OBJECTIVES General: The stud

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 the understanding 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 patient’s 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 client’s situation.
9. To provide nursing care plan and discharge plan to assure client’s 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.

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 100 cases per 100,000 women) and the lowest among Asian countries (10-15 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 patient’s 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 be distinguish.
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.
* 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 client’s situation.
* To provide nursing care plan and discharge plan to assure client’s 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 health pattern. 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 patient’s 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.

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.
Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means 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

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 the breast 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.
* Ultrasound bounces 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 aspiration biopsy 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 biopsy inserts 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 biopsy removes a small piece of tissue for examination.
o Excisional biopsy attempts 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 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 tamoxifen blocks the action of estrogen – a hormone that fuels some breast cancer 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 patient’s 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.
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: 4’11” 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
– 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 fever
B. 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
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
F. SOCIAL HISTORY – INCLUDE THEORIES AND GROWTH AND DEVELOPMENT

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE RESOLUTION INDICATORS OF NEGATIVE RESOLUTION Adulthood 25-65 years Generativity versus 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 FINDINGS INTERPRETATION/ ANALYSIS A. HEAD
1. SKULL
Proportional 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, 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 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 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 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. 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 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
* 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 OF MOTION Freely movable with relative ease. Limited range of motion especially on the left side of the body Due to presence of the mass with wound on her left breast. H. MUSCULAR STRENGTH Symmetrical movements and able to resist force applied by the nurse. Slightly able to move the left upper extremity and to resist force. Due to presence of the mass with wound on her left breast. 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 by surgical incision via CS.

Rise and fall caused by respiration.
Due to the delivery of her baby via CS.
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 mass for 5 years with wound on the left breast.
Due to her condition which is to be under Modified Radical Mastectomy. L. UPPER EXTREMITIES
1. 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, 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. 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
Inspection

Skin varies (pinkish, tan, dark brown), skin is smooth, fine hair evenly 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
Inspection
Five 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 when pressure is released (2 seconds). As pressured is applied to nail beds, color becomes white, colors returns after less than 2 seconds Normal P. LEGS, KNEES, ANKLES, TOES ADDUCTION AND ABDUCTION. Performs with relative ease. Performs with relative 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 38.9º C.
BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION/ ANALYSIS A. HEAD
1. SKULL
Proportional 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, 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 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 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 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. 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 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
* 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 OF MOTION Freely movable with relative ease. Limited range of motion especially on the left side of the body Due to presence of the surgical incision on 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 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 by surgical 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. 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, 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 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
Inspection

Skin varies (pinkish, tan, dark brown), skin is smooth, fine hair evenly 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
Inspection
Five 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 when pressure is released (2 seconds). As pressured is applied to nail beds, color becomes white, colors returns after less than 2 seconds Normal P. LEGS, KNEES, ANKLES, TOES ADDUCTION AND ABDUCTION. Performs with relative ease. Performs with relative ease. Normal
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
4’11” 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 is deprived 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 her daily activities. Cognitive/ Perceptual
– Orientation
– Responsiveness

Oriented to time place and person

Respond approximately to verbal and physical stimuli.
Oriented to time, place and person

Respond approximately 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 relationship with her siblings.
she has good relationship with her husband, they enjoy their lives together
She has good relationship with her children; she cares for them a lot.

Her parents always supported her when they were still alive.
She’s 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 with God. She trusts God for she knows that everything will turn right when he’s there. She wholly gives her full trust to God when she’s inside the hospital for she knows that everything is about His will. Values/ Belief She’s 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
DATE DOCTOR’S ORDERS RATIONALE August 13, 2013
10:35am
5:00pm
> 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

> 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
> 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 of the 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.
> Refer what has been ordered.
> To be ready if ever, during the surgical procedure, the patient loss lots of blood.
> To make the patient’s 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 the patients TPR, BP.
> D5LR is parenteral fluid, electrolyte and nutrient 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

10:00am > Continue Medications
> To follow D5LR x KVO
> Paracetamol 30mg prn > It is being continued because the prescribed one can develop a resistance to antibiotics if they are used 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, electrolyte and nutrient 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
> Repeat Hemoglobin and Hematrocrit 6hrs post bedrest
> To promote rest for the client and 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 patient’s Hemoglobin.
> Since there is a decrease in patient’s hemoglobin, she needs to have blood transfusion.
> To check if there are any changes and progress with the patient’s hemoglobin and hematocrit value.
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.
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. Testing blood 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.

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. Testing blood 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 9.7
29
11,600
69%

31%
261,000 Values decrease in anemia, hyperthyroidism, cirrhosis of the liver and severe hemorrhage.

