Ductal Carcinoma Case Study

8/11/2019 Ductal Carcinoma Case Study

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OBJECTIVES

General:

The study aims to improve the knowledge of the students regarding on Ductal Carcinoma. It gives the

students the opportunity to learn different aspects regarding on the case of the patient. It broadens theunderstanding of the students regarding on the body system involves. It also makes the students see the reality of

what they are studying in lecture of Medical-Surgical Nursing subject.

The study also aims to apply the different skills that the students learned from their related learning

experiences regarding on physical assessment and also on those different nursing interventions that they must

apply to the patients situation.

Aside from the knowledge and skills that this study aims to enhance, it also encompasses the attitude

aspect of the students. Their approach to the patient is important for them to establish rapport; it gives them the

opportunity to build good and trusting relationship with the patient and gather more accurate information and

achieve possible health outcomes.

Specific:

1. To be aware on how this case affects persons and how prevalent this situation is.

2. To be skill-oriented on how to identify and to properly observe the status of this case in our present time.

3. To be well-communicated with the client during the physical assessment and interviews.

4. To enhance our learned skills on assessing the client and how to classify abnormalities with different

aspects such as physical, emotional, mental and spiritual.

5. To make ourselves oriented to different laboratory results and how we can relate it with the situation of

the client.

6. To enhance our knowledge in anatomy and physiology of the system involve.

7. To practice our skills in doing the pathophysiology of the case of the client.

8. To understand the drugs and its uses according to the clients situation.

9. To provide nursing care plan and discharge plan to assure clients total wellness.

10.

To know the proper attitude that an ideal nurse must possess.11. To learn how to make the proper approach to client to get their trust.


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I. INTRODUCTION

a. Background of the Study

I. Incidence, race, gender, age, ratio and proportion

The highest rates of breast cancer occur in Western countries (more than 100cases per 100,000 women) and the lowest among Asian countries (1015 cases per

100,000 women). Men can also have breast cancer, but the incidence is much less when

compared to women. There is a strong genetic correlation since breast cancer is more

prevalent in females who had a close relative (mother, sister, maternal aunt, or

maternal grandmother) with previous breast cancer. Increased susceptibility for

development of breast cancer can occur in females who never breastfed a baby, had a

child after age 30, started menstrual periods very early, or experienced menopause very

late.

In the United States, there were approximately 175,000 cases of breast cancer

in 1999 with more than 43,000 deaths. Breast cancer accounts for 30% of all cancer

diagnosed in American women and for 16% of all cancer deaths. Breast cancer is a

worldwide public health problem since there are approximately one million new cases

diagnosed annually. A woman's lifetime risk of developing breast cancer is one in eight.The incidence rose 21% from 1973 to 1990, but in recent years there has been a decline.

http://www.encyclopedia.com/doc/1G2-3406200301.html

II. Rationale for Choosing the case

Our Clinical Instructor decided to choose the case of Ductal Carcinoma because

this is common among women specially age 45years old and above. This case will help

us dig deeper on how and why it happens to those persons.

Also, the patients data is somehow complicated, such as her age and

background history, which is very interesting to find out if it is parallel to be the cause of

the case. It really make us wonder how it happens to a person and how will it bedistinguish.

III. Significance of the studies

The significance of the study is to enhance and of course to gain knowledge, to develop

skills and to apply the attitudes that must be render to the client whatever the case may

be. This study will also contribute in the widening of the ideas of the student about the

topic of the case.

These are other significance of the study that would support the above statement:

To be aware on how this case affects a person and how prevalent this situation

is. To be skill-oriented on how to identify and to properly observe the status of this

case in our present time.

To be well-communicated with the client during the physical assessment and

interviews.

To enhance our learned skills on assessing client and how to classify

abnormalities with different aspects such as physical, emotional, mental and

spiritual.


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To make ourselves oriented to different laboratory results and how we can relate

it with the situation of the client.

To enhance our knowledge in anatomy and physiology of the system involve.

To practice our skills in doing the pathophysiology of the case of the client.

To understand the drugs and its uses according to the clients situation.

To provide nursing care plan and discharge plan to assure clients total wellness.

To know the proper attitude that an ideal nurse must possess. To learn how to make the proper approach to client to get their trust.

IV. Scope and limitation of the study

The study would only focus on the information gathered from the patient, relatives of

the patient, from her records and laboratory results. This will be covering about the case

of Ductal Carcinoma, all about its anatomy and physiology and how did all of the records

may it be the medications, doctors order and nurses notes correlates to each other.

V. Conceptual Theoretical Theory

LYDIA HALLNURSING THEORY

(Core, Care, and Cure Model)

The Core. The core of human being is his/her needs to meet the Quality of Life (QOL). It is in

these needs that makeup and creates an individual.

The Care. The type of care a nurse will render in any case of altered health pattern can be in the

form of promotive, preventive, curative, rehabilitative and palliative aspects of care. Promotive care focus

on health promotion which is categorized with no source of health information, visits to well-

clinic/centers or oriented to health programs and practicing a healthy lifestyle and with good

environment.

The Cure. This identifies the level of care to be given to a person in case of altered healthpattern. Level 1 Cure covers promotive and preventive care are indications for primary health care

management. The major purposes of this level are to promote wellness and prevent illness or disability.

This level occurs at home or community and the participants in the care of geriatrics is the

private/family/community nurse, family and patients self that will emphasize the development of healthy

lifestyle and environment. Level 2, or early stage of curative phase, is an indication for secondary health

care management.


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VI.

Related Literature of the study

Invasive ductal carcinoma

Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma,

is the most common type of breast cancer. About 80% of all breast cancers are

invasive ductal carcinomas.Invasivemeans that the cancer has invaded or spread to the surrounding

breast tissues. Ductalmeans that the cancer began in the milk ducts, which are the

pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers

to any cancer that begins in the skin or other tissues that cover internal organs

such as breast tissue. All together, invasive ductal carcinoma refers to cancer that

has broken through the wall of the milk duct and begun to invade the tissues of the

breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and

possibly to other areas of the body.

According to the American Cancer Society, more than 180,000 women in the

United States find out they have invasive breast cancer each year. Most of them are

diagnosed with invasive ductal carcinoma.

Although invasive ductal carcinoma can affect women at any age, it is more

common as women grow older. According to the American Cancer Society, about two-thirds of women are 55 or older when they are diagnosed with an invasive breast

cancer. Invasive ductal carcinoma also affects men.

Symptoms

At first, invasive ductal carcinoma may not cause any symptoms. Often, an

abnormal area turns up on a screening mammogram (x-ray of the breast), which leads

to further testing.

In some cases, the first sign of invasive ductal carcinoma is a new lump or mass

in the breast that you or your doctor can feel. According to the American Cancer

Society, any of the following unusual changes in the breast can be a first sign of breast

cancer, including invasive ductal carcinoma:

swelling of all or part of the breast

skin irritation or dimpling

breast pain

nipple pain or the nipple turning inward

redness, scaliness, or thickening of the nipple or breast skin

a nipple discharge other than breast milk

a lump in the underarm area

Complications

Lead to premature death

Spread of cancer to other parts of the body

Prone

Female

Get older

Have a family history of breast cancer


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Diagnosis

Diagnosing invasive ductal carcinoma usually involves a combination of procedures, including

a physical examination and imaging tests.

Physical examination of the breasts: The doctor may be able to feel a small lump in thebreast during a physical examination. He or she also will feel the lymph nodes under the

armpit and above the collarbone to see if there is any swelling or other unusual changes.

Mammography:Invasive ductal carcinoma is usually found by mammography, a test

that obtains x-ray images of the breast. Mammograms are used to screen apparently healthy

women for early signs of breast cancer. One key feature of an invasive breast cancer is

spiculated margins, which means that on the mammography film, the doctor sees an

abnormality with finger-like projections coming out of it. These projections show the

invasion of the cancer into other tissues.

If a screening mammogram highlights an area of concern, additional mammograms often will

be done to gather more information about that area. Mammography will be performed on

both breasts.

Ultrasoundbounces sound waves off of the breast to obtain additional images of the

tissue. Ultrasound is sometimes used in addition to mammography.

Breast MRI:MRI, or magnetic resonance imaging, uses magnetic fields, radio waves, and

a computer to obtain images of tissues inside the body. In certain cases, a doctor may use

breast MRI to gather more information about a suspicious area within the breast.

Biopsy:If you do have a suspicious mammogram or other imaging test result, your

doctor will probably want you to have a biopsy. A biopsy involves taking out some or all of

the abnormal-looking tissue for examination by a pathologist (a doctor trained to diagnose

cancer from biopsy samples) under a microscope.

