeping.
Prescribed medication was done. GRBS monitored. Ot planned on 2079/01/21 due to high
blood sugar level.

Vital signs:
Temperature : 98.6o F
Pulse : 80/m
Respiration : 22/m
BP : 110/70mm of Hg
2079/01/20

Patient's general condition looks worried. She was encouraged for morning care. Vital signs
were taken and recorded. She have normal bowel and bladder habit. Medicines were given as
per cardex and her IV drip was continued. Intake and output chart was maintained. GRBS
monitored

Vital signs:

T-98* F
P-80 /m
R-22 b/m
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BP- 110/70 mmHg

2079/01/21

Patient's general condition looks satisfactory. Vital signs were taken and recorded. Normal
bowel and bladder habit. Patient is in NPO. As her sugar level was not maintained, surgery
postponed for 2079/01/23.

Vital signs:

T-98* F
P-80 /m
R-22 b/m
BP- 110/70 mmHg
2079/01/22

Patient's general condition looks satisfactory. Vital signs were taken and recorded. Normal
bowel and bladder habit. Patient is in diabetic diet. She have normal bowel and bladder habit.
Medicines were given as per cardex and her IV drip was continued. Intake and output chart
was maintained. GRBS monitored

Vital signs:

T-98* F
P-80 /m
R-22 b/m
BP- 120/60 mmHg
2079/01/23

Patient's general condition looks satisfactory. Vital signs were taken and recorded. Normal
bowel and bladder habit. Patient is in NPO. She was informed about her disease condition.

43
Patient then felt anxious and extremely worried. She was upset with family member for not
informing about disease condition. Surgery postponed as her BP raised to 170/90 mm of hg.

Vital signs:

T-98* F
P-90 /m
R-24 b/m
BP- 170/90 mmHg

DIVERSIONAL THERAPY
Diversion therapy is a kind of therapy, which diverts the mind of a person. It is used in
parallel with medicines for the treatment of stressed person because during illness a person
has more concerns about the health and illness, which may lead to emotional or mental
problems. In the case of my patient, I applied the following measures to divert her and
visitors mind in order not to feel anxious:

1. Talk Therapy:
A good interpersonal relationship was established with the patient and healthy interactions
were made with. She was asked about her likes and dislikes. I answered her questions related
to health on which she was curious for a long time.
2. Use of gadgets
Patient was encourage to use social media and watch her favorite TV shows.

3. Family Therapy
Family of the patient was involved and they were allowed to talk to her for some time
in order to divert her attention from pessimistic thoughts.

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 HEALTH TEACHING
Health teaching plays an important role while providing care to the patient .As it helps for the
continuity of our care and prevent from further complications and diseases. One of the most
important role of the nurse is to provide health teaching. So, I being a nurse, I had also
provided health education to the patient and her family.

I had provided education on:

 Mobility: move as tolerance.

 Nutritional diet: Advised to take balanced and nutritious diet to the patient. As
patient was on diabetic diet, I gave informal teaching about it.
 Hygiene: Even though disease is cured if hygiene is not maintained it may cause
other related disease so I also advised her to maintain hygiene.

 Rest and sleep

o Rest and sleep is very necessary so the family members of the patient were advised to
reduce the stimulants during her sleep.
o 8-10 hours of sleep was asked to maintain

 Sign of infection : I told the patient visitors about the signs of infection eg: fever,
swelling, increased pain etc

 Prevention from hazards: I explained patient and visitors about prevention from
injury.

45
  Complications: I advised her not to wear bangles or any type of bracelet which can
hurt her, not to pluck flower with thorns like rose it can hurt her and cause delay in
healing process. I also advised her to not to lift weight or anything from the left hand.
Also made aware of complications so that it could be prevented.

DISCHARGE TEACHING
Discharge teaching is an important guidelines for patient to convey positive and incorporated
information regarding follow up care and further management.Discharge teaching helps the
patient and family to understand the prescribed therapy at clearly and prevent complications.
I provided discharge teaching on:

1. Diet:

I advised her to maintain diabetic diet and take highly nutritious diet rich in protein.

 Plenty of whole fruits and vegetables.

 Moderate amount of lean proteins and healthy fats.
 Moderate amount of whole grains such as bread (brown), pasta, brown rice.
 Fewer foods that have a lot of sugar.
 3-4 meals per day
 Do not skip the meals.

2. Medications:
o I advised her to take medicines regularly at same time daily as prescribed by the
doctor.
o I advised her not to take any other medicine without the prescription of the
doctor.
3. Rest and Activities:
 Heavy working, heavy lifting should be avoided .

46
4. Exercise:
 I gave her information about post-mastectomy exercise.

5. Personal hygiene:
 Personal hygiene should be maintained by the patient to prevent infection.

6. Sign of infection :
 I told the patient visitors about the signs of infection eg: fever, swelling, increased
pain etc and told her to come immediately to hospital if signs of infection appears.

7. Dressing of the wound

 She was told about the importance of dressing of her wound.

