A.

Patient’s Profile

Name: Marlyn Quinola Abalos Age: 45

Diagnosis: Fibrocystic Disease Rule Out Cancer

Occupation: Housewife

Address: #59 Queen of Apostles, Lourdes Proper Baguio City

History of Present Illness: One month prior to admission, patient felt a palpable mass on her
right breast. No consultation was made since mass was not associated with pain. Three weeks
prior to admission, patient experienced breast tenderness and discomfort. Consultation was made
and laboratory tests were performed to diagnose the problem. Patient was scheduled for surgery
to exist mass hence admission.

B. Anatomy and Patho physiology of the organ involved

Anatomy
The breast is a mass of
glandular, fatty, and fibrous
tissues positioned over the
pectoral muscles of the chest
wall and attached to the chest
wall by fibrous strands. A layer
of fatty tissue surrounds the
breast glands and extends
throughout the breast. The fatty
tissue gives the breast a soft
consistency. The glandular
tissues of the breast house the
lobules (milk producing glands
at the ends of the lobes) and the
ducts (milk passages). Toward
the nipple, each duct widens to
form a sac (ampulla). During
lactation, the bulbs on the ends
of the lobules produce milk. Once milk is produced, it is transferred through the ducts to the
nipple. The breast is composed of:

 milk glands (lobules) that produce milk

 ducts that transport milk from the milk glands (lobules) to the nipple
 nipple
 areola (pink or brown pigmented region surrounding the nipple)
 connective (fibrous) tissue that surrounds the lobules and ducts
 fat

Arteries carry oxygen rich blood from the heart to the chest wall and the breasts and veins
take de-oxygenated blood back to the heart. The axillary artery extends from the armpit and
supplies the outer half of the breast with blood; the internal mammary artery extends down from
neck and supplies the inner portion of the breast.

Male and female breasts mature comparably until puberty, when in females estrogen and
other hormones initiate breast development. This development usually occurs from 10 to 16
years of age, although the range can vary from 9 to 18 years. Stages of breast development are
described as Tanner stages 1 through 5.
  Stage 1 describes a prepubertal breast
 Stage 2 is breast budding, the first sign of puberty in a female.
 Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring
around the nipple).
 Stage 4 occurs when the nipple and areola form a secondary mound on top of the breast
tissue.
 Stage 5 the continued development of a larger breast with a single contour.

The breasts are located between the second and sixth ribs over the pectoralis muscle from
the sternum to the mid-axillary line. An area of breast tissue, called the Tail of Spence, extends
into the axilla. Fascial bands, called Cooper’s Ligaments, support the breast on the chest wall.
The Inframammary Fold (or crease) is a ridge of fat at the bottom of the breast.
 Each breast contains 12-20 cone-shaped lobes, which are made up of glandular elements
(lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together. Within
each lobe are smaller chambers called lobules, which contain clusters of Alveolar Glands that
produce the milk when a woman is lactating (producing milk). The alveolar glands of each
lobule pass the milk into the lactiferous ducts, which open to the outside at the nipple.

Pathophysiology

Fibrocystic breast disease is a common and benign change within the breast characterized by a
dense irregular and bumpy consistency in the breast tissue. Mammography or biopsy may be needed to
rule out other disorders.

PREDISPOSING ETIOLOGY: Precipitating Factors:

FACTORS:
Unknown - Radiation exposure
- Genetics - Fat intake and Obesity
- Hormonal - Alcohol use
factors - Cigarette Smoking
- Age - Intake of Contraceptive
- Gender Pills
- Family history
 Somatic mutations in the DNA

Activate oncogenes/deactivate tumor suppressor gene

Malignant transformation of lymphoid stem cell

Uncontrolled proliferation of lymphoblast in the breast

Breast cancer

C. Operation/Surgery Performed
1. Definition

Breast lump removal

Breast lump removal is surgery to remove a lump in the breast and some surrounding tissue
from the breast.

a. Types

A.1. Lumpectomy

Lumpectomy is a surgical procedure performed on a solid breast mass to determine if it is

malignant. The suspicious lump and some surrounding tissue is excised and analyzed.

