Breast cancer

Prepared by:Bien, Lanilyn E.

 Breast cancer
is a disease in which cells in the breast grow out of control. There are
different kinds of breast cancer. The kind of breast cancer depends on
which cells in the breast turn into cancer.
Breast cancer can begin in different parts of the breast. A breast is made
up of three main parts: lobules, ducts, and connective tissue. The lobules
are the glands that produce milk. The ducts are tubes that carry milk to
the nipple. The connective tissue (which consists of fibrous and fatty
tissue) surrounds and holds everything together. Most breast cancers
begin in the ducts or lobules.
Breast cancer can spread outside the breast through blood vessels and
lymph vessels. When breast cancer spreads to other parts of the body, it is
said to have metastasized..
Breast cancer is the second leading cause of cancer death in women (only
lung cancer kills more women each year). The chance that a woman will
die from breast cancer is about 1 in 38 (about 2.6%).
Substantial support for breast cancer awareness and research funding has
helped created advances in the diagnosis and treatment of breast cancer.
Breast cancer survival rates have increased, and the number of deaths
associated with this disease is steadily declining, largely due to factors such
as earlier detection, a new personalized approach to treatment and a
better understanding of the disease
Death rates from female breast cancer dropped 40% from 1989 to 2016.
Since 2007, breast cancer death rates have been steady in women younger
than 50, but have continued to decrease in older women(cancer.org).
These decreases are believed to be the result of finding breast cancer
earlier through screening and increased awareness, as well as better
treatments.The American Cancer Society's estimates for breast cancer in
the United States for 2019 are: About 268,600 new cases of invasive breast
cancer will be diagnosed in women. About 62,930 new cases of carcinoma
in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form
of breast cancer).About 41,760 women will die from breast cancer.
Purpose and Objective
General Objective:
 This aims to present the overall overview of the Breast cancer
complication and understand the nursing implication of the
disease in our patient.
Specific Objective:
Students:
 1. To enhance the knowledge and understand of the
pathophysiology and etiology of the breast cancer.
 2 To know and provide the different nursing interventions
appropriate for the breast cancer.
 3. To analyze and assess the gathered data why the complication of
breast cancer occur.
 Patient:
 1. To educate the patient about the present breast cancer
complication.
 2. To provide some relevant information to the patient about the
breast cancer.
 3. To give the immediate intervention required for breast cancer.
Scope and Limitations
The patient was admitted on August 14,2019 at Mandaluyong City
Medical Center. The Emergency room was located at the 1st floor.It
has at least 6 bed capacity in medical-surgical emergency
department.There are also patients located at the front door whose
under observations patients.The patient E.B,a 60y/o, female who is
a non-smoker, She had a one daughter and two sons. The patient
have a difficulty of breathing and unable to sit properly because of
she was complaining of abdominal pain and a little shortness of
breath and I gathered and collected the required data through the
physical assessment with the methods of inspection and palpation
and also conducted an interview to the patient but I was not able to
interviewed the patient thoroughly because she was in pain
frequently.The patient and her chart alone was the basis of my
information and I used it as my primary source of data. For the
limitations of my study, I only handled the patient for only one day
during our clinical duty in the hospital. The number of days of
interaction with my patient limits the gather of information for my
evaluation of her disease and other complication that present with
her and it was difficult to check all of my physical examination
because the patient was in pain that time and a strict bed rest was
also ordered and the patient was having a difficulty of breathing and
unable to move herself from getting up in bed.
Nursing Health History
1. Biographic Data
 The patient E.B,a 60 years old female, who lives in Brgy.Addition
Hills,Blk.27 487 Welfareville ,Mandaluyong City, she is already a
widow.Her religion is Roman Catholic. She has a Philhealth card as
support for her health care financing during the time of illness and she
had also one sister who was an employee in the city hall who was able
to support her finances and two of her son who was living with her
were also giving her money too.
2. Chief Complaint
 Difficulty of breathing;severe dyspnea
 “Nahirapan akong huminga masyado kaya nagpadala na ako sa ospital”
as verbalized by the patient.
3. Medical Diagnosis
 Admitting Diagnosis:DOB and Bilateral lower leg edema
4. History of Present Illness
 On August 14,she was having a difficulty of breathing, the patient
with her son went to the hospital to check her condition and the doctor
told them to admit the patient because she was having a hard time in
breathing and was representing an edema .Then the doctor ordered
them to have a chest X-ray to check for any abnormalities in the body
and Complete blood glucose monitoring every eight hours.The
patient’s admitting diagnosis was difficulty of breathing and bilateral
lower leg edema.The patient vital signs BP: 110/70 mmHg, PR: 81
bpm, RR: 17 breaths/min and T: 36.0 C and Oxygen sat-97%. A chest
x-ray result shows that it is consider pneumonia bilateral with probable
pleural effusion on her right lung and hazy opacities are seen in both
lower lobes,Aorta is tortous.The patient was ordered to have a
cefuroxime antibiotic medication to treat bacterial infections ,patient
was also using nasal prong for her breathing,furosemide to correct
balance of her water sodium and tramadol for pain relief .
5. Past Medical History
 The patient had recently admitted in the hospital last August
14 because she was having a difficulty of breathing of at least a
week so her son also noticed that she was having a difficulty of
breathing and that was the time they decided to go in the hospital.
Last 2016 the patient had underwent a mastectomy surgery on her
right breast. The patient has no allergies to any food and drugs,
animal bites.The patient used self-medication to treat her
common illnesses such as fever, headache, backache and cough.
6. Socio Economic
 The patient is a widow. They are currently living in
Mandaluyong City with her two sons. She was born May 14 1959.
Her one son used to give finances for their daily living and when
she was not able to work she also said that her sister was also
giving her finance support.Before she was working on that
hospital and she is a utility personnel for six years and was stop
from the time she was undergone surgery in 2016.The patient
doesn’t join in any physical activities or organizations in their
community. The patient was on her room watching television as
her hobby and every Friday she goes to church to pray and visit
her daughter who was living near in Quiapo.
 7. Family Health History
F M

