CHAPTER TWO

ANALYSIS OF DATA

This is the second phase of the nursing process. It involves the act of deducing facts or information that

has been gathered on the client and her condition in order to arrive at the needs of the client and the

problems hindering attainment of health.

COMPARISON OF DATA WITH STANDARDS

The results from laboratory investigation, history, signs and symptoms manifested by the client are

carefully analyzed, comparing them with standard measures to aid in diagnosing the client’s condition.
TABLE 1: DIAGNOSTIC INVESTIGATIONS
DATE SPECIMEN INVESTIGATIO RESULTS NORMAL INTREPRETATIO REMARKS
N VALUES N

12/06/2023 Fine needle To show the tissues Destruction of There should not Not normal Client was sent to
aspiration of the of the breast surrounding be any theater for
breast tissues of the destruction of mastectomy and
outer quadrant surrounding left breast
of the right tissues removed
breast
12/06/2023 Renal function test
Blood Creatinine 3.02 mmol/L 2.50 - 8.30
mmol/L Normal No treatment
Urea 43 umol/L 44-106 umol/L Normal given
BUN/CREAT ratio 33.8 8.0 – 36.0 Normal No treatment
given
No treatment
given
12/06/2023 Blood Liver function test
AST 29.8 U/L 5.0 – 40.0 U/L Normal No treatment
ALP 109.7 U/L 35.0 – 129.0 Normal given
GGT 53.7 U/L U/L Normal No treatment
Total protein 74.1g/L 6.0 -71.0 U/L Normal given
66.0 – 87.0 g/L No treatment
 given
No treatment
given
12/06/2023 Blood Hemoglobin level 12.6g/dL 11.5 - 16.5g/dL Normal No treatment
given

12/06/2023 Blood White blood cell 4.6 x 10⁹/L 3.5 -10.0 x Normal No treatment
count 10⁹/L given

DATE SPECIMEN INVESTIGATIO RESULTS NORMAL INTREPRETATIO REMARKS

N VALUES N
12/06/2023 Blood Red blood cell 4.59 x 10⁶µL 4.50 – 5.50x Normal No treatment
count 10⁶µL given
12/06/2023 Blood Sickling test Negative SS, AS, AC Sickling negative
means client does not No treatment
have the trait. given
12/06/2023 Blood Grouping and cross A Rhesus D A, B, AB, O Within range No blood was
matching positive transfused
 CAUSES

From the literature review, the causes of breast cancer are history of breast cancer in the family, high

fat diet, have never been pregnant, have long menstrual cycles, begin menstruation early or menopause

late, etc.

In the case of my client, the cause was attributed to history of breast cancer.

Table 2: CLINICAL FEATURES

CLINICAL FEATURES ACCORDING TO CLINICAL FEATURES EXHIBITED BY

LITERATURE REVIEW CLIENT

1. Painless, non-tender mass in the affected 1. Client had painless, non-tender mass in the left

breast which is poorly circumscribed. breast which is poorly circumscribed.

2. Changes in size and contours of the 2. Client had changes in size and contours of the

affected breast. left breast.

3. Bleeding or discharge from the nipple. 3. Client had discharge from the nipple.

4. A scaly rash around the nipple 4. Client did not have a scaly rash around the

5. Enlargement of the axillary lymph nodes. nipple.

5. Client had enlargement of the axillary lymph

6. Retraction of the nipple or an area of skin nodes.

over the breast.

7. Acute bone pains in the back or limbs. 6. Client had retraction of the nipple.

8. Itching of the nipple and ulceration. 7. Client did not have acute bone pains in the back

or limbs.

8. Client had itching of the left breast but no

9. Shrinkage or enlargement of the breast ulcerations were seen.

9. Client had enlargement of the left breast.

TREATMENT FOR CLIENT

Treatment modalities used for breast cancer include surgical treatment which involves radical

mastectomy, simple mastectomy, primary tumor excision and lumpectomy. Radiation therapy,

chemotherapy and endocrine therapy are also used in the treatment of breast cancer. Client’s condition

was intervened by surgical means. Radical mastectomy was performed. Besides the surgical treatment,

client was placed on the following drugs;