When possible, your doctor will usually use one of the quicker, less invasive approaches to

biopsy:

o Fine needle aspirationbiopsy involves inserting a very small, hollow needle into the

breast. A sample of cells is removed and examined under the microscope. This method leaves

no scars.o Core needle biopsyinserts a larger needle into the breast to remove several cylinder-

shaped samples of tissue from the area that looks suspicious. In order to get the core needle

through the skin, the surgeon must make a tiny incision. This leaves a very tiny scar that is

barely visible after a few weeks.

In cases where the doctor cannot feel the lump, he or she may need to use ultrasound or

mammograms to guide the needle to the right location. You may hear this referred to as

stereotactic needle biopsy or ultrasound-guided biopsy.

If a needle biopsy is not able to remove cells or tissue, or it does not give definite results

(inconclusive), a more involved biopsy may be necessary. These biopsies are more like

regular surgery than needle biopsies:

o Incisional biopsyremoves a small piece of tissue for examination.

o Excisional biopsyattempts to remove the entire suspicious lump of tissue from the

breast.Again, if the doctor cannot feel the lump, he or she may need to use mammography or

ultrasound to find the right spot. Your doctor also may use a procedure called needle wire

localization. Guided by either mammography or ultrasound, the doctor inserts a small hollow

needle through the breast skin into the abnormal area. A small wire is placed through the

needle and into the area of concern. Then the needle is removed. The doctor can use the

wire as a guide in finding the right spot for biopsy.

These surgical biopsies are done only to make the diagnosis. If invasive ductal carcinoma is

diagnosed, more surgery is needed to ensure all of the cancer is removed along with clear


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margins, which means that a border of healthy tissue around the cancer is also removed.

Usually this means having lumpectomy, or in some cases, mastectomy.

Treatment

Treatment options may include:

Axillary lymph node dissection

Chemotherapy

Lumpectomy

Mastectomy

Radiation therapy

Selective Estrogen Receptor

Modulator

Sentinel Node Biopsy

Targeted Therapy

Lifestyle Changes

Massage

Meditation

Music therapy

Hypnosis

Relaxation techniques, such as guided imagery

Tai chi

Yoga

Medications

The drug tamoxifenblocks the action of estrogen a hormone that fuels some breastcancer cells and promotes tumor growth to reduce your risk of developing invasive breast

cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone

receptor positive cancers).Tamoxifen isn't a treatment for DCIS in and of itself, but it can be

considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease

your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the

future.

Nursing Intervention

1. Support the patient emotionally and offer reassurance.

2.

Administer prescribed medications.3. Provide six small meals a day or small hourly meals as ordered.

4. Schedule care so that the patient gets plenty of rest.

5. Monitor the effectiveness of administered medications, and also watch

for adverse reactions.

6. Assess the patients nutritional status and the effectiveness of measures

used to maintain it. Weigh him regularly.

7. Teach the patient about peptic ulcer disease, and help him to recognize

its signs and symptoms.


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8. Review the proper use of prescribed medications, dicussing the desired

actions and possible adverse effect of each drug.

9. Instruct the patient to take antacids 1 hour after meals.

10. Warn the patient to avoid aspirin containing drugs because they irritate

gastric mucosa.

11. Encourage the patient to make appropriate lifestyle changes.

II. CLINICAL SUMMARY

A. General Data Profile

NAME: Mrs. VAP

ADDRESS: Brgy. Mapagong, Pagbilao,Quezon

AGE: 50y/o

WEIGHT: 69kg

HEIGHT: 411 ft.

BIRTHDAY: Dec. 10, 1963

BIRTHPLACE: Masbate

SPOUSE: Mr. EX

NATIONALITY: Filipino

RELIGION: Roman Catholic

OCCUPATION: House Wife

DATE OF ADMISSION: August. 13, 2013

ADMITTING DIAGNOSIS: Breast Mass Left, Excision Biopsy

ADMITTING PHYSICIAN: Dr. Durbin William Jeffrey N. Tang

B. CHIEF COMPLAINT

-With Mass on the Left Breast for 5 years

C. Nursing History

a.

Childhood Illnesses- Common colds, cough and fever

b. Immunizations

- BCG ( 7yrs/old)

c. Allergies

- No allergy at all.

d. Accidents

-The client had no known accident.

e. Hospitalizations

-Quezon Medical Center year 2001 due to delivery of the baby via Ceasarian section

f. Medications used or currently taking

- Mefenamic if he feels pain and Herbal meds

g. Domestic Travel

-

She is traveling from Palawan, Masbate and Quezon Province to visit her relatives.

D. Health History

A. Medical History

a. Chronic Illness


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- The client is experiencing from Urinary Tract Infection

b.

Current Medications

Drug Dose Route Time

Atracarium 25mg IV

Propofol 80mg + 30mg IV

Butorphanol 1mg IV

Neostigmine +

Atropine Sulfate

5mg + 1mg

respectively

IV

Cefuroxime 750mg IV Every 8 hours

Keterolac 30mg IV Every 6 hours

Tramadol 50mg IV Every 4 hours

Paracetamol 300mg IV Every 4 hours

Cefuroxime 500mg Oral tab Three times a day

Celecoxib 200mg Oral tab Two times a day

c. Childhood Illness

-

Common colds, cough and feverB. Surgical History

a. Problems with anesthesia

- The client stated that she has no problem with anesthesia nor allergies with it.

b. Previous Surgeries

- The client had undergo to surgery at year 2001 due to her delivery to her baby via

Cesarean Section


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E. FAMILY HISTORY

Legend:

Male Male Death

Female Female Death

Patient

Prostitis T B

A&W A&W Tumor on A&W A&W

The colon

A&W A&

A&W Patient

A&W A&W

Mass on

Breast

89 65

12

20

17

18

21

48

12

58

61

15

19

24

70

25 5

50

17

49

17

51

3917


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F. SOCIAL HISTORYINCLUDE THEORIES AND GROWTH AND DEVELOPMENT

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE

RESOLUTION

INDICATORS OF

NEGATIVE RESOLUTION

Adulthood 25-65years

Generativityversus

stagnation

Creativity,productivity,

concern for

other s

Self-indulgence,lack of interests

and

commitments.

According to this theory adulthood had creativity, productivity, concern for other. Based

on what the client said she wanted to sustain the need of her family especially her children future

and education, in spite of her of present condition.

ACCORDING TO SIGMUND FREUD

PSYCHOSEXUALTHEORY

STAGE AGE CHARACTERISTICS IMPLICATION

Genital Puberty and after Energy is directed

toward full sexual

maturity and function

and development of

skills needed to cope

with the environment

Encourages separation

from parents,

achievement of

independence and

decision making

According to this theory, the genital stage correlates to her age because she gains

independence in decision making to do normal things. Though she experiences pain physically due

to her condition it was only now that she experiences it that affected her sexual maturity and

function and development of skills.

G.

ENVIRONMENTAL/ LIVING CONDITION

The environment where they live and work is along a roadside. There are tricycle and

jeep which can be means of transportation. The type of their house not completely cemented,

but is well ventilated.

H. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT

Date of Assessment: August. 14, 2013

General Appearance: Pre-Operative

The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears

blouse and shorts exactly for her body. Upon assessment, the client is lying on bed.

BODY PART NORMAL FINDINGS ACTUAL FINDINGSINTERPRETATION/ ANALYSIS

A. HEAD

1. SKULLProportional to the size

of the body, round, with

prominences in the

frontal area anteriorly

Proportional to the

size of the body,

symmetrical in all

Normal.


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and the occipital area

posteriorly symmetrical

in all planes.

planes.

2. SCALP White, clean, free from

masses, lumps, scars,

nits, dandruff, and lesion

White, clean, free

from masses, lumps,

scars, nits, and lesions

Normal

3. HAIR Black or whitish, evenly

distributed and covers

the whole scalp, thick,

shiny, free from split

ends.

Black hair; evenly

distributed, thin,

bristle-like and coarse.

Normal

4. FACE Oblong/oval/square or

heart-shaped,

symmetrical, facial

expressions that is

dependent on the mood

or true feelings, smooth

and free from wrinkles,no involuntary muscle

movements.

Oval shape.

Symmetrical, free

from wrinkles and

scars. No involuntary

muscle movements.

Normal.

B. EYES

1.EYEBROWS Black, symmetrical,

thick, can raise and

lower eyebrows

symmetrically and

without difficulty, evenly

distributed and parallel

with each other.

