COLLEGE OF NURSING

RELATED LEARNING EXPERIENCE (RLE)

A CASE STUDY

ON

Invasive Ductal Carcinoma, Left Breast Status Post Core Needle Biopsy

Presented by: BSN 4A-GROUP 1

Submitted by:

CATAINA, ANGEL JOY R OLIDAN, NOVELYN

CONCEPCION, HENSON L. ORPILLA, ERICA B.

ENCARNACION, MERRIN M. SALVADOR, KAYLA ZHAINE T.

JANDOC, AILA TRICIA S TASSIE, RUTH M.

Presented to:

Level 4 Clinical Instructors + Other Panelists

April 2023
GOALS AND OBJECTIVES

General Objectives

By the successful completion of the course, BSN 4A nursing students will know more
about Invasive Ductal Carcinoma and be able to produce synthesis based on real
circumstances.

In this case study, we'll examine techniques for managing patients with invasive ductal
carcinoma and enhancing any nursing interventions that might be necessary for their
care.

The nursing students in BSN 4A will be able to define the following after finishing this
case study. The following activities are created with the intention of achieving the
General Goals.

Specific Objectives

• Assess the patient's condition through building rapport, gathering all necessary
information and perform physical assessment on patient to attain baseline data.

• Determine the client's previous and present health history, and how it might
impact the condition they now have

• Recognize how the current illness is physio pathologically represented.

• Discuss the normal outcomes of an Invasive Ductal Carcinoma physical exam,

diagnostic tests, patient signs and symptoms, and nursing care for Invasive Ductal
Carcinoma patients.

• To conduct a drug study to comprehend the purpose, side effects, and

contraindications of the drug given to the patient.

• Evaluate patient’s condition after treatment and establish a home care and health
promotion plan.
OVERVIEW OF THE DISEASE

Definition

Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma the most
common histologic type of breast cancer—accounts for 80% of all cases. The tumors
arise from the duct

system and invade the surrounding tissues. They often form a solid irregular mass in
the breast.

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. Carcinoma refers to any cancer that
begins in the skin or other tissues that cover internal organs such as breast tissue.
INVASIVE DUCTAL CARCINOMA is a cancer that has penetrated through the milk
duct wall and has begun to invade the breast tissues.

Causes

The most common cause of invasive ductal carcinoma is DNA damage of breast tissue
cells, which can be the result of a wide range of triggers including age, gender, medical
history, and hormonal exposure.

Risk factors

 Mutation in BRCA Genes

 Personal and Family history of breast cancer or Ovarian cancer
 Early menarche
 Late menopause
 Obesity
 Alcohol intake and Smoking

Signs and Symptoms

A new lump or tumor in the breast that you or your doctor may feel is sometimes the
first sign of invasive ductal carcinoma. According to the American Cancer Society, any
of the following unusual changes in the breast, including invasive ductal carcinoma, can
be a first sign of breast cancer: swelling of all or part of the breast, skin irritation or
dimpling, breast pain, nipple pain or the nipple turning inward, redness or thickening of
the nipple or breast skin, nipple discharge other than breast milk, lump in the underarm
area. Pain in one particular location of the breast or the nipple, is an unusual symptom
that occurs in about 5% of affected individuals
Diagnostic

To diagnose an invasive ductal carcinoma, a detailed medical history and physical

examination, specifically of the breast and the underarm area, is necessary. Some
imaging may be required in order to reveal an IDC, which tends to grow as a dense,
solid mass with calcifications.

Digital mammography - is an X-ray examination of the breast. It is used to detect and

diagnose breast disease in women who either have breast problems, such as a lump,
pain, or nipple discharge, as well as for women who have no breast complaints.

Ultrasonography- is useful in assessing the consistency and size of breast lumps.

Magnetic Resonance Imaging (MRI) - ideal for describing lesions in soft tissues such
as those found in the breast.

Tissue Biopsy - necessary to confirm the diagnosis of IDC. The biopsy may be
performed through a fine-needle aspiration (FNA), core biopsy, or excisional biopsy.

Treatment

Treatment options include surgery, radiation therapy, chemotherapy, or various targeted

therapies depending on the severity and type of the carcinoma.

Surgical Management

The main goal of surgery is to gain local control of the disease. With breast cancer
being diagnosed today at earlier stages, options for less invasive, breast conserving
surgical procedures are available.

Lumpectomy - is a breast cancer surgery that removes a tumor plus a normal margin
of surrounding healthy breast tissue, may remove only the malignant lesion

Mastectomy - surgical procedure that totally remove the affected breast, or even
remove both breasts

Prevention

Like most cancers, knowing your family history can help you take preventative steps,
such as early screenings and mammograms.

 Maintain a healthy body weight

 Don’t smoke and limit alcohol intake
 Be physically active
 Eat a healthy well-balanced diet
 Undergo genetic testing for gene mutations if recommended based on family
history.
PATIENT’S PROFILE

o Name: Patient PIA

o Age: 60 years Old
o Sex: Female
o Date of Birth: January 03, 1963
o Religion: Roman Catholic
o Civil Status: Married
o Educational Attainment: Elementary Graduate
o Occupation: Housekeeper
o Admission Date: March 22, 2023
o Admission Time: 12:00 PM
o Chief Complaint: Breast Mass (L)
o Admitting Diagnosis: Invasive Ductal Carcinoma, Left Breast Status Post Core
Needle Biopsy (02/22/2023)
o Final Diagnosis: Invasive Ductal Carcinoma, Left Breast Status Post Core
Needle Biopsy (02/22/2023)
o Surgery Diagnosis: Modified Radical Mastectomy, Left (3/24/2023)

PATIENTS MEDICAL HISTORY

PRESENT MEDICAL HISTORY

December 2022, While having a bath, the patient palpated a little mass on her left
breast with no soreness, pain, or associated nipple discharge. The patient did not seek
consultation because she assumed it was a simple acne or pimple, and she ignored it
because it was asymptomatic.

January 2023, the patient noticed that the mass on her left breast seemed to be
growing. This time, she tried to tell her husband about the situation; he initially assumed
it was just some simple acne, but when he tried to palpate it, he felt the mass as well.
After she told her husband about the situation, he persuaded her to see a doctor, but
she declined right away. Her first kid, who was living in Baguio City, was informed by
her husband about the lump on her breast. Her daughter immediately contacted and
forced her to visit a doctor in Baguio City.

On February 10, the Patient and her husband travel to Lower Session, Baguio City,
February 16, the patient examination requested for sonomammogram at Baguio
General Hospital and Medical Center with the requesting Physician Dr. Christine Anne
Saac, and an irregularly -shaped nodule with speculation and microcalcifications
measuring 2.39x1.79x1.50 cm is noted along the 2-3 o’clock inner zone of the left
breast, no visible focal lesion in the right breast and recommend immediately for biopsy.