64

Legend: Male-
Female-
28 30 32
Sister-

Patient-

Daughter-
son-
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
HEALTH “Nung August “Nahirapan ako The patient Some people
PERCEPTION / 14,nagpadala huminga at having some are able to
HEALTH na ako dito sa sobrang sakit ng difficulty of understand of
MANAGEMENT ospital dahil tyan ko”as eating because their health and
nahirapan ako verbalized by she has no illness but they
huminga ng the client appetite and are not aware of
isang linggo na due to her their health
at namamaga condition status they just
din kasi paa “mahina ako take for granted
ko”as kumain ngayon of their lifestyle.
verbalized by hindi ko alam sa Reference:
the client panlasa ko Fundamental of
“Hindi ako halos Nursing edition
nainom wala nakakaubos 8th page 285
akong bisyo” lang ako siguro
one fourth ng
“okay naman kanin”
pagkain ko
mahilig ako sa
matatabang
pagkain”
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
NUTRITIONAL/ “Bago ako “Hindi ko The patient able In nutritional
METABOLIC maospital okay maubos ang to follow to take habits there is
MANAGEMENT naman pagkain pagkain ko her medicine individual
ko halos gawa nga ng iba properly on lifestyle, the
nakakaisa at ang panlasa ko time.. goals that
kalahati akong atsaka madalas provide the
kanin minsan” sumasakit ang client impact of
tyan ko” their present
“Wala naman lifestyle and
akong problema basis of their
sa paglunok ng decisions
pagkain” related to
desired
behavior.
Reference:

