St. Anne College Lucena Inc.

Diversion Road, Lucena City

SY: 09-10

In partial fullfilment of our requirements

In
Related Learning Experience

Case Study Presentation

“BREAST CANCER”

Presented By:
Arzadon, Oliver C.
Villabroza, Hanave
I. Objective

General:

To impart and shared our knowledge regarding the nature, pathophysiology and
management Breast Cancer to all our fellow nursing students.

Specific:

 To know how the disease affects the human body.

 To know how and where the disease occurs.
 To enhanced our knowledge and learning regarding the disease identity.
 To identify the possible complication that may occur during the early and late
phases of disease.
 To have a complete details or background about the patients profile and
nutritional status.
 To be able to make a preventive measures and intervention to those patient
suffering from Breast Cancer.

II. Patient Profile

Patient C is 67 y/o, female, currently residing at Pagbilao,Quezon was born on
March 30, 1942. She is married and was blessed with four children. She is currently
undergoing a chemotherapy sessions at St. Anne General Hospital Inc. She is
currently a housewife, managing the family. At present, source of income comes
from her husband.
She was admitted at Manila Doctors Hospital for MRM (modified Radical
Mastectomy) with complaints of having pain in her right breast.

She is a teacher having the knowledge and ability to read and write. As for
hobbies and interests, she certainly entertains herself by reading, cleaning and doing
household chores and taking care of her family. She verbalized that the greatest gift
from her is her only children.

III. History
A. Nursing history
i. Chief complaint: for chemotherapy and (+) dyspnea
ii. Admitting Diagnosis: Breast Cancer and Bone Metastasis
iii. Physical Exam:
Head & Neck: Pinkish conjunctiva; Persistent reddish or whitish patch
Chest, heart & Lungs: clear breathy sounds heard on both lungs
Breast: Change in contour of breast
Dimpling of skin of breast
Edema or erythema of breast skin
Fixation of a mass to pectoral fascia or chest wall
Nipple retraction
Abdomen: soft, non tender
Extremeties: (+) swollen
Skin: (+) pedal edema
iv. Final Diagnosis:
 B. Present Health History
July 2008 Prior to Admission at Manila Doctors, patient complained,
patient noted a mass before the incision area of the right breast. There was
associated tenderness but no discharged. Consultation was sought and surgery
was scheduled, hence admission.

C. Past Health History

Patient C has no previous history of allergies. She had stated that she had
previous records of hospitalization and operations. Last Operations were
performed on September 2008 at Manila Doctors Hospital. She underwent MRM
(Modified Radical Mastectomy) and Status post a 6 cycle of Chemotherapy
because of presence of tumor on her right breast. She has also a history of
Hypertension.

D. Family Health Background

Patient C verbalized that she is the only one in the family that had cancer.
She has stated that there were Family Medical Diseases known in their neither
family nor hereditary sickness such as hypertension and most commonly in
cancer. She declared that she had cancer due to an unhealthy lifestyle
established during her younger years. Her aunt had breast cancer and survived
and her cousin died due to cancer.

IV. Nutrition
i. 24 hours food recall (PTA) – “walang gana di tulad ng dati”
ii. Regular Routine Diet ( weekly) – “kung anu merun usual diet”
iii. I/O – “2 days before ako maadmit eh dumumi na aq, pero minsan lng
din”
iv. Habits and Vices – “timeful ang work ko before, kasi teacher ako dati.”
V. Disease Entity
A. Definition
BREAST CANCER
 Also called the BREAST CARCINOMA
 An uncontrolled growth of breast cells
 a malignant tumor that starts from cells of the breast.
 happens when cells in the breast begin to grow out of
control and can then invade nearby tissues or spread
throughout the body. Large collections of this out of
control tissue are called tumors. However, some
tumors are not really cancer because they cannot
spread or threaten someone's life. These are called
benign tumors.
 Most commonly the cancer in women but it can also
happen to men.
 B. Etiology

No one knows the exact causes of breast cancer. Doctors often cannot explain
why one woman develops breast cancer and another does not. They do know
that bumping, bruising, or touching the breast does not cause cancer. And breast
cancer is not contagious. You cannot "catch" it from another person.
C. Epidemiology
Breast cancer may be one of the oldest known forms of cancer tumors
in humans. The oldest description of cancer (although the term cancer was
not used) was discovered in Egypt and dates back to approximately 1600 BC.
The Edwin Smith Papyrus describes 8 cases of tumors or ulcers of the breast
that were treated by cauterization. The writing says about the disease, "There
is no treatment.”. For centuries, physicians described similar cases in their
practices, with the same sad conclusion. It wasn't until doctors achieved
greater understanding of the circulatory system in the 17th century that they
could establish a link between breast cancer and the lymph nodes in the
armpit.