February 22, 2023, Dr. Arlene L. Quitasol performed a core needle biopsy on her left
breast, and on March 9, 2023, she was diagnosed with Consistent invasive carcinoma
of no specific type. She was referred to Southern Isabela Medical Center for a Modified
Radical Mastectomy.

March 15, 2023, they travel back To Alicia, Isabela, and she scheduled a mastectomy,
she was admitted at Southern Isabela Medical Center on March 22, 2023, at 12:00 pm
and had her surgery on March 24 2023 at 2:12 pm and ended at 4:07 pm.

PAST MEDICAL HISTORY

The patient had a history of a mild stroke while in Baguio City at the age of 40. She had
her maintenance losartan and there was no record of another mild stroke incidence
after that she mentioned that she was also diagnosed with asthma at the age of 50 and
home medication of Salbutamol, and her husband accompany her to the hospital for her
quarterly checkup.

SOCIAL/PSYCHOLOGICAL HISTORY

According to the patient, her husband has been an active smoker since they got married
and can finish one pack of cigarettes each day. He only quit smoking 10 years ago, her
husband is a heavy drinker also but quit 10 years ago while she drinks occasionally only
or when her friends will invite her to drink. When she was young and single, she worked
as a helper in Baguio City, but when she married, she and her husband opened a
souvenir shop, which has been their financial support, and when the pandemic struck,
they let their shop be rented by others, and went back at Alicia, Isabela and when her
first daughter gave birth to her second child, they stopped working and focused solely
on their grandchildren and also mentioned that she helps her husband in their field.

OB HISTORY

The patient experienced menarche at the age of 16. Menstruation is regular 2-3 days in
duration and uses 3-4 pads a day, patients experienced occasional dysmenorrhea and
had her menopause at the age of 52

YEAR
G1 1991
G2 1993
G3 1995

GYNECOLOGY HISTORY

The patient was 28 years old when she was married and had sexual intercourse. The
patient had her IUD at the age of 42 and had it removed at the age of 52.
 FAMILY HISTORY
GRANDFATHER

&

GRANDMOTHER

S1 S2 S3

-HTN -HTN -HTN

-BREAST CANCER
-DM -DM +HTN
-DM
-ASTHMA
+ASTHMA -ASTHMA -ASTHMA

-BREAST -BREAST -BREAST

CANCER CANCER CANCER
+HTN
-ASTHMA

+BREAST CANCER
+HTN
GRANDFATHER +ASTHMA

&

GRANDMOTHER -HTN
-ASTHMA

LEGEND:
S1 S2 S3 S4 -HTN
-ASTHMA
FATHER SIDE
MOTHER
-HTN -HTN -HTN +HTN

-DM -DM -DM -DM MALE

-ASTHMA -ASTHMA +ASTHMA -ASTHMA FEMALE

-BREAST -BREAST -BREAST -BREAST PATIENT PIA

CANCER CANCER CANCER CANCER
PHYSICAL ASSESMENT (HEAD TO TOE)

General survey : Patient PIA ,60 years old is in High Fowlers position patient is wearing her pajama
and loose white shirts with 2 Jackson Pratt with 25 ml bright red fluid drainage .Patient is conscious
and coherent,patient is oriented with the place,time and date.Patient complain of acute pain in her
incision with rate of 4/10.
Date of Assesment : March 27,2023
Time of Assessment: 8:30 am
Post-operative date: March 24,2023
Day of post -operative : 3 days
Day of Confinement: 5 days
BMI: 25.6kg/m^2
Height: 5.2 ft (158.49cm)
Weight: 64 kg
Vital Signs taken as follow;
Blood Pressure: 130/90 mm/hg
Temperature: 35.6
Pulse Rate: 77 bpm
Respiratory Rate: 23 cpm
SPO2:96%

REVIEW OF SYSTEMS (ROS)

SYSTEMS SYMPTOMS
Integumentary System “anlaki ng tahi ko sa dibdib ko “

Nervous System “medyo sumasakit pa din yung operasyon

ko”
Muscular System “nahihirapan akong igalaw itong kaliwang
braso ko”
Circulatory System No significant findings.
Respiratory System Wheezing sound is noted
Digestive system No significant findings.
Excretory System No significant findings.

Organ/ Technique  Normal Actual Findings Interpretation

System Findings
Head Inspection  (-) lesion  (-) lesion  Normal
(Facial
features)  (-) areas  (-) areas  Normal
deformity deformity

 Symmetric facial  Symmetric  Normal

features facial features

 (+) Moist skin  (+) Moist skin  Normal

 (-) tenderness  Normal

Palpation  (-) tenderness

 Evenly  Brown, evenly  Normal

distributed distributed
Hair Inspection
 (-) infestation  (-) infestation  Normal

 Pink  Pink  Normal

Eyes Inspection Conjunctivae Conjunctivae

 (-) Periorbital  (-) Periorbital  Normal

Puffiness Puffiness

 White Sclera  White Sclera  Normal

 Normal visual  Blurry vision  Normal due

acuity with reading to aging
glasses but
grade is not
stated by the
patient

 Eyelashes evenly  Eyelashes  Normal

distributed evenly
distributed
 (+) PERRLA
 (+) PERRLA  Normal

 Pupil size are

equal  Pupil size are  Normal
equal (2mm)
 No drooping  No drooping
down of eyelids down of
eyelids  Normal

 (-) Same eye

 (-) Same eye
color
color
 Normal

Nose Inspection  (+) Symmetrical  (+)  Normal

 (-) discoloration Symmetrical
 (-)  Normal
 (+) Nasal discoloration
 mucosa is  Normal
pinkish red  (+) Nasal
mucosa is
 (-) discharges pinkish red  Normal

 (-) tenderness  (-) discharges

Palpation  Normal
 (-) lesions  (-) tenderness
 Normal
 (-) masses  (-) lesions
 Normal
 (+) patent  (-) masses

 (+) patent

Ears Inspection  (-) discharge  (+) discharge  Poor

Hygiene

 (-) redness  (-) redness  Normal

 Symmetrically  Symmetrically  Normal

aligned aligned

 Normal hearing  Normal  Normal

acuity hearing acuity
Palpation  Pinna  Pinna  Normal
immediately immediately
Recoil after it is Recoil after it
folded is folded

Mouth Inspection  (-) swelling  (-) swelling  Normal

 (-) lesions  (-) lesions  Normal

 (-) bleeding  (-) bleeding  Normal

 Lips are Pinkish  Lips are  Normal
in color Pinkish in color

 Gums Pinkish in  Gums Pinkish  Normal

color, in color,

 32 permanent  (+) False teeth  Normal

teeth.