Fundamental of
nursing 8th
edition page
284
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
ELIMINATION “wala naman “Ngayon The client was Promote bowel
PATTERN akong nakakadumi having a movement
problema sa naman ako kaya difficulty in emptying the
pagdudumi at lang minsan voiding bladder and had
pag-ihi ”as hirap sometimes. a regular
verbalized by ako”verbalized defacation and
the client by the client. provides proper
nutrition and
fluids intake
including fibers.
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
ACTIVITY- “Nasa bahay “dito nakahiga The patient is Regular
EXERCISE lang ako lagi lang ako dahil unable to walk physical activity
PATTERN napunta ako sa kalagayan ko to do some will promote
minsan sa anak nahirapan na exercise and healthy lifestyle
ko sa Quiapo nga ako”as other thing due based on health
minsa sa bahay verbalized by to her condition need individual.
ng ate ko sa the client and age. Reference:
Barangka”
Fundamental Of
Nursing Page
289
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
SLEEP-REST “nakakatulog “hirap ako the patient has The individual
PATTERN naman ako ng matulog dito difficulty to has a
maayos sa dahil nga sa sleep because physiologic
bahay”as sakit lalo na of the her need such as
verbalized by kagabi hindi ako situation. food , water, the
the client pinatulog sa oxygen and
sakit sobra”as carbon dioxide
verbalized by had enough
the client sleep, and they
had daily
activity.
Also people
involved
planning
become
educated about
the important of
sleep-rest.
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
COGNITIVE- “nakakarinig “dinadaing ko The patient has Refers to a
PERCEPTION- naman ako ng lang talaga yung proper person’s of
SELF- maayos at sakit ng tyan ko coordination general living
CONCEPT nakakakita pa ngayon” and able to including
PATTERN naman yung follow simple individual
mga mata ko”as instructions able patterns that are
verbalized by to hear and see influenced by
the client objects. sociocultural
factors and
personal
characteristics.
(page
168)Fundament
al of Nursing 8th
edition.
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
ROLE “Nasa bahay “yung anak The patient able The client
RELATIONSHIP lang ako kong bunso ang to interact with understand to
madalas sila tumitingin sakin some people fulfill their roles
lang tumitingin ngayon dito sa and has a good are healthy
sakin pag may ospital at relationship to even if they
kailangan kapalitan nya her sister have clinical
ako”as yung ate ko kasi including also illness.
verbalized by yung dalawa her relationship Reference:
the patient kong anak with her son. Fundamental of
nagtatrabaho” Nursing 8th
Edition (page
297)
“wala akong
kaibigan sa
amin dito lang
sa ospital yung
mga nakasama
ko dati ang mga
kaibigan ko”
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
SEXUALITY- “wala na asked the client The client does Sexual health
REPRODUCTIV matanda na at sexuality not have any includes,
E PATTERN wala na ako reproductive abnormalities on biologic,
asawa” as then she said, her sexual psychologic,
verbalized by “wala na akong health. sociocultural,
the client asawa wala and spiritual
naman akong components.
nararamdamang Sexual health is
masakit sa possible for ,any
maselang parte people who
ng katawan have health
ko”as verbalized problems and
by the client disabilities;
these are
aspects of
health and well-
being.

Fundamental of
Nursing, 5th ed;
p. 326
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
COPING AND “yung anak ko “yung anak ko The client has a Most people
STRESS nalang lang at minsan strong understand their
TOLERANCE nakakahalubilo yung mga personality and behavior and
ko saka yung nakatrabaho ko able to knows how to
ate ko” dito sila yung managed to her deal with stress
natingin sakin stress and or changes
kapag wala pa problems to imposed from
yung anak ko overcome either within or
“pag galit ako para difficulties of life. without. Page
galit hindi na magbantay” 435
ako naimik sa Fundamental of
kanila Nursing 8th
papalipasin ko edition’
lang tapos okay
na”
PATTERN BEFORE DURING INTERPRETATI IMPLICATION
HOSPITALIZATI HOSPITALIZATI ON FOR CARE
ON ON
VALUE-BELIEF “Nagsisimba “Hindi ako The client and The client
PATTERN ako tuwing nakakalimot sa her family are understand their
biyernes sa may kanya kaya lang religious relationship with
Quiapo church” nandito ako sa catholic and no the universe
ospital dahil sa special and their
lagay ko gabi- practices perception
gabi ako involves that about the
nagdarasal para can affect her direction and
gumaling na environment. meaning of life
ako”verbalized page 361
by the client Fundamental of
Nursing 8th
edition
2. Objective data
 MINI-MENTAL STATUS EXAMINATION
I. GENERAL APPEARANCE
II. LEVEL OF CONSCIOUSNESS

