Translated from Indonesian to English - www.onlinedoctranslator.

com

PAPER ASSIGNMENT
ABOUT NURSING CARE
WITH CA MAMAE

Group 4

Ermelinda

Kokuma V gedy

Meswan Linga

Veren Bella

NURSING SCIENCE STUDY PROGRAM

MEDICAL SCHOOL

CENDRAWASIH UNIVERSITY

JAYAPURA

2023

i
 Foreword

Praise be to the presence of Allah SWT for all His grace so that we can
complete the paper to fulfill the group assignment for the Community Aggregate
Nursing course with the title: Family Nursing Care with Ca Mamae. We do not
forget to express our gratitude for the assistance from those who have contributed
by providing both ideas and materials.

The author really hopes that this paper can increase the knowledge and experience
of readers. In fact, we hope that this paper can be put into practice by readers in
their daily lives.

We as authors feel that there are still many shortcomings in preparing this paper
due to our limited knowledge and experience. For this reason, we really hope for
constructive criticism and suggestions from readers for the perfection of this
paper.

Jayapura, October 2023

Compiler

Group 4

ii
 List of contents

Foreword..................................................................................................................ii
List of contents.......................................................................................................iii
PIG...........................................................................................................................5
INTRODUCTION...................................................................................................5
1.1. Family Concept.............................................................................................5
1.2 Community Concept.......................................................................................9
1.3 Family nursing..............................................................................................10
1.4 Community nursing......................................................................................11
CHAPTER II..........................................................................................................19
REVIEW THEORY...............................................................................................19
A. Theory Concept........................................................................19
1. Definition..................................................................................19
2. Etiology....................................................................................19
3. Pathophysiology.......................................................................22
4. PATHWAYS............................................................................28
5. Clinical Manifestations.............................................................30
6. Breast Cancer Classification.....................................................31
7. Complications...........................................................................34
8. Supporting investigation...........................................................34
9. Management.............................................................................36
B. Nursing Care Concept..............................................................41
Assessment.....................................................................................................41
Nursing diagnoses...........................................................................................48
BIBLIOGRAPHY..................................................................................................50
CHAPTER III........................................................................................................51
CASE REVIEW.....................................................................................................51
1. Assessment.....................................................................................................51
2. Nursing Diagnosis..........................................................................................84
3. FAMILY NURSING CARE PLAN...............................................................85
4. NURSING IMPLEMENTATION AND EVALUATION...........................102

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iv
 PIG

INTRODUCTION

1. Background

1.1. Family Concept

1.1.1. Definition of family

Definition of Family A family is two or more people who
live together with ties and emotional closeness, whether they are
not related by blood, marriage or adoption and have no boundaries
of membership in the family (Friedman & Bowden, 2010).
The family is the smallest unit in society. Family is defined in
terms of kinship where individuals unite in a marriage bond by
becoming parents. In a broad sense, family members are those who
have personal and reciprocal relationships in carrying out
obligations and supporting members resulting from birth, adoption
or marriage (Stuart, 2014).

1.1.2. Family type

Family types according to Marilynn M Friedman & Bowden,
(2010) consist of 3:
1) The nuclear family (husband and wife) is a family with a
marriage bond consisting of husband and wife and children,
whether from marriage, adoption or both.
2) Family of orientation (family of origin) is the family unit into
which a person is born
3) The extended family is the nuclear family and people who
have blood ties, most often members of the oriental family of
one of the nuclear families. such as grandparents, aunts,
uncles, nieces, nephews and cousins.
1.1.3. Family characteristics

Family characteristics according to Friedman & Bowden, (2010)

are as follows:

1) Organized, where family members are interconnected and

interdependent.

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 2) There are limitations, where family members are free to carry

out their functions and duties but have limitations.

3) There are differences and specificities, each family member

has their own role and function.

1.1.4. Family functions

In general, family functions (Friedman, 2010) are as follows:

1) The affective function is the main family function to teach

everything to prepare family members to relate to other people

outside the home.

2) The function of socialization and a place to socialize is the

function of developing and training children for a social life

before leaving the house to connect with other people outside

the home.

3) The reproductive function is the function of maintaining

generations and maintaining family continuity.

4) The economic function is that the family functions to meet the

family's economic needs and is a place to develop the

individual's ability to increase income to meet the family's

needs.

5) The nursing or health maintenance function is the function of

maintaining the health condition of family members so that

they remain highly productive. This was developed into a task

in the health sector.

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1.1.5. Family role

According to Friedman (2010) family roles can be classified

into two categories, namely formal roles and informal roles. Formal

roles are explicit roles contained in the family role structure.

Informal roles are invisible and are expected to meet the emotional

needs of the family and maintain family balance. The various roles

contained in the family are:

1) Formal roles Parental and marital roles are identified into eight

roles, namely the role of provider, the role of household

organizer, the role of child care, the role of child socialization,

the role of recreation, the role of friendship, the role of

therapeutic (fulfilling affective needs), and sexual roles.

2) Informal roles There are various informal roles, namely the

role of encourager, harmonizer, initiator-contributor,

peacemaker, family pioneer, entertainer, family caregiver, and

family intermediary.

1.1.6. Family Duties

In accordance with the function of health in the family, the

family has duties in the health sector. Friedman & Bowden, (2010)

divides family duties into 5 areas of health, namely:

1) The family is able to recognize the health problems of each

member. The family is able to recognize the changes

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 experienced by family members so that this will indirectly

become the family's concern and responsibility, so the family

will immediately realize and record when and how big the

changes are.

2) The family is able to make decisions to take the right action.

The main task of the family is to be able to decide on the right

action so that health problems can be resolved. If the family

has limitations in solving problems, the family asks for help

from other people around them.

3) Families are able to provide nursing care to family members

who are sick. Families are able to provide first aid if the family

has the ability to care for family members who are sick or

immediately take them to the nearest health service to get

further action if the problem is too serious.

4) The family is able to maintain the atmosphere at home. The

family is able to maintain the atmosphere at home so that it can

provide benefits for members in maintaining and improving

their health.

5) Families are able to utilize existing health facilities. Families

are able to utilize health facilities if a family member is sick.

1.2 Community Concept

According to Kertajaya (2008) a community is a group of people

who care about each other more than they should, where in a community

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there are close personal relationships between members of the community

because of the same interests or values. Soenarno (2002) defines

community as an identity and social interaction that is built on various

dimensions of functional needs.

In a community, individuals in it can have similar intentions,

beliefs, resources, preferences, needs, risks and a number of other

conditions (Wenger, McDermott and Snyder 2002). Iriantara (2004)

defines the meaning of community as a group of individuals who inhabit a

certain location and are usually related to the same interests.

1.3 Family nursing

1.1.7. Definition

Family nursing is a holistic service where the family and its

parts become the center of service where the stages of assessment,

nursing diagnosis, planning, implementation and evaluation involve

all family members (Kholifah & Widagdo, 2016).

Family nursing is the process of nursing care provided in

healthy and sick conditions to all family members to achieve higher

welfare (Friedman et al., 2014). According to Potter et al. (2020),

family nursing is the provision of health services by helping family

members maintain the highest level of health beyond previous

experiences of illness. Family nursing is the provision of holistic

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 health services starting from assessment, diagnosis, intervention,

implementation to evaluation of all family members to improve

health welfare as much as possible.

1.1.8. Goals of family nursing

According to Ali (2010), family nursing generally aims to

increase the family's awareness, desire and ability to increase,

prevent and maintain health until it reaches the optimal level

possible, so that they can carry out their tasks productively. The

specific objectives of family nursing are to increase family

knowledge, awareness and abilities in terms of:

1) Identify health problems the family is facing.

2) Deciding about solving the problem faced (for example, the

problem will be solved by yourself by seeking treatment at a

health service such as a hospital, community health center, or

nursing/medical practice).

3) Improving the quality of family health.

4) Prevention of the emergence of diseases / health problems in

the family.

5) Carrying out efforts to heal or solve family health problems

through nursing care at home.

6) Carry out patient rehabilitation efforts through nursing care at

home.

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 7) Assist health/nursing professionals in dealing with their

illnesses or health problems at home, health referrals and

medical referrals.

1.4 Community nursing

1.1.9. Definition

Community nursing is a synthesis of nursing practice and

public health practice applied to improve and maintain population

health. The targets of community health nursing are individuals,

namely malnourished toddlers, high-risk pregnant women, the

elderly, sufferers of infectious diseases. Target families are families

who are vulnerable to health and priority problems. Special target

groups, communities both healthy and sick who have health or care

problems (Ratih Dwi Ariani, 2015).

Community Nursing is a professional nursing service aimed

at the community with an approach to high risk groups in an effort

to achieve optimal health status through preventing disease and

improving health by ensuring the affordability of needed health

services and involving clients as partners in planning,

implementing and evaluating nursing services. . Community

Nursing Services are for the entire community including

individuals, families and groups at high risk such as families living

in slum areas, isolated areas and inaccessible areas including

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 groups of babies, toddlers, the elderly and pregnant women

(Veronica, Nuraeni, & Supriyono, 2017).

1.1.10. Goals of community nursing

The aim of community nursing is to prevent and improve

public health through the following efforts:

1) Direct nursing services (direct care) for individuals, families,

groups, in a community context.

2) Direct attention to the health of the entire community (general

community health) by considering public health problems or

issues that can affect families, individuals and groups

1.1.11. Community nursing goals

Goals of Community Health Nursing (Ministry of Health,

2006)

a. Individual goals

Individual priority targets are malnourished toddlers, high-risk

pregnant women, the elderly, sufferers of infectious diseases

(pulmonary TB, leprosy, malaria, dengue fever, diarrhea,

ARI/Pneumonia) and sufferers of degenerative diseases.

b. Family goals

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 Target families are families who are vulnerable to health

problems (vulnerable group) or at high risk (high risk group),

with priorities:

1) Poor families have not had contact with health service

facilities (Puskesm and their networks) and do not have

health cards.

2) Poor families who use health service facilities have

health problems related to the growth and development

of children under five, reproductive health, and

infectious diseases.

3) Families are not included in the poor who have priority

health problems and have not utilized health service

facilities

c. Group targets

The target group is a special group of people who are

vulnerable to the emergence of health problems, whether they

are tied to or not tied to an institution.

a) Special community groups that are not tied to an

institution include Posyandu, Toddler Groups, Pregnant

women's groups, Older Age Groups, Groups of people

suffering from certain diseases, groups of informal

workers.

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 b) Special community groups are bound to an institution,

including schools, Islamic boarding schools, orphanages,

elderly homes, detention centers (remand centers),

correctional institutions (lapas).

d. Target community

The target community is people who are vulnerable or

have a high risk of health problems, prioritizing communities

in an area (RT, RW, Subdistrict/Village) that have:

1) The number of babies dying is higher compared to other

areas

2) The number of people suffering from certain diseases is

higher than in other areas

3) Health service coverage is lower than other areas

4) Communities in areas where infectious diseases are

endemic (malaria, diarrhea, dengue fever, etc.)