 Tongue is  Normal
 Tongue is pinkish pinkish

 (-) oral thrush  Normal

 (-) oral thrush

Neck Inspection  Symmetrical  Symmetrical  Normal

 (-) mass and  (-) mass and  Normal
lumps lumps

Palpation  (-) swelling and  (-) swelling and  Normal

lesion lesion

Breast Inspection  (-) discoloration  (+)  post-

discoloration operative
  (-) wound  (+) abrasion  due to
wound removal of
 (-) odor adhesive
 (-) odor tape
 (-) discharge
 (-) discharge  Normal
 (-) dressing
 (+) dressing  Normal
 (-) contraption  post-
 (+) Contraption operative
Jackson Pratt
 to drain
secretion
 Nipple is inverted  Nipple is
inverted  Normal

 Complete  Removed (L)  Modified

mammary gland Breast Radical
Mastectomy

Palpation  (-) palpable  (-) palpable

masses or lesion, masses or  Normal
tenderness lesion

Thorax Inspection  (+) symmetrical  (+)

and Lungs expansion with symmetrical  Normal
respiration expansion with
respiration
Palpation  (+) tactile
fremitus  (+) tactile  Normal
fremitus
Percussion  (+) resonant
sound  (+) resonant  Normal
sound
Auscultation  (+) Normal
vesicular  (+) Wheezing  Abnormal
breathing sounds sound due to
Asthma

Heart Auscultation  (+) regular  (+) regular  Normal

rhythm rhythm

 (-) Murmur  (-) Murmur  Normal

Upper Inspection  (-) redness  (-) redness  Normal
Extremitie
s  (-) swelling  (-) swelling  Normal

Palpation  Moist skin  Moist skin  Normal

 (-) lesion  (-) lesion  Normal
 (-) masses  (-) masses  Normal

Abdomen Inspection  (-) Scars  (-) Scars  Normal

 Flat  Flat  Normal

Auscultation  5-30 bowel  20 Bowel  Normal
sounds per Sounds20
minute bowel sounds
of clicks and
gurgles and
occasional
borborygmus
sounds
Percussion  (+) tympanite  Normal
 (+) tympanite
sounds sounds

 (-) tenderness,  (-) tenderness,  Normal

Palpation masses, lesions, masses, lesions,
swelling swelling

Lower Inspection  (-) lesions  (-) lesions  Normal

Extremitie
s  (-) redness  (-) redness  Normal

 (-) swelling  (-) swelling  Normal

 (-) discharge  (-) discharge  Normal

Inspection  Uniform  Uniform  Normal

Skin complexion complexion

 (-) odor  (-) odor  Normal

 (-) wound  (+) wound  Post-

(incision) operative
surgical
incision
 (-) masses,  (-) masses,
Palpation lesions lesions  Normal
 Inspection  Pinkish  Pinkish  Normal
Nails fingernails and fingernails and
toenails toenails
 Short and clean  Short and dirty  Normal
nails nails
 Normal
 (+) Convex  (+) Convex

 1-2 sec capillary  2 sec capillary  Normal

Palpation
refill time refill time

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

DATE OF INTERVIEW: March 27 ,2023

TIME OF INTERVIEW: 8:25 am

Days of Confinement: 5 Days

LOC: Conscious and coherent

FUNCTIONAL HEALTH BEFORE DURING HOSPITALIZATION

PATTERN HOSPITALIZATION
HEALTH PERCEPTION Patient mentioned that being
AND MANAGEMENT healthy is vital because you cant
perform any activity while you are
sick. Patient has a history of mild
Stroke with a maintenance of
Lozartan, and patient also had a
asthma but patient still patient can
perform normal daily activity. Patient
stated that she never take food
supplements or any vitamins but
every time she felt pain or sick she
would just take pain reliever from
over the counter medication . Her
husband is a heavy smoker before
and quit smoking 10 years ago, she
is an occasional drinker .Patient
don’t have any allergies.
NUTRITIONAL/ The patient states that she
METABOLIC PATTERN consumes 1 ½ cups of rice every
meal. Before she got hospitalized,
she had a good appetite and had no
problem swallowing food. She
Now that her mass on her left
breast is removed as well as her
breast, she felt relieved that the
mass was removed immediately as
soon as it is discovered. She also
mentioned that she needs to boost
her immune system by taking
vitamins because she can’t stand
the fact that she is staying in the
hospital. She added also that she
needs to stop drinking alcohol
Now that she is post operated, she
can eat the food she prefers to eat
but in appropriate amount and
nutrition because of her condition.
She stated too that she only
 drinks water at least 2 liters a day consumes 1 cup of rice and the
and she can drink a 1 bottle of sprite food given by the hospital and She
every. she stated too that she and can drink 2 liters of water
her family usually eat vegetables
and meat.

ELIMINATION PATTERN Before being hospitalized, she The patient can urine well with no
regularly defecates. Once or twice a
difficulty, she stated that she urines
day.
5-6 times a day with yellowish
Feces
color and no foul smelling
 Color: Not stated
 Texture: Not stated odor .Patient mentioned that two
days after her surgery she had her
She doesn’t have any difficulty in
defecating and urinating. bowel

Urine
 Color: Light Yellow
 Consistency: Clear
 Odor: usually unnoticed by
the patient
EXERCISE AND According to the patient, she Patients reported that she remains
ACTIVITY PATTERN
regularly finishes her daily routine. in bed for the majority of the time
She can stretch and exercise her But sometimes she walks around
body by doing household chores her room.
and taking care of her
grandchildren.
SLEEP/REST PATTERN The patient stated that she have at The patient claimed that she have
least 6 hours of sleep every day, a proper sleep and rest while in the
she goes to bed at 10 pm and wake hospital
up at 4 am in the morning
COGNITIVE The patient stated that she speaks The patient is delightful to be
PERCEPTION PATTERN
Tagalog, Ilocano, and Igorot around and responds to all of the
(kankana-ey), she has no hearing healthcare personnel' inquiries
problem but have a blurry vision, about her
and that she wear reading glasses
but grade is not stated by the
patient. She cooperates and
communicates efficiently.