 Physical examination (head to toe assessment)

 Vital signs
 BP: 110/70
 PR: 85
 RR: 17
 TEMP: 36.0
 O2 sat: 99%
 HEIGHT: n/a
 WEIGHT: n/a
 BMI: n/a
 Area of Method of Normal findings Actual findings Analysis
examination examination

Appearance and
mental status

Inspection
Proportionate, varies with Proportionate, varies
Body build lifestyle
with lifestyle

Clean and neat

Inspection
Hygiene Relaxed, erect posture ,
not groomed Complete bed rest as by
coordinated movement
physician’s order
not done
Inspection
Gait
Level of
consciousness

Signs of distress Asking Alert and respond Alert and respond

Client’s attitude appropriately appropriately

Quantity of speech Healthy able to speak

Inspection/asking
appearance clearly

Cooperative Cooperative

Listening Understandable, Understandable,

moderate pace; moderate pace;
exhibits thought exhibits thought
association association
Skin Observation Varies from light to deep Pale in color
brown
Skin color
No abrasions or other Scar on her right chest
Skin lesions
Palpation/observation lesions and some
Palpation pigmentation on her
Moisture in skin folds lower extremities
Skin moisture
Palpation Moisture in skin folds
Skin temperature Uniform, within normal
Warm to touch in the
range
upper extremities and
cold to touch in the
Pinching skin on an
Skin turgor When pinched, skin lower extremities
extremities
springs back to previous
state
Edema Measuring
circumference with mm No edema Bilateral edema on lower
tape extremities
Hair Inspection Evenly Evenly distributed Normal The patient has
Evenness of distributed hair hair evenly
growth over the And normal hair
scalp growth

Thick hair Gray Thick hair

Hair thickness or Inspection
thinness

Hair texture and Silky resilient hair Oily, sticky hair

oiliness Inspection dirty but no
infestation
Infestation
No infestation Normal
Presence of
infestation Inspection Variable Variable

Amount of hair
Inspection
Nail Inspection Convex Convex Slightly pale, Prompt to return
Plate shape curvature; angle curvature; angle return to normal of pink or usual
curvature and of nail plate about of nail plate about when doing color in less than
angle 160 degree 160 degree capillary refill four seconds

Smooth texture Smooth texture

Finger and toenail Inspection
texture
Highly vascular Pale in color
Fingernail and and pink in light-
toenail bed color Inspection skinned client

Prompt return to
usual color
Slightly pale and
Blanch Test return the
capillary refill
Pressing nail
Skull and face Inspection Rounded Rounded Normal The patient has
(normocephalos (normocephalos normal size and
and symmetric and symmetric shape of skull and
with no frontal, with no frontal, face, no there is
parietal, and parietal, and nodule palpated
occipital occipital on the neck which
prominences) prominences) indicates body
smooth scull smooth scull initial defense to
contour contour infection.
Reference:
Fundamentals of
nursing 8th Edition
Smooth uniform Smooth uniform
Nodules or consistency; consistency;
masses Palpation absence of absence of
nodules and nodules and
masses masses

Symmetric or
symmetric facial
Facial features features; equal
Inspection sizes; symmetric
nasolabial folds