A.2.Wide local excision

A surgical procedure to remove a small area of diseased or problematic tissue with a

margin of normal tissue. This procedure is commonly performed on the breast and to skin
lesions, but can be used on any area of the body.

A.3Excisional biopsy

An excisional biopsy is a procedure where tissue samples are cut out of the body.

A.4 Limited breast surgery

A surgical removal of the tumor and a small region of the surrounding, normal breast
tissue. In many lumpectomies, some of the lymph nodes under the arm also are removed.

A.5 Segmental mastectomy

The surgical removal of the tumor, some of the breast tissue around the cancer, and the
lining over the chest muscles below the cancer. Usually, some of the lymph nodes under the
arm also are removed.

A.6 Breast conservation therapy or surgery

An operation to remove the breast cancer while removing as little of the breast as
possible

A.7 Tylectomy

Surgical removal of a lump, especially a cancerous one.

A.8 Partial mastectomy

The surgeon removes more breast tissue than with a lumpectomy. The cancerous area and
a surrounding margin of normal tissue are removed, and radiation therapy is usually given
after surgery for six to eight weeks
 b. Indications

Early detection of a breast lump is very important to a patient's prognosis (probable

outcome). Most breast lumps are not diagnosed at the doctor's office; they are detected by
women who give themselves breast self-examinations at home. Any breast lump that persists
beyond a few days must be reported to a physician.

In some cases, a needle aspiration of a breast lump can be performed. If the tissue
obtained is clearly not cancerous, if no blood was seen on the aspirate, and if the lump
disappears after aspiration and does not recur, physicians will often simply observe patients.

Otherwise, the breast lump must be removed surgically to determine if cancer is present.

2. Discussion of the procedure

A breast lump may either be a cyst filled with fluid or a solid mass of tissue. A sample of the
breast tissue (biopsy) must be made to determine whether malignant (cancerous) cells are
present. Almost two-thirds of all breast lumps are benign but the chance of a malignant lump
is greatly increased if the woman is past menopause.

While the patient is awake and pain-free (using local anesthesia) or asleep and pain-free
(using general anesthesia), an incision is made over the lump.

The incision for a lumpectomy is usually around 3 to 4 centimeters long. The incision will
also depend on the size of the lump that needs to be removed. After the lump is removed in
one piece, it is sent to the laboratory for immediate examination. If the lump is found to be
cancerous nearby lymph nodes will be removed to check for the extent of the cancer
spreading.

D. Nursing Intervention

1. Pre Operative Preparation of the patient

a. Physical
  Observe and record overall condition like nutritional status, physical defects, hearing
and sight difficulties.
 Obtain chest X-ray, ECG, laboratory findings such as blood, urine and stool.
 Take the pre-op history and assess the physical present condition.
 Determine any drug allergies.
 Hygienically prepare the patient.
 Insert IV, NGT and indwelling catheter if ordered.
 Administer pre-op medications.
 Provide quite rest and bed rails before bringing to OR.

b. Special Preparation
 Perform and supervise skin preparation and cleaning of the affected part.
 Carry out pre-op nursing interventions like notifying physician of drug allergies,
abnormal ECG and abnormal laboratory results.
 See to it that consent has been signed by relatives.
 Provide pre-op checklist.
 Check if history and physical examination findings are on the patient’s chart.
 Chart the pre-op medications.
 Remove dentures, nail polish, hair pins, jewelries and contact lenses.
 Upon entering the OR, attached cardiac monitor and pulse oximeter to monitor initial
vital signs.