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
REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
Name of test INDICATION Normal range Results Significance of the result HEMOGLOBIN
HEMATOCRIT
RBC COUNT
MCV
MCH
MCHC
WBC COUNT
PLATELET COUNT
CLOTTING TIME
BLEEDING TIME Blood test can be used to find out what is happening in many parts of the body. Testing blood 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)
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, hyperthyroidism, cirrhosis of the liver and severe hemorrhage.

Values decrease in anemia, leukemia, cirrhosis and hyperthyroidism.

DATE: August 16, 2013

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

DATE: August 16, 2013

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
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
Invasive means that the cancer has “invaded” or spread to the surrounding breast tissues. Ductal means 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.
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 invasion requires 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 of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.

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.

ECG RESULT: NORMAL

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 DATE: JULY 17, 2013

NAME OF TEST INDICATION MICROSCOPIC EXAMINATIONS RESULTS REFERENCE VALUE SIGNIFICANCE 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 patient’s health.
Color Yellow YELLOW NORMAL Transparency Slightly Turbid CLEAR Indicates high concentration of solutes Reaction 5.0 4.5 – 7.5 NORMAL Specific Gravity 1.030 1.015 – 1.025 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 2 – 3HPF 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 DATE: July 18, 2013

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 15-20 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
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 of the 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 common to 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.

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 consequent to 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