Black, symmetrical.

Thin. Can raise and

lower eyebrows.

Normal

2. EYELIDS Upper lids cover a small

portion of the iris,

cornea, and the sclera

when the eyes are open.

When the eyes are

closed, the lids meet

completely. Symmetrical

color is the same as the

surrounding skin.

Upper lids cover a

small portion of the

iris, cornea, and the

sclera when the eyes

are open. When the

eyes are closed, the

lids meet completely.

Same color of

surrounding skin.

Normal

3. LID MARGINS

4. CONJUNCTIVA

Clear, without scaling or

secretions, lacrimal duct

openings are evident at

the nasal ends.

Pink, without lesions

Clear, without scaling

or secretions

Pink without lesions

Normal

Normal

5. SCLERA White and clear. White and clear. Normal


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6. IRIS Proportional to the size

of the eye, round,

black/brown, and

symmetrical.

It is symmetrical,

round and

proportional to size.

Normal

7. PUPIL From pinpoint to almost

the size of the iris,

round, symmetrical,constrict with increasing

light and

accommodation.

Symmetrical

constricted to light

and accommodatedfrom light.

Normal

8. CORNEA Clear Clear Normal

9. EYE MOVEMENT Able to move eyes in full

range of motion or able

to move in all directions.

Able to move eyes in

six field of gaze.

Normal

C. EARS Pinkish, clean, with scant

amount of cerumen and

a few cilia.

Cerumen and a few

cilia.

Normal

1. HEARING ACUITY Able to hear whisper

spoken words 2 feet

away.

Able to hear whisper

spoken words 2 feet

away.

Normal

2. EAR CANAL No erythema, no scaling,

no swelling, absence of

foreign body and odor.

No erythema, no

scaling, absence of

foreign body and

odor.

Normal

D. NOSE Midline, symmetrical,

and patent.

Midline, symmetrical,

and patent.

Normal

1. INTERNAL NARES Clean, pinkish, with few

cilia.

Clean, pinkish, with

few cilia.

Normal

2. SEPTUM Straight. Straight. NormalE. MOUTH Pinkish, symmetrical lip

margin, well-defined,

smooth and moist.

Pinkish, symmetrical,

lip margin, well-

defined, smooth and

moist.

Normal

1. LIPS Pinkish, smooth, moist,

no swelling, no

retraction, no discharge.

Pinkish lips. No

swelling.

Normal

2. TEETH 28-32 permanent teeth,

well-aligned free from

caries or filling, no

Halitosis.

28-32 permanent

teeth, well-aligned

free from caries or

filling, no Halitosis.

Normal

3. TONGUE Large, medium, red or

pink, the lateral margins,

moist, shiny, and freely

Movable.

Medium, red, the

lateral margins, moist,

shiny, and freely

movable.

Normal

4. CHEEKS

(BUCCAL MUCOSA)

Pinkish, moist. Pinkish, moist. Normal

5. PALATE Pinkish, moist, and Moist, and smooth. Normal


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lesions and edema. for 5 years with

wound on the left

breast.

under Modified Radical Mastectomy.

L. UPPER

EXTREMITIES1. ARMS

Inspection Skin varies (pinkish, tan,

dark brown), skin is

smooth, fine hair evenly

distributed, muscles

symmetrical, length

symmetrical.

Tan skin muscle,

length symmetrical,

fine hair evenly

distributed.

Normal

Palpation Warm, dry and elastic,

no areas of tenderness.

Muscle appears equal

with good muscle tone.

Warm, dry and no

areas of tenderness.

Normal

M. NAILS Nails are transparent,smooth, & convex with

pink nail beds & white

translucent tips.

Five fingers in each

hand. As pressure is

applied to the nail bed,

it appears white or

blanched & pink color

returns immediately as

pressure is released.

Complete fingers, 5each hand.

Nails are short, thick,

transparent, & convex

with pale nail beds &

white translucent tips.

As pressure is applied

to the nailbed, it

appears white and

color returns after 2

seconds.

Normal

N. SHOULDERS,

ARMS, ELBOWS,

HANDS & WRISTS

ABDUCTION AND

ADDUCTION.

Performs with relative

ease.

Physical mobility of

the upper extrimities

is slightly impaired,

especially on the left

side.

Due to pain associated with the presence

of surgical incision on the left breast.

O. LOWER

EXTREMITIES

1. LEGS




distributed, absence of

varicose veins, muscles

symmetrical, lengthsymmetrical.

Skin is uniformed in

tan color Hair evenly

distributed.

Normal

Palpation Muscles appear equal,

warm & with good

muscle tone.

Muscles appear equal,

warm & with good

muscle tone.

Normal

2. TOES

InspectionFive toes in each foot: Five toes in each foot.

Normal


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sole and dorsal surface

is smooth: With pink nail

beds & translucent tips.

Sole and dorsal

surface is smooth

Palpation As pressure is applied,

the nail beds appear

white or blanched; pink

color returns whenpressure is released (2

seconds).

As pressured is

applied to nail beds,

color becomes white,

colors returns afterless than 2 seconds

Normal

P. LEGS, KNEES,

ANKLES, TOES

ADDUCTION AND

ABDUCTION.


ease.


ease.

Normal

Date of Assessment: August. 15, 2013

General Appearance: Post-Operation

The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears

blouse and shorts exactly for her body. Upon assessment, the client is lying on bed, with a blood pressure of

120/80 mmHg, pulse rate of 79 beats per minute, respiration rate of 17 breaths per minute, and temperature of

38.9 C.

BODY PART NORMAL FINDINGS ACTUAL FINDINGSINTERPRETATION/ ANALYSIS

A. HEAD

1. SKULLProportional to the size

of the body, round, with

prominences in the

frontal area anteriorly

and the occipital area

posteriorly symmetrical

in all planes.

Proportional to the

size of the body,

symmetrical in all

planes.

Normal.

2. SCALP White, clean, free from

masses, lumps, scars,

nits, dandruff, and lesion

White, clean, free

from masses, lumps,

scars, nits, and lesions

Normal

3. HAIR Black or whitish, evenly

distributed and covers

the whole scalp, thick,

shiny, free from split

ends.

Black hair; evenly

distributed, thin,

bristle-like and coarse.

Normal

4. FACE Oblong/oval/square or

heart-shaped,symmetrical, facial

expressions that is

dependent on the mood

or true feelings, smooth

and free from wrinkles,

no involuntary muscle

movements.

Oval shape.

Symmetrical, freefrom wrinkles and

scars. No involuntary

muscle movements.

Normal.

B. EYES


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1.EYEBROWS Black, symmetrical,

thick, can raise and

lower eyebrows

symmetrically and

without difficulty, evenlydistributed and parallel

with each other.

Black, symmetrical.

Thin. Can raise and

lower eyebrows.

Normal

2. EYELIDS Upper lids cover a small

portion of the iris,

cornea, and the sclera

when the eyes are open.

When the eyes are

closed, the lids meet

completely. Symmetrical

color is the same as the

surrounding skin.

Upper lids cover a

small portion of the

iris, cornea, and the

sclera when the eyes

are open. When the

eyes are closed, the

lids meet completely.

Same color of

surrounding skin.

Normal

3. LID MARGINS

4. CONJUNCTIVA

Clear, without scaling or

secretions, lacrimal duct

openings are evident at

the nasal ends.

Pink, without lesions

Clear, without scaling

or secretions

Pink without lesions

Normal

Normal

5. SCLERA White and clear. White and clear. Normal

6. IRIS Proportional to the size

of the eye, round,black/brown, and

symmetrical.

It is symmetrical,

round andproportional to size.

Normal

7. PUPIL From pinpoint to almost

the size of the iris,

round, symmetrical,

constrict with increasing

light and

accommodation.

Symmetrical

constricted to light

and accommodated

from light.

Normal

8. CORNEA Clear Clear Normal

9. EYE MOVEMENT Able to move eyes in full

range of motion or able

to move in all directions.

Able to move eyes in

six field of gaze.

Normal

C. EARS Pinkish, clean, with scant

amount of cerumen and

a few cilia.

Cerumen and a few

cilia.

Normal

1. HEARING ACUITY Able to hear whisper

spoken words 2 feet

away.

Able to hear whisper

spoken words 2 feet

away.

Normal

2. EAR CANAL No erythema, no scaling, No erythema, no Normal


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no swelling, absence of

foreign body and odor.

scaling, absence of

foreign body and

odor.

D. NOSE Midline, symmetrical,

and patent.

Midline, symmetrical,

and patent.

