CONCEPT

CONCEPT
MAPPING
MAPPING
GROUP 1
 MEMBERS:
 ACOB, Maurelle Joyce  BITUIN, Aira Jane
 ALFON, Rhys Abegail  CADUTDUT, Jella Rose
 ANAVISO, Jeremy Kent  CAGA, Prince Cedrick
 ANDONG, Geron  CONSTANTINO, Rianne
 BARRIDO, LJ  DACARA, Shiela Rose
 BERNAL, Danica  DAG-AY, Saira
 BESANA, Retchel Ann
 CASE
CASE
SCENARIO
SCENARIO
PUERPERAL MASTITIS
 CASE SCENARIO OF PATIENT WITH PUERPERAL MASTITIS
A 26-year-old first time mother who was
breastfeeding her seventh-month-old baby boy
seek consultation to OPD with a three-day
Clinical diagnosis:
history of headache, fever, general malaise on
Puerperal Mastitis
the day of admission. On further questioning,
she also reported increasing pain in her left
Laboratory results:
breast over the last 24 hours.
• Blood count: Presence of left shift with 80 percent
neutrophils (total white blood cell count of 9.8×109
Admission findings:
cells/L)
(+) tender left breast
• Cerebral computed Tomography (CT): Normal
(+) erythematous left breast
• Magnetic Resonance Imaging (MRI) scan: Normal
(+) indurated in the right lower lateral quadrant
• Blood culture: Normal
in left breast
(-) area of abscess
Medication orders:
(+) tender left axillary adenopathy
• Nafcillin 1g q 6hrs IV
(+) restlessness and irritable
• Paracetamol 300mg q 4hrs IV
(+) headache, fever, and general malaise
Post admission orders:
Vital signs:
Dicloxacillin 500mg q 6hrs for 10 days PO
Temperature: 38.5C
 THE CONCEPT
MAPPING FOR
PUERPERAL MASTITIS
ETIOLOGY
&
DIAGRAM
 ETIOLOGY
NON-MODIFIABLE RISK Common causative agent: Staphylococcus MODIFIABLE RISK FACTORS
FACTORS aureus followed by coagulase-negative
• Headache
• SEX: FEMALE
Staphylococci. • Fever
• AGE: 26 YEAR OLD • General malaise
• First time mother • Pain in the left breast

PATHOPHYSIOLOGY
THEORITICAL:
Mastitis is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You
might also have fever and chills. It is most commonly affects women who are breast-feeding (lactation mastitis).

Breast infection can be a pathologically based negative influence on breast feeding. There are basically five types of lactational mastitis: subclinical mastitis,
acute puerperal mastitis (cellulitis and adenitis), suppurative mastitis, mammary infection with uncommon organisms, and virus infection in mammary
neoplasms. Puerperal mastitis is the inflammation of the breast in connection with pregnancy, breastfeeding or weaning. Since one of the most prominent
symptoms is tension and engorgement of the breast, it is thought to be caused by blocked milk ducts or milk excess. Puerperal mastitis does not present
until several weeks or months after delivery and may go unrecognized by health care providers if women do not seek medical treatment. Puerperal mastitis
is reported to occur in 2% to 24% of breastfeeding women from several weeks to up to 1 year after delivery in women who continue to breastfeed.

The source of infection is the nursing infants nose and throat; the organisms being Staphylococcus aureus and Streptococcus spp. Due to a breach in the
nipple-areola complex, such as a cracked nipple, there is retrograde dissemination of these normal commensals. This is further favored by stasis of milk as
stagnant milk is an excellent medium for bacterial growth. Staphylococcus aureus infections tend to be more invasive and localized leading to earlier abscess
formation; while Streptococcus infections tend to present as diffuse mastitis with focal abscess formation in advanced stages.

CLIENT-BASED:
In this case scenario, the patient experienced symptoms of puerperal mastitis as related to an increasing pain in her left breast over the last 24 hours and
signs due to headache, fever, general malaise on the day of her admission. In this situation the client experience slightly tender left axillary adenopathy, no
area of abscess although purulent milky secretions expelled from left nipple with mild peri-areolar pressure and secretions were cultured indicative of
puerperal mastitis.

