BREAST CANCER

Case Analysis

Barredo, Mary Melody M.

BSN-4A
Name: M.B.
Address: Caloocan City
Age: 45 years old
Gender: Female
Date of Birth: February 2, 1974
Marital Status: Single
Occupation: Fashion Design Assistant
Religion: Born Again Christian
Attending Physician: Dr. Segismundo/Dr. David
Health Insurance/Hospitalization plan: Philhealth
Date and Time of Admission: February 2020 4:05 PM
Admitting Diagnosis: Invasive Ductal Carcinoma Right Tumor
Final Diagnosis: Invasive Ductal Carcinoma
S/P Modified Radical Mastectomy, Right
Tumor Recurrence, Right
Operation(s)/Procedure(s) Performed: s/p MRM Wide Excision of Breast Mass, Right
s/p Local Advancement Fasciocutaneous Flap
Chief Complaint: Breast Mass, Right

HISTORY OF PRESENT ILLNESS

4 years prior to admission, patient noticed small breast mass, right, painful, soft, movable
with no discoloration, no discharge. No consult was done.
3 years prior to admission, patient consulted at East Ave and was advised biopsy of the
mass. Biopsy revealed Invasive Ductal Cancer. Patient underwent Mastectomy of right breast
followed by Chemotherapy and radiation. Patient was started on Tamoxifen which she took for 2
years.
2 months prior to admission, patient started notice a lump on her right chest. She tried
herbal medicine her peers advised her to use. No consult was done.
1 month prior to admission, patient noticed that the lump was progressively increasing in
size, painful, firm, non-movable, with reddish discoloration, no discharge. Patient consulted at the
Oncological unit of East Avenue Medical Center. Tamoxifen was changed to Letrozole 20mg/tab.
Patient then consulted at the OPD of FEU-NRMF where she was advised admission.

PAST HEALTH HISTORY

Patient doesn’t remember any childhood diseases and immunizations. Patient has no
allergies on drugs or food. Patient has never been on an accident or had any injury. She had her
first hospitalization when she was 20 years old. She had Typhoid Fever and was admitted in the
hospital for four days. She went back to the hospital in 2016 as the first occurrence of her breast
cancer happened. Consequently, she had her Mastectomy this year. The only foreign travel she
had was in Malaysia in 2014. She was there for seven days. Additionally, patient makes local travel
when she goes back to her hometown in Mindanao. Patient has no hypertension and diabetes.
Patient did occasional smoking in her younger years.

FAMILY HISTORY
The patient’s mother is 73 years old and has hypertension. The patient’s father died four
years ago because of cardiac arrest. She had six siblings and one of her sisters died from Cervical
Cancer in 2016.

COURSE IN THE WARD

November 8, 2019: The day of patient admission
At 12 : 00 pm patient was admitted and oriented to room at station 4C, and oriented for
pre operation preparation; nail polish removal, denture, pre-op medication and nothing per orem 8
hours prior to procedure for the scheduled right wide breast mass excision on Saturday November
9, 2019 under Dr. Segismundo and Dr. David; consent signed by the patient. 1L D5LR started at
right metacarpal to run for 97cc/hr
Referred and approved to cardio department for CP clearance, 7:46 pm kalium durule is
order and given 2 tablet now and 1 tablet 1 hour prior to NPO, 11: 30 pm esomeprazole 40mg 1
tab given
November 9, 2019: 1st day
The patient was re oriented for nothing per-mouth, health teaching done for post operation
recovery and encourage to notify nurse on duty for any concern or need of assistance. Orders and
consent reviewed, vital signs monitored and recorded.
Cefuroxime 1.5g through IV one hour prior to operating room given. Patient sent to
operating room
6:00 pm patient returned to room, post OP-Assistance done; patient transferred to bed at
moderate high back rest, kept warm and comfortable, vital sign monitored and recorded, with IV
bottle number 2, 1L PLR to run for 97cc/hr. Post op medications ordered nalbuphine 5mg diluted
in 10cc PNSS every 8 hours or when needed for severe pain. Ketorolac order and given every 8
hours

November 10, 2019: 2nd day

Patient on diet as tolerated, was taught and advised to do deep breathing exercise,
postoperative assessment done, safety provided, post op medication dexketoprofen 25 mg per
tablet every 8 hours, sultamicillin tosylate 750 mg per tablet, 1 tablet BID given. Bottle number 3,
1L PLR with same rate to consume