PATHOPHYSIOLOGY

Book based

Client Based
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 hospital by the surgeon during a routine office visit after surgery.
REFERENCE: http://surgery.about.com/od/proceduresaz/ss/Mastectomy_3.htm
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 patients neuromuscular status before therapy and reassess regularly
2. Be alert for adverse reactions and interaction
3. Monitor respiration closely until patient fully recovers from neuromuscular blockade, as evidence by by tests of muscle strength
4. Give sedatives or general anesthetic before neuromuscular blockers. Neuromuscular blockers don’t decrease consciousness or alter pain threshold.
5. Don’t give by I.M injection
6. Prior use of succinycholine doesn’t prolong duration of action but quickens onset and may deepen neuromuscular blockade
7. Give analgesics for pain. Patient may have pain but unable to express it.
8. Keep airway clear. Have emergency equipment and drugs available.
9. After spontaneous recovery starts, reverse atracarium-induced neuromuscular blockade with an anticholinesterase (such as neostigmine or endophonium). These drugs usually are given with an anticholnergic (such as atropine)
Reference: SPRINGHOUSE Nurse’s Drug Guide 2007 Eight Edition
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility Propofol 80mg + 30mg IV > Nonbarbiturate Anesthetics
(General Anesthetics) > Exerts its sedative-hypnotic effects through a GABAA receptor interaction. 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 support to 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, or shock;
> Malignant hyperthermia
CNS
1)headache
2)prolonged somnolence
3)delirium
CV
1)hypotension
2)shock
3)decreased cardiac output
4)arrhythmias
RESPI
1)respiratory depression
2)laryngospasm
3)bronchospasm
4)hiccups
5)coughing
GI
1)nausea 2)vomiting 1. Assess for any known allergy to general anesthetics; impaired liver or kidney function; myasthenia gravis; history of malignant hyperthermia; cardiac or respiratory disease
2. Include screening for baseline status before beginning therapy and for any potential adverse effects.
3. The drug must be administered by trained personnel
4. Have equipment on standby to maintain airway and provide mechanical ventilation
5. Monitor temperature for prompt detection and treatment of malignant hyperthermia
6. Monitor pulse, respiration, blood pressure and cardiac output during administration (dosage adjustment may be needed to alleviate potential problems and maximize overall benefit with the least toxicity
7. Monitor the patient until recovery phase is complete and the patient is conscious, able to move and communicate to ensure patient safety
8. Provide comfort measures to help patient tolerate drug
9. Provide pain relief as appropriate, skin care and turning to prevent skin breakdown, & supportive care for conditions such as hypotension and bronchospasm
10. Offer support and encouragement to help the patient cope with procedure and the drugs being used. Reference: SPRINGHOUSE Nurse’s Drug Guide 2007 Eight Edition
Name of Drug Classification Mechanism of Action Indication Contraindication 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 > Contraindicated in patients with opioid addiction; may precipitate withdrawal syndrome.
> Patients with hypersensitivity to drug or preservative (benzethonium 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 patient’s pain before therapy, and reassess during therapy
2. Be alert for adverse reaction and drug interactions
3. Periodically monitor post operative vital signs and bladder function. Drug decreases both rate and depth respirations, & monitoring arterial oxygen saturation may aid in assessing respiratory depression.
4. Caution ambulatory patient to get out of bed slowly and walk carefully until CNS effects are known.
5. Warn outpatient to refrain from driving and performing other activities that require mental alertness until drug’s CNS effects are known
6. Warn patient that drug can cause physical and psychological dependence. Tell him to use drug only as directed and that abrupt withdrawal after prolonged use produces intense withdrawal symptoms. Reference: SPRINGHOUSE Nurse’s Drug Guide 2007 Eight Edition
Name of Drug Classification Mechanism of Action Indication Contraindication Side effects Nursing Responsibility Neostigmine 5mg + Atropine Sulfate 1 mg > Cholinesterase Inhibitor
> Muscle stimulant > Inhibits destruction of acetylcholine released from parasympathetic and somatic efferent nerves. Acetylcholine accumulates, increasing stimulation of receptor. > Myasthenia gravis
> To diagnose myasthenia gravis
> Postoperative abdominal distention and bladder atony
> Antidote for nondepolarizing neuromuscular blockers
> Supraventicular tachycardia from tricyclic antidepressant overdose
> Decrease small bowel transit during radiography > Contraindicated in patient hypersensitive to cholinergics or bromide and in those with peritonitis or mechanical obstruction
> Use cautiously in patient with renal impairment, neuromuscular disorders or ulcerative bowel lesions CNS
1) dizziness
2) Headache
3) Mental Confusion
CV
1) Bradycardia
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
GU
1) Urinary frequency
MUSCULOSKELETAL
1) Muscle cramps
2) Muscle weakness
3) Muscle fasciculation
RESPI
1) Depressed respiratory drive
2) Bronchospasm
3) Bronchoconstrictions
4) Respiratory arrest
SKIN
1) Rash (with bromide)
2) diaphoresis
Other
1) Hypersensitivity reaction
2) Anaphylaxis 1. Assess patients condition before starting therapy
2. Monitor patient’s response after each dose. Watch closely for improvement in strength, vision, and pstosis 45 to 60 minutes after each dose. Show patient how to record variations in muscle strength.
3. Monitor V/S frequently
4. Although drug is is commonly used to reverse effects of nondepolarizing neuromuscular blockers in patient who have undergone surgery, it may worsen blockade produced by succinylcholine
5. Patient may develop resistance to drug
6. Give oral drug with food or milk to reduce GI distress
> Anticholinergic, belladonna alkaloid
> Antiarrythmic, vagolytic > Inihibits acetylcholine at parasympathetic neuroeffector junction, blocking vagal effects on SA node. This enhances through AV node and speeds heart rate. > Anticholinesterae 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, 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 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
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) Nausea
5) vomiting
GU
1) Urine retention
Hematologic
1) leukocytosis
Other
1) anaphylaxis 1. Obtain history of patient’s underlying condition and reassess regularly
2. Be alert for adverse reaction and drug interaction
3. Monitor patient, especially those receiving doses of 0.4 to 0.6 mg , for paradoxical initial bradycardia, which is caused by a drug effect in CNS and usually disappears within 2 minutes
4. Watch for tachycardia in cardiac patients because it may cause ventricular fibrillation
5. Give with or without food
6. If ECG disturbances occur, withhold drug, obtain a rhythm strip, and notify prescriber immediately
7. Have emergency equipment and drugs on hand to treat new arrhythmias. Other anticholinergics may increase vagal blockage
8. Use physostigmine salicylate as antidote for atropine overdose.
9. Teach patient how to handle distressing anticholinergic effect. Reference: SPRINGHOUSE Nurse’s Drug Guide 2007 Eight Edition