SELF PERCEPTION AND Patient bathe once a day and The patient stated that she feels
SELF CONCEPT
shower in the afternoon, no history better and relief now that her mass
PATTERN
of plastic surgeries or semi- in her left breast is removed, even
permanent make-up, she stated that though her left breast is gone
she is proud to herself, she is proud
to her beauty since according to her
it is a gift given by the Almighty God.
ROLE RELATIONSHIP The patient stated that she gets The patient's had her
PATTERN
along well with her neighbors and husband to take care of her
family members specially to her
grandchildren. she’s a kind and
loving wife to her husband, the
patient also claimed that she always
participate in different kinds of
community activities.
SEXUALITY AND She had her first menstrual period at No sexual intercourse since
REPRODUCTIVE
the age of 16 and have a regular admission and no problem in
PATTERN
menstruation, she had IUD implant reproductive system is noted.
at 42 years old and menopause at
the age of 52 she otherwise had no
issues with her reproductive system.
She also remarked that she and her
husband no longer sexually active
because of their age
COPING AND STRESS If a patient has a difficulty or is She spends the most of her time
TOLERANCE PATTERN
stressed because of her worries, resting, lying down, and using her
she will just seek the guidance of phone to watch videos and also
the almighty father and she likes reading her bible
reading bible, or she will do some
fun stuff with her grandchildren, she
also communicate with her husband
that she had problems
VALUE-BELIEF The patient is a roman catholic and The patient stated that her faith is
PATTERN
she believes in any kinds of bigger than her problems,
“pamahiin” and ghost.
Anatomy and Physiology

Breast

The breast is an organ whose structure reflects its special function: the production of milk for
lactation. The epithelial component of the tissue consists of lobules, where milk is made, which
connect to ducts that lead out to the nipple. Most cancers of the breast arise from the cells which
form the lobules and terminal ducts. These lobules and ducts are spread throughout the background
fibrous tissue and adipose tissue that make up the majority of the breast. The male breast structure is
nearly identical to the female breast, except that the male breast tissue lacks the specialized lobules,
since there is no physiologic need for milk production by males.
Anatomically, the adult breast sits stop the pectoralis muscle which is stop the ribcage. The breast
tissue extends horizontally from the edge of the sternum out to the midaxillary line A tail of breast
tissue called the "axillary tail of Spence” extend into the underarm area. This is important because a
breast cancer can develop in this axillary tail, even though it might not seem to be located within the
actual breast.

The breast tissue is encircled by a thin layer of connective tissue called fascia. The deep layer of this
fascia sits immediately atop the pectoralis muscle, and the superficial layer sits just under the skin.
The skin covering the breast is similar to skin elsewhere on the body and has similar sweat glands,
hair follicles, and other features. A clinician will examine the skin in addition to the breast tissue itself
when performing a breast exam.

Blood Supply & Lymph Nodes

The blood supply from the breast comes primarily from the internal mammary artery, which
runs underneath the main breast tissue. The blood supply provides nutrients, such as oxygen, to the
breast tissue. The lymphatic vessels of the breast flow in the opposite direction of the blood supply
and drain into lymph nodes. It is through these lymphatic vessels that breast cancers metastasize or
spread to lymph nodes. Most lymphatic vessels flow to the axillary lymph nodes, while a smaller
number of lymphatic vessels flow to internal mammary lymph nodes located deep to the breast.
Knowledge of this lymphatic drainage is important, because when a breast cancer metastasizes, it
usually involves the first lymph node in the chain of lymph nodes. This is called the "sentinel lymph
node,” and a surgeon may remove this lymph node to check for metastases in a patient with breast
cancer.
Course in the Ward

Date and Time Doctor’s Order Rationale

March 22, 2023  Please admit patient  For proper monitoring and
(12 PM) management evaluation
 Secure consent form  Ethical consideration for the
for admission patient in making decisions for
their health care.
 DAT  For patient’s ability to eat and
tolerate food
 IVF; TF  To follow

Laboratory:
 CBC with BT  To check the adequacy of
blood components
 UA  To check urinary abnormalities

 PT  To monitor the prothrombin

level
 CREA
 To check kidney function
 SGPT
 To assess liver function
 Na
 To monitor condition that affect
the balance of fluid and
electrolytes
 K
 To measure how much
potassium is in your blood
  BUN  To check if there is kidney
disease
 Lipid Profile  To assess total cholesterol
level
 FBS  To measure the patient’s blood
sugar after an NPO
 12 L ECG  To check the electrical
conductivity of the heart
 CXR x PA
 To visualize lungs and the size
of the heart
 Meds TF
 Monitor VS q4 and  For baseline data and
comparison
record
 Monitor I & O q shift
 For monitoring of fluid status
and record
 Refer
 For collaborative management
March 23, 2023  Refer to IM for MRA
10:30 AM  For MRM, left
tomorrow
 Conscious,  Secure consent for  For legal purposes

coherent, NICRD procedure

 (-) SOB  OR notif c/o SRIC
 (-) Chest pain  Inform AROD & OR
Staff
 Normal VS  NPO Post Midnight
 For maintenance to prevent
 IVF D5LRS 1L q8 hypoglycemia
once on NPO  Treatment for Infection
 Cefoxitin 2g/IV 1-2
hours prior to OR
 Omeprazole  Used to inhibit the

40mg/IV OD once production of acid in the

on NPO stomach

March 23, 2023 Pre-Op Anesthesia Order

11:20 AM  Pt. was seen and  To ensure the patient
examined, Hx and progress and need to
1. Invasive Ductal PF reviewed undergo surgery
Carcinoma  For OR tomorrow
P> MRM, Left  Secure consent for  For legal purposes and
Vital Signs anesthesia ensure that the patient
BP: 130/80 mmHg understand the nature or
PR: 89 bpm treatment.
RR: 20 cpm  Risk and technique  For the patient and SO
 Temp: 36.7 C explained and understand the case and
SPO2: 99 understand by Pt. acceptance of medical
and S.O. services to rendered
 NPO for 8 hours  To prevent aspiration prior
prior OR to surgery
 IVF: D5LRS 1L q8  For maintenance to prevent
once NPO hypoglycemia
Medication:
 Used to inhibit the
 Omeprazole
production of acid in the
40mg/IV OD Once
stomach
NPO
 To prevent post operative
 Ondansetron nausea and vomiting
4mg/IV 30 mins
prior OR
 Losartan 50mg/tab,
 For Hypertension
1 tab per orem at 4
am with sips of
water
 Follow up MRA,
relay once available
 Secure 1unit PRBC  To treat blood loss prior to
properly typed and surgery
crossmatched for
OR use
 Refer Accordingly  For collaborative
management

March 23, 2023 MRA

3:43 PM  Patient is stratified
as intermediate risk
in developing intra
OP & post OP
Cardio pulmonary
complications
 RCRI Class II Risk
with 6 % 30 days,
risk of death MI or
Cardiac Arrest
 Please see attached
MRA form for
recommendation  For collaborative

 refer management
March 24, 2023  For MRM Left today
9:30 AM  Still to NPO
 Refer  For collaborative management