Symmetric facial
movements

Symmetric facial
Symmetry of movement
facial movements By asking to
elevate eyebrows,
frown, close eyes
tight, puff checks,
and show the
teeth
Eye Inspection Hair evenly Hair 20/50 is the The
Structure distributed distributed eyesight of structure
and visual skin intact thin intact the patient and visual
acuity with or are equal
eyebrows without alignment
eyeglasses. and
He’s using movement of
reading eyebrows
glasses.
Bulbar
conjunctiva Inspection Skin intact Skin intact Reference:
no no fundamental
discharge; discharge; s of nursing
no no It’s shiny and 8th Edition
discoloratio discoloratio smooth. page 588
n n

Palpebral
conjunctiva Inspection
Shiny, Shiny,
smooth and smooth and The patient
pink or red slightly pink shows shiny,
and smooth
slightly pink
Lacrimal Inspection Shiny, Shiny,
gland smooth and smooth and
pink or red slightly
pink
No edema
or There is no
tenderness edema, or
over tenderness
lacrimal over
gland lacrimal
gland
Cornea Inspection Transparent Brown Normal
Corneal shiny and
sensitivity(t smooth;
rigeminal) details of
the iris are
visible;
equal in
size; is 3mm
in diameter;
round
smooth
border, iris
flat and
round
Pupils Brown in Black in
color; equal coor; equal
in size; in size
normally 3 normally 3
to 7mm in to 7mm in
diameter; diameter
round round,
Illuminated smooth smooth
pupil border, iris border, iris
Inspection constrict flat and flat and
and (direct round round
Pupil’s palpation response)
direct and Pupils
consensual Pupils constrict
reaction to constrict when
light when looking near Pupil
(oculomotor Inspection looking near objects; constricts
and objects; pupils dilate respond is
trochlear) pupils dilate when brisk
when looking at
Pupil’s looking at far objects
reaction to far object.
accommodat
Visual Inspection When When The vision
acuity by looking looking looking of the
Distance near object straight straight patient
vision and far ahead, ahead, range to
object client can client can 20/70.
see object see object
in the in the The client
periphery periphery uses of eye
Both eyes Both eyes glasses to
coordinate coordinate read
d; move in d ; move in newspaper
uniform in uniform s.
unison with
with parallel
parallel alignment
alignment
Able to
read
newspaper
Ask the Patient able
client to to read but
read slightly
newspaper blurred uses
of reading
glasses
Ears and Inspection Color same as Color same as Normal The patient
gearing facial skin, facial, skin, has no
auricle symmetrical symmetrical hearing
External ear Normal voice Normal voice problem and
canal and tone audible tone audible able to
tympanic respond
membrane Able to hear Able to hear accurately
Able to hear Able to hear
Whisper tests ticking in both ticking in both
Gross hearing ears ears Reference:
acuity Watch tick test Sound is Sound is Fundamental
heard in both heard in both of nursing 8th
ears or is ears or edition page
Tuning fork localized at localized at 897
test the center of the center of
(weber test) the head the head
Air Air
conduction is conduction is
greater than greater than
bone bone
Rinne test conduction conduction
Nose and sinuses Inspection Symmetric and Symmetric and Normal The patient has no
External nose straight; no straight; no patency in her
discharge or discharge or both nostrils; no
flaring; uniform in flaring, in uniform palpable masses or
color color nodules on her
No tender no No tender; no nose.
Patency of nasal lesions lesions
cavities Palpation
Air moves freely as Air moves freely as
the client breathes the client breathes
Ask the client to through the naris through the naris
close the mouth ,
exert pressure on
one naris, and
breathe through
the opposite naris,
(repeat to the
other side)
Mouth and Inspection Uniform in, Slightly pale No brushing Lips buccal
oropharynx pink color, of teeth mucosa, and
Lips and soft, moist, Symmetry since 6 days gums
buccal smooth of contour of slightly pale
mucosa texture hospitalizati due of her
Smooth, on poor
white, shiny hygiene
Inspection Symmetry enamel,
of contour slightly pale
gums
Teeth and slightly pale
gums