8. Follow up:
 I remind her to come for follow up.

LESSON LEARNT

Case study is very good opportunity to fulfill learning need by learning about the nursing
practice as well as the related disease in detail. It helps us in comprehensive study of a
selected patient in comparison with book and real situation.
This case study was indeed a part of a large field on which ploughing upon we can achieve
knowledge about every subject concern with it. I got incredible opportunity to broaden my
knowledge with the help of this case study. I learnt about following things.

1. About the disease:

I studied about Breast cancer in various books, internets and also asked to the health
personnel. It helped me to learn about the disease in detail, its causes,
pathophysiology, investigation, clinical feature, medical and nursing management
in comparision between books and my patient.
2. Preparation Of Oncology Case Study:
I learnt difference about oncology case study and other case studies that I had done
before. It helped me to learn about the essential subject which we should not miss
during oncology case study. This will later help me learn about any case related to
oncology in the future.
3. About the patient and her family:
 Throughout my case study I knew many things about my patient, her history, habits,
lifestyle and its influence to health and illness in detail. I also compared the normal
developmental task and need of her age with book.

47
 I also got information about her family members, their socioeconomic status, health
and illness nutrition, religion, belief, her relationship with family members and also
patients environment in which she is living.
4. About the nursing care:
 I got opportunity to apply nursing process and provide holistic nursing care to the
patient using nursing theory. It made me capable to provide holistic care to achieve
optimum benefit by the patient in hospital setting. I got opportunity to apply
theoretical knowledge in real situation.
5. About the hospital policy:
 During the case study, I was involved in many activities like reporting, recording,
admission and discharge procedure of patient and related policy of Bhatkapur Cancer
Hospital.

48
 SUMMARY
With the reference to Purbanchal University, a requirement for conducting case study was
given. According to my case, my patient’s name is Til Kumari Shrestha, 51 years, female
patient, admitted in surgical ward of Bhaktapur Cancer Hospital with the chief complain of
redness, itching and burning sensation on nipple area of lt. breast. She visited on 2079/01/09
and consulted Dr. Utsab Man Shrestha. She underwent different diagnostic investigation
such as Punch Biopsy, Mammography and CT scan of Chest and Abdomen.

She was unknown about her condition but her family knows. She was planned to do surgery
on 2079/01/19 but due to her high blood sugar level it got postponed to 2079/01/21. She was
informed about her disease condition before surgery due to which she had high blood
pressure so, it got postponed as well.

Breast cancer is a disease in which cells in the breast grow out of control. There are different
kinds of breast cancer. The kind of breast cancer depends on which cells in the breast turn
into cancer. Breast cancer arises in the lining cells (epithelium) of the ducts (85%) or lobules
(15%) in the glandular tissue of the breast. Initially, the cancerous growth is confined to the
duct or lobule (“in situ”) where it generally causes no symptoms and has minimal potential
for spread (metastasis).
Breast cancer became the most common cancer globally as of 2021, accounting for 12% of
all new annual cancer cases worldwide, according to the World Health Organization.
My Patient is diagnosed with Pagets disease with underlying ductal carcinoma insitu. Pagets
disease of the breast is a rare type of cancer that forms in or around your nipple. It’s involved
in 1% to 4% of all breast cancers. It may be linked with an underlying breast cancer, either
ductal carcinoma in situ or invasive breast cancer.

I formulated nursing care plan according to the findings gathered from the nursing
application theory of Henderson’s. I provided necessary care and health teaching to optimize
her condition and to regain her self- dependent.

I gained theoretical as well as practical knowledge regarding its cause, signs and symptoms,
management and treatment. Proper Management helps to prevent from further deterioration
in the condition and it directly effects and gives well outcome.

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 CONCLUSION

In conclusion, with the reference to Purbanchal University, a requirement for conducting case
study was given. I am very grateful for the opportunity provided. According to my case, my
patient’s name is Til Kumari Shrestha, 51 years, female patient, was admitted in the hospital
with the chief complain of redness, itching and burning sensation on nipple area of lt. breast.
Later her diagnosis turned out to be Breast Cancer. Her condition was managed and needed
medical and nursing assistance was offered to the patient.

In order to maintain her optimum health status and to fulfill her basic needs Henderson’s
nursing theory was applied. Viewing the finding derived from the nursing theory application,
I prepared a nursing care plans that could make her condition much better. The patient was
examined virtually deeming all the abnormal possibilities that could be present in the patient.
Comparisons were made between patient picture and book picture on sign and symptoms,
causes and developmental tasks. I prepared progress report on the patient which showed her
progression with passing days. For the sustainability of her optimum health status, health
teaching and discharge to the patient was offered. To distract patient’s attention from pain
diversional therapy was given to the patient as well.

This case study was an incredible opportunity to learn about onncology medical disorder. I
would like to thank every helping hand that helped me complete my case study.

Hence, all my set objectives are fulfilled.

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REFERENCES

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