5) People in refugee camps/barracks, due to disasters or other

consequences

1.1.12. Community Health Nursing Services

According to the Ministry of Health (2006) Community

health nursing services can be provided directly in all health service

settings, namely:

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a. In health service units (hospitals, community health centers,

etc.) that have outpatient and inpatient services.

b. At home, home care nurses provide direct services to families

at home who suffer from acute or chronic illnesses. The role of

home care can improve family function in caring for family

members who are at high risk of health problems.

c. In schools, school nurses can provide day care in various

educational institutions (kindergarten, elementary school,

middle school, high school and tertiary institutions, teachers

and employees). School nurses carry out health screening,

health maintenance and health education programs.

d. In orphanages or other special groups, such as children's

orphanages, nursing homes, and other social institutions as

well as detention centers (rutan) or correctional institutions

(Lapas). Chapter 1. Basic Concepts of Community Health

Nursing.

e. Services for high risk groups

1) Care services for women, children and the elderly receive

violent treatment

2) Nursing services in mental health service centers

3) Nursing services in drug abuse service centers

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 4) Nursing services in shelters for elderly groups, homeless

scavengers/beggars, groups of HIV sufferers

(PLWHA/People with Hiv-Aids), and WTS.

1.1.13. Community nursing intervention strategies

a. Group process: A person can recognize and prevent disease, of

course after learning from previous experience, apart from

individual education/knowledge factors, mass media,

television, counseling carried out by health workers, and so on.

Likewise with environmental health problems around the

community, of course the description of the disease they most

often encounter previously greatly influences the efforts they

make to treat or prevent disease. If people are aware that

individual treatment will not be able to prevent, let alone

eradicate, certain diseases, then they have approached health

problem solving using group processes.

b. Health education (health promotion) Health education is a

dynamic process of behavior change, where the change is not

just a process of transferring material/theory from one person

to another and is not a set of procedures.

The main goal of health education is so that a person is able to:

1) Define their own problems and needs;

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 2) Understand what they can do about the problem, with the

resources they have and additional support from outside

3) Deciding on the most appropriate activities to improve

the standard of healthy living and welfare of the

community.

c. Cooperation (Partner Ship) Various health problems that

occur in the community, if not handled properly, will become

a threat to the wider community. Therefore, cooperation is

really needed in an effort to achieve the goals of community

nursing care, through this effort various problems in the

community environment will be resolved more quickly

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 CHAPTER II

REVIEW THEORY

A. Theory Concept

1. Definition
Ca mammaeis a disturbance in the growth of normal mammary cells
where abnormal cells arise from normal cells, multiply and infiltrate the
lymphatic tissue and blood vessels. (Sofian, 2012).
Breast cancer is a malignant disease that most commonly attacks
women. This disease is caused by irregular division of body cells so that
cell growth cannot be controlled and will grow into tumors or cancer.
(Wijaya & Putri, 2013).

2. Etiology
There is no single specific cause, instead there are a series of genetic,
hormonal and environmental factors that can contribute to the occurrence
of breast cancer. Breast cancer shows the malignant proliferation of
epithelial cells that line the ducts or lobes of the breast. Initially there is
only cell hyperplasia with the development of atypical cells and then
progresses to carcinoma in situ and invades the stroma. Cancer takes 7
years to grow from a single cell to a mass.
Steroid hormones produced by the ovaries also play a role in the formation

of breast cancer (estradisol and progesterone undergo changes in the cellular

environment). (Bunner & Suddarth).

a. Risk Factors for Mammary Ca:

According to Mulyani & Nuryani (2013); Sukaca & Suryaningsih (2009)

there are several factors that have an influence on the occurrence of

mammary ca, including:

1) Gender

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 Women have a greater risk of developing ca mammae than men, the

ratio is 99 to 1.

2) Family History

Women whose mothers or siblings suffer from breast cancer are 2 to 3

times more likely to suffer from breast cancer. (Erik T, 2005: 43-46).

3) Have a history of breast cancer

A woman who has ca mammae in one breast has a 3 to 4 times greater

risk of suffering from breast cancer.

4) Breast Changes

If a woman has breast tissue changes known as atypical hyperplasia

(according to biopsy results), then a woman has an increased risk of

mammary ca.

5) Menstrual Period

Women who are starting to have early menstrual periods (early

menarche) before the age of 12 years or who have gone through the

changes in the menopausal phase after the age of 55 years have a

slightly higher risk of developing mammary ca.

6) Hormone Use

Harvard School of Public Healthstates that there is an increased risk

of ca mammae with long-term use of estrogen hormone therapy

7) Nulliparous

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 Women who have not had children orgive birth to first child after 30

years,exposure to the hormone estrogen is relatively longer than

women who already have children so they may also be at risk of

developing mammary ca.

8) Not Breastfeeding for Postpartum Women

Based on research, longer breastfeeding times have a stronger effect in

reducing the risk of breast cancer. This is due to a decrease in estrogen

levels and the secretion of carcinogenic substances during

breastfeeding.

9) Early Exposure to Breast Radiation

The woman whoexposed to ionizing radiation after puberty or before

the age of 30 years has a 2-fold risk of developing mammary ca

10) Age

The risk of developing ca mammae increases with age because of the

possibility of "mutagenic" changes occurring with age.

11) Obesity

Obesity has a stimulating effect on the development of breast cancer,

estrogen is stored in adipose tissue (fat tissue). Some breast cancers

are estrogen receptor positive (ER+), meaning that estrogen

stimulates the growth of breast cancer cells. So the more adipose

tissue there is, the more estrogen binds to the ER+ of cancer cells.

12) Alcohol Consumption

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 Women who frequently consume alcohol are at risk of developing ca

mammae because alcohol causes a fatty liver, so the liver works

harder making it difficult to process estrogen out of the body and the

amount will increase.

13) Smoke

Smoking can increase the risk of developing mammary causation

because the ingredients contained in cigarettes are very dangerous.

3. Pathophysiology
Breast cancer is not the only disease but there are many, depending on the

breast tissue affected, its estrogen dependence, and the age of onset. Malignant

breast disease before menopause is different from malignant breast disease

after menopause. The response and prognosis for treatment is different from

various other dangerous diseases.

Some tumors known as “estrogen dependent” contain receptors that bind

estradiol and their growth is stimulated by estrogen. These receptors are not

manual in normal breast tissue or in tissue with dysplasia.

The presence of Estrogen Receptor Assay (ERA) tumors in tissue is higher

than hormone dependent breast cancers. These cancers respond to hormone

treatment (endocrine chemotherapy, oophorectomy, or adrenalectomy).

(Smeltzer, et al, 2002: 1589).

A tumor is a group of changed cells characterized by excessive cell

proliferation and does not follow the influence of the structure of the

surrounding tissue.

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 Malignant neoplasms consist of cancer cells that showUncontrolled

proliferation disrupts normal tissue function by infiltrating and then entering

and spreading to distant organs. In these cells biochemical changes occur,

especially in the nucleus. Almost all malignant tumors grow from a cell in

which malignant transformation has occurred and turned into a group of

malignant cells among normal cells.

a. The long-term process of breast cancer has 4 phases:

1) Induction phase: 15 to 30 years

Until now the cause of cancer has not been confirmed, but environmental

factors may play a large role in the occurrence of cancer in humans.

Contact with carcinogens can take years to turn dysplastic tissue

into a malignant tumor. This depends on the nature, amount and

concentration of the carcinogen, the place where the carcinogen is

exposed, the duration of exposure, the presence of other carcinogens or

co-carcinogens, tissue and individual susceptibility.

2) In situ phase: 1 to 5 years

In this phase, tissue changes appear to become pre-cancerous lesions

which can be found in the uterine cervix, oral cavity, lungs,

gastrointestinal tract, bladder, skin and finally found in the breasts.

3) Invasion phase

The cells become malignant, multiply and infiltrate through the cell

membrane into the surrounding tissue into the blood vessels and lymph.

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 The time between the 3rd and 4th phases lasts between several weeks to

several years.

4) Dissemination phase: 1-5 years

If the tumor gets bigger, the possibility of spreading to other places

increases.

b. Stage or Development of Breast Cancer

The stage in cancer is to describe the condition of the cancer, namely its

location, how far it has spread, and the extent of its influence on other body

organs.

Knowing the stage of cancer is one way to help doctors determine what

treatment is appropriate for the patient. (Mulyani & Nuryani, 2013).

Ca mammae stage according to the American Society of Clinical

Oncology, 2006:

a) Stage 0:

Ca mammaenon-invasiveThere are 2 types, namely DCIS and LCIS

b) Stage I (Early Stage):

The size of the tumor at this early stage is no more than 2-2.25 cm, and it

does not spread to the axillary lymph nodes. At this stage the chance of

complete healing is only around 70%

b) Stage II:

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 The tumor at this stage is around 2.25 cm in size and metastases have

occurred in the lymph nodes in the armpit. In stage II, the possibility of

complete recovery is around 30-40%, depending on the extent of the

spread of the cancer cells.

In stage I and II cancer, surgery will be carried out to remove the

cancer cells in all parts of the spread, and after the operation is complete,

radiation will be carried out to ensure that there are no more cancer cells

remaining in the body or not.

c) Stage IIa:

The diameter of the tumor is 2 cm smaller and has been found at points in

the lymph channels in the armpit.

d) Stage IIb:

The tumor diameter is wider than 2 cm but does not exceed 5 cm, has

spread to points in the axillary lymph vessels, and the tumor diameter is

wider than 5 cm but has not spread.

e) Stage III:

The tumor at this stage is quite large and the cancer cells have spread to

all parts of the body and the sufferer has little chance of recovering from

the tumor when it has entered this stage.

Treatment to cure breast cancer is no longer meaningful. Usually,

women who have experienced breast cancer up to stage III can only be

cured through chemotherapy, which is the administration of drugs that

can kill cancer cells. Sometimes the breasts are also removed when they

24
 are already severe. This effort is only to inhibit the process of breast

development to other organs and to relieve the sufferer's suffering as

much as possible.

f) Stage IIIa:

The diameter of the tumor is smaller than 5 cm and has spread to points

in the axillary lymph vessels.

g) Stage IIIb:

The tumor has spread to the chest wall or caused swelling or a festering

wound in the breast can be diagnosed as inflammatory breast cancer. It

may or may not have spread to points in the lymph vessels in the armpits

and upper arms, but has not spread to other parts of the body.

h) Stage IIIc:

Like stage IIIb, but has spread to points in the lymph vessels in group

N3.

i) Stage IV:

At this stage, cancer cells have attacked other parts of the patient's body,
usually the bones, lungs, liver or brain. Or it could even attackskin glands
and lymph nodes in the patient's neck.

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26
4. PATHWAYS

27
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5. Clinical Manifestations
To find out the symptoms and signs of breast cancer, you can do it in several

ways, including:

a. There is a lump in the breast

The lump that occurs usually feels different from the tissue in the breast and

surrounding areas. This lump does not cause pain and usually has irregular

edges, is small like a marble, etc. In breast cancer sufferers who are still in

the early stages, the existing lump can be moved and pushed with the

fingers. However, in advanced stages it usually sticks to the chest wall or

surrounding skin. In advanced stages, the existing lumps can swell and there

may also be ulcers on the skin.

b. Lumps in the armpit

Breast tissue expands and spreads through the lymph nodes under the armpit

so that one sign of breast cancer is a lump under the armpit.

c. The skin color of the breast changes to red

Apart from being characterized by a lump, breast cancer is also

characterized by a change in skin color. Changes usually occur with skin

that is redder, thicker, has a rash, and feels painful.

d. Nipple pain

Breast cancer also makes the nipples sore because the nipples sink inward.

e. Abnormal discharge from the nipple

Spontaneous discharge of abnormal fluids such as blood, yellow or green

pus.

f. The shape of the breast changes

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 Changes in breast shape to become larger, smaller or irregular. This is

because cancer cells havedamage breast tissueaffect its shape.

g. Changes in breast skin

The presence of breast cancer can also cause one part of the breast to shrink

like orange peel, being darker in color and rough when touched.

h. Swollen breasts

Breast cancer will cause swelling which makes the breasts feel continuously

painful, inflamed, red, which results in health conditions continuing to

decline because the cancer continues to grow and destroy more healthy body

tissue.