Normal

1. INTERNAL NARES Clean, pinkish, with fewcilia.

Clean, pinkish, withfew cilia.

Normal

2. SEPTUM Straight. Straight. Normal

E. MOUTH Pinkish, symmetrical lip

margin, well-defined,

smooth and moist.

Pinkish, symmetrical,

lip margin, well-

defined, smooth and

moist.

Normal

1. LIPS Pinkish, smooth, moist,

no swelling, no

retraction, no discharge.

Pinkish lips. No

swelling.

Normal

2. TEETH 28-32 permanent teeth,

well-aligned free fromcaries or filling, no

Halitosis.

28-32 permanent

teeth, well-alignedfree from caries or

filling, no Halitosis.

Normal

3. TONGUE Large, medium, red or

pink, the lateral margins,

moist, shiny, and freely

Movable.

Medium, red, the

lateral margins, moist,

shiny, and freely

movable.

Normal

4. CHEEKS

(BUCCAL MUCOSA)

Pinkish, moist. Pinkish, moist. Normal

5. PALATE

SOFT PALATE

HARD PALATE

Pinkish, moist, and

smooth.

Slightly pinkish.

Moist, and smooth.

Slightly pinkish.

Normal

Normal

6. UVULA At the center,

symmetrical, and freely

movable.

At the center,

symmetrical, and

freely movable.

Normal

7. TONSILS Pinkish, non-inflamed,

no exudates.

Pinkish, non-inflamed,

no exudates.

Normal

8. VOICE No hoarseness and well-

modulated.

No hoarseness and

well-modulated.

Normal

F. NECK Proportional to the size

of the body and head,

symmetrical and

straight.

Proportional to the

size of the body and

head, symmetrical and

straight.

Normal

G. RANGE OFMOTION

Freely movable withrelative ease.

Limited range ofmotion especially on

the left side of the

body

Due to presence of the surgical incisionon the left breast.

H. MUSCULAR

STRENGTH

Symmetrical movements

and able to resist force

applied by the nurse.

Able to resist force

applied only at the

right side of the body.

Due to presence of the surgical incision

on the left breast


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I. HEART Regular beats

(60-100 beats per

minute).

Regular beats (79

beats per minute)

Normal

J. ABDOMEN

Inspection

1. Abdomen skin

2. Contour and

Symmetry

3. Movements

associated w/

respiration

Unblemished skin;uniform color.

Flat, rounded;

symmetric contour.

Symmetric movements

caused by respiration.

With scar caused bysurgical incision via CS.

Rise and fall caused by

respiration.

Due to the delivery of her baby via CS.

Normal

Auscultation Audible bowel sounds

(5-30/min); absence of

arterial bruits and

friction rubs.

Audible bowel sounds

(10/min).

Normal

Palpation No tenderness; relaxed

abdomen with smooth,

consistent tension.

No area of

tenderness; no

presence of lumps and

masses absence of

lesion.

Normal

K. CHEST (THORAX)

Inspection Chest symmetrical, skin

intact, no tenderness, no

masses.

Chest symmetrical. No

lumps, tenderness and

masses.

Respiration of 17

breaths per minute

Normal

Breast The breast has no

lesions and edema.

With presence of

surgical incision on

left breast. The right

breast has no lesions

and edema.

Due to removal of the mass on the left

breast.

L. UPPER

EXTREMITIES

1. ARMSInspection Skin varies (pinkish, tan,



distributed, muscles

symmetrical, length

symmetrical.

Tan skin muscle,

length symmetrical,

fine hair evenly

distributed.

Normal

Palpation Warm, dry and elastic,

no areas of tenderness.

Warm, dry and no Normal


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Muscle appears equal

with good muscle tone.

areas of tenderness.

M. NAILS Nails are transparent,

smooth, & convex with

pink nail beds & whitetranslucent tips.

Five fingers in each

hand. As pressure is

applied to the nail bed,

it appears white or

blanched & pink color

returns immediately as

pressure is released.

Complete fingers, 5

each hand.

Nails are short, thick,transparent, & convex

with pale nail beds &

white translucent tips.

As pressure is applied

to the nailbed, it

appears white and

color returns after 2

seconds.

N. SHOULDERS,

ARMS, ELBOWS,

HANDS & WRISTS

ABDUCTION ANDADDUCTION.


ease.

Physical mobility of

the upper extrimities

is slightly impaired,

especially on the leftside.

Due to pain associated with the presence

of surgical incision on the left breast.

O. LOWER

EXTREMITIES

1. LEGS




distributed, absence of

varicose veins, muscles

symmetrical, length

symmetrical.

Skin is uniformed in

tan color Hair evenly

distributed.

Normal

Palpation Muscles appear equal,

warm & with good

muscle tone.

Muscles appear equal,

warm & with good

muscle tone.

Normal

2. TOES

InspectionFive toes in each foot:

sole and dorsal surface

is smooth: With pink nail

beds & translucent tips.

Five toes in each foot.

Sole and dorsal

surface is smooth

Normal

Palpation As pressure is applied,

the nail beds appear

white or blanched; pink

color returns whenpressure is released (2

seconds).

As pressured is

applied to nail beds,

color becomes white,

colors returns afterless than 2 seconds

Normal

P. LEGS, KNEES,

ANKLES, TOES

ADDUCTION AND

ABDUCTION.


ease.


ease.

Normal


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I. PATTERNS OF FUNCTIONING

Functional Health

Pattern

Before

Hospitalization

During

Hospitalization

(after operation)

Interpretation

Health management

pattern

She is taking

analgesics if she

feels pain and herbal

meds.

The client is

dependent on what

the physician has

ordered her to do.

She takes OTC drugs

whenever she feels

something and

herbal meds as what

the elders has told

her.

Nutritional/ Metabolic

Pattern

- Number of meals

per day

- Appetite

- Glass of water per

day

- Body Built

- Height and weight

3 times a day

w/ very good

appetite

6 glasses of water

w/ normal body built

411 and 69 kg

NPO

With normal body

built

Her number of meals

is now deprived

because it is needed

in preparation for

her pre and post

operation.

Elimination

- Frequency of

urination

- Amount of urine

per day

- Frequency of bowel

- Consistency of feces

- Amount defecated

6 times a day

moderate

2

Formed

Moderate

2 times a day

Moderate

1

Formed

scanty

Her frequency of

urination and

defecation isdeprived because

she is placed on NPO

and IVF acts as her

food.

Activity and Exercise

- Exercise

- Fatigability

- ADL

Daily walking

Easily get tired

Independent

Unable to performed

exercise

Easily get tired

Slightly dependent

She considers

walking as her daily

exercise but when

she is hospitalized

she became slightly

dependent and

unable to performed


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her daily activities.

Cognitive/ Perceptual

- Orientation

-

Responsiveness

Oriented to time

place and person

Respondapproximately to

verbal and physical

stimuli.

Oriented to time,

place and person

Respondapproximately to

verbal and physical

stimuli.

She is well oriented

and can respond to

verbal and physical

stimuli.

Roles/ Relationship

- As a daughter

- As a sister

- As a wife

- As a mother

She has a good

relationship with her

parents

She has good


siblings.

she has good


husband, they enjoy

their lives together

She has good


children; she cares

for them a lot.

Her parents always

supported her when

they were still alive.

Shes supported by

her siblings during

her hospitalization.

Her husband really

do support her and

settle all the things

for her during her

hospitalization

She always takes

care of her children

and supports them

with their needs.

There are good

relationship

between the family

members.

Self Perception and

concept

Have a high self

worth/ importance

Have a high self

worth/ importance

In spite of her

present condition,

she still has a high

self worth and

importance.

Coping/ Stress She seeks advice

from her husband,

and even sometimes

with her friends,

relatives and also

She trusts God for

she knows that

everything will turn

right when hes

there.

She wholly gives her

full trust to God

when shes inside

the hospital for she

knows that


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with God. everything is about

His will.

Values/ Belief Shes aware and she

trust God and believe

that He did exist.

Her trust to God

boosted more and

more confident

whenever praying.

she really did trust

God ever than the

way she trust Him

before.

J. COURSE IN THE WARD

DATEDOCTORS ORDERS

RATIONALE

August 13, 2013

10:35am

Please admit to Female Surgery Ward

Secure Consent

TPR

NPO

CBC

Blood Typing

Urine Analysis

IVF D5LR x 8hrs

Cefuroxime 750mg IV q8 ANST

For MRM (Modified Radical Mastectomy)

Left tomorrow

In preparation for surgical

procedure

To properly have consent

from the relatives of the

patient.

