I N T R O D U C T I O N

We acquire the strength of what we have overcome. - Ralph Waldo Emerson

So many women you know may have had breast cancer friends and neighbors, coworkers, relatives. It seems as if every time you turn around, breast cancer is being talked about in the newspaper or on TV. You may be fearful of developing breast cancer for the first time or of receiving a diagnosis after a mammogram or other testing. If youve had breast cancer, you may be fearful of a possible recurrence or even of the possibility that breast cancer could take your life. Breast cancer is an uncontrolled growth of breast cells. To better understand breast cancer, it helps to understand how any cancer can develop. Cancer develops when cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because of out-of-control growth of abnormal cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more rapidly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries. Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to form new abnormal cells. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all its activities. Most of the time when DNA becomes damaged the body is able to repair it. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a persons DNA becomes damaged by exposure to something in the environment, like smoking. Cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body. The breast cancers stage refers to how far the cancer cells have spread beyond the original tumor, A tumor can be benign (not dangerous to health) or malignant (has the potential to be dangerous). The term breast cancer refers to a malignant tumor that has developed from cells in the breast. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast.

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Breast cancer is always caused by a genetic abnormality (a mistake in the genetic material). However, only 5-10% of cancers are due to an abnormality inherited from your mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and the wear and tear of life in general. Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 35(about 3%). In 2008, about 40,480 women will die from breast cancer in the United States. Death rates from breast cancer have been declining since about 1990, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier detection through screening and increased awareness, as well as improved treatment. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years. We have chosen the case because we want to broaden our knowledge about Breast Cancer regarding to the nursing interventions and medical management. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years.

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P A T I E N T S

P R O F I L E

I. BIOGRAPHICAL DATA Name: Mrs L.H.D. Address: Block 13 Lot 35 FVR1 Phase1 Norzagaray, Bulacan Age: 45 Gender: Female Religious Affiliation: Roman Catholic Room and Bed#: Female Ward Bed No.2 Chief Complaint: Abdominal pain Provisional Diagnosis: Breast carcinoma with Liver Metastasis, Invasive ductal CA Attending Physician: PSI Anna Marie L. Cabasal, M.D. II. NURSING HISTORY A. Past Health History The client had measles when she was about 8 years old. She said that she was not hospitalized but she only rest, drink a lot of water and take a bath. The client said that she doesnt know if she has complete immunization. She added, Nung panahon namin hindi pa uso yung mga ganon, alam ko lang meron ako BCG. The client claimed no known allergies in food or any medication. In terms of accidents or hospitalizations, the client said that she undergone a breast surgery (mastectomy) on October 2007 wherein her right breast was removed. The client traveled to Kuwait on 1988 to work as a factory worker and she also went to Baguio on 1990 just for a vacation. B. History of Present Illness On her first visit to PNPGH-OPD, her chief complaint was her abdominal pain and she was advised by the physician to undergone an abdominal CT Scan. During her current visit, she wants the results to be interpreted by her physician but when the doctor saw the results, she said that her breast cancer spreads to her liver so the physician advised her to be admitted in the hospital. Her provisional diagnosis was Breast carcinoma with Liver Metastasis, Invasive ductal CA. C. Family History With regards to the health of her family, she was not able to recall the names as well as the condition of all of her 9 siblings. She was only able to remember 6 of her siblings. She said that because her siblings were all in La Union, she does not have any communication with them and does not know their current condition. The only thing that she was able to remember is her mother who died because of Breast cancer. She also said that her father is already dead but does not know the cause.

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G E N O G R A M

F.D.

C.D.

T.D.

D.D

L.D.H. 45y/o.

B.D.

P.D.

M.D.

B.D.

Legend: Male Female

Male(Deceased) Female(Deceased)
Female with Breast Cancer

Client The client was not able to recall the names as well as the condition of all of her 9 siblings. She said that because her siblings were all in La Union, she does not have any communication with them and does not know their current condition. The only thing that client was able to remember is her mother who died because of Breast cancer. The client also said that her father is already dead but does not know the cause.