March 24, 2023 Post Op Anesthesia Order

3:55 PM  To PACU
 O2 at 2-3 LPM/NC  to facilitate oxygenation
 S/P MRM, Left  Monitor VS q15mins  for baseline data and to detect
Under GA- x 2 hours then q1 abnormalities after the
Inhalation LMA thereafter operation

 Low salt, Low fat  for nutritional purposes

VS: diet once full awake
PB: 140/90  IVF: To consume
PR: 80 bpm D5LRS 900 ml x q8
RR: 20 cpm  continuation of maintenance to
 PNSS 1L x 12
sPo2: 99% prevent hypoglycemia
Medications:
 for IV access for medication
 Paracetamol 1g IV
q6 x 4 doses
 for pain management
 Ketorolac 30mg IV
q8 x 3 doses ANST  for pain management
 Tramadol 50mg
SIVP q8 PRN for
 for pain management
breakthrough Pain
 Continue other
medication
 Moderate high back
rest  to balance thermal inputs and
 Keep patient thermal losses so as to
thermoregulated maintain its core temperature
nearly constant
 to monitor fluid status
 I & O q shift and
record  to prevent further
 WOF untoward s/sx complications
 for collaborative management
 refer
March 24, 2023  DAT one fully awake  Patient’s ability to eat and
4:00 PM tolerate food
 Secure specimen for
GS histopath
S/P MRM (L)  Maintain pressure  To protect the surgical incision
OR Tech Consulted dressing and control bleeding
Histopath form done  Monitor JP Drain output
 cc/cc q shift and record
 Continue cefoxitin 1g IV
q8
 Avoid left Arm
Abduction
 For collaborative management
 Refer
March 25, 2023  DAT  Patient’s ability to eat and
8:30 AM tolerate food
 IVF: PNSS 1L x 12  For IV access for medication
Awake, NICRD hours
Afebrile  Continue Meds
 To promote healing and to
 Daily wound care-
prevent infection
pressure dressing
March 26, 2023  MGH  Patient’s may go home
11:00 AM  Daily wound care
with pressure
(-) Fever, (-) DOB, (-) dressing
Chest Pain  Maintain JP Drain,
(+) Day operation wound monitor and record
(-) Discharge cc/cc
JP Drain 10cc Take Home Medications:
 Inhibits synthesis of bacterial
 Cefuroxime
cell wall causing cell death
Stable VS 500mg/tab BID for 7
days
 To relieve pain
 Celecoxib
200mg/tab BID PRN
for pain
 TCB on March 31,
2023 OPD Surgery
or anytime if with
untoward s/sx
LABORATORIES AND DIAGNOSTICS

Patient Name: Patient PIA (HEMATOLOGY)

Age: 60 Sex: Female

Study Date: March 22, 2023 Time: 1:03 PM

LABORATORY RESULTS INTERPRETATIONS

Patient Normal Value

Reading

White blood cells 10.28 10^9/L 4.00-10.00 The number of white blood cells
in your body goes up when
you’re sick and your body is
trying to fight off what’s
attacking it.

Neutrophils % 64.0% 50.0-70.0 Normal

Lymphocytes % 25.5% 20.0-40.0 Normal

Monocytes % 6.3% 3.0-12.0 Normal

Eosinophil % 3.7% 0.5-5.0 Normal

Basophils % 0.5% 0.0-1.0 Normal

 RBC 4.60 10^12/L 3.50-5.50 Normal

Hemoglobin 13.8 g/dL 11.0-15.0 Normal

Hematocrit 43.1 % 37.0-47.0 Normal

MCV 93. 7 fL 80.0-100.0 Normal

MCH 30.0 pg 27.0-34.0 Normal

MCHC 32.0 g/dL 32.0-36.0 Normal

Platelet  289 10^9/L 150-450 Normal

RDW-CV 12.9 % 11.0-16.0 Normal

RDW-SD 44.9 fL 35.0-56.0 Normal

MPV 9.3 fL 6.5-12.0 Normal

PDW 15.9 15.0-17.0 Normal

PCT 0.270% 0.108-0.282 Normal

(Procalcitonin)

NRBC% 0.00% 0.00-9999.99 Normal

RESULTS
 INTERPRETATIONS
PATIENT RANGES
READING
Potassium 4.04 3.50-5.10 Normal
Sodium 140.0 135.0-145.0 Normal
Creatinine 42.7 46.0-92.0 Low creatinine levels can mean
you have chronic kidney
disease or serious kidney
damage. Kidney damage can be
from condition such as a life-
threatening infection, cancer, or
urinary tract blockage.
Urea Nitrogen 9.7 7.0-17.0 Normal
AST 55 14-36 AST and ALT were both

ALT 47 0-35 increased in patient with chronic

diseases.

March 23, 2023

5:22

RESULTS
INTERPRETATIONS
PATIENT RANGES
READING
Triglycerides 2.17 0.70- 1.70 Being physically inactive, eating
foods that are high in fat and
sugar, or drinking too much
alcohol may increase blood
triglycerides. Some medicines
use to treat breast cancer and
other conditions may also raise
blood triglyceride levels.
VLDL 0.99 0.00-0.30 High levels of VLDL and
triglycerides in your blood may
mean you are at risk for CVD.
Cholesterol 5.31 3.90-6.20 Normal
Direct HDLC 1.47 1.03-1.80 Normal
LDL 2.85 0.00-3.90 Normal

Urinalysis Report
March 22, 2023

1:41 pm

Particle Category p/HPF Ref. Modified

(p/HPF)
RBC 0-2 1.29 0..2 No
WBC 0-2 <0.68 0..2 No
EPITHELIAL RARE <1.14 0..2 No
CELLS
YEAST NEGATIVE 0 0..1 No
BACTERIA FEW 17.46 0..1 Few Bacteria means that you
have a urinary tract infection or
bladder infection
MUCUS RARE 0.96 0..1 No

Analyte Result Note Interpretation

COLOR Yellow
CLARITY Clear
SPECIFIC GRAVITY 1.011
pH 6.0
UROBILINOGEN 0.2 E.U./dL NEGATIVE
GLUCOSE Negative
BILIRUBIN Negative
KETONES Negative
BLOOD Trace Blood in your urine
may be a symptom
of a serious health
problem, including
cancer
PROTEIN Negative
NITRITE Negative
LEUKOCYTE Trace High leukocyte
levels in the urine
may indicate a
urinary tract
infection or other
underlying
inflammatory
medical problems.
ALBUMIN 30 mg/L POSITIVE A moderate
amount of albumin
 could mean early
stages of kidney
disease

ULTRASOUND REPORT

Name: Mrs. V
Age: 60 y/o
Sex: F
Examination Requested: Sono mammogram
Requesting Physician: Dr. Christine Anne Saac
Date: February 16, 2023

An irregularly-shaped hypoechoic nodule with speculation and microcalcifications measuring 2.39 x

1.79 x 1.50 cm. is noted along the 2-3 o’clock inner zone of the left breast.