6. Breast Cancer Classification

Breast cancer can be classified into various types based on the cancer
cells seen under a microscope (American Cancer Society, 2013),
namely as follows:
a. Non-invasive Breast Cancer / Ductal Carcinoma In Situ (DCIS)

Non-invasive or pre-invasive breast cancer is cancer that occurs in the

milk sac (the connection between the alveoli or glands that produce milk

in the nipple).

DCISThis means that the cells lining the ducts change to look like

cancer cells. Cancer cells through the duct wall to the surrounding breast

tissue have not spread (invaded). Because it has not invaded, DCIS

cannot spread beyond the breast. However, in some cases it can turn into

invasive cancer (American Cancer Society, 2013).

b. Invasive Breast Cancer / Invasive Ductal Carcinoma (IDC)

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 Invasive breast cancer is cancer that has started to spread outside the milk

sac and has attacked other parts.

IDCbegins in the milk ducts of the breast, breaks through the duct walls,

and grows into the fatty tissue of the breast. Cancer can spread to other

parts of the body through the lymphatic system and bloodstream. About 8

in 10 invasive breast cancers are infiltrating ductal carcinoma (American

Cancer Society, 2013).

c. Invasive Lobular Carcinoma (ILC)

ILCbegins in the lobule glands that produce milk. Like IDC, cancer can

spread to other parts of the body.

d. Inflammatory Breast Cancer(IBC)

IBCis a condition where the breasts look inflamed (red and warm) with

hollows and thick edges caused by cancer cells that block the lymph

vessels of the skin covering the breasts, growing rapidly. This rare type

of invasive breast cancer accounts for about 1% to 3% of all breast

cancers. Usually there is no single lump or tumor. On the other hand,

inflammation of breast cancer makes the skin on the breast look red and

feel warm. It can also give thick breast skin, an appearance that looks like

an orange peel (American Cancer Society, 2013).

e. Paget's Disease of the Nipple(paget's disease of the nipple)

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 Paget's disease of the nipple is a type of mammary ca that starts from the

milk ducts, then spreads to the areola and nipple of the breast, symptoms

that appear like the breast skin will crack, become red, ulcers appear, and

ooze. This breast cancer starts in the breast duct and spreads to the skin

of the nipple and then to the areola. This cancer is rare, accounting for

only about 1% of all breast cancer cases. The skin of the nipple and

areola often appears crusty, scaly, and red, with areas of bleeding or

oozing. Patients may feel burning or itching (American Cancer Society,

2013).

f. PhylloidesTumor

Phylloidestumoris a type of cancer that can be benign or malignant and

develops in the connective tissue of the breast which can be treated with

surgical removal. This breast tumor very rarely develops in the

connective tissue of the breast, in contrast to carcinoma, which develops

in the ducts or lobules. Other names for this tumor include phylloides

tumor and phylloides cystosarcoma. (American Cancer Society, 2013).

g. Medullary Carcinoma

Medullary carcinomais a type of invasive mammary ca that forms an

unusual boundary between tumor tissue and normal tissue.

h. Mucinous Carcinoma

Mucinous carcinomaformed by cancer cells that have mucus (mucus) and

usually appear with other types of cancer. Its growth is slow, but over

time it can expand.

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 i. Tubular Carcinoma

Tubular carcinomais a special type of invasive mammary ca.

j. Angiosarcoma

This form of cancer starts in the cells that line blood vessels or lymph
vessels. This rarely occurs in the breast. It usually develops as a
complication of previous radiation treatment. This is a very rare
complication of breast radiation therapy that can develop
approximately 5-10 years after radiation. This cancer tends to grow
and spread quickly (American Cancer Society, 2013).

7. Complications
The main complication of ca mammae is the spread of surrounding tissue
through the lymph nodes and blood vessels to other organs. The places
where metastases often occur are the lungs, pleura, bones and liver.

8. Supporting investigation
a. Non invasive

1) Mammography

Mammography is the most reliable examination for detecting breast

cancer. Slow-growing cancers can be identified by mammography at

least 2 years before they reach a size that can be detected by palpation.

Mammography is more accurate than clinical examination for the

detection of early stage mammary ca, with an accuracy rate of 90%. The

National Cancer Center Network (NCCN) recommends that every

woman over 20 years should have a breast examination every 3 years,

while for those aged over 40 years, a breast examination should be

carried out every year accompanied by a mammography examination.

33
 2) Ultrasonography (USG)

Ultrasound is an important supporting examination to help with unclear

or doubtful mammography results, whether used to determine a solid

mass.

On ultrasound examination, mammary cysts have a clear border

with smooth borders and an echo-free area in the center. Benign breast

masses usually show smooth contours, oval or round shape, weak echo in

the central part.

Ultrasound is also used to direct fine-needle aspiration biopsy

(FNAB), coreneedle biopsy and needle localization of breast lesions.

3) Magnetic Resonance Imaging (MRI)

MRIIt also serves to determine the spread of carcinoma or determine the

response to neoadjuvant chemotherapy.

4) PET(Positron Emission Tomography) Scan

A PET scan helps doctors find out what happens to tissues and organs in

the body and describes the anatomy and metabolism of cancer cells. This

examination uses radiation rays which are captured by organs in the body

with the help of radioactive substances that have been injected at the

beginning of the examination.

b. Invasive

1) Biopsy

34
 A biopsy is an action to take a sample of breast tissue with a microscope

lens. In this way, it can be seen that there are mammary ca cells that are

lodged.

2) Biomarkers

Biomarkers are used as endpoints in short-term chemopreventive

studies and include histological changes, indices of proliferation and
genetic disturbances that lead to cancer.

9. Management
Mulyani & Nuryani (2013); Suryaningsih & Sukaca (2009), explained that the

management of ca mammae depends on the type and stage experienced by the

sufferer. The various types of management of ca mammae are as follows:

a. Lumpectomy or Surgery

A lumpectomy is performed to take a tissue sample (biopsy) from the lump.

The tissue will then be examined through a microscope in the anatomical

pathology laboratory. If it is known and confirmed that the lump is breast

cancer, the breast must be removed completely to avoid spreading to other

bodies. The types of surgery for lumpectomy are:

a) Radical Mastectomy

Radical mastectomyis an operation to remove part of the breast and this

operation is always followed by radiotherapy. Lumpectomy is usually

recommended for patients whose tumor is less than 2 cm and is located

on the edge of the breast.

b) Total Mastectomy

35
 Total mastectomyThis is an operation to remove the entire breast, not the

armpit glands.

c) ModifiedRadical Mastectomy

ModifiedRadical Mastectomyis an operation to remove the entire breast,

breast tissue in the breastbone, collarbone and ribs as well as lumps

around the armpit.

b. Radiotherapy

Radiotherapy is a very effective and highly targeted treatment method for

destroying cancer cells that may remain after surgery.

Radiation in cancer treatment is called ionizing radiation. This radiation

can reduce the risk of cancer recurrence. Usually radiation therapy uses

high-energy x-rays or other particles to kill cancer cells. This therapy is

carried out regularly per week (5 days) for 6 weeks depending on the size,

location, type of cancer, general health of the patient, and other treatments.

c. Hormone therapy

Hormone therapy can inhibit the growth of sensitive tumors and can be used

as adjunct therapy after surgery at the final stage. This is known as anti-

estrogen therapy to block the ability of the estrogen hormone to stimulate

the development of mammary ca.

The aim of this hormone therapy is to prevent estrogen from affecting

cancer cells in the body

d. Chemotherapy

36
Chemotherapy is a therapy given with certain drugs with very strong effects,

which can be given orally or intravenously (IV).

Adjuvant chemotherapy is given after surgery for types of mammary ca

that have not spread with the aim of reducing the risk of reappearance of

mammary ca. Cancer cells can break away from the original breast tumor

and spread through the bloodstream. These cells do not cause symptoms, do

not show up on x-rays, are not found on physical examination, but have the

opportunity to grow and form new tumors elsewhere in the body. This

adjuvant chemotherapy can be given to find and kill these cells.

1) How to administer chemotherapy drugs:

a) Orally

Given in series, usually taken for 2 weeks and take a break for 1 week

b) IV

Given in 6 chemo sessions, 3 weeks apart for the full dose.

2) Side effects that chemotherapy patients generally experience are:

a) Hair loss

b) Nails, skin black and dry

c) Nausea and vomiting

d) Anorexia

e) Changes in the menstrual cycle

f) Tired easily

3) Chemotherapy drugs commonly used in mammary ca are:

a) Cyclophosphamide (Cytoxan, Neosar)

37
 b) Methotrexate

c) Fluorouracil (5-Fu, Adrucil)

d) Paclitaxel (Taxol)

e) Docetaxel (Taxotere)

f) Vinorelbine (Navelbine)

g) Gemcitabine (Gemzar), etc.

4) Examples of drug combinations:

a) CMF (Cyclophosphamide, Methotrexate, And 5-Fu)

b) FAC (5-Fu, Doxorubicin, Cyclophosphamide)

c) TAC (Docetaxel, Doxorubicin, Cyclophosphamide)

d) GT (Gemcitabine And Paclitaxel), etc.

5) Patient care after chemotherapy:

a) Anorexia

Treatment that can be done is to teach patients how to manage food,

such as the need for carbohydrates, as a source of energy they must be

consumed regularly, can be obtained from flour, cereal, pasta and

bread, but avoid things that are too sweet such as candy and wet

cakes. The need for protein is important because it contains lots of

vitamins and minerals. To increase protein intake, you can also eat

boiled eggs, meat, yoghurt.

b) Changes in the sense of taste

38
 Avoid bitter foods, soft protein foods (milk, fish, chicken), maintain a

sweet taste, consume additional foods, do a taste test, carbohydrates in

patients who don't like sweets.

c) Nausea and vomiting

To prevent or minimize nausea and vomiting:

- Eat cold foods or those served at room temperature because hot

foods increase the sensation of nausea.

- Drink a glass of apple juice, lemon, gelatin, or tea to relieve nausea.

- Avoid foods that are too sweet, fatty and too spicy.

- Avoid eating and drinking 1 to 2 hours before and after

chemotherapy.

- Use distraction techniques (music, radio, TV)

- Use it to sleep when you feel nauseous

d) Diarrhea

Avoid foods that irritate the stomach, such as: cereal, flour bread, nuts,
seeds, chocolate, fresh or dried fruit, fruit juices (bananas, avocados,
apples and grapes), raw vegetables, avoid foods that contain a lot of gas, as
well as foods and drinks that contain caffeine.