The laboratory results include normal blood count, except for the presence of left shift with 80 percent neutrophils of total white blood cell count of 9.8x109
cells/L. Cerebral computed tomography (CT) and magnetic resonance imaging (MRI) scans, blood cultures which results were all normal. Nafcillin was given
to treatment with intravenous, continue pumping her breast milk and Dicloxacillin through oral for 10-day course.
 MEDICAL DIAGNOSIS
PUERPERAL MASTITIS

CLINICAL
MANIFESTATIONS
Headache; fever; general
malaise; increasing pain
in her left breast over the
last 24 hours
DIAGNOSTIC TEST
MEDICAL & SURGICAL Blood culture: Normal
MANAGEMENT Cerebral computed
Cerebral computed tomography (CT); tomography (CT): Normal
Magnetic resonance imaging (MRI) Magnetic resonance
scans; CBC blood cultures; imaging (MRI) scans:
intravenous initiated Nafcillin, 1g q 6h Normal
and Paracetamol 300mg q 4h

SIGNIFICANCE/PERTINENT FINDINGS
Blood count: Presence of left shift with 80% neutrophils
(total white blood cell count of 9.8×109 cells/L)
 ANATOMY
&
PHYSIOLOGY
A N AT O M Y & P H Y S I O L O G Y
PAT H O P H Y S I O L O G Y
T H E O R I T I C A L PAT H O P H Y S I O L O G Y
PUERPERAL MASTITIS

STAPHYLOCOCCAL INFECTION

Infection takes place in the fatty tissue of the breast

causing swelling

Inflammation

Incorrect breastfeeding techniques

Poor attachment

Obstruction (Milk stasis)

Breast engorgement

Breast swelling that results to painful tender breast

 C L I E N T- B A S E D PAT H O P H Y S I O L O G Y
Three-day history of Headache, Fever, General malaise

Patient reported increasing pain in her left breast over the last 24 hours

Patient is restless and irritable and was febrile 38.5C

There is a tender left breast that was erythematous and indurated in the right lower lateral quadrant

Slightly tender left axillary adenopathy

Blood count: presence of a left shift with 80 percent neutrophils (total white blood cell count of 9.8×109
cells/L).

PUERPERAL MASTITIS
DIAGNOSTIC
&
LABORATORY
 DIAGNOSTIC TEST
Cerebral computed tomography
(CT):
To check if there is a rare form of breast cancer,
which is the inflammatory breast cancer, because
it could be initially confusing with mastitis, since
inflammatory breast cancer has a signs of
redness and swelling also.
RESULT: Normal
Blood culture:
To check if there is foreign invaders like bacteria,
yeast, and other microorganisms in the patient
blood.
RESULT: Normal
M a g n e ti c r e s o n a n c e i m a g i n g ( M R I )
scans:
To check if the patient is positive with breast
cancer. There is a breast MRI machine wherein
they can detect even smaller than 1 cm.
RESULT: Normal
Blood count:
Left shift means immature WBC. If there is left
shift present then there is inflammation or
infection.
RESULT: There is a presence of left shift with 80%
neutrophils (total white blood cell count of
9.8×109 cells/L)
B LOO D C OU NT R ES ULT
AND
AN ALYS I S
 TEST RESULT NORMAL VALUES INTERPRETATION ANALYSIS

Hemoglobin There is no abnormalities

130g/l 120-150g/l Normal
(Hgb) present

Hematocrit (Hrt) 40 vol% 37-47 vol % Normal The result is normal

(+) left shift with 80% neutrophils There is a presence There is an inflammation or
WBC 5-10 x 10/l
9.8×109 cells/L of left shift infection

There is no abnormalities seen

Platelets 200 150-350 Normal
in the test

Segementers .60 .50-.70 Normal There is no abnormalities

present

Lymphocytes .30 .20-.40 Normal There is no abnormalities

present

Eosinophils .03 .02-.04 Normal The result is normal

There is no abnormalities seen

Stabs .04 .03-.05 Normal
in the test
 C L I N I C A L M A N I F E S TAT I O N

P H Y S I C A L E X A M I N AT I O N C L I N I C A L R E S U LT

• Restless
• Irritable
Three-day history of: • Febrile: 38.5C
• Headache • Tenderness in left breast that
• Fever
was erythematous and
• General malaise
indurated in the right lower
lateral quadrant
• Increasing pain in her left breast • No area of abscess although
over the last 24 hours purulent milky secretions
• Slightly tender left axillary
adenopathy
 T R E AT M E N T
&
L A B O R AT O R Y
MEDICAL/SURGICAL MANAGEMENT

MEDICAL MANAGEMENT

• Cerebral computed tomography

(CT)
• Magnetic resonance imaging (MRI)
scans
• CBC blood cultures
• Intravenous initiated Nafcillin, 1g q
6h
• Intravenous initiated Paracetamol
300mg q 4h