There is no visible focal lesion in the right breast.

No ductal ectasia demonstrated.

No axillary lymphadenopathy or mass.

Bilateral retromammary areas are unremarkable.

COMMENT:

LEFT BREAST NODULE WITH FEATURES HIGHLY SUGGESTIVE OF MALIGNANCY.

RECOMMEND

IMMEDIATE BIOPSY.

HISTOPATHOLOGY REPORT

Post-operative Diagnosis: Left Breast Mass, t/c Malignancy

Operation Performed: Core Needle Biopsy, left Breast Mass

Specimen: Breast Mass Core Tissues

Date Received: Feb 22, 2023

Date Reported: March 9, 2023

HISTOPATHOLOGIC DIAGNOSIS:
 CONSISTENT WITH AN INVASIVE CARCINOMA OF NO SPECIAL TYPE

Remarks: Evaluation is limited by the small focus of atypical cells seen in the submitted
specimen. Dr. Arlene L. Quitasol, FPSP concurs with the diagnosis 

GROSS DESCRIPTION: 

The specimen consists of several elongated fibro-fatty fragments measuring from 0.3 x 0.2 x
0.2 cm to 1.5 x 0.2 x 0.2 cm.

The entire specimen is taken for study-2 blocks.

MICROSCOPIC DESCRIPTION:

Sections show tissue cores with scant infiltrating neoplastic cells exhibiting enlarged,
hyperchromatic, and pleomorphic nuclei surrounded by scant to ample eosinophilic cytoplasm.

X-RAY RESULT

March 9, 2023 March 22, 2023

Clinical data: Invasive carcinoma of special Suspicious opacities are seen in the right lung
type, left breast apex.
CHEST: The heart is not enlarged. Calcific densities line
Both lungs are normoaerated. the aortic knob.
No active lung opacities. The trachea is midline.
Heart is not enlarged. The costophrenic angles and hemidiaphragms
Pulmonary vascular markings are within normal. are intact.
Both hemi diaphragms and costophrenic sulci The osseous and soft tissue structures are
are intact. unremarkable.
Rest of the visualized osseous and soft tissue
structures are unremarkable. IMPRESSION:
IMPRESSION: Atherosclerotic aorta.
NORMAL CARDIOPULMONARY FINDINGS
Remarks: An apicolordotic view is suggested for
further evaluation.
 NURSING CARE PLAN

NURSING CARE PLAN: PRIORITY 1

NAME: PATIENT PIA
DATE OF ASSESMENT: March 27,2023
TIME: 8:00 AM

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: Acute pain related to Within 1 hour of nursing Independent: After 1 hour of nursing
“medyo sumasakit pa Modified radical intervention clients pain  Acknowledged  Promotes trust intervention clients pain
and cooperation
din yung operasyon ko mastectomy on the left scale is reduced to 2/10 the pain to regimen scale was reduced to
kaya nahihirapan akong breast experience and 2/10
igalaw itong kaliwang convey
braso ko” acceptance of
as verbalized by the client’s response
patient to pain
Pain scale: 4/10  Assessed non-  Useful in
evaluating pain,
verbal/verbal choice of
Objective: reports of pain, intervention and
effectiveness of
-grimacing noted noting location, therapy
-Tenderness on the intensity
incision surrounding  Helps refocuses
 Encouraged client
attention and assist
-Skin discoloration is to use relaxation client to manage pain
more effectively
noted (purple) technique such as
-JP drain is seen with focused breathing
drainage characterized or distraction
of bright red fluid activities like
Vital sign: watching or
RR:23 socialization  To prevent fatigue

 Encouraged that can impair

adequate rest ability to manage

periods or cope with pain

Dependent:  to maintain

 Administered acceptable level

analgesics such of pain, reduces

as ketorolac, pain and

celecoxib, discomfort,

tramadol as enhances rest

indicated to
maximum dosage
NURSING CARE PLAN: PRIORITY 2
NAME: PATIENT PIA
DATE OF ASSESMENT: March 27,2023
TIME: 8:00 AM
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
Subjective: Impaired skin integrity Within 2 hours of nursing Independent:  To clarify After 2 hours of nursing
 Determine client’s intervention
“anlaki ng tahi ko sa related to post surgery intervention the patient intervention the patient
level of discomfort needs and
dibdib ko “ will demonstrate priorities will demonstrate
 Handle client  Skin of older is
As verbalized by the understanding of self- understanding of self-
gently also thin, less
patient care activities elastic and prone care activities
to injury such as
skin tears
Objective:  Instructed patient  To reduce of
to have good skin dermal trauma
 dry incision is hygiene (shower and promote
seen instead of bath, comfort
washing
 hematoma is thoroughly using
noted mild nondetergent
and drying it
 disruption of skin gently
surface  Encourage early  promotes
ambulation or circulation and
 destruction of the mobilization reduces risk
skin layer associated with
mobility
 Instruct patients  to provide a
to consume food positive nitrogen
rich in VIT A, C, balance to aid in
D, E and protein skin and tissue
 Instruct patient to healing
 to assist body’s
keep the surgical
 area clean and natural process of
dry, carefully repair
dress wounds