B. Nursing Care Concept

Assessment
1) Assessment
According to Suprajitno (2004:29) assessment is a stage when a nurse
continuously collects information about the family they are coaching.
Assessment is the first step in implementing family nursing care. In order to

39
 obtain assessment data that is accurate and appropriate to the family
situation, nurses are expected to use their mother tongue (the language used
every day), be direct and simple (Suprajitno: 2004). Activities carried out in
the assessment include collecting information in a systematic way using a
family assessment tool, classifying and analyzing it (Friendman, 1998: 56).
2) Data collection
1) Identity
The families studied were age, occupation, place of residence, and family
type
2) Family History and Stage of Development
1) At the current stage of family development, the family's expectations
are determined by the eldest child from the nuclear family.
2) Unfulfilled stage of family development
Explain the developmental tasks that have not been fulfilled by the
family as well as the obstacles to why these developmental tasks have
not been fulfilled.
3) Nuclear family history
Explain the family's health history
core, which includes history of hereditary diseases, health history of
each family member, attention to disease prevention (immunization
status), sources of health services commonly used by the family and
experiences with health services.
4) Previous family history
The medical history of the husband and wife's family is explained.
3) Environmental Assessment
1) House characteristics
House characteristics are identified by looking at the area of the
house, type of house, number of rooms, number of windows, distance
of the septic tank to the water source, source of drinking water used
and the house plan.
2) Characteristics of neighbors and RW communities

40
 Explain the characteristics of neighbors and local communities which
include habits, physical environment, rules/agreements of local
residents, local culture that influence health.
3) Geographic mobility of the family
The geographical mobility of a family is determined by the family's
habit of moving from place to place.
4) Family gatherings and interactions with the community
Explains the time the family spends gathering and existing family
gatherings and the extent of the family's interaction with the
community.
5) Family support system
What is included in the family support system is the number of
healthy family members, the facilities the family has to support health.
Facilities include physical facilities, psychological facilities or support
from family members and social facilities or support from the local
community.
4) Cultural background/family habits
1) Eating habit
These eating habits include the types of food consumed by the family.
2) Utilization of health facilities
Family behavior in utilizing health facilities is an important factor in
disease management.
3) Traditional medicine
It is a choice for the family to determine the desired treatment or
alternative choice, namely traditional treatment.
5) Socioeconomic Status
1) Education
The level of family education influences the family's recognition of a
disease and its management. It also influences your mindset and
ability to make decisions in overcoming problems appropriately and
correctly.

41
 2) Employment and Income
Unbalanced income also affects families in providing treatment and
care for family members who are sick, one of which is caused by an
illness. According to (Effendy, 1998), one of the reasons is that the
family's inability to care for sick family members is due to an
imbalance in the family's existing resources.
6) Developmental level and family history
According to Friedmen (1998: 125), family history from birth to the
present, including a history of developments and events as well as unique
or health-related health experiences that occur in family life that have not
been fulfilled, has an impact on a person's psychology which can result in
anxiety.
7) Activity
The activity pattern chosen by a family can influence the occurrence of a
disease and a family's lifestyle.
8) Environmental Data
a. House characteristics
How to modify a good physical environment such as house floors,
good lighting and ventilation can reduce the factors that cause disease.
b. Environmental Characteristics
According to (Friedman, 1998: 22) the degree of health is influenced
by the environment. The tranquility of the environment greatly
influences the level of health.

9) Family structure
1) Communication patterns
According to (Friedman, 1998) all nurse interactions with patients are
based on communication. The term therapeutic communication is a
technique in which an attempt is made to invite the patient and family

42
 to exchange thoughts and feelings. These techniques include verbal
and nonverbal skills, empathy and a high sense of caring.
2) Power Structure
Power in the family influences health conditions, authoritarian power
can cause psychological stress.
3) Role structure
According to Friedman (1998), family members accept and are
consistent with the roles they play, this will make family members
satisfied or there will be no conflict in their roles, and conversely, if
the roles are unacceptable and not in line with expectations, this will
result in tension in the family.
10) Family functions
1) Affective function
Families must respect each other so as not to cause certain problems
or stressors for the family members themselves.
2) Socialization function.
The family provides freedom for family members to socialize with the
surrounding environment. If the family does not give freedom to its
members, it will result in family members becoming lonely. This
situation threatens to make emotional status unstable and easily
stressed.

3) Health function
According to Suprajitno (2004), the function of developing and
training children to live a social life before leaving the house to
connect with other people outside the home.
The things that need to be studied to find out the extent to which the family
fulfills its family care duties are:
1) To determine the family's ability to recognize health problems, what
needs to be studied is the extent to which the family understands the facts
of health problems which include: understanding, signs and symptoms,

43
 factors that cause and influence them and the family's perception of the
problem.
2) To determine the family's ability to make decisions regarding appropriate
health actions, things that need to be studied are;
a. To what extent is the family's ability to understand the nature and
extent of the problem?
b. Are there any health problems experienced by the family?
c. Does the family feel like they have given up on the problems they are
experiencing?
d. Does the family fear the consequences of the disease?
e. Does the family have a negative attitude towards health problems?
f. Can the family reach existing health facilities?
g. Does the family lack trust in health workers?
h. Does the family receive wrong information regarding actions to
overcome the problem?
3) Knowing the extent of the family's ability to care for sick family
members, including the ability to maintain the environment and use
existing health resources/facilities in the community, what needs to be
studied is;
1) Does the family know the nature and development of care needed to
overcome health problems/diseases?
2) Does the family have the resources and facilities necessary for care.
3) Family skills regarding the type of care required are adequate.
4) Does the family have a negative view of the care needed?
5) Are there individual conflicts and selfish behavior in the family
6) Are families less able to maintain profits in preserving the
environment in the future?
7) Which does the family have efforts to improve health and prevent
disease?
8) Is the family aware of the importance of health facilities and how the
family views these facilities?

44
 9) Does the family feel afraid of the consequences of the action
(diagnostics, treatment and rehabilitation).
10) How does the family's philosophy of life relate to treatment and
prevention efforts?
11) Reproductive function
Things that need to be studied regarding the reproductive function of the
family are:
a. How many children?
b. How the family plans the number of family members
c. What methods do families use to control the number of family
members?
12) Economic function
Things that need to be studied regarding the economic function of the
family are:
A. The extent to which the family meets its needs for clothing, food and
shelter
B. The extent to which the family utilizes existing resources in the
community in an effort to improve the family's health status.

13) Family stress and coping

1. Short and long term stressors
a. Short-term stressors are stressors experienced by families that
require resolution in less than 6 months.
b. This long-term stressor is a stressor experienced by the family that
requires resolution within more than 6 months.
2. The family's ability to respond to situations/stressors. What needs to
be studied is the extent to which the family responds to
situations/stressors.
3. Coping strategies used Coping strategies used by families when facing
problems.
4. Dysfunctional adaptation strategies

45
 5. Dysfunctional adaptation strategies used by families when facing
problems
14) Physical examination
Physical examinations were carried out on all family members. The
methods used in physical examinations are no different from physical
examinations in clinics.
15) Family expectations
At the end of the assessment, the nurse asks the family's hopes
towards existing health workers.

Nursing diagnoses
According to Nurarif & Kusuma (2013), diagnoses that may appear in

ca mammae patients are:

a. Pain is related to pressure on the tumor mass

b. Anxiety related to changes in body image

c. The risk of nosocomial infections is related to environmental

conditions

d. Lack of knowledge about the condition, prognosis, and treatment of

the disease is related to lack of information.

e. Impaired tissue integrity is associated with mastectomy.

f. Body image disturbances associated with mastectomy

Imbalanced nutrition less than body requirements is related to

hypermetabolism in tissues.

46
 BIBLIOGRAPHY

Friedman, M.M., & Bowden, V.R. (2010). Family nursing textbook. EGC.

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2014). Textbook of Family Nursing
Research, Theory & Practice (E. Tiar (ed.); 5th ed.). EGC Medical Book
Publishers.

Ali, Z. (2010). Introduction to Family Nursing. EGC Medical Book Publishers.

Azza, A., & Setyowati, T. (2015). Health and Economic Empowerment of Women
Suffering from HIV/AIDS Through Life Skills Education. Nursing Journal,
10(1), 183– 188. http://dx.doi.org/10.20473/jn.v10i1.2158/ accessed 21 October
2023

47
 CHAPTER III

CASE REVIEW

Health agencies : Jayapura City Hospital

Group : IX

Institutional advisor :Eva Sinaga, S.Kep., Ns., MNg

Assessment date :

1. Assessment

A. General Data Review

1. Name of Head of Family :Mr. W
2. Age :59 Years
3. Religion : Islam
4. Education : SENIOR HIGH SCHOOL
5. Work : Private
6. Tribes :East Java
7. Address :Klofkam
8. Family Composition
No Name Age JK Connection Education Work Note.

JUNIOR
1. Mrs. S 46 P Wife HIGH IRT
SCHOOL

2 His 31 P Child S1 IRT

3 SDR.N 24 L Child SENIOR TNI

HIGH
 SCHOOL

9. Family Type:
Middle Age (middle-aged couple) A family consisting of a husband and wife
who live at home because their children already have a household, and the
others are migrating away

10. Family Nature

a. Decision-making
Mr. W said that their family had been making decisions as the head of
the family
b. Daily Habits
1) Sleep/Rest Habits
Mr. W said they usually sleep from 21.00 WIT – 04.30 WIT and
sometimes take a nap from 13.00 WIT – 14.00 WIT
2) Recreational Habits
Mr. W said that when he goes on holiday, he usually goes to the
beach for recreation, but because his wife is sick, he never goes on
holiday anymore, just focuses on treatment
3) Family Eating Habits
Mr. W said he had lunch and dinner with his wife
11. Family Socioeconomic Status
Mrs. S said her husband's income was uncertain, and now he is not even
working because he accompanies him for treatment
12. Ethnicity (Health Habits Related to Ethnicity)
Mr. W said that when his family is sick they usually drink warm water that
smart people read to them.
13. Religion (Health Habits Related to Religion)
 Mr. W said that when his family was sick, he sometimes said prayers with
his neighbors.

B. Data on the assessment of sick individuals

A. Assessment

Date of entry : Wednesday, April 12 2023

Assessment date : Monday, 11October 2019

Medical Record No : 504878

Room/Ward : Women's Surgery at Jayapura Regional Hospital

Medical diagnosis : Ca Mammae

1. Identity

Patient identity

Name : Mrs.S

Gender : Woman

Age : 46year

Marital status : Marry

Religion : Islam

Tribes : Sunda, West Java

Education : JUNIOR HIGH SCHOOL

Work : Housewife

Address : Jl. Perintis behind POM, Kloofkam

2. Main complaint

When entering the hospital : Pain in the left chest

 When studied : The patient says he is weak, pain in the left

chest down to the hand, nausea and vomiting

more than 10 times in the morning, dizziness,

no appetite, hasn't defecated for 2 weeks,

right leg is difficult to lift, can only be

moved.

3. Chief Complaint History

1) The pain was felt 1 week ago, radiating to the left hand, heartburn,

weakness accompanied by cough ± 1 year ago.

2) The patient underwent a left mastectomy (removal of the breast)

around May 22 2020 at Manokwari General Hospital and underwent

chemotherapy 8 times.

3) The patient's chemotherapy drugs ran out, he was referred to Jayapura

Regional Hospital to continue chemotherapy. The first chemotherapy

at Jayapura Regional Hospital will be on 10 February 2023 and the

second chemotherapy is planned on 12 October 2022.

4. Family Health History

The patient said that no one had previously experienced breast cancer in

her family.

5. Functional Health Patterns

1) Health management patterns

 The patient said he had been suffering from cancer for 2 years,

initially it was just a lump like a marble in the left breast, over time it

started to enlarge, mucus mixed with blood came out of the nipple,

the nipple went inward. In the past, patients only received herbal

treatment, but there was no change and finally the patient decided to

receive medical treatment. The patient underwent surgical removal

(masetectomy) of the left breast on May 22 2020 and has undergone

chemotherapy 8 times at RSU Manokwari.