To monitor if there is

deviation from normal with

regards to the temperature,pulse and respiration of the

patient.

To prepare the patient for

the surgical procedure and to

depress the GI tract.

To monitor if there is any

deviation from normal values

of the components of blood

of the patient.

To know the blood type ofthe patient so that if ever

blood transfusion will be

done, the blood to be

administered has the same

type.

To know if the patient has

any disorder regarding to her

kidney or Urinary tract.

D5LR is parenteral fluid,

electrolyte and nutrient

replenisher It fights against bacteria

during infection.

MRM is for those patient

who has mass on their breast

and diagnosed to be

removed.

To refer if something urgent

happened to the patient.


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5:00pm

Refer OR/ AROD/ SROD

Refer Accordingly

Prepare 1 u FWB (Fresh Whole Blood)

properly typed and crossed match

NPO post midnight

Discontinue present IVF

IVF of D5LR 1L to be inserted at 5am

Refer to Dr. Encanto

Refer what has been

ordered.

To be ready if ever, during

the surgical procedure, the

patient loss lots of blood.

To make the patients GI

tract depress for the surgical

procedure to be done.

To give way for the

procedure to be done.

To get ready for the

procedure.

To endorse to the doctor

who will handle the patient.

August 14, 2013

9:25am

Post OR order

DAT when fully awake

Monitor VS every 10 mins for 6hrs, then

every 15 mins until stable.

IVF D5LR1L x 8hrs

IVF D5LR 1L x 8hrs

Cefuroxime 750mg IV q8

Keterolac 30mg IV q6/amp x 4doses ANST

Oxygen inhalaton 2-3L

Refer accordingly

Tramadol 50mg IV q4

For the patient easy

recovery. DAT will be

administered when fully

awake and not during

unconscious state to avoid

the occurrence of aspiration.

To monitor the adaptation of

the patient to the procedure

and if there are any deviation

from normal value of thepatients TPR, BP.

D5LR is parenteral fluid,


replenisher

It fights against bacteria

during infection

It is for relief from pain due

to surgical procedure

To support the Oxygen

inhalation of the patient

Refer what has been

ordered.

Given for pain relief due to

surgical procedure.

August 15, 2013 Continue Medications It is being continued because

the prescribed one can

develop a resistance to

antibiotics if they are used


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10:00am

To follow D5LR x KVO

Paracetamol 30mg prn

appropriately which can

make it even more difficult to

treat the client next time and

also it being continue for

faster recovery and treat for

the prevention of the

disease. D5LR is parenteral fluid,


replenisher

For the sudden increased in

temperature of the client.

August 16, 2013

DAT

IVF PNSS 1L x KVO

For repeat Hemoglobin and Hematocrit

Cefuroxime 500mg TID

Celecoxib 200mg BID

Add supplemex KVO

For the patient to eat what

the stomach can tolerate and

to return to normal function

of the GI tract.

Normal Saline is a sterile,

nonpyrogenic solution for

fluid and electrolyte

replenishment.

To check if the patient has

normal value of Hemoglobin

and Hematocrit after the

surgical procedure.

It fights against bacteria

during infection.

Use to treat pain

Supplement in IV form in

support for the recovery of

the patient.

August 17, 2013

Facilitate Bed rest

IVF same rate

Continue medications

Refer

Hgb = 7.4

Prepare and transfer 3 u Fresh Whole

Blood

To promote rest for the clientand blood circulation.

For same way of treatment.

For continuous treatment

and recovery of the patient.

To be refer accordingly due

to decreased Hgb.

There is a decreased from

the normal value (12-16 g/dl)

of patients Hemoglobin.

Since there is a decrease in

patients hemoglobin, she

needs to have blood

transfusion.

To check if there are any

changes and progress with

the patients hemoglobin and

hematocrit value.


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Repeat Hemoglobin and Hematrocrit 6hrs

post bedrest

August 18, 2013 MGH

Home meds as ordered

Follow up check up on

August 23, 2013 8am at OPD. For continuous adherence to

medication regimen.


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K. LABORATORY RESULTS:

DATE: August 13, 2013

REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)

Name of test INDICATION Normal range Results Significance of the result

HEMOGLOBIN

HEMATOCRIT

WBC COUNT

-Neutrophils

-Lymphocytes

-Monocytes

-Eosinophil

-Basophil

PLATELET COUNT

CLOTTING TIME

BLEEDING TIME

Blood test can be used to

find out what is

happening in many parts

of the body. Testingblood is easier than

obtaining a tissue sample.

Any test designed to

discover abnormalities in

a sample of blood to

determine blood groups

(Merck Manual of

Medical information p.

888)

M:14-18 gm/dl

F:12-15 gm/dl

M:40-50%

F:30-40%

5,000-10,000

40%-50%

35%-45%

2%-5%

2-4%

0-1%

150,000-450,000

11.1

35.9

11,700

71%

29.7%

100%

Values decrease in anemia, hyperthyroidism, cirrhosis of the

liver and severe hemorrhage.

NORMAL

Values increase in acute infections, trauma, some malignant

disease, and some cardiovascular disease

Neutrophils increase in acute infections.

Lymphocytes increase during antigen-antibody reactions.


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HEMOGLOBIN

HEMATOCRIT

WBC COUNT

-Neutrophils

-Lymphocytes

-Monocytes

-Eosinophil

-Basophil

PLATELET COUNT

CLOTTING TIME

BLEEDING TIME


find out what is


of the body. Testing

blood is easier than






(Merck Manual of


888)

M:14-18 gm/dl

F:12-15 gm/dl

M:40-50%

F:30-40%

5,000-10,000

40%-50%

35%-45%

2%-5%

2-4%

0-1%

150,000-450,000

9.7

29

11,600

69%

31%

261,000



Values decrease in anemia, leukemia, cirrhosis and

hyperthyroidism.

Values increase in acute infections, trauma, some malignant

disease, and some cardiovascular disease

Neutrophils increase in acute infections.

NORMAL.

NORMAL



28/72




HEMOGLOBIN

HEMATOCRIT

RBC COUNT

MCV

MCH

MCHC

WBC COUNT

PLATELET COUNT

CLOTTING TIME

BLEEDING TIME


find out what is


of the body. Testing

blood is easier than






(Merck Manual of


888)

12.0-16.0

0.37-0.43

4.0-5.4

78-102

39.0-54.0

481-574

4.0-10.0

170-400

7.40

0.23



Values decrease in anemia, leukemia, cirrhosis and

hyperthyroidism.


29/72


BLOOD TYPING AND CROSSMATCHING RESULTS

PATIENTS ABOGROUP: O RH GROUP: positive

Source

of

blood

Donor

number

ABO

group

RH typing Interpretation Released

by:

Taken by Date and

time

QMC 1390-13 O Positive Saline phase

LISS/coombs-

37C

COMPATIBLE

Autocontrol Negative for agglutination


30/72

Diagnosis:

Breast mass, left, excision biopsy

INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2

POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2

INVASIVE DUCTAL CARCINOMA

Invasivemeans that the cancer has invaded or spread to the surrounding breast tissues.Ductalmeans that the cancer began in the

milk ducts, which are the pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers to any cancer that

begins in the skin or other tissues that cover internal organs such as breast tissue. All together, invasive ductal carcinoma refersto cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal

carcinoma can spread to the lymph nodes and possibly to other areas of the body.http://pathology.jhu.edu/breast/grade.php

Grade I or low-grade DCIS cells look very similar to normal cells or atypical ductal hyperplasia cells. Grade II or moderate-grade DCIS cells grow faster than

normal cells and look less like them. Grade I and Grade II DCIS tend to grow slowly and are sometimes described as "non-comedo" DCIS. The term non-comedo

means that there are not many dead cancer cells in the tumor. This shows that the cancer is growing slowly, because there is enough nourishment to feed all

of the cells. When a tumor grows quickly, some of its cells begin to die off.

http://www.breastcancer.org/symptoms/types/dcis/diagnosis

=POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.

When LVI is present, doctors assume this means that the cancer has acquired the genetic mutation it needs to create its own blood vessels, a process called

angiogenesis. Because a tumor that has the ability to create its own blood vessels may have already begun to spread cancer cells to other parts of the body, the

presence of LVI is an indicator that treatment should most likely include chemotherapy or hormone therapy (if the tumor is hormone sensitive).

