PATIENT’S DATA

NICOLE REYES
42 YRS.OLD
FEMALE

PATHOPHYSIOLOGY

SIGNIFICANT DATA  SHE REPORTS THAT

A MATERNAL AUNT
 COMPLAINT OF SEVERE DOB DIED OF BREAST
 SWELLING ON HER CANCER.
RIGHT
BREAST,DISCHARGED
AND CRUSTING ON
NIPPLE
 V/S: 150/90, RR 40, SPO2 88%,
TEMP: 36.5 C
 ON EXAMINATION, THE
PHYSICIAN NOTE THAT HER
BREAST FEEL NODULAR BUT
WITH DISCRETE MASSES T-3
>5 CMS, N-3, M-1. OTHER
FINDINGS INCLUDE
EVIDENCE OF
INFLAMMATION, W/
AXILLARY NODE ENLARGED.
 THORAX ASSESSMENT AS
FOLLOWS: DECREASED
CHEST MOVEMENT, STONE
DULLNESS TO PERCUSSION,
MEDICAL DIAGNOSIS DIMINISHED BREATH
BREAST CANCER STAGE III, SOUNDS, DECREASED
PNEUMONIA, COVID 19-SUSPECT RESONANCE AND FREMITUS,
+ PLEURAL FRICTION RUB
AND EGOPHONY,
 SHE RELATES THAT SHE IS A
“HEAVY COFFEE DRINKER”
MEDICAL AND SURGICAL AND IS UNDER A GREAT DEAL
HISTORY THE MASS WAS NOTICED 5 OF STRESS IN HER JOB
YEARS AGO WITH NO CONSULTATION
 THE MASS WAS NOTICED 5
WAS MADE DUE FINANCIAL
YEARS AGO WITH NO
CONSTRAINT.
CONSULTATION WAS MADE
DUE FINANCIAL CONSTRAINT.
 DIAGNOSTIC TEST

 CHEST X-RAY
 BREAST EXAMINATION
 MRI
 MAMMOGRAM

MEDICATIONS

 DOXORUBICIN
(ADRIAMYCIN)
 EPIRUBICIN (ELLENCE)
 PACLITAXEL (TAXOL)
 CARBOPLATIN
 FEAR RELATED TO INEFFECTIVE BREATHING
NURSING

RISK FOR SKIN INTEGRITY

DIAGNOSI

NURSING
DIAGNOSI
SITUATIONAL CRISIS AS
RELATED TO EFFECTS OF PATTERN RELATED TO SEVERE
EVIDENCED BY EXPRESSED

NURSING
DIAGNOSI
CONCERNDUE FINANCIAL RADIATION AND DIFFICULTY OF BREATHING AS
S

CHEMOTHERAPY

S
CONSTRAINT. EVIDENCED BY HOOKED TO O2

S
INHALATION AT 5 LPM

SYMPTO
BREAST CANCER STAGE III

SIGNS
 DYSPNEA, TACHYPNEA

AND
 ENCOURAGE
 ABNORMAL BREATH
PATIENT TO

SYMPTOM
SOUNDS (RHONCHI,
SHARE THOUGHTS
BRONCHIAL LUNG

SIGNS
AND FEELINGS.

AND
 ASSESS DENTAL SOUNDS, EGOPHONY)
 REVIEW
HEALTH AND ORAL  CHANGES IN RATE, DEPTH
PATIENT’S AND
HYGIENE OF
SO’S PREVIOUS
PERIODICALLY. RESPIRATION
EXPERIENCE
 DISCUSS WITH S
WITH CANCER.
INTERVENTIO

 PERMIT PATIENT AREAS

EXPRESSIONS OF NEEDING
ANGER, FEAR, IMPROVEMENT AND
INTERVENTIO
NS

DESPAIR WITHOUT DEMONSTRATE

CONFRONTATION. METHODS FOR GOOD
 PLACE PATIENT WITH
GIVE ORAL CARE.
PROPER BODY ALIGNMENT
NS

INFORMATION  INSTRUCT REGARDING

FOR MAXIMUM BREATHING
THAT FEELINGS DIETARY CHANGES:
PATTERN.
ARE NORMAL AND AVOID HOT OR SPICY

INTERVENTIO
 MAINTAIN A CLEAR AIRWAY
ARE TO BE FOODS, ACIDIC JUICES;
BY ENCOURAGING PATIENT
APPROPRIATELY SUGGEST USE OF
TO MOBILIZE OWN
EXPRESSED. STRAW; INGEST SOFT
SECRETIONS WITH

NS
 EXPLAIN THE OR BLENDERIZED
SUCCESSFUL COUGHING.
RECOMMENDED FOODS, POPSICLES, AND
ICE CREAM AS  ASSESS AND RECORD
TREATMENT,
TOLERATED. RESPIRATORY RATE AND
ITS PURPOSE,
DEPTH AT LEAST EVERY 4
AND POTENTIAL  ENCOURAGE FLUID
HOURS.
SIDE EFFECTS. INTAKE AS
INDIVIDUALLY  OBSERVE FOR
HELP PATIENT
TOLERATED. BREATHING PATTERNS.
PREPARE FOR
EXPECTED
OUTCOME

TREATMENTS.

THE PATIENT WILL DEMONSTRATE USE OF EFFECTIVE COPING

TCOM
ECTE
MECHANISMS AND ACTIVE THE PATIENT WILL MAINTAINS AN
PARTICIPATION IN TREATMENT EFFECTIVE BREATHING PATTERN,

EXPECTED
REGIMEN.

OUTCOME
THE PATIENT WILL VERBALIZE AS EVIDENCED BY RELAXED
UNDERSTANDING OF CAUSATIVE BREATHING AT NORMAL RATE AND
FACTORS. DEPTH AND ABSENCE OF DYSPNEA.