2) Nutrition and Metabolism Patterns

Table 3.1 Nutrition and Metabolism Patterns

Information Before Illness During Illness

Frequency 3-4x/day 1-2x/day
Food menu Rice, side dishes, Porridge, side
Appetite fruit, etc dishes, vegetables
Portions run out /1x Good Decrease
Eat 1 serving finished 1-2 tablespoons
Abstinence from
eating Ready meals, etc Ready meals, etc
Complaint No complaints Nausea every
time I eat
Eat

Drink

Information Before Illness During Illness

Frequency 3-4x/day 4x/day
Type of drinking Water, tea, etc Warm water
 Amount of 1 drink ±350 ml ±20 ml
Complaint No complaints Nauseous

3) Elimination Pattern

Table 3.2 Elimination Patterns

CHAPTER

Information Before Illness During Illness

Frequency 1x/day Not defecating
yet (±2 weeks)
Consistency Soft, dense -
Smell Typical feces -
Color Brownish yellow -
Drug use Do not use laxatives Dulcolax 2/10 mg
laxative In the toilet (supposutorial)
How to defecate No complaints With Pampers
Complaint Can't defecate yet

BAK

Information Before Illness During Illness

Frequency 2-3x/day 3x/day
Quantity 1x BAK ±200cc ±150cc (weighed)
Smell Ammonia Ammonia
Color Dark-yellow Yellow
Complaint No complaints Can't stand up to
urinate in the
AIDS Do not use tools toilet
Using diapers
4) Activity Patterns

Table 3.3 Activity Patterns

 Information Before Illness During Illness
Routine mobility Doing homework Mobilization in bed /
Relax with family bedrest
Leisure time Morning walk Rest
(1x a month)
Sport Do not use tools Never
No complaints
Use of assistive Do not use tools
devices Can't stand, can't lift
my right leg, only
Complaint move it

5) Personal Hygiene

Table 3.4 Personal Hygiene

Information Before Illness During Illness

Bathe 2x/day 1x/day, assisted
Washing hair 3-4x/week Never
(because hair
falls/bald)
Brushing teeth 3x/day 1x/day, assisted
Trimming nails 5x/week 4x/week
Genetalia hygiene Every time you Every time you
shower, defecate and bathe, change
Complaint urinate diapers
No complaints Can't stand up

6) Rest-Sleep Pattern

Table 3.5 Rest-Sleep Pattern

Information Before Illness During Illness

Nap time Seldom ±1-2 hours
Night sleep hours ±8 hours ±4-6 hours
bedtime Watch TV Chat with
family
Sleep disorders No distractions Pain felt
 The feeling of Relaxed, fresh Dizzy,
waking up There isn't any uncomfortable
Complaint Can't sleep well
because of the pain
from the surgery
wound reaching my
left hand

6. Physical examination

a. General condition: Looks seriously ill

b. Awareness

1) Qualitative: Composmentis (fully aware)

2) Quantitative: Eyes opens spontaneously = 4

Verbal orientation can carry out a conversation =5

Motor response to verbal commands =6

TotalGCS=15

c. Vital Signs (TTV)

1) Blood Pressure (BP): 120 (systole) / 80 (diastole) mmHg

2) Body temperature (SB) in the axilla: 36.9oC

3) Respiration (RR): Frequency 20x/m with slow, regular (regular)

pulses

4) Pulse (ND): 89x/minute

d. Body Weight (BB)

1) Before illness: 63 kg

2) During illness: 47 kg
e. Height: 160 cm

BMI 50 kg: (160)2 = 19

f. Head

1) Inspection:

a) The condition of the hair is bald, there are only fine hairs,

there are no lesions, lumps, dandruff

b) Head shape is normocephalic, symmetrical

2) Palpation:

1) No palpable tenderness

2) No visible enlargement of the head

g. Face / face

1) Inspection:

a) Symmetrical face shape

b) The facial expression appears grimacing, weak and pale

2) Palpation:

a) No palpable tenderness

b) There was no visible deformity on the face

h. Eye

1) Inspection:

a) The lines of both eyes are symmetrical

b) The condition of the eyeballs is enophthalmos (drawn inward)

c) The eyelids appear drooping or ptosis

 d) Anemic or pale conjunctiva

e) The color of the sclera is white, there are no visible cataracts

on the cornea, iris or lens.

f) Pupillary reflex to light

Direct: +/-

Indirect : -/-

2) Palpation:

a) No palpable tenderness

i. Nose

1) Inspection:

a) There does not appear to be any obstruction or discharge in the

nose

b) No nostril breathing is visible

c) The shape of the nose looks symmetrical right and left

2) Palpation:

a) No palpable tenderness or septal deviation

j. Mouth

1) Inspection:

a) The shape of the mouth is symmetrical, there is no visible

deviation to one side, stomatitis or inflammation of the oral

mucosa

b) Lips look pale, dry, slightly chapped

 c) The tongue looks clean, there are no canker sores visible, the

color is white.

d) There was no visible enlargement of the tonsils

e) The number of teeth is 21, the teeth are neatly positioned,

there is no visible dental caries, cavities or inflammation

f) There are no visible gaps or lumps in the midline of the palate

(tonus palatinus).

2) Palpation:

a) No palpable tenderness in the mouth

k. Ear

1) Inspection:

a) The right and left earlobes are symmetrical, there is no visible

inflammation or deformity

b) The ear canal looks clean, the tympanic membrane is intact,

there is no visible swelling

c) Not using hearing aids, good hearing at a distance of ± 6

meters

2) Palpation:

a) There was no palpable tenderness on the masthead process

l. Neck

1) Inspection:

a) There was no visible thyroid enlargement

 b) There was no visible inflammation or enlargement of the

jugular veins

2) Palpation

a) The thyroid gland is not palpable (when swallowing)

b) There is no palpable enlargement of the lymph nodes and

thyroid gland

c) There is no palpable stiff neck

m. Thorax (Chest)

1) Inspection:

a) Normal chest shape cest

b) Respiratory frequency 20x/m, with slow breathing)

c) There was no visible intercostal retraction, use of accessory

muscles for breathing

d) Regular respiratory rhythm, chyne-stokes type of breathing

(rapid deep breathing followed by slow shallow breathing then

apnea for a while)

2) Palpation:

a) Vocal premitus: same left-right vibration

b) Chest wall expansion is the same

c) No palpable swelling, tenderness or crepitus

3) Auscultation:
 1) Breath sounds: vesicular (inspiration > breath sounds and

length of expiration)

2) Additional breath sounds: coughing sounds

4) Percussion:

1) Lungs: sonor sound

2) Heart: faint, no enlargement

3) Liver: no enlargement, dim

n. Breast

1) Inspection:

a) Breast shape is not symmetrical

b) There is a scar from surgery to remove the left breast ± 3-4 cm

c) On the right breast wrinkles like orange peel,

2) Palpation:

a) Palpable tenderness in the left breast, felt spreading to the left

hand

P: Surgical wound

Q: Spreads to the left hand

R: Left mammary

S : 3 (1-10)

T: 1 minute (disappears - appears)

o. Heart

1) Palpation:
 a) Ictus cordispalpable at the 5th left anterior axillary ics

2) Percussion:

a) Dim, no heart enlargement

b) Heart limit:

- Upper right SIC II linea parasternalisis dextra

- Lower right SIC IV linea parasternalisis dextra

- Upper left SIC II left parasternal line

- Lower left SIC IV linea medio

3) Auscultation:

a) BJ I ICS 4 linea sternalis sinistra, ICS 5 linea medio

davicularis sinistra (Closing of the tricuspid and mitral valves,

LUB sound).

b) BJ II ICS 2 linea sternalis dextra, ICS 2 and 3 linea sternalis

sinistra (closure of the arterial and pulmonary valves, DUB

sound)

p. Abdomen

1) Inspection:

a) The abdomen is flat, there are no rashes or lesions, scar tissue

and shiny, tense skin

b) There is no venous mesh

2) Auscultation:

a) Bowel sounds heard 4x/minute (5-10x/minute)

 b) Peristalsis is increased in ileus obstruction

3) Percussion:

a) Tympanic sounds on the surface of the abdomen

b) Dull sound in the lymph area or no enlargement

c) Faint sound in the liver area or no enlargement

4) Palpation:

a) There was no palpable abdominal distension, tenderness or

shifting dullness

b) There was no palpable enlargement of the liver or lymph

q. Extremities

Upper extremity:

1) Motor:

a) Muscle strength 5555 3333

Left right

b) Weak motor coordination (right-left)

2) Reflex:

a) Right-left biceps flexes forearm

b) Right-left triceps forearm extension

3) Sensory:

a) Patients may feel pain

b) Patients can differentiate between hot, warm and cold

temperatures
 c) The patient can feel when touched or touched

Lower extremities:

1) Motor:

a) The patient said he could not stand independently because his

right leg was weak

b) Right and left muscle strength

2222 5555

c) Right muscle tone +1 (weak), left +2 (normal)

2) Reflex:

a) KPR (Knee Pess Reflex)/ right-left patella reflex motor

contraction quadriceps femoris leg extension positive (+)

b) APR (Achillcs Pess Reflex)right-left triceps motor contraction

sure or positive foot plantarflexion (+)

c) Babinski right-left dorsiflexion of toes and flexion of other

toes

3) Sensory:

a) Pain stimuli can be felt by the patient

b) Patients can differentiate between hot, warm and cold

temperatures

c) The patient can feel touch or touch

r. Skin
 1) CRTs>2 seconds, skin turgor looks moist, the acral feels slightly

warm

7. Diagnostic Examination

- Laboratory examination

RSUD Clinical Laboratory Installation

Inspection date: 12 October 2023

Table 3.6 Laboratory Examination

Inspection Results Reference Value

Hemoglobin levels 8.5 g/dL 11.0-14.7
Platelets 489 10^3/uL 140-400
Eosinophil Cells 0.5 % 0.6-5.4
Monocyte Cells 15.8% 4.3-10.0
Blood Cl 107.50 mEq/L 98-106

- Radiological Examination (Abdominal Ultrasound)

SMF Jayapura Regional Hospital

Inspection date: 14 October 2023

Impression: No visible nodules in the liver

No ascites visible; There was no visible KBG enlargement in

the aorta

- CT-ScanHead

Date: October 13, 2023

Impression: No visible masses or metastases, no ischemia or bleeding

- Histopathological Examination

Citos Clinical Laboratory

Examination date: 28 October 2020

Results : 02 March 2020

Organ : Mastectomymammaesinistra

Macroscopic : Tissue size 5.6x5.5x3.4 cm, brown,

bumpy, capsuled, brownish white in cross

section.