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility Cefuroxime 750mg IV q8? > Antibiotic, Cephalosporin (second generation) > Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death. > Pharyngitis, tonsillitis caused by Streptococcus pyogenes
> Otitis media caused by Streptococcus pneumoniae, S. pyogenes, Haemophilus influenzae, Moraxella catarrhalis
> Lower respiratory infections caused by S. pneumoniae, Haemophilus parainfluenzae, H. influenzae
> UTIs caused by Escherichia coli, Klebsiella pneumoniae
> Uncomplicated gonorrhea (urethral and endocervical)
> Dermatologic infections, including impetigo caused by Streptococcus aureus, S. pyogenes
> Treatment of early Lyme disease > Patient with known allergy to cephalosporin and penicillin CNS
1)Headache
2)Dizziness
3)Lethargy
4)Paresthesia
GI
1)Anorexia, Nausea & Vomiting
RENAL
1)Nephrotoxicity 1. Don’t give cephalosporin together with amino glycosides because it will increase the risk for kidney toxicity.
2. Avoid giving cephalosporin with anticoagulant because it will increase bleeding tendency.
3. Obtain culture and sensitivity test before administering the drug
4. Monitor renal function during the entire therapy
5. Instruct the patient to finish the full course of the therapy
6. Provide small frequent meals as tolerated.
7. Take medication with food if gastric irritations occurs
8. Provide health teachings such as:
a. Change position carefully
b. Avoid driving and hazardous task, drinks lots of fluids,
c. Avoid alcohol drinks 72 hours after completing the entire course 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 management of pain > Hypersensitivity
> Cross-sensitivity with other NSAIDs may exist¨Pre- 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) dyspepsia
6) GI pain
7) nausea
GU
1) oliguria
2) renal toxicity
3) urinary frequency
DERM
1) pruritis
2) purpura
3) sweating
4) urticaria
HEMAT
1) prolonged bleeding time
LOCAL
1) injection site pain
NEURO
1) paresthesia
– MISC:
1) allergic reaction, anaphylaxis > Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.
> Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration.
> Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.
> Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.
> Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.
> Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.
Name of Drug Classification Mechanisms of Action Indication Cotraindication Side effects Nursing Responsibilities Tramadol > Analgesics > Binds to mu-opioid receptors and inhibits the reuptake ofnorepinephrine and serotonin; causes many effects similar to theopioids–dizziness, somnolence, nausea, constipation–but does not have the respiratory depressant effects. > Relief of moderate to moderately severe pain > Contraindicated with pregnancy; allergy to tramadol; acute intoxication with alcohol, opioids, psychotropic drugs or other centrally acting analgesics; lactation.
> Use cautiously with seizures, concomitant use of CNS depressants or MAOIs, renal or hepatic impairment 1. Sedation,
2. dizziness/vertigo
3. headache
4. confusion
5. Dreaming
6. Sweating
7. Anxiety
8. Seizures
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
1. Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.
2. Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.
3. Discontinue drug and notify physician if S&S of hypersensitivity occur.
4. Assess bowel and bladder function; report urinary frequency or retention.
5. Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.
6. Monitor ambulation and take appropriate safety precautions.
REFERENCE:http://www.nursing-nurse.com/drug-study-tramadol-178/
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility Paracetamol 300mg IV q4 > Non-narcotic analgesic
> Antipyretic > Decreases fever by a hypothalamic effect leading to sweating and vasodilation
> Inhibits pyrogen effect on the hypothalamic-heat-regulating centers
> Inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin synthesis
> Does not cause ulceration of the GI tract and causes no anticoagulant action.
> Control of pain due to headache, earache, dysmenorrhea, arthralgia, myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy
> reduce fever in viral and bacterial infections
> As a substitute for aspirin in upper GI disease, bleeding disorders clients in anticoagulant therapy and gouty arthritis > Renal Insufficiency
> Anemia
Special Concerns:
> Liver toxicity (hepatocyte necrosis) may occur with doses not far beyond labeled dosing.
> If 3 or more alcoholic drinks per day are consumed, consult a physician prior use.
1) Minimal GI upset.
2) Methemoglobinemia
3) Hemolytic Anemia
4) Neutropenia
5) Thrombocytopenia
6) Pancytopenia
7) Leukopenia
8) Urticaria
9) CNS stimulation
10) Hypoglycemic coma
11) Jaundice
12) Glissitis
13) Drowsiness
14) Liver Damage
1. Do not exceed 4gm/24hr. in adults and 75mg/kg/day in children.
2. Do not take for >5days for pain in children, 10 days for pain in adults, or more than 3 days for fever in adults.
3. Extended-Release tablets are not to be chewed.
4. Monitor CBC, liver and renal functions.
5. Assess for fecal occult blood and nephritis.
6. Avoid using OTC drugs with Acetaminophen.
7. Take with food or milk to minimize GI upset.
8. Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.
9. Report paleness, weakness and heart beat skips
10. Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.
11. Phenmacetin may cause urine to become dark brown or wine-colored.
12. Report pain that persists for more than 3-5 days
13. Avoid alcohol.
14. This drug is not for regular use with any form of liver disease. Reference: http://rnspeak.com/drug-study/paracetamol-biogesic-drug-study/
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility Cefuroxime 500mg TID > Antibiotic, Cephalosporin
(second generation) > Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death. > Pharyngitis, tonsillitis caused by Streptococcus pyogenes
> Otitis media caused by Streptococcus pneumoniae, S. pyogenes, Haemophilus influenzae, Moraxella catarrhalis
> Lower respiratory infections caused by S. pneumoniae, Haemophilus parainfluenzae, H. influenzae
> UTIs caused by Escherichia coli, Klebsiella pneumoniae
> Uncomplicated gonorrhea (urethral and endocervical)
> Dermatologic infections, including impetigo caused by Streptococcus aureus, S. pyogenes
> Treatment of early Lyme disease > Patient with known allergy to cephalosporin and penicillin CNS
Headache
Dizziness
Lethargy
Paresthesia
GI
Anorexia, Nausea & Vomiting
RENAL
Nephrotoxicity 1. Don’t give cephalosporin together with amino glycosides because it will increase the risk for kidney toxicity.
2. Avoid giving cephalosporin with anticoagulant because it will increase bleeding tendency.
3. Obtain culture and sensitivity test before administering the drug
4. Monitor renal function during the entire therapy
5. Instruct the patient to finish the full course of the therapy
6. Provide small frequent meals as tolerated.
7. Take medication with food if gastric irritations occurs
8. Provide health teachings such as:
a. Change position carefully
b. Avoid driving and hazardous task, drinks lots of fluids,
c. Avoid alcohol drinks 72 hours after completing the entire course
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility Celecoxib 200mg BID > NSAID
> Analgesic (nonopioid)
> Specific COX-2 enzyme > Celecoxib has COX-2 specific inhibitory activity. It inhibits the conversion of arachidonic acid to prostaglandins while having no effect on the formation of prostaglandins that mediate the normal homeostasis in the GI tract, kidneys and platelets catalyzed by COX-1. > Acute and long-term treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis
> Reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP)
> Management of acute pain
> Treatment of primary dysmenorrhea
> Relief of signs and symptoms of anklylosing spondylitis
> Relief of signs and symptoms of juvenile rheumatoid arthritis > Hypersensitivity including those in who attacks of angioedema, rhinitis and urticaria has been precipitated by aspirin, NSAIDs or sulfonamides.
> Severe hepatic impairment;
> Severe heart failure; inflammatory bowel disease; peptic ulcer; renal impairment (CrCl <30 ml/min);
> Pregnancy and lactation. 1) Abdominal pain
2) Diarrhea
3) Nausea
4) Edema
5) Dizziness
6) Headache
7) Insomnia
8) upper respiratory tract infections
9) rash
Potentially Fatal:
1) Serious skin reactions such as exfoliative dermatitis, Stevens-Johnson syndrome, and toxic epidermal necrolysis.
1. Be aware that patient may be at increased risk for CV events, GI bleeding; monitor accordingly.
2. Administer drug with food or after meals if GI upset occurs.
3. Establish safety measures if CNS, visual disturbances occur.
4. Arrange for periodic ophthalmologic examination during long-term therapy.
5. If overdose occurs, institute emergency procedures-gastric lavage, induction of emesis, supportive therapy.
6. Provide further comfort measures to reduce pain (eg, positioning, environmental control) and to reduce inflammation (eg, warmth, positioning, and rest).
7. Take drug with food or meals if GI upset occurs.
8. Take only the prescribed dosage; do not increase dosage.
9. You may experience these side effects: Dizziness, drowsiness (avoid driving or the use of dangerous machinery while taking this drug).
10. Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision. REFERENCE:http://www.rnpedia.com/home/notes/pharmacology-drug-study-notes/celecoxib

Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility D5LR x 8?, 12? > Hypertonic
> Nonpyrogenic
> Parenteral fluid
> Electrolyte
> Nutrient replenisher > Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy. > The Dextrose 5% in Lactated Ringers Solution (D5LRS) is useful for daily maintenance of body fluids and nutrition, and for rehydration. > Hypersensitivity to any of the components. > Redness or pain at the injection site may occur.
> Fever
> trouble breathing
> swelling
1. Do not administer unless solution is clear and container is undamaged.
2. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin.
3. Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis.
4. Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus.
5. Discard unused portion.
6. In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.
7. Properly label the IV Fluid
8. Observe aseptic technique when changing IV fluid Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibility PNSS x KVO > Isotonic Table salt (sodium chloride) > Normal saline solution has an osmolality of 308mOsm/L. Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF, does not cause red blood cells to shrink or swell .Isotonic fluids expand the ECF volume. > Used to give intravenous fluids to the patients suffering from salt and water deprivation
> Used in blood transfusions, hyponatremia, and burn victims
> Used for irrigation during surgery, to dilute medications, and to clean wounds out
> Used because it has little to no effect on the tissues and make the person feel hydrated preventing hypovolemic shock or hypotension > None > Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation, and hypervolemia.
1. Monitor pt. frequently for:
a. Signs of infiltration / sluggish flow
b. Signs of phlebitis /infection
c. Dwell time of catheter and need to be replaced
d. Condition of catheter dressing
2. Check the level of the IVF.
3. Correct solution, medication and volume.
4. Check and regulate the drop rate.
5. Change the IVF solution if needed
6. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary. REFERENCE:http://www.rxlist.com/normal-saline-drug/side-effects-interactions.htm