November 11, 2019: 3rd day

Patient oral medication to be consumed. Safety, comfort and continuity of care provided.
Advised for discharge, home medication prescribed with mupirocin ointment for wound BID, may
go home with JP drain, health teaching and instructions regarding the JP drain done.
PATHOPHYSIOLOGY

PREDISPOSING FACTOR PRECIPITATING FACTOR

-SEX BREAST CANCER
-HIGH FAT DIET
-AGE -LACK OF EXERCISE
-GENETIC RISK FACTORS -ANTIPERSPIRANT USE
-NON-BREAST FEEDING

Over expressed
estrogen receptor

Increased estrogen
exposure

INCREASED ESTROGEN
METABOLSIM

Increased cell
proliferation

Initiation:
Carcinogens bind to cell’s DNA
results to alteration of functions.
 LABORATORY AND DIAGNOSTICS

Section of CLINICAL CHEMISTRY

Test Name November 7, October 29, Reference Interpretation
2019 2019 Range
3:25 PM 11:02 AM
Creatinine 43.00 40.00 45.00 – 84.00 Abnormal to
Normal
Sodium 142.00 x 135.00 – 148.00 Normal
Potassium 3.46 x 3.50 – 5.30 Normal
SGPT x 21.60 10.00 – 35.00 Normal
SGOT x 30.00 10.00 – 35.00 Normal
ALP x 60.45 35.00 – 104.00 Normal
BILIRUBIN
(DIAZO)
Indirect Bilirubin x 6.51 3.40 – 11.90 Normal
Direct Bilirubin x 3.66 0.00 – 8.60 Normal
Total Bilirubin x 10.17 3.40 – 20.50 Norma

Analysis: Decreased creatinine level on October 29. The patient has a fatty liver that built
overtime due to her diet. Poor liver function interferes with creatinine production, which can
cause low creatinine.
 Section of HEMATOLOGY
Test Name October 29, 2019 Reference Range Interpretation
11:02 AM
CBC and Platelet
White Blood Cells 6.71 3.98 – 10.04 Normal
Red Blood Cells 4.23 3.93 – 5.22 Normal
Hemoglobin 131.00 112.00 – 157.00 Normal
Hematocrit 0.38 0.34 – 0.45 Normal
Mean Corpuscular 88.90 79.40 – 94.80 Normal
Volume
Mean Corpuscular 31.00 25.60 – 32.20 Normal
Hb
Mean Corpuscular 34.80 32.20 – 35.50 Normal
Hb Conc.
RBC Distribution 11.40 11.60 – 14.60 Abnormal
Width
Platelet Count 219.00 150.00 – 450.00 Normal
Mean Platelet 8.40 6.50 – 12.00 Normal
Volume
Differential Count
Neutrophils 59.30 34.00 – 71.00 Normal
Lymphocytes 31.90 19.00 – 52.00 Normal
Monocytes 6.70 5.00 – 12.00 Normal
Eosinophil 1.80 1.00 – 7.00 Normal
Basophil 0.30 0.00 – 1.00 Normal

Analysis: Deacresed RBC distribution width. The RBC distribution width test helps diagnose
types of medical condition including cancer. It is a measure of the range of variation of red blood
cell volume that is reported as part of a standard complete blood count.

Chest CT
October 30, 2019
A mass measuring 4.6 x 3.2cm is noted in the mastectomy site. There is no plane
cleavage with the pectoralis muscle/ chest wall suggestive of infiltration. Linear strandings are
also seen in the mastectomy site.
Linear strandings in the right upper and middle lobes underneath the mastectomy site
may relate to post radiation fibrosis. Aorta is calcified. Heart size is normal. No pleural or
pericardial effusion. No evidence of enlarged lymph nodes.
Mild hypertrophic changes are noted in the osseous structures. Incidental note of patchy
hepatic steatosis.
 DRUG STUDY