Tongue/flo Inspection Smooth,

or of the white, shiny Moist ,firm
mouth tooth texture
enamel Pink gums.
gums(bluish
or brown
patches in
dark-
skinned
clients)
Tongue Inspection Moist, firm Patient has
of tongue texture to white
movement. gums. coating
Palpations Patient has tongue
white Moves no
coating freely
tongue tenderness
Moves Pale in
freely no color,
tenderness smooth,
lateral
margins; no
lesions
Palpations Moves
freely no Pale in
tenderness color,
smooth,
lateral
margins; no
lesions
Oropharynx Palpations Pink, color, Pale in color,
and tonsils smooth, smooth,
lateral lateral
margins; no margins; no
lesions lesions
Raised
Inspection Raise papillae papillae
(taste buds) Moves freely;
Moves freely, no tenderness
no tenderness
Smooth
tongue base
with Smooth
prominent tongue base
veins with
Smooth with prominent
no palpable veins
nodules Smooth with
Pink and no palpable
smooth nodules
posterior wall Pale smooth
posterior wal
No discharge
No discharge
Neck Normal
Neck and muscles Inspection Muscles equal in Muscles equal in
(sternocleidomastoi size; head centered size; head centered
d and trapezius)

Coordinated Coordinated
Observation of head smooth movement smooth movement
movement with no discomfort with no discomfort
Central placement Central placement
in midline of neck; in midline of neck;
Lymph nodes spaces are equal on spaces are equal on
both sides. both sides
Palpation Not visible in Not visible in
palpation palpation

Thyroid gland

Palpation
Extremities Inspection No edema No edema Normal
No hematoma No hematoma
Thorax Inspection Spine vertically Normal
aligned
Skin is intact; no
tenderness; no
masses; full and
symmetric chest
expansion
Vesicular and
bronchovesicular
sound

Skin is intact; no
tenderness; mo
masses; full and
symmetric chest
expansion

Vesicular and
bronchovesicular
sound

Lungs Auscultation
Abdomen Inspection Skin Not done
uniform in
color
Palpation Silver
where
striae or
surgical
scars

Muscle are
intact and
no
Musculosk Inspection associated
eletal Muscle are tenderness
system intact and
Muscles no
associated
tenderness
Bones Inspection Flat Bones are
rounded or aligned
scaphoid
Joint Observatio (concave) Moves
n Moves freely
Neurologic freely she
System Asking she can response to
(neurologic response simple
exam) simple commands
commands she could
Language Asking she could recall
Memory (neurologic recall information
exam) information given early
given early in the
in the interview
interview
Reflex Triceps +2 normal Normal
reflex responses response
Knee-jerk-
Motor reflex can can
function Patellar alternately alternately
reflex supinate supinate
Alternatin and and
g pronate pronate
supination hands at hands and
and rapid pace
pronation
of hands
and knees

able to
able to discrimina
Pain discrimina te sharp
sensation te sharp and dull
and dull sensation
sensation
Diagnostic Procedure:
 Chest x-ray
Date obtained:08/14/2019
Chest consider pneumonia bilateral with probable pleural
effusion in right
Hazy opacities are seen in both lower lobe
Aorta is tortous
Bony thorax
Anatomy and Physiology
Lymphatic system, a subsystem of the circulatory system in the
vertebrate body that consists of a complex network of vessels,
tissues, and organs. The lymphatic system helps maintain fluid
balance in the body by collecting excess fluid and particulate
matter from tissues and depositing them in the bloodstream. It also
helps defend the body against infection by supplying disease-
fighting cells called lymphocytes. This article focuses on the human
lymphatic system.
 Lymph nodes are small, bean-shaped collections of immune system cells
(cells that are important in fighting infections) that are connected by
lymphatic vessels. Lymphatic vessels are like small veins, except that they
carry a clear fluid called lymph (instead of blood) away from the breast.
Lymph contains tissue fluid and waste products, as well as immune system
cells. Breast cancer cells can enter lymphatic vessels and begin to grow in
lymph nodes.