Name of Drug Classification Mechanism of Action Indication Contraindication Side effects Nursing Responsibility Isoflurane > Anesthetics > It potentiates glycine receptor activity, which decreases motor function.
> It inhibits receptor activity in the NMDA glutamate receptor subtype.
> Isoflurane inhibits conduction in activated potassium channels.
> Isoflurane also affects intracellular molecules.
> It activates calcium ATPase by increasing membrane fluidity.
> It binds to the D subunit of ATP synthase and NADH dehydrogenase. > Isoflurane, USP may be used for induction and maintenance of general anesthesia. Adequate data have not been developed to establish its application in obstetrical anesthesia > Known sensitivity to Isoflurane, USP or to other halogenated agents. Known or suspected genetic susceptibility to malignant hyperthermia. 1) increase in the white blood cell count (even in the absence of surgical stress) and also shivering
2) Nausea and vomiting (during the postoperative period).
3) Increase in heart rate Rare cases of bronchospasm
4) Rare reports of mild, moderate and severe (some fatal) post-operative hepatic dysfunction.

Adverse Reaction
1) Hypotension
2) Respiratory depression
3) arrhythmias
1. Used with caution in patients with coronary artery disease
2. Monitor blood pressure and temperature to detect residual hypotension and the possibility of malignant hyperthermia.
3. Must be given with a licensed anesthesiologist
4. Emergency kit must be made available REFERENCE:http://www.drugs.com/sfx/isoflurane-side-effects.html

IV. NURSING PROCESS
A. LONGTERM OBJECTIVE

The nursing plan aims to return the patient to its normal body feeling. It also aims to restore the healthy body of the patient. And to ensure the physiological well-being of the patient by providing patient and family teachings through addressing emotional and psychosocial needs.

B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM RANKING JUSTIFICATION > Acute Pain related to tissue trauma from Surgical Incision 1 Acute pain should be the first because if pain is not present or will be diminish, for it won’t be totally removed because of presence of surgical incision, the patient will be comfortable and other problem will be somehow light. > Ineffective thermoregulation related to trauma of breast tissue 2 This should be second because if the patient has fever, the activity will be limited, also this indicate that she has infection. > Disturbed body image related to loss of body part secondary to Modified Radical Mastectomy 3 This should be third because the patient needs to have a good ambulation or movement of her body parts. If she will be limited, other problem such as impaired skin integrity will follow. > Impaired skin integrity related to post operative incision secondary to surgery 4 This should be fourth because it is just present because of complimentary situations just like disturbed body image which should be managed first. > Risk for injury 5 Tchis risk should be less prioritized because it is just foreseeing the possibility that may occur. > Risk for edema 6 Impaired skin integrity related to post operative incision secondary to surgery. > Decrease hemoglobin secondary to anemia 7 This should be the last because the management of increasing hemoglobin takes a long term.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE:
“Mababa daw ang pula ngdugokosabeng doctor” as verbalized by the patient.

OBJECTIVE:
> Pale in appearance
> Weak
> Fatigue
> Hemoglobin result of 7.4 gm/dL Decrease hemoglobin secondary to Anemia After one hour of nursing intervention the client will be able to:

> Verbalizes understanding about the causes and effects of iron deficiency.

Long term:

> Report in increase hemoglobin in CBC result. > Explain about the signs and symptoms of anemia.
> Instructed about increase intake of iron rich food and iron supplement.
> Note changes in balance/ gait disturbance, muscle weakness.
> Plan activity progression with patient, including activities that the patient reviews essential. Increase levels of activities as tolerated

> Recommended quiet atmosphere, bed rest if indicated. > For the patient to know about the possible
Causes of anemia.

> Iron is needed for formation of RBC

> May indicate neurological changes associated with vitamin B12 deficiency, affecting patient’s safety or risk for injury.

> Promotes gradual return to normal activity level and improved muscle tone or stamina without undue fatigue.

> Enhances rest to lower body’s oxygen requirements, and reduces strain on the heart and lungs. > After one hour of nursing intervention the client was able to verbalize understanding about the causes and effects of iron deficiency.

> The nursing intervention was not met.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE:
“Kumportable ako pag inilalagay ko itong bag sa tabi ko”. As verbalized by the patient.