DRUG MECHANISM INDICATIONS CONTRAINDICATIONS SIDE EFFECTS/ NURSING

OF ACTION ADVERSE RESPONSIBILITIES
REACTIONS
Generic Name After Prophylaxis for  Hypersensitivity  Pseudomembranous  Instruct patient to
Sultamicillin absorption, breast cancer colitis immediately report
tosylate sultamicillin surgery on the  Anaphylactic shock signs and
releases prevention of  Dizziness symptoms of
Brand Name ampicillin and surgical site  Somnolence hypersensitivity
Zunamyn sulbactam into infection  Sedation reaction, such as
the system.  Headache rash, fever, or
Classifications Ampicillin  Dyspnea chills.
Penicillin exerts  GI disorders  Advise patient to
antibacterial minimize GI upset
Dose activity against by eating small,
750 mg/tab; sensitive frequent servings
one tablet organisms by of food and
twice a day inhibiting drinking plenty of
biosynthesis of fluids.
Route cell wall  Inform patient that
Oral mucopeptide drug lowers
whereas resistance to
sulbactam certain infections.
irreversibly Tell patient to
inhibits most promptly report
important beta- unusual bleeding or
lactamases that bruising.
occur in
resistant strains.
 DRUG MECHANISM INDICATIONS CONTRAINDICATIONS SIDE EFFECTS/ ADVERSE NURSING
OF ACTION REACTIONS RESPONSIBILITIES
Generic Name It is a non- Postoperative  History of asthma  CNS: Trouble in sleeping,  Lab tests: Monitor
Dexketoprofen steroidal anti- pain attack, bronchospasm, nervousness, headache, baseline and
trometamol inflammatory acute rhinitis/nasal dizziness; depression, periodic
drug (NSAID) polyp drowsiness, confusion, evaluations of
that reduces  Urticaria/angioneurotic migraine, vertigo. hemoglobin, renal
Classifications prostaglandin edema  CV: Peripheral edema, and hepatic
Non-steroidal synthesis via  Gastric ulcer/chronic palpitations, hypertension, function.
anti- inhibition of dyspepsia, gastric tachycardia.  Monitor for S&S of
inflammatory cyclooxygenase bleeding, Crohn’s  Special Senses: Visual GI ulceration (e.g.,
drug pathway (both disease/ulcerative disturbances; Dry nose or stool for occult
COX-1 and colitis throat, tinnitus, hearing blood, persistent
Dose COX-2)  Severe cardiac failure impairment. indigestion).
One tablet activity  Moderate to severe  GI: Dyspepsia, nausea,  Report promptly
every 8 hours renal dysfunction vomiting, diarrhea, signs of jaundice as
 Severe liver constipation, flatulence, well as the
Route dysfunction stomach pain, anorexia, dry following: blurred
Oral hemorrhagic diathesis mouth. vision, tinnitus,
 Coagulation disorders  Skin: Rash, pruritus, urinary urgency or
 Anticoagulant therapy urticaria, erythema, frequency,
photosensitivity. unexplained
bleeding, weight
gain with edema.
 Note: Possible
CNS adverse
effects (e.g., light-
headedness,
dizziness,
drowsiness).
 DRUG MECHANISM INDICATIONS CONTRAINDICATIONS SIDE EFFECTS/ NURSING
OF ACTION ADVERSE RESPONSIBILITIES
REACTIONS
Generic Name Inhibits cell- Perioperative  Hypersensitivity  Hypersensitivity  Monitor patient for
Cefuroxime wall synthesis, prophylaxis reactions signs and
sodium promoting  Diarrhea, nausea, symptoms of
osmotic pseudomembranous superinfection and
Classifications instability; colitis diarrhea.
Second- usually  Decreased Hb  Instruct patient to
generation bactericidal. concentration &/or notify prescriber
cephalosporins eosinophilia, about rash, loose
leucopenia, & stools, diarrhea, or
Dose neutropenia may evidence of
 1.5 g thru occur superinfection
IV 1 hour  Transient rise in  Advise patient
prior to OR SGOT & SGPT, & receiving drug I.V.
ANST bilirubin to report
 750 mg discomfort at I.V.
TIV q8 insertion site.