Microscopic : The preparation shows that the tumor tissue

consists of epithelial elements in the form of

proliferation of round, oval, elongated and

branched glands. The mesenchymal element is

a ploferation of connective tissue that grows

intracanalicularly and pericanalicularly. There

were signs of malignancy

Conclusion :

- Left mammary mastectomy: Invasive (ductal) carcinoma of NST

grade III

- Metastases to 16 lymph nodes were found

- Lymphavascular invasion(+)

- Parineural invasion(+)
 - Distance from the operating base to the nearest tumor (1 mm)

- pT4N2 Mx

8. Medical Therapy

Table 3.7 Medical Therapy

Medicine name Dose Way of giving Delivery time

Voralbine 40 mg IV 1x / Every 24 hours
(Diplos NaCL 50
cc)
Diphenhydramine 10 mg IV 1x / Every 24 hours
Dexamethasone 4 mg IV 1x / Every 24 hours
Ambroxol 3x30 mg (tab) Orally 13.00 WIT-17.00
WIT-21.00 WIT
Jurnistha 1x8 mg Orally 13.00 WIT
Omeprazole 2x40 mg IV 19.00 WIT-07.00
Antrain 3x500 mg IV WIT
23.00 WIT-19.00
Ranitidine 2x50 mg IV WIT -07.00 WIT
07.00 WIT-19.00
Neurobion 2x100 mg IV WIT-23.00 WIT
07.00 WIT-15.00
Ondancentron 2x4 mg IV WIT-19.00 WIT
Ceftriaxone 2x1000 mg IV 07.00 WIT-19.00
Paracetamol 1x50 mg IV WIT
IVFD NaCl 500 ml IV 2 : 1 07.00 WIT-19.00
0.9%, IVFD 1000 ml WIT
Clinimix 8.4 mg/patch Attached 19.00 WIT / KP
Dorugesic between ICS 2- Per-24 hours expired
3 mid clavicle / 20 TPM

1x3 (days)

C. Family History and Stages of Development

1. Current Stage of Family Development
 Mr. W said a family with adult children, where there are 2 children, the first
child is married and has children, and the second child has grown up and has
a job.
2. Unfulfilled Stages of Family Development
According to Mr. W currently has a family that has grown-up children, but
has not yet found a candidate for marriage
3. Nuclear Family History
Mr. W said he had no complaints regarding his health, Mr. W had never
been hospitalized, Mr. W also did not smoke and had no history of
hypertension.
Mrs. S has been suffering from breast cancer for 2 years and was
hospitalized for chemotherapy 8 times and the tumor on her left breast was
removed. Currently, Mrs. S's complaint is that sometimes she still feels pain
in her left breast like it is throbbing.
4. Previous Family History
Mr. W said they had no previous family history of breast cancer.

D. Environment
1. House Characteristics
Mr. W's family lives in a rented house measuring 3x4 m.
2. Ventilation And Lighting
Mr. W's family residence only has a main door, ventilation with lighting
using PLN lights at night, during the day by opening the windows of the
house.
3. Clean Water Supply
Mr. W said the need for clean water comes from well water and uses gallons
of water for cooking
4. Waste disposal
 Mr. W said he threw away the rubbish, put it in the rubbish bin at home and
then threw it in the rubbish bin.
5. Waste disposal
Mr. W said to throw the waste water in the trash.
6. Jambang/WC
Mr. W said the latrine was combined with the bathroom, it looked like a
bathroom with a tub

7. House plan

P
Sitting room

4m T. sleep

TV

Kitche KM
n
3m

8. Environment Around the House

The inside of the house looks neat and orderly.
9. Communication and Transportation Facilities
Mr. W said the means of communication used when outside the home was a
cellphone and the transportation used was a motorbike taxi or taxi.
10. Entertainment Facilities
TV, Mobile etc
11. Medical facility
 Mr. W said that the closest health facility was the Jayapura City Hospital and
the family had an active BPJS which was covered by the government.

E. Social
1. Neighborhood and Community Characteristics
The distance between one house and another is very close. And have friendly
neighbors
2. Family Graphic Mobility
Mr. W said that previously he lived in Manokwari, then moved and rented a
house in Jayapura because he was seeking treatment and contracting at D
Jayapura Hospital.
3. Family Gatherings with Interaction with the Community
Mr. W said the family does not have any special gatherings, only friendly
gatherings during Eid, celebrations and large events with good interactions
with the community.
4. Family Support System
Mr. W's family currently lives alone with his wife.

F. Family Structure
1. Family Communication Patterns
Mr. W said he usually communicates using Indonesian, a two-way
communication pattern. When there is a problem, always discuss it together.
2. Family Power Structure
Mr. W's family is a nuclear family consisting of husband, wife and children.
3. Role Structure (Formal and Informal)
Formal : Mr.W plays the role of father
Mrs. S plays the role of mother
Informal :
4. Family Values and Norms
 Mr. W said that his family always applies the value of courtesy to everyone.

G. Family Functions
1. Affective Function
Mr. W's family loves and respects each other. Mrs. S also always makes time
to watch TV with her children and husband.
2. Socialization Function
Mr. W said he rarely participates in organizational activities in the
community because he is busy working, and Mrs. S also rarely participates
in organizational activities in the community because her relationship with
local residents remains good.
3. Health Care Functions
a. Recognizing Health Problems
Mr. W said that his family did not know enough about health problems
such as causes and effects, as well as factors in the family's perception of
health problems. Mr. W only knows that complaints from his family
members who are sick are something that needs to be handled
immediately.
b. Take the right decision
Mr. W's family only knows that the nature and health problems
experienced by his family members need to be treated immediately so that
the problem does not get worse. Mrs. S said that initially the family
decided to only have a midwifery check-up because her breasts felt hard
and there were lumps, but the midwife suggested that she carry out
further examinations at the hospital regarding her condition.
c. Provide care to sick family members
Mr. W's family does not yet fully know how to provide self-care at home
for sick family members related to their illness. The family only knows
 how to treat it, such as avoiding fast food, burnt food, and taking
medication from a doctor
d. Environmental Modification
Mr. W can modify his environment well, this can be seen from the front
window which is always open during the day.
e. Utilizing Existing Health Services
Mr. W said that if the family experiences health problems, they always
take them to the nearest health center as Mr. Family's health facility. W.
4. Economic Functions
Mr. W said that to this day the income earned is still sufficient to support his
family.

H. Stress and Family Coping

1. Stressors
a. Short Term Stressors
According to Mr. W is currently thinking about when Mrs. S will recover
from hypertension
b. Long Term Stressors
According to Mr. W, he is worried about the survival of his family
members, especially his youngest child who is not yet married, and Mrs.
S is afraid that her daughter will also get the same disease as her.
2. Family Ability to Respond to Situations or Stersors
Mr. W is now trying to learn to be a good husband and father, taking care of
his wife and helping his children earn a living.
3. Coping Strategy
To deal with stressors Mr. W based on her parents' past or experience to deal
with health problems, namely going to a midwife and consuming medicinal
plants for pain.
 4. Dysfunctional Adaptation Strategies
Mr. W said that when he was sick he would go to the midwife's health
facility and if he didn't get better he would go to the community health
center.

I. Family Physical Examination

1. Physical Examination Mr.W
a. General Condition : Healthy
b. Awareness : Composmentist
c. Vital sign :
1) TD : 150/90 mmHg
2) Pulse : 85 x/m
3) RR : 22x/m
4) SB : 36.5oC
d. Head
1) Hair
Clean, even distribution, black in color, does not fall off easily.
2) Eye
The sclera is not icteric, the conjunctiva is not anemic, the pupil
shrinks when exposed to light, the vision is good, the eyes feel soft.
3) Nose
No visible discharge, no polyps, no tenderness.
4) Ear
It appears that the ear canal has cerumen, there is no tenderness on the
tragus.

5) Mouth
 Teeth look clean, no cavities, lips look moist and not pale, tongue
looks clean, tonsils are symmetrical left and right.
e. Chest/thorax
1) Inspection
Normal chest shape, respiratory frequency 20 x/m chest respiratory
characteristics, regular respiratory rhythm, no use of accessory muscles
for breathing.
2) Percussion
Pulmonary percussion sounds sonor and dull in the heart
3) Palpation
No palpable lump, no tenderness.
4) Ascultation
Vesicular breath sounds, I heart sound LUB, II heart sound DUB
f. Abdomen
1) Inspection
Looks distended, no visible injuries.
2) Auscultation
Intestinal peristalsis 15 x/m
3) Percussion
Tympanic percussion sound
4) Palpation
No lumps, no tenderness
g. Genetalia
Not studied
h. Extremity
1) On
Right and left muscle strength 5/5
2) Lower
Right and left muscle strength 5/5
2. Physical Examination Mr.M
a. General Condition : Healthy
b. Awareness : Composmentist
c. Vital sign :
1) TD : 120/80 mmHg
2) Pulse : 95 x/m
3) RR : 21 x/m
4) SB : 37oC
d. Head
1) Hair
Clean, straight and black hair, even distribution
2) Eye
Sclera is not icteric, conjunctiva is not anemic, pupils shrink when
exposed to light, vision is good
3) Nose
No visible discharge, no polyps, no tenderness
4) Ear
It appears that the ear canal has cerumen, there is no tenderness on the
tragus
5) Mouth
Teeth look clean, no cavities, lips look moist and not pale, tongue
looks clean, left and right tonsils symmetrical
e. Chest/thorax
1) Inspection
Normal chest shape, respiratory frequency 19x/m chest respiratory
characteristics, regular respiratory rhythm, no use of respiratory aids
2) Percussion
The percussion sound is sonor and dull in the heart
 3) Palpation
No palpable lump, no tenderness
4) Auscultation
Vesicular breath sounds, I heart sound lub, II heart sound dub
f. Abdomen
1) Inspection
Looks distended, no visible injuries
2) Ascultation
Intestinal peristalsis 13x/m
3) Percussion
Tympanic percussion sound
4) Palpation
No lumps, no tenderness
g. Genetalia
Not studied
h. Extremity
1) On
Right and left muscle strength 5/5
2) Lower
Right and left muscle strength 5/5

J. Family Hope
Mr. W's family hopes that the arrival of health workers can provide the family
with more information about Ca Mamae's disease and the effects of
chemotherapy as he experienced
B.DATA ANALYSIS

No Data Problem Reason

1. Subjective data: Self-Concept Program
- Mrs. S complained that her Disorders (body Treatment
hair was experiencing image) program
problems lossso it
becomes bald Andfamily's
- Mrs. S complained that the inability to
tips of her nails were black recognize breast
- Mrs. S said she was cancer
embarrassed by her current
condition
Objective Data:
- It looks like Mrs. S's hair is
bald
- Seen edges
nailMrs. S turned black
- One of the breasts is visible
Mrs. S has been appointed.
2. Subjective data: Anxiety Ignorancefami
- His family said they were ly about the
afraid that the same disease prognosis
would happen to him
- The family said they were
afraid that Mrs. S's disease
would recur
- Mrs. S said she was worried
about it relapse
cancerher breasts are back
 - Mrs. S said he was afraid that
his child would also suffer
from the same disease
- Mrs. S is afraid that she will
no longer be able to have
children because she has lost
one of her breasts.

Objective Data:
- When taking anamnesis, the
client and family appear
restless and facial
expressions are visible
worried.

3. Subjective data: Knowledg Not

- The family said they were e deficiency enoughexpo
unaware of any health sed to
problems information
memberhis family
- Mrs. S said he did not know
the cause of breast cancer
- Mrs. S said she did not know
the signs and symptoms of
breast cancer
- Mrs. S said she did not know
how to prevent breast cancer
-The family said no
understand how to care for
Mrs.S
Objective Data:
- Mrs. S only knew so much when
asked about the signs and
symptoms of breast cancer,
trigger factors, and how to
manage it.
Breast cancer itself
 Problem Prioritization

Nursing diagnosis: Self-concept (body image) disorders related to treatment and

the family's inability to recognize health problems.