Perivascular invasionrequires at least two cell types: the endothelial cells that form the vascular tubes and the tumor cells. Perivascular invasion does not

have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence ofcancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.
http://www.breastcancer.org/symptoms/types/dcis/diagnosishttp://www.breastcancer.org/symptoms/types/dcis/diagnosishttp://www.breastcancer.org/symptoms/types/dcis/diagnosis


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JULY 17, 2013

CHEST X-RAY

Both lung fields are clear

Heart, aorta and pulmonary vascular markings are within normal limits

Diaphragm and sinuses are preserved

Intact both thorax

IMPRESSION:

ESSENTIALLY NORMAL CHEST FINDINGS.


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ECG RESULT: NORMAL


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DATE: JULY 17, 2013

TEST VALUE REFERENCE

RANGE

REMARKS

CREATININE 1.63 mg/dl 0.6-1.3 Creatinine increase in certain

kidney disease and infections.

BUN 20.40 mg/dl 7-18 Values increase in response to

increased in dietary protein intake.

GLUCOSE 80.24 mg/dl 70-105 NORMAL

URIC ACID 7.17 mg/dl 2.6-7.2 NORMAL

TRIGLYCERIDES 50.61 mg/dl 0-150 NORMAL

CHOLESTEROL 142.41 mg/dl 0-200 NORMAL


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DATE: July 18, 2013

NAME OF

TESTINDICATION

MICROSCOPIC

EXAMINATIONSRESULTS

REFERENCE

VALUESIGNIFICANCE OF THE RESULT

Urinalysis Urinalysis is a laboratory

diagnostic procedure which

involves testing of urine for

bacteria, protein, or other

molecules that can provide

information about patientshealth.

Color Yellow YELLOW NORMAL

Transparency Slightly

Turbid

CLEAR Indicates high concentration of solutes

Reaction 5.0 4.57.5 NORMAL

Specific Gravity 1.030 1.0151.025 Increased urine specific gravity may be due to:

Dehydration,Diarrhea that causes dehydration,Glucosuria,Heart failure (related to decreased

blood flow to the kidneys), Renal arterial stenosis,

Shock, Syndrome of inappropriate antidiuretic

hormone secretion (SIADH)

CLINICAL TEST

Sugar Negative NEGATIVE NORMAL

Albumin negative NEGATIVE NORMAL

PREGNANCY TEST - - -

URINE BILE - - -

Red Blood Cell 2-3 23HPF NORMAL

Epithelial Cells Few FEW NORMAL

Mucus Threads FEW RARE -

Bacteria MODERATE NEGATIVE -

Crystals - NONE -

Calcium Oxalates - - -

A. Uric Acid - 1.48

4.43mmol/day

-

Fine Granular - NONE -

Course Granular - NONE -

Hyalines - OCCASSIONAL -

Others Yeast cells many
http://www.nlm.nih.gov/medlineplus/ency/article/000982.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000158.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000394.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000394.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000158.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000982.htm


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III. CLINICAL MANIFESTATION

A . ANATOMY AND PHYSIOLOGY

Breast

The breast is the upper ventral region of the torso of a primate, in left and right sides, containing

the mammary gland which in female can secrete milk used to feed infants.

Both men and women develop breasts from the same embryological tissues. However, at

puberty, female sex hormones, mainly estrogen, promote breast development which does not occur

in men due to the higher amount of testosterone. As a result, women's breasts become far more

prominent than those of men.

During pregnancy, the breast is responsive to a complex interplay of hormones that cause tissue

development and enlargement in order to produce milk. Three such hormones are estrogen,

progesterone and prolactin, which cause glandular tissue in the breast and the uterus to change

during the menstrual cycle.

Each breast contains 1520 lobes. The subcutaneous adipose tissue covering the lobes gives the

breast its size and shape. Each lobe is composed of many lobules, at the ends of which are sacs where

milk is produced in response to hormonal signals.

Anatomy

The Breast: cross-section scheme of the mammary gland.

1. Chest wall

2. Pectoralis muscles

3. Lobules

4. Nipple

5. Areola

6. Milk duct

7. Fatty tissue

8. Skin
http://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.pnghttp://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.pnghttp://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.png


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Morphology

The human breast has two aspects: the functional aspect and the anatomic aspect.

The functional breast

The breast is an apocrine gland that produces milk to feed an infant child; for which the nipple ofthe breast is centered in (surrounded by) an areola (nipple-areola complex, NAC), the skin color of

which varies from pink to dark brown, and has many sebaceous glands.

The anatomic breast

In women, the breasts overlay the pectoralis major muscles and usually extend from the level of

the second rib to the level of the sixth rib in the front of the human rib cage; thus, the breasts cover

much of the chest area and the chest walls. At the front of the chest, the breast tissue can extend

from the clavicle (collarbone) to the middle of the sternum (breastbone). At the sides of the chest,

the breast tissue can extend into the axilla (armpit), and can reach as far to the back as the latissimus

dorsi muscle, extending from the lower back to the humerus bone (the longest bone of the upper

arm). As a mammary gland, the breast is an inhomogeneous anatomic structure composed of layers

of different types of tissue, among which predominate two types, adipose tissue and glandular tissue,

which effects the lactation functions of the breasts.

Lymphatic drainage

Approximately 75% of the lymph from the breast travels to the ipsilateral (same-side) axillary

lymph nodes, whilst 25% of the lymph travels to the parasternal nodes (beside the sternum bone), to

the other breast, and to the abdominal lymph nodes. The axillary lymph nodes include the pectoral

(chest), subscapular (under the scapula), and humeral (humerus-bone area) lymph-node groups,

which drain to the central axillary lymph nodes and to the apical axillary lymph nodes. The lymphatic

drainage of the breasts is especially relevant to oncology, because breast cancer is a cancer commonto the mammary gland, and cancer cells can metastasize (break away) from a tumors and be

dispersed to other parts of the woman's body by means of the lymphatic system.

Shape and support

The topography of the breasts indicates the glandular body, the nipple-areola complex (NAC),

and the inframammary fold (IMF).

Size

Breast size varies with race and ethnic origin. A study released in 2013 suggests the existence of a

single genetic mutation responsible for multiple characteristics of East Asians, including thicker hair,more sweat glands and smaller breasts on women.


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Hormonal change

On the skin envelope of the breast, stretch marks may indicate the relative-size increments and

decrements occurred during the life of the woman.

Because the breasts are principally composed of adipose tissue, which surrounds the milk glands,their sizes and volumes fluctuate according to the hormonal changes particular to the larche

(sprouting of breasts), menstruation (egg production), pregnancy (reproduction), lactation (feeding of

offspring), and menopause (end of menstruation). For example, during the menstrual cycle, the

breasts are enlarged by premenstrual water retention; during pregnancy the breasts become

enlarged and denser (firmer) because of the prolactin-caused organ hypertrophy, which begins the

production of breast milk, increases the size of the nipples, and darkens the skin color of the nipple-

areola complex; these changes continue during the lactation and the breastfeeding periods.

Afterwards, the breasts generally revert to their pre-pregnancy size, shape, and volume, yet might

present stretch marks and breast ptosis. At menopause, the breasts can decrease in size when the

levels of circulating estrogen decline, followed by the withering of the adipose tissue and the milk

glands. Additional to such natural biochemical stimuli, the breasts can become enlarged consequentto an adverse side effect of combined oral contraceptive pills; and the size of the breasts can also

increase and decrease in response to the body weight fluctuations of the woman. Moreover, the

physical changes occurred to the breasts often are recorded in the stretch marks of the skin

envelope; they can serve as historical indicators of the increments and the decrements of the size and

the volume of a woman's breasts throughout the course of her life.