SURGICAL MANAGEMENT
Not needed at the moment
DRUG STUDY
MEDICATION ACTION INDICATION CONTRAINDI- DRUG TO ADVERSE NURSING
CATION DRUG EFFECT CONSIDERATION
INTERACTION
GENERIC NAME PHARMACO- • Systemic • Hypertensive • Aminoglyco GI: • Before giving drug, ask
Nafcillin DYNAMICS infections to drug or sides • Nausea patient about allergic
Exerts caused by other • Cyclosporin • Vomiting reactions to penicillin.
BRAND NAME bactericidal susceptible penicillin e • Diarrhea
Nafcillin sodium activity via organisms • Patients with • Probenecid Hematologic: • Monitor WBC counts
inhibition of (methicillin- drug allergies • Rifampin • Transient twice weekly in
CLASSIFICATION bacterial cell wall sensitive especially to • Warfarin leukopenia patients receiving
Antibiotic synthesis by Staphylococcus cephalosporin • Neutropenia nafcillin for longer
binding one or aureus) s • Granulocyto than 2 weeks.
DOSAGE & more of the penia Neutropenia
FREQUENCY penicillin binding • Thrombocyt commonly occurs in
1g q 6h proteins (PBPs). openia the third week
Exerts bacterial Other:
ROUTE autolytic effect by • Hypersensiti • If urinalysis is
Intravenous (IV) inhibition of vity abnormal. Notify
certain PBPs reactions prescriber this may
related to the • Vein indicate drug-induced
activation of a irritation interstitial nephritis
bacterial • thrombophl
autolytic process. ebitis
PHARMACO-
KINETICS
 PHARMACOKENETICS of N A F C I L L I N

LIBERATION Drug enters the

body ABSORPTION
INTRAVENOUSLY

Metabolized in PROTEIN-BOUNDED:
liver
70% to 90%
Undergoes METABOLISM
enterohepatic
circulation
Widely
distributed
DISTRIBUTION

EXCRETION Excreted primarily in bile;

25% to 30% is excreted in
urine unchanged
MEDICATION ACTION INDICATION CONTRAINDICATION DRUG ADVERSE NURSING
INTERACTION EFFECT CONSIDERATION
GENERIC NAME PHARMACO- • Fever • Hypersensitivity • Barbiturates Hematologic: • Check that the patient is
Paracetamol; DYNAMICS • Mild to • Carbamazep • hemolytic not taking any other
Acetaminophen Mechanism and site of moderate ine anemia medication containing
action may be related pain • Hydantoins • Neutrope paracetamol.
BRAND NAME to inhibition of • Isoniazid nia
prostaglandin synthesis Small amounts may pass
Ifimol IV, Napa, in CNS. • Rifampin • Leukopeni •
Paraciv, Renova, Sulfinpyrazo a into breast milk.
Analgesic action: • However, there are no
Reset, Tamen, Analgesic effect may be ne • Pancytope known harmful effects
etc. related to an elevation • Warfarin nia when used by
of the pain threshold. • Zidovudine • Thromboc breastfeeding mothers.
CLASSIFICATION Antipyretic action: ytopenia
Non-narcotic Drug may exert Hepatic:
antipyretic effect by • Evaluate therapeutic
analgesic; direct action on • Liver response.
Antipyretic hypothalamic heat- damage
regulating center to (with toxic
DOSAGE & block effects of doses)
FREQUENCY endogenous pyrogen. • Jaundice
300mg q 4h This results in Metabolic:
increased heat • Hypoglyce
ROUTE dissipation through mia
sweating and
Intravenous (IV) vasodilation. Skin:
• Rash
PHARMACO- • Urticaria
KINETICS
 PHARMACOKENETICS of
PA R A C E TA M O L

LIBERATION Drug enters the ABSORPTION

body Rapid & Complete
INTRAVENOUSLY

PROTEIN-
90% to 95%
BOUNDED: 25%
metabolized METABOLISM
in liver Widely
distributed to
MOSTLY BODY
DISTRIBUTION
TISSUES

EXCRETION PARACETAMOL is excreted

through URINE
MEDICATION ACTION INDICATION CONTRAINDICATION DRUG ADVERSE NURSING
INTERACTION EFFECT CONSIDERATION
GENERIC NAME PHARMACO- Treatment of • Carbapenem • Methotrexat Hematologic: • Ask the patient for
Dicloxacillin DYNAMICS the following hypersensitivity e history of
Binds to one or infections • Cephalosporin • Tetracyclines • Agranuloc hypersensitivity to
BRAND NAME more penicillin due to hypersensitivity • Warfarin ytosis penicillin or
Dycill, Dynapen, binding proteins, penicillinase- • Penicillin • Eosinophil cephalosporins. With
Mondoxyne NL, which in turn inhibit producing hypersensitivity ia history of
Monodox synthesis of staphylococci • Hemolytic cephalosporin
bacterial cell wall : anemia reaction, have
CLASSIFICATION synthesis. For • Mastitis • Neutrope emergency
Oral Anti-Acne treatment of nia equipment,
Non-Retinoids infections caused by • Inhibition medications available.
Penicillinase- penicillinase- of platelet
Resistant producing aggregatio • Culture/sensitivity
Penicillin staphylococci. n must be done before
Antibiotics Renal: first dose (may give
Resistance to this • Interstitial before results are
DOSAGE & drug results from nephritis obtained).
FREQUENCY alterations in CNS:
500mg every 6 penicillin-binding • Seizures • Assess WBC results,
hours proteins. Other: temperature, pulse,
• Jarisch- respiration.
ROUTE PHARMACO- Herxheim
Oral KINETICS er
Reaction
 MEDICAL DIAGNOSIS