No Criteria Weight Score Justification

1. The nature of
the
3/3 x 1 = 1 1
problemActu
al =3
Risk =2
Potential = 1
2. Possibilityproblems
can be changed
Height = 2 2/2 x 2= 2 2
Medium = 1
Low = 0
3. Potential problems to 2/3 x 1 = 2/3 2/3
prevent
Easy = 3
Sufficient = 2
Unable = 1
4. Highlighting the 1
2/2 x 1 = 1
problem Problem felt,
and handled
immediately = 2
Problem felt = 1
Problem not felt
=0
Total 4 2/3
Nursing Diagnosis: Anxiety in Mr. W's family, especially Mrs. S, is related to
the family's inability to manage stress.

No Criteria Weight Score Justification

1. The nature of
the
2/3 x 1 = 2/3 2/3
problemActu
al =3
Risk =2
Potential = 1
2. Possibilityproblems
can be changed
Height = 2 2/2 x 2= 2 2
Medium = 1
Low = 0
3. Potential problems to 2/3 x 1 = 2/3 2/3
prevent
Easy = 3
Sufficient = 2
Unable = 1
4. Highlighting the
2/2 x 1 = 1 1
problem Problem felt,
and handled
immediately = 2
Problem felt = 1
Problem not felt
=0
Total 4 1/3
Nursing Diagnosis: Knowledge Deficiency in Mr. W, especially Mrs. S, is related
to the family's ignorance of breast cancer
.
No Criteria Weight Score Justification
1. The nature of
the
3/3 x 1 = 1 1
problemActu
al =3
Risk =2
Potential = 1
2. Possibilityproblems
can be changed
Height = 2 1/2 x 2= 1 1
Medium = 1
Low = 0
3. Potential problems to 2/3 x 1 = 2/3 2/3
prevent
Easy = 3
Sufficient = 2
Unable = 1
4. Highlighting the
2/2 x 1 = 1 1
problem Problem felt,
and handled
immediately = 2
Problem felt = 1
Problem not felt
=0
Total 3 2/3
2. Nursing Diagnosis

1. Self-concept (body image) disorders are related to treatment and the

family's inability to recognize health problems.
2. Anxiety to your family. H, especially Mrs. H, is related to the family's
inability to manage stress.
3. Knowledge Deficiency in Your Family. H, especially Mrs. H, is related to
the family's ignorance of breast cancer.
3. FAMILY NURSING CARE PLAN

Nursing Object Evaluat

No ive ion Action plan
diagnoses
General Special Criteri Standa
a rd
1. Disorders of After a 5 x 30 1.After a 1 x 30 a. Family Body image disorders 1. Explore family
self-concept minute nursing minute visit are feelings, knowledge about
(body image) visit, the body capablemention experiences, attitudes the meaning of
related to image familyAble to the meaning of and evaluations that one self-concept
treatment disturbance was recognize concept disorder has disorders
resolved problems with self 2. Give it a chance
Andthe family's self-concept somebody regarding the familyto express
inability to disorders (body (bodyimage) body which includes feelings about
recognize the image) according body shape, body size change
problem to and body weight which
discuss leads to positive and imagebody
negative physical 3. Give families the
Alone:a person's appearance. opportunity to ask
judgment about questions.
their own body, 4. Give positive
in a reinforcement for
way actions done
physical family.
appearance,
overall body
 weight.

b. Family 1. Explore the

family's knowledge
capablementions 3 about the causes of
of the disorder
5 reason
 disturbance Reason self concept (body
image)
draftself (body disturbanceself-concept 2. Discuss with the
image): (body image): family about the
1. Injury 1. Injury causes of body
2. Disease 2. Disease image disturbances
3. Treatment 3. Disturbance by using
program flip sheets and
(radiation, functionpsychosoci leaflets.
chemothera al 3. Give families the
py, surgery) opportunity to ask
questions.
4. Give positive
4. Treatment program
reinforcement for
(radiation,
actions done
chemotherapy,
family.
surgery)
5. Changes in self-
perception
2. After Family The family stated that 1. Discuss with the
their decision was family the
incarry out capablestate acceptable problems that exist
nursing or not in overcoming in the family
visits for 1 x Andtake the the problem of breast 2. Make a
30 minutes, decision to cancer decision
if the family overcome it 3. Reiterate what has
can afford it been discussed
: problembreast with the family
Make cancer 4. Give positive
decisions to reinforcement for
solve the actions taken
problems by the family
concept
disorder

self
 (body image)

3. After Family capable Families are able to care 1. Motivation

a nursing visit nurse member for sick family members familyto care for
is carried out family with by providing positive members family
for 1 x 30 disturbance of self- reinforcement and who are sick with
minutes, the concept (body motivation For breast cancer
family can image) by increase 2. Teaching family
afford it providing
:ca reinforcement flavorself-confident aboutmethod
ring for increasebody
family And
members with positive image:Optimistic
concept motivation to about life
disorders increase self- Certaincan
confidence overcomevarious
self(body
image) problemWhich
faced, Full
please And
confident that you
can achieve life

Whichbetter, get
up immediately

fromfailure and
insolvency in
sorrowprolonged,
 There is nothing
that is not
Possible,Full of
confidence
3. Repeat what has
been discussed and
done with family
4. Give reinforcement
 positive about the
actions taken by
the family
4. After Family Family 1. Discuss
family together with the
nursing visits capablemodify the capable modify the family in creating
are carried out environment to environment according a safe and
for 1x 30 supportfamily to health standards: comfortable
minutes, the health: adequate lighting, environment.
family is able maintained room 2. Get involved
openwindow humidity, air ventilation familyin
:modifying so and windows, dirt and modifying the
the thatair exchange dust free house, keep environment
environment occurs, noise down 3. Give positive
to support reinforcement on
family health arrangelighting action
so
thatsunlight can Whichdone by the
enter to family
inHouse
with
open

curtain,keep the
noise down.
5. After Family capable Conduct discussions so 1. Review
family bring that families take knowledgefamily
nursing visits advantage of services about
are carried out member families healthto benefit
for 1x 30 suffering from breast overcome breast cancer
minutes, the cancer to the nearest problems such as: facilityhealth
family is able health service preventing breast cancer 2. Discuss
problems as early as togetherfamily
:make use of possible Howmake use of the
available facilities
health family,know servicehealth.
services And 3. Evaluation
inspect problem returnHow
health, make use of the
facilities health
astreatment services
 to all family
members
4. Praise the family for
the correct answers.

2. Knowledge After a 5 x 30 1. After a. Family Breast cancer is a 1. Dig

deficiency is minute nursing a nursing malignant tumor that is knowledgefamily
related to the visit, visit is capablemention formed from breast about
family's inability carried out meaning cells that grow and understanding
to recognize the familyable to for 1 x 30 develop uncontrollably
problem care for family minutes, the cancerbreast so that they can spread cancerbreast.
family can between tissues or 2. Discuss
Which afford it according organs near the breast withfamily about
Sick toLanguage or to other parts of the understanding
:caring for a Alone: body. cancer
cancerbreast family Cancer breast breast
member is emergence
with breast lump withuse
cancer. sheet come
onbreast. back

Andleaflets
3. Give families the
opportunity to ask
Risk factors for questions.
breast cancer are: 4. Give positive
reinforcement for
actions done
 1. Type family.

b. Family sex:woman
own 1. Explore family
capablementions 9 knowledge about
of breast cancer risk
11 factor factors.
riskbreast 2. Discuss with
cancer: family about
1. There are
family
members
 who greater risk of breast cancer risk
suffer developing factors
from breast cancer withusing
breast sheets come
cancer back
2. Genetic: breast
2. Pill Use cancer is Andleaflets.
KB caused by 3. Give families the
during 8 inherited opportunity to ask
year genetic damage questions.
4. Give positive
fromparent reinforcement for
actions
3. Age: woman donefamily.
Which aged
3. Aged
>50 years
>50year
and
And have
haveMonopaus
menopause
e has risks

cancerbreast

morebig
4. Have ever
had a tumor 4. Patient
withFamily
benignprevi history of
ously. breast cancer
 5. Woman Which
5. Once gave birth to
expose her first child
d to after
radiatio
n
 on the chest aged 30 years
or before the
age of 20 years
6. Give birth 6. Menarche
to your first early: woman
child when Whichhistory
you are of menarche
over 30
years old beginningbefor
e age
12 year
have a higher
risk of breast
cancer
7. Have a
history of 7. Woman
early Whichthe age
menarche of menopause
before age is late
12year oron age
50year has
risks
cancerbreast
morebig
8. The
menopause 8. Woman
is late or Whichhave had
on50 years a benign tumor
 old 9. Woman Which
9. Patient
 become have been
obese after exposed to
entering radiation to the
menopause chest

10. Woman
Whichbecome
obese after
entering
menopause

11. Use of
contraceptives,
such as: birth
control pills for
more than 8-10
years, birth
control
injections for
c. Family able to more than 8-10
name 4 of6 signs years from 1. Explore family
and symptoms of 5 knowledge about the
breast cancer: year signs and symptoms
1. A lump
of breast cancer
appears in canincrease 2. Discuss with your
the breast risk family about signs
and symptoms
 cancerbreast of breast cancer
with

Signs and
symptoms of breast
cancer are:
1. The appearance
of a lump

onbreast.
2. The emergence 2. The appearance using flip sheets and
lump in the of a lump leaflets
armpit 3. Give
onarmpit chancefamily
3. The sizes of (axillary). Forask
the two 4. Give positive
breasts are 3. Form reinforcement for
different And actions done
Breast size may family
appear to
change. Can be
smaller or more
big
from the
4. Nipples opposite breast.
breasts feel It can also be
seen going down
itchy,
And 4. Discharge from
the nipple.
interestedente
r into

5. Change on the
nipples: the
nipples feel like
burning, itching,
and sores
appearing

difficult
healed; the
nipple is pulled
inward
(retracted); red
nipples.
 6. The breast skin
appears wrinkled
like orange peel.
2. After The family is able The family states their 1. Discuss with the
to express and decision whether they family the
incarry out make decisions in are able or not to problems that
nursing dealing with the overcome the problem exist in the family
visits for 1 x problem of breast of breast cancer 2. Do
30 minutes, cancer decision-
if the family making
can afford it 3. Reiterate what
: has been
Make a discussed with the
decision to family
overcome 4. Give positive
the problem reinforcement on
of breast action
cancer
Whichdone by the
family
3. After a. Families are able a. Nurses play a role 1. Family
a nursing to care for sick as a motivator motivation to care
visit is family members in motivating for family
carried out with families to be able to members who are
for 1 x 30 problem care sick with breast
minutes, the cancer
family can cancerbreast membersick family 2. Teaching family
afford it with Forwarm
 withprovide compress
:caring for compression problembreast 3. Teaching family
members cancer and teaching about
family warmFor families about how technique
with to cope
overcomepain pain with attractedFor
compression reduce
that arises
techniques warm,
 breast distraction technique. painful,
cancer.
likewatch
b. The family is b. The family is
motivated to care motivated to care and tv,listening to
is able to care music,
membersick family
with member families who readbook.
are sick with breast 4. Repeat what has
problembreast cancer problems, been discussed
cancer like: and
giving a warm donewith family
compress For 5. Give positive
reduce pain, reinforcement on
clean breast cancer action
wounds every day,
pay attention to the Whichdone by the
diet of family family
members with breast
cancer
4. After Family Family 1. Discuss with
family family
nursing visits capablemodify the capablemodify the increate an
are carried out environment environment in environment
for 1x 30 to accordance Whichsafe and
minutes, the supportfamily with comfortable.
family is able health: 2. Involve the family
standardhealth: in modifying the
:modify the openwindow lighting environment
environment so 3. Give positive
for thatair exchange WhichEnough, reinforcement for
supports occurs, actions done
health humidityroom family
arrangelighting awake,
so there are air
thatsunlight can ventilation and
enter to in windows, the house
House with is dirt free
open and dust, keeping
noise at bay.
curtain,
 family keep the noise down.