2. Intra operation Anesthesia/OR technique

a. Skin preparation
 Apply betadine antiseptic to the area that will be exposed for the operation. Maintain
aseptic technique.
 After skin care, assist patient for the induction of the anesthesia. Monitor the onset of
anesthesia on patient for it has a relaxing effect on the patient's body, which can
suppress cardiovascular function or heighten cardiovascular irritability. It may also
result in respiratory depression, loss of consciousness, paralysis, and lack of
sensation. These effects, some of which are intentional for the period of the surgery,
mean the patient is in a very vulnerable position. It is the responsibility of the health
care team in the operating room to maintain the patient's safety and yet facilitate
surgery.

b. Draping
 Drape patient aseptically. Usually, a lap sheet is being used to drape the patient and
exposing only the operative site to minimize the risk of cross contamination.
 Hold the drapes high enough to avoid touching nonsterile area but avoid touching the
overhead light.
 Hold the drape high until it is directly over the proper area, then drop (open fingers
and release sheet) it down where it is to remain. NEVER ADJUST ANY DRAPE. If
the drape is incorrectly placed, leave it in place and place another drape over it.
 Protect the gloved hands by cuffing the end of the sheet over them. Do not let the
gloved hand touch the skin of the patient.

c. Instrumentation
 Clamp is an instrument without teeth, used primarily for grasping vascular tissue
in gynecologic procedures. It could be a curved or straight Kelly clamp.

Allis has sharp teeth to hold tissues firmly but

sometimes can cause damage so only used on
tissue which will be excised. It is used to grasp a
tissue; usually; heavy Allis holds breast tissues.

Towel Clips are used to clip towels, which restrict

the surgical fields attached to the patient. A
Backhaus towel clip is used to hold towels and
drapes in place,
Needle Holder is a surgical forceps used to hold and pass a suturing needle through
tissue. Most needle holders also have a clamp mechanism that locks the needle in place,
allowing the user to maneuver the needle through various tissues. To maintain a firm grip
on the needle, the jaws are often textured.

Tissue Forceps are forceps without teeth or

with one or more small teeth at the end of each
blade, designed for handling tissues with
minimal trauma during surgery.

Retractors are curved instruments used to hold

tissue aside during surgery. In breast cancer
surgery, retractors are used to hold the incision
open so that the tumor or breast tissue can be
removed.
 Metzenbaum scissors are a type of surgical tool typically used to cut delicate soft tissues.
Not only are they the most commonly used scissors for cutting tissue, but they are
designed only to be used for that purpose. Because of their specific function, they
sometimes are called Metzenbaum dissecting scissors.

Scissors

Mayo Scissors

A Mayo Scissor is heavy-duty surgical scissors with narrowed but

blunt pointed blades, which may be straight or curved.

Straight-bladed Mayo scissors are designed for cutting body tissues

near the surface of the wound. As the straight Mayo scissor is also
used for cutting sutures, or stitches, it’s also sold as suture scissors.
Many surgeons use separate pairs of straight-bladed Mayo scissors for
tissue and suture cutting since using the scissor on sutures tends to
dull its blades.

Curved-bladed Mayo scissor styles allow deeper penetration into the

wound than the type with straight blades. The curved style of Mayo
scissor is used to cut thick tissues such as those found in the uterus,
muscles, breast and foot. Mayo scissors used for dissection are
placed in tissue with the tips closed. The scissors are then opened so
that the tips open and spread out the tissue during the dissection
process.

d. Equipment Needed
 Cautering Device
 Cautery: A method for providing hemostasis to a bleeding tissue surface comprises
providing and pressing an electrical cautery device having a thermal delivery
element, against the hemorrhaging tissue at a predetermined temperature for an
interval sufficient to cauterize the tissue and provide hemostasis.

e. Supplies Needed
 Anesthetic Agents
 Suture, Needles and Sponges
 IV fluids
 Saline solutions

3. Post Operative Care

a. Presentation of Complications
>There was no presentation of complications after the surgery.

OR Write Up

Submitted to:

Ms. Jennifer Mariňas

Clinical Instructor

Submitted by:
Elynor Chrisma V. Caberto
BSN III-33 Grp 4

Exposure Date:
May 9-11, 2011
Pines City Doctors Hospital