NURSING CARE PLAN: PRIORITY 3

NAME: PATIENT PIA
DATE OF ASSESMENT: March 27,2023
TIME: 8:00 AM
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
Subjective: Impaired Physical After 2 hours of nursing Independent: Within 2 hours of nursing
“hindi ako masyadong mobility related to intervention, the client  Establish rapport intervention, the client
 To gain trust and
gumagalaw kasi masakit discomfort as evidenced will be able to verbalize cooperation of was able to verbalize
patient
yung operasyon ko at di by limited range of understanding of understanding of
ko den maiflex itong motion, slowed situation and individual  Evaluate for  To determine if situation and individual
presence and pain management
kaliwang balikat ko” as movement ,reluctance to treatment regimen and can improve treatment regimen and
verbalized by the patient attempt movement and safety measures degree of pain, mobility safety measures
difficulty in flexing left independently listening to independently
Objective: arm client’s
 Limited range of description about
motion manner in which
 Slowed pain limits
movement mobility
 Reluctance to  Instruct patient to  To prevent risk
associated with
attempt have client immobility
movement reposition self on
 Difficulty in flexing regular schedule
 To reduce
left arm  Encourage
pressure on
regular skin sensitive areas
and prevent
examination and
development of
care problem in skin
integrity
  To help ease the
 Encourage pain and
numbness
patient to move
the affected part
from time to time
 Promotes well-
 Encourage being and
adequate intake maximize energy
production
of nutritious foods
and fluids  Multiple options
provide clients
 Discussed safe choices and
ways that can variety

exercise

Dependent:  To relieve mild or

 Administered moderate pain
analgesic
medication as
prescribe by the
physician

NURSING CARE PLAN: PRIORITY 4

NAME: PATIENT PIA
DATE OF ASSESMENT: March 27,2023
TIME: 8:00 AM
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
Objective: Risk for surgical site Within 1 hour of nursing Independent:  To gain trust and After 1 hour of nursing
 establish patient’s cooperation of the
Swelling over the infection intervention, the patient intervention client
rapport patient
incision area will be able to identify  Promote proper  To avoid cross understand the
handwashing contamination
and demonstrate importance of
techniques before
interventions to prevent and after touching interventions to prevent
the incision
or reduce risk of infection.
region, and
infection advise the patient
to sanitize or
wash her hands
before and after
touching the
incision area.  prevention for
 Instructed patient infection
on proper wound
care and instruct
patient to use
clean or sterile
pad for coverings  wound infection
 Inspect the are accompanied
wound for by signs of
swelling, unusual inflammation and
drainage, odor, delay in healing
redness or
separation of the
suture lines and
instructed patient
to report it
immediately if any
of these sign is
 noted
 to prevent
Dependent:
infection
 Take antibiotics
as prescribed by
a physician,
instructed to take
medicines on time

DRUG STUDY
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Inhibits cell-wall synthesis Indication:  Nausea Before:
Cefoxitin promoting osmotic instability Perioperative prophylaxis. Tell patient to report adverse
 Vomiting
usually bactericidal. Treatment for infection. reactions promptly.
Brand Names:  Diarrhea
Mefoxin
 Swelling
Classification: Contraindication:  Redness During:
Antibiotics Contraindicated in patients Instruct patient to report
 Pain or soreness at the discomfort at IV site.
hypersensitive to drug or
Dosage: injection site may occur
2g other cephalosporins.

Route: After:
Intravenous Advice patient to report loose
stools or diarrhea.
Frequency:
1-2 hours

Timing:
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: May block 5-HT3 in the Indication:  Headaches Before:
Ondansetron chemoreceptor trigger zone To prevent postoperative Advice the patient to report
 Fatigue
and in the peripheral nervous nausea and vomiting. hypersensitivity reaction.
Brand Names: system on nerve terminals of  dry mouth
Zuplenz the vagus nerve.
 malaise
Classification: Contraindication:  constipation During:
Antiemetics Contraindicated in patients Instruct patient to report
hypersensitive to drug.  weakness discomfort at IV site.
Dosage:  drowsiness
4 mg

Route: After:
Intravenous Instruct patient to immediately
report difficulty of breathing
Frequency:
30 minutes after drug administration.

Timing:
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Inhibits proton pump activity Indication: CNS: Before:
Omeprazole Used to inhibit the production Assess for possible
by binding to hydrogen-  Dizziness
contraindications and
Brand Names: of acid in the stomach
potassium adenosine  Drowsiness cautions: history of allergy to a
Prilosec proton pump inhibitor to
triphosphatase, located at  Fatigue
reduce the risk of
Classification: secretory surface of gastric  Headache hypersensitivity reaction
Antiulcer drugs Contraindication:
parietal cells, to suppress Contraindicated in patients  Weakness
Dosage: gastric acid secretion. hypersensitive to drug or its
40 mg During:
components and in patients CV: Instruct patient to report
Route:  chest pain discomfort at IV site.
Intravenous receiving rilpivirine containing
products
Frequency: GI:
OD
 abdominal pain After:
 acid regurgitation Tell patient to report all
hypersensitivity reaction.
 Constipation
 Diarrhea
 Flatulence
 Nausea and vomiting
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Unknown. Thought to bind to Indication:  sleepiness. Before:
Tramadol for pain management Instruct patient to immediately
opioid receptors and inhibits  headache.
report hypersensitivity
Brand Names: reuptake of norepinephrine  nervousness. reaction.
Ultram
and serotonin.  uncontrollable shaking
Contraindication:
Classification: Contraindicated in patients of a part of the body. During:
Analgesics Assess patient’s level of pain
hypersensitive to drug or  muscle tightness. at least 30 minutes after
Dosage: opioids.  changes in mood. administration.
50 mg
 heartburn or
Route: indigestion. After:
Intravenous Discontinue drug and notify
 dry mouth.
physician if sign and
Frequency:
Q8 symptoms of hypersensitivity
occur
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Inhibits vasoconstrictive and Indication:  chest pain Before:
Losartan aldosterone secreting action For hypertension Tell patient to avoid salt
 diarrhea
on angiotensin II by blocking substitutes.
Brand Names: angiotensin II receptor on the  fatigue
Cozaar surface of vascular smooth
Contraindication:  hypoglycemia During:
muscle and other tissue cells.
Classification: Contraindicated in patients  headache Advise patient to report all
Antihypertensives hypersensitive to drug.  fainting hypersensitivity reaction.
 dizziness
Dosage:
50 mg After:
Monitor patient response to
Route: therapy through blood
Oral pressure monitoring.

Frequency:
4 am
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Thought to produce Indication:  Nausea Before:
Paracetamol analgesics by inhibiting for pain management. Assess the patient’s pain level
 Vomiting
prostaglandin and other before administering the
Brand Names: substances that sensitive pain  Constipation medication.
receptors. Contraindication:
Classification:  Pruritus
Contraindicated in patients
Analgesics  abdominal pain During:
hypersensitive to drug. Tell patient to report all
Dosage: hypersensitivity reaction.
1g

Route: After:
Intravenous Monitor the patient’s response

Frequency: to the medication.

Q6
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: May inhibits prostaglandin Indication:  Nausea Before:
Ketorolac synthesis to produce anti- for pain management. Advise patient to maintain
 stomach pain
inflammatory, analgesic, and adequate fluid intake.
Brand Names: antipyretic effects.  indigestion
Acular
 diarrhea During:
Contraindication:
Classification: Hypersensitivity to ketorolac,  dizziness Monitor injection site for pain,
Nonsteroidal anti- swelling, and irritation.
inflammatory (NSAID) aspirin, or other NSAIDs.  drowsiness
 headache After:
Dosage: Tell patient to report all
30 mg  swelling. hypersensitivity reaction.