Most lymphatic vessels in the breast connect to lymph nodes under the arm
(axillary nodes). Some lymphatic vessels connect to lymph nodes inside the
chest (internal mammary nodes) and those either above or below the
collarbone (supraclavicular or infraclavicular nodes).

It is important to find out if the cancer cells have spread to lymph nodes
because if they have, 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 the treatment plan. Still, not all women with
cancer cells in their lymph nodes develop metastases, and some women
can have no cancer cells in their lymph nodes and later develop
metastases.
 Pathophysiology (Patient-based)
 .
Modifiable factors:
Non-modifiable
Diet(fatty and salty
Gender:Female
foods)
Age:60 y/o
Non-compliance to
Genetics
treatment
Unknown

Genetic mutation of
DNA(p53,BRCA 1 & 2 genes

Activation of growth promoting Inactivation of tumor Alteration in the gene that

oncogenes suppressor genes controls apoptosis
 Unregulation proliferation and
differentiation of cancer cells in the milk
duct
 .

Growth of
malignant tumor

Signs and symptoms:

Pain on her right upper abdomen
Sudden unexplained weight loss
Change in warts or mole
Edema on bilateral lower extremities
PLANNING
List of identifies nursing Diagnosis according to priority

Nursing Diagnosis Explanation Rationale

Acute pain related
The pain varies to the client
that affects the activity daily
living (ADL) of the client due to
her disease.
The distressing unpleasant,
feeling that cause of intense
pain experienced by the
patient. Wherein the
physiological signs that occur
with acute pain arising to the
body’s response to pain
stressor these related to
symptoms of her disease.

Sleep deprivation related to The client was unable to have Prolonged period of time
discomfort a proper sleep time because of without sleep sustained natural,
his condition and periodic suspension of relative
uncomfortable environment. consciousness.
Assessment Diagnosis Planning Intervention Rationale Evaluation

S:“Nahirapan Acute pain After 30mins Foresee the Early After 30mins
ako huminga related of nursing need for pain intervention of nursing
at sobrang tounderlying intervention relief. may intervention
sakit ng tyan disease the client will decrease the the client l
ko”as be able to total amount was able to
verbalized by demonstrate of analgesic demonstrate
the client relaxation required. relaxation
Pain scale skills and skills and
8/10 diversional Acknowledge diversional
O: activities. reports of One’s activities.
Irritable pain perception of
facial immediately. time may
grimace become
restless distorted
during
Vs taken: painful
Bp- experiences.
110/70mmHg Pain can be
PR-85bpm aggravated
RR-17bpm with anxiety
T-36.0 C and fear esp
ecially when
pain is
delayed.
An
immediate
response to
reports of
pain may
decrease
anxiety in
the patient.
patient’s
welfare and
comfort
fosters the
development
of trusting
relationship.
Provide rest Experiences
periods to of pain may
promote become
relief, sleep,exaggerated
and as a result of
relaxation. exhaustion.
Pain may
result in
fatigue,
which may
result in
exaggerated
pain.
Provide Opioids are
pharmacolog indicated for
ical severe pain,
intervention: especially in
Opioid the hospice
analgesics or home
as prn setting.
Non-
pharmacolog To divert and
ical:like back to lessen the
rubbing, stress,
Distraction tension,
techniques subsequentl
Relaxation y decreasing
exercises, the pain.
biofeedback,
breathing
exercises,
music
therapy
Assessment Diagnosis Planning Intervention Rationale Evaluation