5. After 1x family Family Family 1. Review

nursing visit knowledgefamily
30 capable mention 2 of 3 capablemention 3 about
benefits of health profit benefit
minute,well-to- facilities:
do family a. To find out and facilityhealth: facilityhealth
: make use of inspecthealth a. Make use of the 2. Discuss
health services problems. facilities health togetherfamily
b. As a treatment For prevent Howmake use of the
Whichavailable service as early as Possible facilities
problem Cancer servicehealth.
Breast 3. Evaluation
returnhow to utilize
onfamily. the facilities
b. To find out and healthto all family
check for health members
problems. 4. Praise the family for
c. As a treatment the correct answers.
service
3. Anxiety in the After a 5 x 30 1. After Family Risk factors for 1. Explore family
family is minute nursing Nursing breast cancer are: knowledge about
related to the visit, the visits are capable mentions 9 of breast cancer risk
family's family's anxiety carried out 1 11 risk factors for factors.
inability to was resolved x 30 breast cancer: 1. Type sex: 2. Discuss with
manage family 1. There are family woman family
minutes can members who aboutcancer risk
afford: owngreater risk factors
sufferbreast cancer
stress Recogni experiencebreast breast
ze the cancer withusing
problem 2. Use of birth 2. Genetics: sheets come
a. Explain the control pills for 8 back
risk factors years cancerbreasts are
for Breast caused by genetic Andleaflets.
Cancer damage inherited 3. Give families the
from parents opportunity to ask
questions.
3. Age: women aged 4. Give positive
3. Aged >50 >50 years and reinforcement for
yearand have gone has actions done
through menopause Monopause family
carries a risk of
cancer

breastbigger

4. Once suffer 4. Patient with a

tumor family history of
breast cancer
benign
previously. 5. Woman
Which give birth
to their first child
5. Once after the age of
exposedradiation to 30 years or
the chest before the age of
20 years
 6. Early menarche:
woman
6. Give birth to child Whichhistory
The first is when
you are over 30 menarche
years old
 Early before the
age of 12 years
have a higher risk
of breast cancer

7. Has a history of 7. Women who are

menarche at menopause
beginning before late or over the
aged 12year age of 50 years
have risks

cancer
bigger breasts
8. Monopause
8. Woman
hislate or over the
Which have had a
age of 50 years
benign tumor
9. The patient is obese 9. Woman Which
after have been
enter exposed to
radiation to the
periodmenopause chest

10. Woman
Whichare obese
after
enter
 periodmenopause

11. Use

toolcontraception
,
 like: pill
KBmore
from 8-
10years,
injectable
contraceptives
for more than 5
years can
increase the risk

cancerbreast
2. After nursing Family The family states their 1. Discuss with the
intervention is decision whether they family the problems
carried out for capablestate are able or not to that exist in the
1 x 30 minutes overcome the problem family
Andtake the decision of breast cancer 2. Make a decision
familycapable in 3. Reiterate what has
: overcome been discussed with
Making the the family
decision to problembreast cancer 4. Give
overcome
breast cancer reinforcementpositiv
e for that action
done
family
3. After a nursing a. The family is able to a. Family capable 1. Family motivation to
visit during care nurse care
1 membersick family
 membersick family member sick families with
x30minute, with givewarm by giving warm Cancerbreast
compress to relieve compresses to relieve 2. Teach
familycapable the pain that arises the pain that arises methodwarm
: compress
caring for a b. The family was able b. Family 3. Helping clients do
family member to repeat the deep breathing
with breast technique capableDemonstrate exercises
cancer. demonstration deep breathing 4. Repeat what has been
techniques discussed
And
 breath in done
Whichtaught
togetherfamily
5. Give

reinforcementpositive
4. After 1x family Family Family 1. Discuss together
nursing visit family in
30 capablemodify the capable modify the creationenvironm
environment to environment according ent
minute,well-to- supportfamily to health standards: Whichsafe and
do family health: adequate lighting, comfortable.
: maintained room 2. Get involved
openwindow humidity, air ventilation familyin
modifyenviron so and windows, dirt and modifying the
ment to support thatair exchange dust free house, keep environment
family health occurs, noise down 3. Give positive
reinforcement on
arrangelighting action
so
thatsunlight can Whichdone by the
enter to family
inHouse
with
open

curtain,keep the
noise down.
5. After 1x family Family capable Conduct discussions so 1. Review
nursing visit bring that families take knowledgefamily
30 advantage of services about
member families healthto benefit
minute,well-to- suffering from breast overcome breast cancer
do family cancer to the nearest problems such as: facilityhealth
: make use of health service preventing breast cancer 2. Discuss with the
health services problems as early as family how to use
possible the facilities
Whichavailable servicehealth.
family,know 3. Evaluation return
And how to
inspect problem utilize
health,

astreatment services
 health facilities for
all family members
4. Give praise to the
family on
correct answer.
4. NURSING IMPLEMENTATION AND EVALUATION

Nursing diagnoses Implementat Evaluat TT/Date/Time

ion ion
Dx 1 TUK 1: Recognize the Problem S: The client and family said Wednesday, October 14,
1. Exploring client and family they already knew about the 2023
knowledge about breast cancer disease 14.00 WIT
2. Discuss the meaning, signs,
symptoms, causes and risk factors of O: When evaluated again, the
breast cancer client and family can repeat the
3. Give clients and families the meaning, signs, symptoms and
opportunity to ask questions risk factors, but sometimes
some people forget.
A : Problem partially resolved

P: The intervention continues

TUK 2: Making Decisions
1. Mention again the complaints that
Mrs. H is currently feeling.
2. Motivate individuals and families to
make decisions in caring for Mrs. H
S: The client and family agree Wednesday, October 14,
and are willing to make a 2023
decision to overcome Mrs. H's 14.00 WIT
breast cancer problem
O: The client and family agree
and are willing to make a
decision to overcome Mrs. H's
breast cancer problem
 A: Problem partially

resolved P: Intervention

continues
Dx I : TUK 3: Caring for family members S: The client said he was more Wednesday, October 14,
Disorders of self-concept confident than before 2023
5. State the meaning of self-concept 14.00 WIT
(body image) related to
disorders (body image) O: The client seems more
treatment 6. Mention the causes of impaired self- confident and no longer
concept (body image) embarrassed by his current
7. Teaching families how to improve body condition
And the family's inability image: Optimistic about life, Confident
that they can overcome the various A: Problem partially
to recognize the problem
problems they face, Full of hope and
of breast cancer confidence that they can achieve a better resolved P: Intervention
life, Immediately rise from failure and
not get lost in prolonged sorrow, continues
Nothing is impossible, Full self-
confident
8. Ask the family to repeat what has been
discussed
9. Give the family the opportunity to ask
questions
Diagnosis II: TUK 3: Caring for Family Members S: Clients and families say they Friday, October 17, 2023
have become more relaxed hours
14.00
 1. State the meaning of relaxation after demonstrating
Anxiety on techniques
familyMr H, 2. State the purpose of relaxation techniquerelaxation
techniques
especially Mrs H 3. Name the types of relaxation
relate 4. Mention the implementation O : Face client
procedures and steps together looksindicates a relaxed
5. Do relaxation techniques state
withfamily's inability to 6. Give chance family
Forask A: Problem partially
manage stress
resolved P: Intervention

continues

Diagnosis II: 1. Ask again about the meaning of S: The client said that his Friday, October 17, 2023
Anxiety in Mr H's family, relaxation techniques, goals and steps. anxiety had reduced because in hours
2. Ask the client to practice the steps his free time the client also 14.00
especially Mrs H, is again practiced it
related with 3. Provide positive reinforcement
O: The client looks relaxed
family's inability to
A: Problem partially
manage stress
resolved P: Intervention

continues
Diagnosis III: Counseling clients and families regarding S: The client said that so far he Friday, October 17, 2023
The lack of knowledge in breast cancer understands what breast cancer hours
1. State the meaning of breast cancer is, the signs and symptoms, and 14.00
Mr. H's family, especially 2. Mention sign And symptom the risk factors
Mrs. H, is related to the cancerbreast
3. List the risk factors for breast cancer O: the client can mention again
family's ignorance of 4. Explain how breast cancer is managed the meaning, signs and
5. Give the family the opportunity to ask symptoms, risk factors, and
breast cancer.
questions management

A: Problem partially resolved

 P: intervention continues
Diagnosis III: Demonstrate warm compresses with the client S: client say Friday, October 2023
and family Already 17, 2023 hours hours
Knowledge deficiency in Do a warm compress if you
1. Mention the purpose of a warm compress 14.00
2. Mention tools and materials feel pain
Mr H's family in particular 3. Mention steps
H's mother related to the procedurewarm compress O: The client can explain the
4. Ask the client to return to the warm purpose and method of
family's ignorance of the applying a warm compress
compress method
situation 5. Give chance family
breast cancer. Forask
A: problem partially resolved

P:intervention continues

Diagnosis III: Discuss or review all activities that have S: Clients say they already Friday, October 2023
Knowledge deficiency in been carried out know about breast cancer and 17, 2023 hours hours
its management, even though 14.00
Mr H's family in some people forget a little.
particular
Mrs. H related to the
O: the client can repeat the
family's ignorance of meaning, signs and symptoms,
risk factors and how to apply
breast cancer.
warm compresses
A: Problem partially resolved

P: intervention continues
Diagnosis III: Demonstrate making herbs S: The client and family said Wednesday, October 14,
Forprevent recurrence of they understood 2023
Knowledge deficiency in
breast cancer what are the causes of breast 14.00 WIT
Mr H's family in 1. Mention the causes of breast cancer cancer and how to make herbal
particular 2. Mention the herbal ingredients that medicine
will be used
H's mother is related to 3. Mention method
Family ignorance about making Andusage O: when asked again, the client
4. Together do and family can mention again
breast cancer.
methodpotion making how to make herbal
5. Give chance family concoctions that have been
Forask made
used
A : Problem partially resolved

P: Intervention continues

TUK 4: Modifying the Environment
1. Discuss with the family how to create
a safe and comfortable environment
2. Together, open the windows and open
the ventilation so that light comes in
from outside for air exchange, tidying
up the living room
3. Suggest the family folds washed
clothes.
4. Advise family so that
S: Clients say that they rarely Friday, October 18, 2023
fold cloths that have just been hours
washed and rarely open the 13.00 WIB
living room window
O: You can see freshly washed
cloth scattered on the mattress
and the window doesn't appear
to be open
 stillkeep the house clean. A: The problem has not
5. Give positive reinforcement
been resolved P:

Intervention continues
TUK 5: Utilization of Health Services S: Mrs. H said she Saturday, October 19, 2023
1. Ask Mrs. H when she last went to a already understood the hours
health facility to control the signs and use of control at the 14.00
symptoms of breast cancer puskesmas
2. Explain the importance of regular
control of health services O: The client seemed
3. Explain the consequences of not
enthusiastic in this discussion
having regular check-ups with health and was able to mention again
services why it is important to have
4. Students give families the opportunity
regular check-ups at the health
to ask questions about the explanation center and the consequences if
the student has given not.
5. Students provide positive A: Problem partially resolved
reinforcement
Q: Intervention continues