Route:
Intravenous

Frequency:
Q8
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: Inhibits cell-wall synthesis Indication: GV: Before:
Cefuroxime promoting osmotic instability to treat a wide variety of Tell patient to take drug as
 Phlebitis
usually bactericidal. bacterial infections. prescribed, even if feeling
Brand Names:  Thrombophlebitis better.
Zinacef

Classification: Contraindication: Skin: During:

Antibiotics Contraindicated in patients Instruct patient to swallow
 Rash
hypersensitive to drug or tablets whole; do not crush
Dosage:  Temperature them. Take the drug with food.
500 mg other cephalosporins.
elevation
Route:  Urticaria After:
Oral Asses patient for
hypersensitivity reaction.
Frequency: GI:
BID
 Diarrhea
 Nausea
 Vomiting
 Anorexia
 Stomach pain
 Dizziness/drowsiness
 DRUG NAME MECHANISM OF ACTION INDICATION AND ADVERSE REACTION NURSING
CONTRAINDICATION RESPONSIBILITIES
Generic Name: May inhibits prostaglandin Indication: CNS: Before:
Celecoxib synthesis to produce anti- To relieve pain Tell patient to report history of
 Headache
inflammatory, analgesic, and allergic reactions to
Brand Names: antipyretic effects.  Dizziness sulfonamides, aspirins, or
Contraindication:
Celebrex other NSAIDs before therapy.
Contraindicated in patients  Insomnia
Classification: hypersensitive to drug or
Nonsteroidal anti-
other cephalosporins. CV: During:
inflammatory (NSAID)
 HTN Instruct patient to take drug
Dosage: with food if stomach upset
200 mg  Peripheral Edema occurs.
EENT:
Route:
Oral  Rhinitis After:
 Sinusitis Advice the patient to
Frequency: immediately report
BID GI: hypersensitivity reaction.
 Abdominal Pain
 GI Reflux
 Nausea
Musculoskeletal:
 Back Pain
 DISCHARGE PLAN

MEDICINE  Instructed the patient to continue medication at home at the proper dose, time, frequency, and route.
 Take home medication as follows;
 Cefuroxime to treat infections caused by bacteria.
 Celecoxib for an anti-inflammatory drug.
 Educated the client and the SO about the medication’s name, why it is important, what it treats, and the needed doses.
 Provided verbal and written advice on how to take home medications.
 Advised the SO and client to put medication in a container, and label them on how and when to take it to avoid medication
errors.
 Discussed with the patient and SO the side effects of the drugs for the patient to be prepared and thus be able to cope.
 When it comes to medication safety, advise the patient and SO to keep it in direct sunlight.
ENVIRONMENT AND EXERCISE  Instructed the client to have a walk every morning, but not get too tired
 Instructed the client that housework isn't advised until the JP drain is removed
 Educate the patient to lessen exercises or exaggerated movements.
 Advised the patient to avoid strenuous activity, heavy lifting, and vigorous exercise until the stitches are removed.
 Advised patient to maintain a quiet, clean, comfortable and stress free environment to promote relaxation and prevent any
build-up of disease or infection that could affect the incision.
TREATMENT  Aside from educating the patient on properly taking medicines, she must also engage in a range of motion.
 Encourage the patient to take multivitamins to enhance her immunity
 Teach the patient about proper wound care with a pressure dressing.
 Taught the patient about Jackson-Patt (JP) drain, on how to empty the drain two to three times per day or when the bulb is
full. Instructed the SO and the patient to write down the amount drained.
 Advised patient on how to prevent getting breast mass and proper massage on the breast to lessen the chance of getting
the mass again.
 Advised to apply ice on incision for 15 to 20 minutes every hour or as directed. Cover it with a towel. This helps prevent
tissue damage and decreases swelling and pain.
 Advised to elevate arm nearest to incision above the level of heart. This will help decrease swelling and pain
  Instructed patient to always maintain a good personal hygiene
 Instructed the patient to wash or sanitize hand before and after touching the incision site
 Educated patient to clean the area surrounding the incision so that infection won’t develop
 Advised patient not to wear any tight clothes that may cause irritation on the incision site.
 Check for signs of infection each day (redness, swelling, and drainage). Also watch the edges of the incision to be sure it's
not opening up.
 Empty your drain as directed
 Instructed patient not to sleep on her stomach as it will put too much pressure on your incision. Sleep on back or on the
opposite side of incision.
 Elevate arm nearest to incision above the level of heart. This will help decrease swelling and pain

HYGIENE  Instructed to check the incisions daily for signs of infection. These include redness, swelling, and drainage. Also, watch the
edges of the incision to be sure it's not opening up.
 Advise patient to keep her nails short
 Instructed patient to always maintain a good personal hygiene
 Wash or sanitize hand before and after touching the incision site
 Educated patient to clean the area surrounding the incision so that infection won’t develop
OUTPATIENT- FOLLOW UP  The patient was instructed to return to the hospital on March 31, 2023, for a follow-up examination to monitor the healing
process and determine whether there have been any additional postoperative issues.
 Advised patient to return to the hospital anytime if untoward signs & symptoms occur.
 Instructed to seek medical attention right away when experiencing any issue or difficulties
DIET  Advised the patient to drink at least 8 glasses of water daily.
 Instruct patients to never skip meals.
 Instructed the patient to eat more plant-based protein and eat less animal-based protein
 Instructed to decrease food additives like artificial flavors
 Advised patient to eat vegetables like broccoli, cauliflower, kale, and cabbage, these are antioxidants that may help offset
the toxins and carcinogens.
 Also advised to have more protein-rich foods like lean cuts of meat, fish, eggs, nuts, seeds, and beans, also include
healthy fats such as avocado or unsalted peanut butter.
  Eat whole, nutrient-dense foods like fruits and vegetables, whole grains (chicken, salmon, and plant-based proteins
sources like lentils)
 Foods high in healthy fats and protein (nuts and seeds, avocados, olive oil, eggs, fish)
 Eat high fiber foods (flax seeds, legumes, vegetables and fruits)
 Consume fewer process food and other high sodium items.
SPIRITUAL AND SEXUAL  Encouraged to keep seeking God's guidance and understanding.
TEACHING  Emphasized the significance of prayer in healing
 Encouraged to seek heavenly assistance in all situations
 Encouraged to maintain a cheerful attitude in life.
 Encouraged to pursue interests and hobbies for enjoyment in the future as an alternative to sexual desire