The French surgeon Jean Louis Petit (1674-1750) and later the Scottish
surgeon Benjamin Bell (1749-1806) were the first to remove the lymph nodes,
breast tissue, and underlying chest muscle. Their successful work was carried
on by William Stewart Halsted who started performing mastectomies in
1882. He became known for his Halsted radical mastectomy, a surgical
procedure that remained popular up to the 1970s.

VI. Management
A. Medical Management
Cancer Management:
Surgery
Lumpectomy: A surgical procedure to remove a tumor (lump) and a small
amount of normal tissue around it.
Partial mastectomy: A surgical procedure to remove the part of the
breast that contains cancer and some normal tissue around it. This
procedure is also called a segmental mastectomy.
Total mastectomy: A surgical procedure to remove the whole breast that
contains cancer. This procedure is also called a simple mastectomy.
Modified radical mastectomy: A surgical procedure to remove the whole
breast that contains cancer, many of the lymph nodes under the arm, the
lining over the chest muscles, and sometimes, part of the chest wall
muscles.
Radical mastectomy: A surgical procedure to remove the breast that
contains cancer, chest wall muscles under the breast, and all of the
lymph nodes under the arm. This procedure is sometimes called a
Halsted radical mastectomy.
Radiation therapy uses high energy rays (similar to x-rays) to kill cancer cells. It
comes from an external source, and it requires patients to come in 5 days a week for up
to 6 weeks to a radiation therapy treatment center.
 Chemotherapy is the use of anti-cancer drugs that go throughout the entire
body.

Hormonal Therapy: When the pathologist examines your tumor specimen, he

or she finds out if the tumor is expressing estrogen and progesterone receptors.

Biologic Therapy: The pathologist also examines your tumor for the presence
of HER-2/neu overexpression. HER-2/neu is a receptor that some breast cancers
express. A compound called Herceptin (or Trastuzumab) is a substance that blocks this
receptor and helps stop the breast cancer from growing.

B. Nursing Management
1. Pass on that last call for alcohol.
2. Quitters DO prosper - when it comes to
smoking.
3. Get physical/Regular aerobic exercise
4. Be aware of your family breast cancer
history.
5. Avoid hormone replacement therapy if
possible.
6. Check your breasts every month.

7. Try to keep a low fat diet/Your diet can play an important role in breast cancer
prevention.
8. Don't forget to get a mammogram - it's not a choice.
9. Have children earlier in life, if possible
10. Consider breastfeeding instead of formula feeding.

C. Pharmacologic Management

Brand Name Indication Classification Nursing

Consideration
Candesartan Hypertension Angiotensin II Check the blood
8mg/tab 1 Tab Antagonists presure before and
OD after giving the
medication.
Tramadol Moderate to Analgesics
150 mg IV q 6 severe acute (Opiod)
RTC or chronic
pain & painful
diagnostic or
therapeutic
measures.
Morphine Relief of Antivertigo
16 mg 1 tab moderate of Drugs
q 12 severe pain
not
responsive to
non-narcotic
analgesics.
Premed.
Analgesic
adjunct in
 general
anesth esp in
pain
associated
with cancer,
MI, & surgery.
Alleviates
anxiety
associated
with severe
pain.
Dexamethason
e 4 mg 1 tab, 2
tabs q12 x 4
doses p.o.
Lasix 20 mg/tab Edema to the Diuretics
IVP q8 cardiac,
hepatic and
renal disease,
burns; mild to
moderate
HTN,
hypertensive
crisis, acute
heart failure,
chronic heart
failure,
nephrotic
syndrome.
Tagicef 1 gm
IVP q8 ANST(-)

CHEMOTHERAPY

 Paclifoxel 100 mg in D5W 50 cc

 Ibandromic Acid (bondonat) 6 mg in PNSS 500 ml

*In all given meds, OBSERVE THE 10 RIGHTS OF MEDICATION:

1. Right patient 6. Right Documentation

2. Right Route 7. Right Education
3. Right Dose 8. Right Evaluation
4. Right Time 9. Right Assessment
5. Right Drug 10. Right Approach
 VII. Laboratory/ Diagnostic Procedures
A. Blood analysis