REFERENCE: http://en.wikipedia.org/wiki/Breast
http://en.wikipedia.org/wiki/File:Schwangerschaftsstreifen.JPG


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Cellular Aberrations

Ca Cell Proliferation

Disrupt normal cell growth and

interfere with tissue function

Pressure

Obstruction

Pain

Effusion

Ulceration

Vascular Thrombosis, Embolism,

Thrombophlebitis

Malignant cells

produce enzymes,

hormones and other

(Paraneoplastic

Syndrome)

Anemia

Hypercalemia Edema

DIC

Anorexia and

Cachexia Syndrome

Tissue wasting

Severe weight

loss

Severe

debilitation

Reference : Medical Surgical Nursing Concept and Clinical Application 2ndEdition, 2009

Author: Jose, Quiambao, Udab

And

http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/invasive_d

uctal_carcinoma.html


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Client Based

Precipitating Factor:

Lifestyle

She like to eat high in salt and fatty foods

Always wearing brassier with wire

Environment

Her breast is often bumped by his son

Predisposing Factor:

Nulliparous or older than 30

years at the birth of a first child

Late menarche

Signs and symptoms:

Lump in the breast

For 5 years

Sore of the breast

Since November 2012 up to august 13

2013

New pain in left side of breast

Cellular Aberrations

Ca Cell Proliferation

Disrupt normal cell growth and

interfere with tissue function

Pressure

Obstruction

Pain

Malignant cells produce

enzymes, hormonesand other

(Paraneoplastic

Syndrome)

Anemia

Ductal Carcinomaoma

Possible complication:

Lymphedema

Bleeding

Hematoma formation

Brachial plexus injuries
http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.htmlhttp://www.rightdiagnosis.com/l/lymphedema/intro.htmhttp://www.rightdiagnosis.com/h/hemorrhage/intro.htmhttp://www.rightdiagnosis.com/medical/hematoma_formation.htmhttp://www.rightdiagnosis.com/b/brachial_plexus_injury/intro.htmhttp://www.rightdiagnosis.com/b/brachial_plexus_injury/intro.htmhttp://www.rightdiagnosis.com/medical/hematoma_formation.htmhttp://www.rightdiagnosis.com/h/hemorrhage/intro.htmhttp://www.rightdiagnosis.com/l/lymphedema/intro.htmhttp://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.html


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Modified Radical Mastectomy

A modified radical mastectomy is a type of mastectomy that combines the removal of all breast tissue

from the affected breast with lymph node removal from the armpit on the affected side of the body.

This surgery typically includes the removal of both the nipple and areola, but the surgery can be

performed using skin and nipple sparing techniques.

Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length

that begins on the inside of the breast, near the breast bone, and extends upward and outward toward

the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can

improve the cosmetic outcome if reconstruction is desired.

Once the breast tissue is removed, the incision is closed with either absorbable sutures or staples that

are removed during an office visit 10 to 14 days after surgery. There may also be drains in place to

decrease the amount of swelling in the area. These drains are covered with bandages to protect the

incision site and the drain placement. The drains are typically removed after discharge from the hospitalby the surgeon during a routine office visit after surgery.

REFERENCE: http://surgery.about.com/od/proceduresaz/ss/Mastectomy_3.htm


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Name of

Drug

Classification Mechanism of

Action

Indication Contraindication Side Effects Nursing Responsibility

Atracarium

25mg IV

no depolarizing

neuromuscu-lar

blocker

Skeletal Muscle

Relaxant

Prevents

acetylcholine

from binding

to receptors

on muscle end

plate, thus

blocking

depolarization

and resulting

in skeletal

muscle

paralysis.

Adjunct to

general

anesthesia, to

facilitate

endotracheal

intubation and

cause skeletal

muscle

relaxation

during surgery

or mechanical

ventilation

Contraindicated

in patients

hypersensitivity

to drug

Use cautiously

in patients with

CV disease;

severe

electrolyte

disorders,

bronchogeneic

carcinoma;

hepatic, renal,

or pulmonary

impairment;

neuromuscular

diseases; or

myasthenia

gravis; and in

debilitated

patients;

CV

1)Flushing,

2)increased heart

rate,

3)bradycardia

4)hypotension

RESPI

1)Prolonged dose

related apnea,

2)wheezing,

3)increased

bronchial

secretions

SKIN

1)Erythema,

2)pruritus,

3)urticaria

Other

1)anaphylaxis

1. Obtain history of patie

neuromuscular sta

before therapy a

reassess regularly

2. Be alert for adve

reactions and interaction

3. Monitor respiration clos

until patient fully recov

from neuromuscu

blockade, as evidence by

tests of muscle strength

4. Give sedatives or gene

anesthetic befo

neuromuscular blocke

Neuromuscular block

dont decrea

consciousness or alter p

threshold.

5. Dont give by I.M injectio

6. Prior use of succinychol

doesnt prolong duration

action but quickens onand may deep

neuromuscular blockade

7. Give analgesics for pa

Patient may have pain b

unable to express it.

8. Keep airway clear. Ha

emergency equipment a

drugs available.

9. After spontaneous recov

starts, reverse atracariu

induced neuromuscu

blockade with

anticholinesterase (such

neostigmine

endophonium). Thedrugs usually are given w


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Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition

an anticholnergic (such

atropine)

Name of

Drug

Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilit

Propofol

80mg +

30mg IV

Nonbarbiturate

Anesthetics

(General

Anesthetics)

Exerts its sedative-

hypnotic effects

through a GABAA

receptorinteraction. GABA

is the principal

inhibitory

neurotransmitter in

the CNS.

Indicated for

producing

sedation,

hypnosis,anesthesia,

amnesia,

unconsciousness

to allow

performance of

surgical

procedures.

Status asthmaticus

b/c of the difficulty

in providing

ventilator supportto the patient and

risk of

exacerbation of

the problem with

CNS depression

Absence of suitable

vein for

intravenous

administration

Caution should be

used in cases of

severe

cardiovascular

disease,

hypotension, orshock;

Malignant

hyperthermia

CNS

1)headache

2)prolonged

somnolence3)delirium

CV

1)hypotension

2)shock

3)decreased

cardiac output

4)arrhythmias

RESPI

1)respiratory

depression

2)laryngospasm

3)bronchospasm

4)hiccups

5)coughing

GI1)nausea

2)vomiting

1. Assess for any kno

allergy to gene

anesthetics; impai

liver or kidnfunction; myasthe

gravis; history

malignant

hyperthermia;

cardiac or respirat

disease

2. Include screening

baseline sta

before beginn

therapy and for a

potential adve

effects.

3. The drug must

administered

trained personnel4. Have equipment

standby to maint

airway and prov

mechanical

ventilation

5. Monitor temperat

for prompt detect

and treatment

malignant

hyperthermia

6. Monitor pu

respiration, blo

pressure and card

output dur


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administration

(dosage adjustm

may be needed

alleviate poten

problems a

maximize ove

benefit with the le

toxicity

7. Monitor the pati

until recovery pha

is complete and t

patient is conscio

able to move a

communicate

ensure patient safe

8. Provide comf

measures to h

patient tolerate dru

9. Provide pain relief

appropriate, skin c

and turning

prevent s

breakdown,

supportive care

conditions such

hypotension a

bronchospasm10.Offer support a

encouragement

help the patient co

with procedure a

the drugs being use


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Name of

Drug

Classification Mechanism of Action Indication Contraindicatio

n

Side effects Nursing Responsibility

Butorphanol

1mg IV

Opioid agonist-

antagonist

Analgesic, adjunct to

anesthesia

Binds with opiate

receptors in CNS,

altering both

perception of and

emotional response

to pain through

unknown mechanism

Moderate to

severe pain

Preoperative

anesthesia or

preanesthesia

Adjunct to

balance

anesthesia

Contraindicat

ed in patients

with opioid

addiction;

may

precipitate

withdrawal

syndrome.

Patients with

hypersensitivi

ty to drug or

preservative

(benzethoniu

m chloride)

Use

cautiously in

patients with

head injury,

increase

intracranial

pressure,

acute MI,

ventricular

dysfunction,

coronary

insufficiency,

respiratory

disease or

renal and

hepatic

dysfunction.

CNS

1) sedation

2) headache

3) vertigo

4) floating sensation

5) lethargy

6) confusion

7) nervousness

8) unusual dreams

9) agitation

10) euphoria

11) hallucinations

12)

flushing

CV

1) palpitations

2) fluctuation in

blood pressure

EENT

1) diplopia

2) blurred vision

3) nasal congestion

(with nasal spray)

GI

1) Nausea

2) vomiting

3) constipation

4) dry mouth

RESPI

1) Respiratory

depression

SKIN

1) Rash

2) Urticaria

3) Clamminess

4) Excessive sweating

1. Obtain history of patients p

before therapy, and reas

during therapy

2. Be alert for adverse reaction

drug interactions

3. Periodically monitor p

operative vital signs and blad

function. Drug decreases b

rate and depth respirations

monitoring arterial oxy

saturation may aid in asses

respiratory depression.

4.

Caution ambulatory patient

get out of bed slowly and w

carefully until CNS effects

known.

5. Warn outpatient to refrain f

driving and performing ot

activities that require me

alertness until drugs CNS eff

are known

6. Warn patient that drug

cause physical and psycholog

dependence. Tell him to

drug only as directed and t

abrupt withdrawal a

prolonged use produces inte

withdrawal symptoms.