OBJECTIVE:

> Seen placing shoulder bag on the operative site.
> Hemoglobin level of 7.4gm/dL
> Absence of Significant other for assistance. Risk for Injury After 1-2 hours of nursing intervention the client will demonstrate behaviors to reduce risk factors and to protect self from injury. > Instructed to ask for assistance in performing ADLs.

> Encourage patient to prevent doing things beyond what her body can perform.

> Assess mood, coping capabilities and personality styles like aggression and impulsive behaviour.

> Encourage use of techniques to reduce stress and vent emotions such as anger.
> Provide adequate rest. > To promote safe physical environment and individual safety.

> Impulsive behaviors may contribute and increase risk of the patient to injury.

> These may result in carelessness or increased risk taking without consideration of consequence
> To reduce the occurrences of injury

> Adequate rest can strengthen the patient. After 1-2 hours of nursing intervention the client was able to demonstrate behaviors to reduce risk factors and to protect self from injury.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE:
“Hindi ko maitaas ang kaliwang braso ko kasi masakit”. As verbalized by the patient.

OBJECTIVE:

> Unable to raise left arm

> Presence of suture on left breast adjacent to armpit.

> Inability to have exercise of the operative site. Risk for edema After one hour of nursing intervention the client will able to demonstrate the instruction to prevent risk for edema. > Instructed to raise the left arm

> Encourage minimal exercise on the affected area
> Instructed to wear loose clothing
> Do not carry purse or anything heavy on the affected site
> Avoid exposure to hot object that may cause burns
> Avoid the use of blood pressure cuffs to the affected area.
> Raising the left arm or the operative site to promote drainage and prevent edema.
> Exercise can promote proper circulation
> Tight clothing can increase the pressure in the operative site
> To avoid pressure and swelling on the operative site
> Hot objects can further increase the risk for edema
> Blood pressure cuffs can increase pressure in the operative site After one hour of nursing intervention the client was able to demonstrate the instructions to prevent risk for edema.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION S: “Ang nararamdaman ko lang talaga dito sa suso ko ay yung sakit, pero di naman siya makati”,as verbalized by the patient.

Objective:
* Presence of surgical wound on the left breast where incision was made
* Pain rated as 10 out of 10 as 10 as the highest.
Impaired skin integrity related to post operative incision secondary to surgery After 1-2 hours of nursing interventions, the patient will participate in prevention measures and treatment program. > Assess incision site taking note of size, color, location, temperature, texture, consistency of wound/ lesion if possible.
> inspect surrounding skin for erythema, induration, maceration
> assess for odors and drains coming out from the skin/ area of injury
> inspect skin on a daily basis, describing lesions and changes observed
> keep the area clean/dry, carefully dress wounds, support incision, and prevent infection
> use appropriate wound coverings
> encourage adequate rest and sleep
> encourage early ambulation and mobilization
> provide position changes
> practice aseptic technique in cleansing/dressing and medicating lesions
> instruct proper disposal of soiled dressing
> to provide comparative baseline data
> to assess extent of involvement

> to assess early progression of wound healing, development of hemorrhage or infection
> to promote timely intervention/revision of plan of care
> to assist body’s natural process of repair
> protect the wound and/or surrounding tissue
> to prevent fatigue

> to promote circulation and reduce risks associated with immobility
> to prevent bed ulcers from occuring
> to reduce risk of cross-contamination
> to prevent spread of infectious agent
After 1-2 hours of nursing intervention, the client was able to participate on the preventive measures and treatment program for her condition.

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION S:”Masakit yung parte na may tahi, hindi ko nga maigalaw ng maayos yung katawan ko”, as verbalized by the patient.

Objective:
> Facial grimace
> Guarding behavior
> Pain scale of 10 out of 10 as 10 as the highest.
> Autonomic alteration of muscle tone Acute pain related to tissue trauma from surgical incision After 1-3 hours of nursing intervention, client’s pain scale will be reduced. > Monitor vital signs
> Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration
> Place in Semi-Fowler’s position and support head/neck in neutral position with small pillows as required in immediate postoperative phase
> Instruct client to use hands to support neck during movement and to avoid hyperextension of neck

> Encourage client to use relaxation techniques e.g., guided imagery, soft music, progressive relaxation
> Administer analgesics as ordered.
> For baseline data
> Useful in evaluating pain, choice of interventions, effectiveness of therapy

> Prevents hyperextension of the neck and protects integrity of the suture line

> Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness
> Helps refocus attention and assist client to manage pain more effectively

> Reduces pain and discomfort. S:”Masakit pa rin siya pero di na naman masyado tulad kanina kasi may tinuturok nman sila para sa kirot”,as verbalized by the patient.