Hematology Result

Name: Patient C Age: 67/f Hosp: Interpretations

Ward: Sanggumay Time:9:15 am
Normal Values RESULT
Hemoglobin 102 F 120-160 l/l 78
Hematocrit 0.30 F 0.37-0.47l/l 0.23
WBC Count 5.0-10.0x10g/L 21.1 Presence of
Infection
DIFFERENTIAL COUNT
Neutrophils 0.50-0.70 0.84
Lymphocytes 0.20-0.40 0.15
Midcell 0.03-0.09
Eosinophil 0.00-0.07 0.01 Normal
Monocyte 0.00-0.07
Band 0.00-0.05 1.00
TOTAL 1.00
Red Cell Count F 4.04 -5.48 x 10 12/L
Platelet Count 150-400x 10g/l Markedly
increased
LE Cell Prep.
Malarial Smear
Bleeding Time 1-5 minutes
Clotting Time 2-6 minutes
Lee & white C.T 5-10 minutes
PROTHROMBIN TIME (PT)
Patient 10-14 seconds
Control 10.8-13.8 seconds
INR
% Activity
PARTIAL PROTHROMBIN TIME (PTT)
Patient 26-36 seconds
 Control 29.6-37.6 seconds
ERYTHROCYTE SEDIMENTATION RATE
Wintrobe Method F0-20mm/Hr
Westergren Method Adult 0-10 mm/Hr
Retailocyte Count 0.5-1.5%

REMARKS:

Midcells may include less frequently occurring and rare correlating to

monotype, eosinophils, basophils, blast and other precursor.
Blood Type: “O”
Rh: “Positive”

IMPLICATION:

Chemotherapy affects production of white blood cells in the bone marrow. 

Normally white blood cells help fight off infection.  After chemotherapy, if your
white blood cells are low, you are more likely to get infections.  Any infection can
also worsen more quickly – a trivial infection could become life threatening within
hours if it isn’t treated.

When your white blood cell count is at its lowest you can feel very tired
(fatigued).  Some people also say they feel depressed.  This can be really hard to deal
with and make you wonder if you really want to go on with your treatment.  Try to
hang in there.  Things should improve and you will start to feel better again before
your next treatment, as your blood counts rise.  Unfortunately, they'll go down again
after each treatment.  But once your treatment is finished your blood cell counts will
remain at normal levels.

B. X-rays
Chest X-ray Result
Follow up chest x-ray, both thorax is itill blunted.
Suggest of possible pleural iffusion bilateral.
C. UTZ
UTZ Report
Free pleural fluid are seen on both hemithorax
Right – 265 cc
Left - 353 cc
Impression: Hydrothorax, bilateral
D. Other Laboratory examinations/procedures

Specimen Collected Specimen Collected

Pleural Fluid in the left lung Pleural fluid in the right lung
Color - Red Color – Dark yellow
Transparency – Turbid Transparency – slightly turbid
Glucose = 164.2 mg/dl
Ldh = 38
Total Protein = 123.68
Differential Count Differential Count
i. WBC = 24 i. WBC = 7
ii. RBC = 1412 ii. RBC = 252

Gram Staining
Pleural fluid left polymorphonuclear cells 1-3 organism seen.

ABG Exam
PH = 7.38
PCO2 = 27.3
PO2= 46 (abnormal)
HCO3 = 16.5
BE = (-) 8
TCO = 92
FIO2 = 28
 VIII. Anatomy and Physiology

The Breasts

In order to understand breast cancer, it helps to have some basic knowledge about the
normal structure of the breasts. The female breast is made up mainly of lobules (milk-producing
glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty
tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic
vessels).

Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in
the cells that line the lobules (lobular cancers), while a small number start in other tissues.
 Knowing if the cancer cells have spread to lymph nodes is important because if it has,
there is a higher chance that the cells could have also gotten into the bloodstream and spread
(metastasized) to other sites in the body.

The more lymph nodes that have breast cancer, the more likely it is that the cancer may
be found in other organs as well. This is important to know because it could affect your
treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases,
and in some cases a woman can have negative lymph nodes and later develop metastases.
Angiogenesis
 Continued tumor growth requires persistent new blood vessel
growth
 Shedding of malignant cells into the venous drainage
 Tumor cells release soluble factors that require angiogenic
response (angiogenesis factors)
X. Pathophysiology ( Patient Related)

MODIFIABLE FACTORS: NON-MODIFIABLE FACTORS:

 Age  exposure to radiation and

certain chemicals
 Gender  having a sibling with leukemia
 Genetic  chromosomal translocations
Abnor malities
 Lifestyle

ETIOLOGY: UNKNOWN

DAMAGE TO THE DNA

ACTIVATE ONCOGENE/DEACTIVATE
TUMOR-SUPPRESSOR GENE

TRANSFORMATION
NORMAL CELL

ABNORMAL CELL

GROWTH ABNORMAL CELL

MULTIPLY

LOCAL INVASION

ANGIOGENESIS

METASTASES
XI. Discharge Plan

M-Take meds as prescribed by the Physician

E-Provide therapeutic environment such as:

 Remove unnecessary materials on bed

 Proper ventilation
 Provide proper waste disposal

T-treatments as prescribed based on the prescription of attending physician.

H-Instruct the patient to continue full of course of meds as prescribed.

 Encouraged verbalization of feelings

 Proper diet
 Proper hygiene
 Proper hand washing

O- Encouraged patient to follow-up checkup

D-balanced diet