1. Intravenous Ringer’s Lactate 2 liters × 48 hours

2. Intravenous Dextrose Saline 2 liters × 48 hours

3. Intravenous Normal Saline 2 liters × 48 hours

4. Injection Pethidine 50mg bd ×48 hours

5. Tablet Amoxiclav 625mg bd × 48 hours

6. Tablet Zincovit one daily ×15 days

7. Suppository Diclofenac 100mg bd ×7 days

 TABLE 3: PHARMACOLOGY OF DRUGS

DATE DRUG DRUG ROUTE OF CLASSIFICATIO DESIRED ACTUAL ACTION SIDE

ADMINISTRATIO N EFFECT OBSERVED EFFECT
N
12/06/202 Ringer’s 2 liters for 24 hours Isotonic electrolyte Restores normal Client fluid and Circulatory
3 lactate intravenously infusion fluid and electrolyte electrolyte balance was overload and
balance maintained pulmonary
oedema if too
much is given
in a short
time. None
was observed.
12/06/2023 Dextrose 2 liters for 24 hours Isotonic caloric Corrects dehydration Client was well hydrated. Apnea, muscle
saline intravenously electrolyte infusion and fluid in balance. Fluid and electrolyte pain and
It also provides balance was maintained tension in the
energy and maintains chest and
electrolyte balance. abdomen.
None was
observed.
12/06/202 Normal 2 liters for 24 hours Isotonic electrolyte Restores normal Client fluid and Circulatory
3 saline intravenously fluid and electrolyte electrolyte balance was overload and
balance. maintained pulmonary
oedema if too
much is given
in a short
 time. None
was observed.
DATE DRUG DRUG ROUTE OF CLASSIFICATIO DESIRED ACTUAL ACTION SIDE
ADMINISTRATIO N EFFECT OBSERVED EFFECT
N
12/06/202 Injection 50mg two times daily Narcotic analgesic Depresses pain Client’s pain was Drowsiness,
3 Pethidine for 48 hours transmission at relieved dizziness,
intramuscularly spinal cord level by headache and
interacting with confusion.
opioid receptors None was
observed.
12/06/202 Suppository 100mg two times Analgesic anti- To relieve fever, Client’s headache and Drowsiness,
3 Diclofenac daily for 7 days per inflammatory headache and pain pain was relieved dyspnea,
rectum blurred vision,
malaise. None
was observed.
12/06/202 Tablet 625mg two times Anti-infective Beta- To inhibit enzyme No sign of infection was Diarrhea3.,
nausea,
3 Amoxiclav daily for 7 days orally lactamase antibiotic (beta lactamase) observed
vomiting,
amino-penicillin rash, urticaria,
Candida
vaginitis. No
side effects
noticed.
12/06/2023 Tablet 1 tablet daily for 15 Dietary supplements Boosts immunity No sign of infection was Vomiting,
Zincovit days orally and antibiotics and protein synthesis observed nausea. No
side effects
noticed.
COMPLICATIONS

With reference to the complication stated in the literature review my client developed none of

them because of early diagnosis, prompt attention and management she received. She had a

successful surgery and healing of wound.

PATIENT/ FAMILY STRENGTHS

This is the ability of client and her family to participate in the care for the achievement of set

goals. The following were identified strengths.

Client was conscious from the day of admission till she was discharged. She was able to maintain

her personal hygiene before the operation and was assisted to maintain her personal hygiene after

the surgery.

Her family supported her emotionally and psychologically by advising and reassuring her that,

she was going to be well and be with them soon. They visited her every day and brought all the

things she needed during hospitalization.

Mrs. Adelaide Nyanteh was able to pay her bills it was been taken care off by the army. She was

also very co-operative and friendly and therefore made friends with the other patients and the

staff on the ward.

HEALTH PROBLEMS

Pre-operative problems

1. Pain

2. Anxiety

3. Anticipatory grieving
Post operative problems

1. Pain

2. Self-care deficit

3. Situational low self-esteem

4. Potential for hemorrhage

5. Potential for airway obstruction

6. Risk for fluid volume deficit

NURSING DIAGNOSES

This is the second stage in the nursing care plan which deals with the identification of the client

actual problem and potential problems from the information gathered on the client.

The diagnosis changes from day to day depending on the condition of the client and response to

the treatment given.

After assessing Mrs. Adelaide Nyanteh, the following nursing diagnoses were made:

1. Acute pain related to the inflammatory process of the condition

2. Anxiety due to knowledge deficit (cancer of the breast and mastectomy) related to the

disease condition.

3. Anticipatory grieving related to loss of physiological well-being (loss of left breast)

Post-operative nursing diagnosis

4. Impaired skin integrity (wound) related to surgical incision.

5. Self-care deficit (partial) related to presence of drainage tubes at site of incision and

intravenous infusion in situ.

6. Situational low self-esteem related to loss of the left breast.

7. Risk for altered tissue perfusion (hemorrhage) related to surgical incision.

8. Risk for airway obstruction related to altered level of consciousness produced by general

anesthesia.

9. Alteration in comfort (pain) related to surgical incision.