Route
IV
 DRUG MECHANISM INDICATIONS CONTRAINDICATIONS SIDE NURSING
OF ACTION EFFECTS/ RESPONSIBILITIES
ADVERSE
REACTIONS
Generic Name Reduces gastric Prophylactic  Hypersensitivity  CNS:  Monitor patient for
Esomeprazole acid secretion agent for acid headache, rash or signs and
and decreases aspiration dizziness symptoms of
Classifications gastric activity.  GI: hypersensitivity.
Proton Pump abdominal  Instruct patient to
Inhibitors pain, alert prescriber if
constipation, rash or other signs
Dose diarrhea, dry and symptoms of
40 mg tablet 30 mouth, allergy occur.
minutes prior flatulence,
NPO nausea,
vomiting
Route  Skin:
Oral pruritus
 Medications Mechanism of Indications Contraindications Side Effects/ Nursing
Action Adverse Effects Responsibilities
Brand Name: Principal intracellular - To prevent and treat -Contraindicated in -Arrythmias, heart block, -Monitor I&O ratio and
Kalium Durule cation; essential for potassium deficit patients with oliguria hypotension, cardiac pattern in patients
maintenance of secondary to diuretic & anuria. arrest, hyperkalemia, receiving the parenteral
Generic Name: intracellular or corticosteroid respiratory paralysis drug.
Potassium Chloride isotonicity, therapy. Also -Patient with untreated
transmission of nerve indicated when Addison’s disease or -Nausea, vomiting, and -If oliguria occurs, stop
Classification: impulses, contraction potassium is depleted with acute abdominal pain. infusion promptly and
Potassium salt, of cardiac, skeletal, by severe vomiting. dehydration and heat notify physician.
electrolytic and and smooth muscles, cramps.
water balance agent. maintenance of - Diarrhea, intestinal -Lab test: Frequent
normal kidney drainage, fistulas, or -Use cautiously with serum electrolytes are
Dosage and function, and for malabsorption. patient cardiac disease warranted.
Route: enzyme activity. and renal impairment.
Adults: Initially, 20 Plays a prominent -Prolonged diuresis, -Monitor and report
mEq of Potassium role for both diabetic acidosis signs of GI ulceration
supplement P.O. formation and (esophageal or
Daily, in divided correction of - Effective in the epigastric pain or
doses. Adjust doses, imbalances in acid- treatment of hematemesis)
as needed, based on base metabolism. hypokalemia
Potassium levels. -Monitor patients
receiving parenteral
potassium
 Medications Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities
Action
Brand Name: It primarily works by -Indicated for the -Contraindicated in Skin: Burning, stinging, -Watch for signs and
Bactroban inhibiting bacterial topical treatment of patients with known pain, pruritus, rash, symptoms of
protein synthesis. impetigo due to hypersensitivity to erythema, dry skin, superinfection. Prolonged
Generic Name: Due to its unique susceptible isolates of mupirocin or any of tenderness, swelling. or repeated therapy may
Mupirocin mode of action of Staphylococcus aureus the excipients of result in superinfection by
topical/ointment inhibiting the activity (S. aureus) and Bactroban oinment. Special nonsusceptible organisms.
of bacterial Streptococcus Senses: Intranasal, local Reevaluate drug use if
Classification: isoleucyl-tRNA pyogenes (S. stinging, soreness, dry patient does not show
Carboxylic acid synthetase, pyogenes). skin, pruritus. clinical response within 3–
mupirocin does not 5 d.
Dosage and Route: demonstrate cross- -Discontinue the drug and
BACTROBAN resistance with other notify physician if signs of
ointment contains 20 classes of contact dermatitis develop
mg mupirocin in a antimicrobial agents, or if exudate production
water-miscible giving it a increases.
ointment base therapeutic
supplied in 22-gram advantage. -Discontinue drug and
tubes. Topical contact physician if a
application only sensitivity reaction or
chemical irritation occurs
(e.g., increased redness,
itching, burning).
 Medications Mechanism of Indications Contraindications Adverse Effects Nursing
Action Bn Responsibilities
Brand Name: -Binds to opiate -Indicated for relief of -Hypersensitivity to CNS: Sedation, -Reassess patients’
Nalbuphine receptors in the CNS, moderate to severe nalbuphine, sulfites, clamminess, sweating, level of pain at least
hydrochloride alters the perception pain. It can also be lactation. headache, nervousness, 15-30 minutes after
of and responses to used as a supplement restlessness, depression, parenteral
Generic Name: painful stimuli while to balanced anesthesia -Use cautiously with crying, confusion, administration
Nubaine producing generalize for preoperative, emotionally unstable faintness, hostility, - Alert: Drug causes
CNS depression. postoperative clients or those with a unusual dreams, respiratory depression,
Classification: analgesia, for history of narcotic hallucinations, euphoria, which at 10mg is
Narcotic agonist- obstetrical analgesia abuse; head injury; dysphoria, dizziness, equal to respiratory
antagonist analgesic during labor and increased ICP; vertigo, floating feeling, depression.
delivery. impaired ventilation, feeling of heaviness, -Monitor circulatory