PUERPERAL MASTITIS

There is a sign and symptoms of Puerperal Mastitis seen in the patient during
physical examination and clinical result. Such as increasing pain, tenderness
and erythematous on her left breast. Also, the patient has a fever (38.5C).

Furthermore, in her diagnostic test result there is a left shift or immature

White Blood Cells (WBC) seen in her blood count. If immature WBC is
present it means there is an inflammation or infection in the body.
 S I G N I FA N C E / P E R T I N E N T F I N D I N G S

Blood count: Presence of left shift with 80%

neutrophils (total white blood cell count of 9.8×109
cells/L)
NURSING
CARE
PLAN
 NURSING EXPECTED
ASSESSMENT GOALS NURSING INTERVENTION OUTCOMES
DIAGNOSIS
Subjective: Acute pain related Short term: INDEPENDENT: After nursing
“Pasakit ng pasakit yung to inflammation of After 30 mins of nursing • Advise the patient to apply intervention, the
kaliwang parte ng breast tissues as intervention, the client warm compress to the affected client reported a
dibdib ko sa loob ng 24 evidenced by breast every 2 hours and wear
will be report decrease in supportive bra decrease in pain from
oras. 9/10 po yung pain increasing pain in pain 9/10 to 4/10
niya” as verbalized by • Advise the patient to continue
the left breast breastfeeding on the affected
the patient. Long term: breast to keep breast empty of
After 9hrs of nursing milk
Objective: intervention, the patient • Advise the client to full drain
• (+) Face grimaced will be free from the the milk from the patient’s
• Restless and irritable breast to avoid prolonged
is noted signs and symptoms of overfilling of breast with milk
• Present of tender Puerperal Mastitis before breastfeeding
left breast that was • Assist the client on proper
erythematous positioning of breastfeeding
indurated in the • Advise the client to perform
right lower lateral adequate breast and nipple
quadrant care.
• Present of slightly DEPENDENT:
tender left axillary
adenopathy • Administer medications as
prescribed by the doctor
• T: 38.5C
THE DISCHARGE
PLANNING
 MEDICATION ENVIRONMENT TREATMENT HEALTH TEACHING

• Advise to continue emptying

Advise significant other or
the family to :
• Create a relaxing home
• Encourage the patient to apply
environment to keep
stress level down and
Take medication at the
promote proper rest.
right time and right
dose as prescribed by
• Keep the living space
the physician clean in order to avoid
• Encourage to massage the
further
infections/complications.
• Maintain an emotional
support to promote
mental well-being
• Advise to wear a supportive
the breast to keep milk flowing
from milk ducts. If needed
used breast pump to express
milk between feedings.
a moist compress to the
affected area before
breastfeeding and cold
compress after.
area in a gentle circular
motion starting from outside
of the affected are toward the
nipple.
and comfortable bra that
doesn't compress the breast.
Provide patient and significant
others a written and verbal
information regarding the ff:
• Teach a proper
breastfeeding technique
that will allow for a good
latching by infant.
• Proper hand washing and
cleaning nipples before and
after breast feeding.
• Avoid using nipple creams
or ointment that is not
prescribed by the physician.
• Seek medical advice from
health care if notices
further complications.
 OUT-PATIENT FOLLOW UP DIET SPIRITUALLY

• Encourage the mother to drink

fluids such as water, milk and fruit
• Encourage the mother
juices.
and significant others to
continue to pray for the
• Advice to eat vegetables and fruits
fast recovery.
which contains vitamins and
The client is advised to have
antioxidants to help fight the
a follow up check-up with a • “For behold, the days are
infections
healthcare provider within 2- coming when they will
3 days after consultation. say, ‘Blessed are the
• Advice to eat well-balanced meals
barren, and the wombs
and add 500 extra calories a day
that never bore, and the
while breastfeeding
breasts that never nursed.
“- Luke 23:29
• Advice to consume good fats to
reduce the inflammation.
BSN 2Y2-5; GROUP 1: CONCEPT MAPPING

Thank you for listening!

Have a nice day

CLINICAL INSTRUCTOR:

Ma’am Daisy Yadan & Ma’am Belen Uy