Name of Drug Classification Mechanism of

Action

Indication Contraindication Side effects Nursing Responsibilit

Neostigmine 5mg

+ Atropine Sulfate

1 mg

Cholinesterase

Inhibitor

Muscle

stimulant

Inhibits

destruction of

acetylcholine

released from

parasympatheti

Myasthenia

gravis

To diagnose

myasthenia

gravis

Contraindicated

in patient

hypersensitive

to cholinergics

or bromide and

CNS

1) dizziness

2) Headache

3) Mental Confusion

CV

1) Bradycardia

1. Assess patie

condition befo

starting therapy

2. Monitor patien

response after ea


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c and somatic

efferent

nerves.

Acetylcholine

accumulates,

increasing

stimulation of

receptor.

Postoperative

abdominal

distention and

bladder atony

Antidote for

nondepolarizing

neuromuscular

blockers

Supraventicular

tachycardia

from tricyclic

antidepressant

overdose

Decrease small

bowel transit

during

radiography

in those with

peritonitis or

mechanical

obstruction

Use cautiously

in patient with

renal

impairment,

neuromuscular

disorders or

ulcerative bowel

lesions

2) Hypotension

3) Cardiac arrest

EENT

1) Blurred vision

2) Lacrimation

3) miosis

GI

1) Nausea

2) Vomiting

3) Diarrhea

4) Abdominal cramps

5) Excessive

salivation

GU1) Urinary frequency

MUSCULOSKELETAL

1) Muscle cramps

2) Muscle weakness

3) Muscle

fasciculation

RESPI

1) Depressed

respiratory drive

2) Bronchospasm

3) Bronchoconstricti

ons

4) Respiratory arrest

SKIN

1) Rash (with

bromide)

2) diaphoresis

Other1) Hypersensitivity

reaction

2) Anaphylaxis

dose. Watch clos

for improvement

strength, vision, a

pstosis 45 to

minutes after ea

dose. Show pati

how to reco

variations in mus

strength.

3. Monitor V

frequently

4. Although drug is

commonly used

reverse effects

nondepolarizing

neuromuscular

blockers in pati

who ha

undergone surge

it may wors

blockade produc

by succinylcholine

5. Patient may deve

resistance to drug

6. Give oral drug w

food or milk

reduce GI distress

Anticholinergic,

belladonna

alkaloid

Antiarrythmic,

vagolytic

Inihibits

acetylcholine

at

parasympatheti

c neuroeffector

junction,

blocking vagal

effects on SA

node. This

enhances

Anticholinestera

e insecticide

poisoning

Preoperatively

for decreasing

secretions and

blocking cardiac

vagal reflexes

Contraindicated

in patients

hypersensitive

to drug and

those with

acute angle-

closure

glaucoma,

obstructive

uropathy,

CNS

1) Headache

2) Restlessness

3) Ataxia

4) Disorientation

5) Hallucinations

6) Delirium

7) Coma

8) Insomnia

9) Dizziness

10) Excitement

11) Agitation

12) confusion

1. Obtain history

patients underly

condition a

reassess regularly

2. Be alert for adve

reaction and d

interaction

3. Monitor patie

especially tho

receiving doses


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through AV

node and

speeds heart

rate.

obstructive

disease of GI

tract, paralytic

ileus,toxic

megacolon,

intestinal atony,

unstable CV

status in acute

hemorrhage,

asthma, or

myasthenia

gravis

Use cautiously

in patient with

Down syndrome

CV

1) Tachycardia

2) Palpitations

3) Angina

4) Arrhythmias

5) flushing

EENT

1) Photophobia

2) Blurred vision

3) Mydriasis

GI

1) Dry mouth

2) Thirst

3) Constipation

4)

Nausea5) vomiting

GU

1) Urine retention

Hematologic

1) leukocytosis

Other

1) anaphylaxis

0.4 to 0.6 mg ,

paradoxical ini

bradycardia, wh

is caused by a d

effect in CNS a

usually disappe

within 2 minutes

4. Watch

tachycardia

cardiac patie

because it m

cause ventricu

fibrillation

5. Give with or witho

food

6. If ECG disturban

occur, withh

drug, obtain

rhythm strip, a

notify prescri

immediately

7. Have emerge

equipment a

drugs on hand

treat n

arrhythmias. Ot

anticholinergics mincrease va

blockage

8. Use physostigm

salicylate

antidote

atropine overdose

9. Teach patient h

to handle distress

anticholinergic

effect.



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early Lyme

disease

Reference: Nursing Pharmacology 4th Edition-Amy Karch

Name of Drug Classification Mechanisms of

Action

Indication Contraindication Side effects Nursing

Responsibilities

Keterolac Nonsteroidal

anti-

inflammatory

agents

nonopioid

analagesics

Inhibits

prostaglandin

synthesis,

producing

peripherally

mediated

analgesia

Also has

antipyretic and

anti-

inflammatory

properties.

Therapeutic

effect:Decreased

pain

Short

term manage

ment of pain

Hypersensitivity

Cross-sensitivity

with other NSAIDs

may existPre- or

perioperative use

Known alcohol

intoleranceUse

cautiously in:

1) History of GI

bleeding

2) Renal impair-

ment (dosage

reduction may be

required)

3) Cardiovascular

disease

CNS

1)drowsiness

2)abnormal

thinking

3)dizziness

4)euphoria

5)headache-

RESP

1)asthma

2)dyspnea

CV

1) edema

2) pallor

3) vasodilation

GI

1) GI Bleeding

2) abnormal

taste

3) diarrhea

4) dry mouth

5) dyspepsia6) GI pain

7) nausea

GU

1) oliguria

2) renal toxicity

3) urinary

frequency

DERM

1) pruritis

2) purpura

3) sweating

4) urticaria

HEMAT

Patients who ha

asthma, aspi

induced aller

and nasal poly

are at increas

risk

developing

hypersensitivity

reactions. Ass

for rhini

asthma, a

urticaria.

Assess pain (n

type, locati

and intens

prior to and 1-2

following

administration.

Ketorolac thera

should always

given initially the IM or

route. O

therapy should

used only as

continuation

parenteral

therapy.

Caution patient

avoid concurr

use of alcoh

aspirin, NSAI

acetaminophen

or other O


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1) prolonged

bleeding time

LOCAL

1) injection site

pain

NEURO

1) paresthesia

- MISC:

1) allergic

reaction,

anaphylaxis

medications

without

consulting hea

care profession

Advise patient

consult if ra

itching, vis

disturbances,

tinnitus, wei

gain, edem

black sto

persistent

headche,

influenza-like

syndromes

(chills,fever,mu

es aches, pa

occur.

Effectiveness

therapy can

demonstrated

decrease

severity of pa

Patients who

not respond

one NSAIDs m

respond another.

Name of Drug Classification Mechanisms of

Action

Indication Cotraindication Side effects Nursing Responsibilitie

Tramadol Analgesics Binds to mu-

opioid receptors

and inhibits the

reuptake

ofnorepinephrine

and serotonin;

causes many

effects similar to

Relief of

moderate to

moderately

severe pain

Contraindicated

with pregnancy;

allergy

to tramadol;

acute intoxication

with

alcohol, opioids,

psychotropic

1. Sedation,

2. dizziness/vertigo

3. headache

4. confusion

5. Dreaming

6. Sweating

7. Anxiety

8. Seizures

1. Assess for level of p

relief and adminis

prn dose as need

but not to exceed

recommended to

daily dose.

2. Monitor vital signs a

assess for orthosta


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theopioids--

dizziness,

somnolence,

nausea,

constipation--but

does not have

the respiratory

depressant

effects.

drugs or other

centrally acting

analgesics;

lactation.

Use cautiously with

seizures,

concomitant use

of CNS

depressants

or MAOIs, renal

or hepatic

impairment

9. Hypotension

10.Tachycardia

11.Bradycardia

12. Sweating

13. Pruritus

14. Rash

15.pallor,

16. urticaria

17. Nausea and

vomiting,

18. dry mouth

19.constipation

20.flatulence

hypotension or signs

CNS depression.

3. Discontinue drug a

notify physician if S

of hypersensitiv

occur.

4. Assess bowel a

bladder functi

report urin

frequency

retention.

5. Use seiz

precautions

patients who have

history of seizures

who are concurren

using drugs that low

the seizure threshold

6. Monitor ambulat

and take appropri

safety precautions.

REFERENCE:http://www.nursing-nurse.com/drug-study-tramadol-178/

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilit

Paracetamol

300mg IV q4

Non-

narcoticanalgesic

Antipyretic

Decreases fever

by a hypothalamiceffect leading to

sweating and

Ductal Carcinoma Case Study

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