Dosage and Route: MI accompanied by numbness, tingling, and respiratory status,
N/V, upcoming biliary flushing, warmth, blurred bladder and bowel
Adults: Usual dose is surgery, and hepatic vision. function. If
10 mg/70 k, SC, IM or renal disease. respirations are
or IV q 3-6h as CV: Hypotension, shallow or rate is
necessary. hypertension, below 12 breaths/mon,
Individualize dosage. bradycardia, tachycardia withhold dose and
In nontolerant notify prescribed.
Dermatologic: Itching, -Constipation is often
burning, uritcaria severe with
maintenance therapy.
GI: Vomiting, cramps, Make sure stool
dyspepsia, bitter taste, softener or other
dry mouth. laxative is ordered.
-Psychological and
GU: Urinary urgency physical dependence
may occur with
Respiratory: prolonged use
Respiratory depression,
dyspnea, asthma
 Medications Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities
Action
Brand Name: -Inhibits Short term -Hypersensitivity CNS: Drowsiness, -Monitor BP upon
Ketorolac prostaglandin management for pain -Cross-sensitivity with abnormal thinking, administration. If BP is
synthesis, producing (not to exceed 5 days other NSAIDs may dizziness, euphoria, <90/80 do not administer.
Generic Name: peripherally total for all routes exist pre-or- headache Refer to doctor.
Toradol mediated analgesia. combined) perioperative use -Patients who have
-Also has antipyretic -Known alcohol RESPI: Asthma, asthma, aspirin induced
Classification: and anti- intolerance. dsypnea allergy, and nasal polyps
Nonsteroidal anti- inflammatory -Use cautiously in: are at risk for developing
inflammatory agents, properties. a.) History of GI CV: Edema, pallor, hypersensitivity
nonopiod, analgesics -Therapeutic effect: bleeding vasodilation reactions. Assess for
Decreased pain b.) Renal impairment rhinitis, asthma and
Dosage and Route: (dosage reduction may GI: Gi bleeding, uriticaria.
30 mg TIV q6h be required) abnormal taste, diarrhea, - Assess pain (note type,
c.) Cardiovascular dry mouth, dyspepsia, GI location, and intensity)
disease pain, nausea prior to and 1-2 hrs
following administration.
GU: Oliguria, renal -Ketorolac therapy should
toxicity, urinary usually be given initially
frequency by 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.
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Anxiety/fear related After nursing Independent: Independent: Goal was met:
“Natatakot ako na to reoccurrence of interventions done 1. Encourage client 1. Provides Patient was able to
bumalik ulit ang breast cancer as patient will be able to share thoughts opportunity to demonstrate use of
cancer ko” as evidenced by to demonstrate use and feelings. examine realistic effective coping
verbalized by the increased tension, of effective coping fears and mechanism and
patient “ fear and distress mechanism and 2. Provide accurate, misconceptions participate actively
active participation consistent about a diagnosis. in treatment
information
Objective: in treatment regimen.
regarding diagnosis
>Increased tension regimen. and prognosis. 2. Can reduce
>Shakiness Avoid arguing anxiety and enable
>Distressed about client’s client to make
>Fear perceptions of decisions and
situation. choices based on
realities.
3. Explain the
recommended
treatment, it’s 3. The goal of
purpose, and cancer treatment is
potential side to destroy
effects. Help client malignant cells
prepare for while minimizing
treatment. damage to normal
ones. Treatment
Collaborative:
may include
1. Refer to curative,
additional resources preventive, or
for counselling and palliative surgery as
support as needed.
well as
chemotherapy,
internal, or external
radiation, or newer,
organ-specific
treatments such as
whole-body
hyperthermia or
biotherapy.

Collaborative:

1. May be useful
from time to time to
assist client and
family in dealing
with anxiety.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain related After 8 hours Independent: Independent: Patient’s pain was
“Masakit siya kaya to tumor recurrence nursing 1. Provide non- 1. Promotes relieved with a pain
di ako nakapasok sa right intervention done pharmacological relaxation and helps scale 5 out of 10.
comfort measures,
trabaho ko” as patient will report focus attention.
such as massage,
verbalized by the relief of pain. repositioning, and
patient backrub, as well as 2. This information
diversional helps establish
Objective: activities, such as realistic
-Pain scale of 7 out music, reading and expectations and
10 tv. confidence in own
-With presence of ability to handle
2. Inform client and
facial grimace family of the what happens.
-Irritability expected
-Restlessness therapeutic effects Collaborative:
-Pain upon touch and discuss 1. An organized
management of side plan beginning with
effects. the simplest dosage
schedules and least
Collaborative:
invasive modalities
1. Develop
individualized pain- improves chance
management plan for pain control.
with the client and
physician. Provide
written copy of plan
to client, family and
health care
providers.