S: “hirap ako Sleep After 1 hour Determine To know the After 1 hour
matulog dito deprivation of nursing the presence factors that of nursing
dahil nga sa related to intervention of physical affect the intervention
sakit lalo na prolonged the client will and patient the client was
kagabi hindi discomfort be able to psychological causing able to have
ako pinatulog have an stressors,env sleep pattern an adequate
sa sakit adequate ironmental changes. sleep pattern
sobra”as sleep pattern factors as well as
verbalized by as well as rest periods.
the client rest periods. Recommend Proper
O: positions for support like
Irritable sleep that pillow for side
facial provide lying position
grimace adequate promotes
restless support relaxation
and aids
Vs taken: sleep.
Bp-
110/70mmHg .
PR-85bpm
RR-17bpm
T-36.0 C
Assessmen Diagnosis Planning Intervention Rationale Evaluation
t
Promote To provide
deep pain relief
breathing
exercises
and other
non
pharmacolog
ical
intervention
Assessment Diagnosis Planning Interventio Rationale Evaluation
n
S: Fluid Volume After 1 hour Review It can assist to After 1 hour
Excess related of nursing patient’s direct of nursing
to excessive intervention history to management. intervention
fluid intake the client determine the History may the client
O: verbalizes probable include verbalized
Irritable awareness of cause of the increased awareness of
facial grimace causative fluid fluids or causative
Restless factors and imbalance. sodium factors and
Edema in behaviors intake. behaviors
bilateral essential to essential to
lower legs correct Monitor input To control correct
fluid excess and output fluid shifting. fluid excess
Vs taken: closely.
Bp-
110/70mmH
g Record intake This provides
PR-85bpm if patient is on information
RR-17bpm fluid
T-36.0 C restriction.
Assessment Diagnosis Planning Interventio Rationale Evaluation
n
Limit sodium Restriction of
intake as sodium aids in
prescribed. decreasing
fluid
retention

Elevate Elevation
edematous increases
extremities, venous return
and handle to the heart
with care. and, in turn,
decreases
edema.
 Drug study
 CEFUROXIME SODIUM
 Classifications: ANTIINFECTIVE; ANTIBIOTIC; SECOND-GENERATION
CEPHALOSPORIN
 Dose/frequency-Moderate to Severe Infections
Adult: PO 250–500 mg q12h IV/IM 750 mg–1.5 g q6–8h
 Actions-Semisynthetic second-generation cephalosporin antibiotic with
structure similar to that of the penicillins. Antimicrobial spectrum of activity
resembles that of cefonicid.
 Indications -
 Contraindications-Hypersensitivity to cephalosporins and related antibiotics;
pregnancy (category B), lactation.
 Adverse Effects-Chills,diarrhea,feve,rgeneral feeling of illness or
discomfort,Headache,itching of the vagina or genital area,pain during
sexual intercourse rigidity,sweating,thick, white vaginal discharge with
no odor or with a mild odor

 Nursing considerations:
1.Determine history of hypersensitivity reactions to cephalosporins,
penicillins, and history of allergies, particularly to drugs, before therapy
is initiated.
2.Report onset of loose stools or diarrhea
3.Monitor I&O rates and pattern: Especially important in severely ill
patients receiving high doses. Report any significant changes.
Tramadol-ULTRAM
Dose/frequency-tablets, 50 mg,prn
Classifications-Opiod analgesic
Actions- Tramadol hydrochloride is a centrally acting synthetic opioid
analgesic. mechanisms appear applicable: binding of parent and M1
metabolite to μ-opioid receptors and weak inhibition of reuptake of
norepinephrine and serotonin.
Indications- is indicated for the management of moderate to
moderately severe pain in adults.
Contraindications: hypersensitivity to tramadol, any other component
of this product or opioids. Tramadol hydrochloride is contraindicated in
any situation where opioids are contraindicated, including acute
intoxication with any of the following: alcohol, hypnotics, narcotics,
centrally acting analgesics, opioids or psychotropic drugs. Tramadol
hydrochloride may worsen central nervous system and respiratory
depression in these patients
Adverse effects:dizziness,pruritus,vomiting,constipation,dry mouth
Nursing considerations:

 Monitor for hypertension during loading dose; reduction of

loading dose may be required.
 Monitor cardiovascular status continuously; notify physician
immediately if hypotension or bradycardia occur.
Thank you!