Objective:
> Pain scale of 8 out of 10
ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION S:”Iba na ngayon yung pakiramdam ko nung nawala yung kaliwa kong suso, ang sama ng tingnan sana hindi na mangyari dun sa kabila”,as verbalized by the patient.

Objective:
> Evident removed left breast

Disturbed body image related to loss of body part secondary to modified radical mastectomy After 1-3 hours of nursing intervention the client will verbalize understanding of body changes and acceptance of self in situation. > Assess perception of change in structure or function of body part.
> Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities
> .Encourage verbalization of positive or negative feelings about actual or perceived change
> .Maintain therapeutic communication and demonstrate positive caring in routine activities

> Teach patient adaptive behavior like using of adaptive equipment that conceals altered body part breast pad
> Help patient identify ways of coping and divertional activities
> To identify existing problem and plan certain therapeutic actions
> To help the client sustain his physical and social needs while she is unable

> To allow the client to express herself and release tension on feelings.
> To facilitate good nurse-patient interaction and also gain clients trust to cooperate.

> To help the client gain back her confidence by concealing altered body part.

> To make the client focus on activities she’s interested and happy instead of her altered body part S:”Hindi naman ako masyadong pinanghihinaan ng loob dahil lang dito, yun lang talaga sana hindi na siya mangyari dun sa kabila kung suso”, as verbalized by the patient.

> Goal still on progress.
ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALES EVALUATION S:”Nilalamig na naman ako kasi nilagnat ako simula nung maopera ako”, as verbalized by the patient.

Objective:
> Flushed skin
> Warm to touch
> Temp: 38.9(r)C Ineffective Thermoregulation related to trauma of breast tissue After 1-2 hours of nursing intervention the client will maintain core temperature within normal range > Administer fluids, electrolytes and medications, as ordered.
> Monitor body temperature
> Promote client safety
> Maintain bedrest
> Discuss importance of adequate fluid intake
> To treat underlying cause

> To asses baseline data
> To assist with measures to reduce body temperature
> To reduce metabolic demands and oxygen consumption

> To prevent dehydration. After 1-2 hours of nursing intervention the client’s body temperature reduced from 38.9 to 38.6(r)C

> Goal partially met.

D. Discharge Plan
Medications
a.) Advised the patient to take the medications prescribed by the physician for her to take continuously at home:
a. Cefuroxime 500mg 1tab/three times a day (8am-1pm-6pm)
b. Celecoxib 200mg 1cap/two times a day (8am-6pm)
b.) Instructed to always check the expiration date before taking the medication.
Environment
a.) Provided safety measures to promote a safe environment.
b.) Maintain quiet, well ventilated and cal environment for fast and good recovery of the patient.
Treatment
a.) Treatment for all types of IDC is determined by the exact type of cancer and staging. Depending on the size and spread of the tumor(s), most women will undergo a combination of any of the following treatments:
* Lumpectomy
* Mastectomy
* Sentinel node biopsy
* Axillary node dissection
* Breast reconstruction
* Radiation
* Chemotherapy
* Hormonal therapy
* Biologic targeted therapy

Health teaching
a.) Instructed the patient to avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed.
b.) Advised the patient to elevate the arm to avoid edema on arm and hand.
c.) Reiterated the importance of coping stress through stress theraphy such as stress reduction at home.
Out Patient referral check up
a.) After discharge, advised the patient to come back for follow up check up at OPD after one week (August 23, 2013) after discharge.

Diet
a.) Instructed the patient to avoid salty food.
b.) Advised the patient to resume regular diet after recovering from anesthesia.
c.) Encourage the patient to Inceased fluid intake and avoid Caffeinated beverages.
d.) Advised to take plenty of fruits and vegetables.
Manuel S. Enverga University Foundation
College of Nursing and Allied Health Sciences
Lucena City

A Case Study of

Ductal Carcinoma
In Partial Requirement of
Nursing Care Management 103- Related Learning Experience
Surgery Department
Quezon Medical Center
Submitted by:

BSN LEVEL III- Group II

ANCHETA, GENESIS
BANTOC, ROYCE ANNE
CAPACIA, JAN MARIZ
ESCALA, EMILY
ESTRADA, RAY JUNDIE
GALLANO, MARY CONCEPTION
MACASAET, LESLIE
MENDOZA, MARGOTT
SARGENTO, TOM FRANCIS
Submitted to:

EDWIN Q. YABUT RN, MSN
Clinical Instructor