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III. PATTERNS OF FUNCTIONING A. PSYCHOLOGICAL HEALTH 1. Coping Patterns A stressful event for the client is when her husband is away from home. She said that she is always worried whenever her husband is out for work as a police. The client verbalized, Syempre pulis, natatakot ako pag nasa trabaho siya. She handles that stress by making herself busy doing household works. For the past years, the biggest problem that the client encountered was being diagnosed with breast cancer. She verbalized, Sa una,mahirap tanggapin pero nung tumagal natanggap ko na rin. The client admitted that she cried a lot when she first found out that she has cancer but her faith to God gave her enough strength to accept it. The client verbalized, Ngayon tanggap ko na. Alam ko hindi ako pababayaan ni Lord. Interpretation: The client cope with the disease by crying at first but then she was able to accept it with the help of her faith to God. Analysis: Coping mechanism can be viewed as an active method of problem solving developed to meet lifes challenges. Cooperative or friendly, expressive feelings appropriate to the situation, verbalizes positive things regarding others and the future express positive coping mechanism. (Source: Fundamentals of Nursing, 7th Edition by: Barbara Kozier, Glenora Erb, Audrey Berman & Shirlee Snyder, page 193) 2. Interaction Patterns Whenever the client has personal problems, she usually keeps it to herself. She said that by that way of handling it, she can solve her problems. However, if it is a family problem, she and her husband usually interacts just to try to solve them. She verbalized, Usap lang talaga ang kailangan. Even though they usually face a lot of problems, they never lose hope and have a good faith in God. With regards to her interaction with other people around her, she said that she has a good relationship with her neighbours since whenever her husband and son is not around, she usually talks to them and share her thoughts. She is also there for their neighbours and ready to listen to them. Interpretation: Personal problems were solved by the client but when it comes to a family problem, an open communication is established which is a helpful and best way to settle up things. Through those ways, she/they can solve her/their problems. Analysis: Mature persons are open to new experiences and continued growth; they can tolerate ambiguity, flexible and can adapt to change. In addition, mature people have the quality of self acceptance; they are able to be reflective and insightful about life and to see themselves as others see them. An open communication is one way of knowing a

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person. It is also a best way to settle things up. (Source: Kozier, Fundamentals of Nursing, p. 398) 3. Cognitive Patterns The client can read, write and speak even though she said, Kahit highschool lang natapos ko. However, the client is experiencing difficulty with reading because of her vision. She added, Minsan hindi ako nakakabasa kasi malabo pero may reading glasses naman ako. On the other hand, the client is also experiencing some problems with regards to her hearing ability. The client verbalized, Hindi naman ako bingi talaga, pero mahina lang pandinig ko. The client seek a doctor with regards to this and found out that she has impacted cerumen thats why she is now cleaning her ears for about twice a week with cotton buds. With regards to her memory, the client said that she became more forgetful recently. The client verbalized, Nagiging makakalimutan na ako pero yung ngayon-ngayon lang naman. Kunwari may pinatong ako, hindi ko na matandaan pero ung mga damit na matagal ko na tinago, naaalala ko pa. On the other hand, the clients chief complaint was her abdominal pain. When asked to rate the pain she is feeling at that moment, she rated it as 9 out of 10 (0 as no pain and 10 as severe pain). She verbalized, Sobrang sakit na ng tiyan ko nung December pa to. The client added that the pain hinders her to do her household chores. She said, Hindi na nga ako makagawa nang ayos dahil dito (pertaining to the pain). During the interview, the clients hand is over her abdomen as if guarding it. Interpretation: The client has problems with her senses especially her vision and hearing but she was able to deal with it. However, the pain she is experiencing really affects her ADL and the pain is really her concern. With regards to her memory, she has problems dealing with new information but can easily recall past information. Analysis: The ability of middle age adults to learn is unimpaired and often enhanced by experiencially enhanced motivation, flexibility, confidence, and maturity. Problems are viewed from a broader perspective, improving solutions; however, because the middle ager tends to consider more variables, the process may appear slower. In general, middle-aged cognition involves integrating and synthesizing expanding life experiences, actively seeking alternate perspectives and new knowledge, and thoughtful confrontation with self and others. (Source: Hitchcock, Community health nursing: caring in action, Volume 1, page 572) 4. Self-Concept Patterns Because of the surgery she had undergone in 2007 where her right breast was removed, she feels not that good all the time. When asked to rate self-esteem, she verbalized, Siguro mababa mga 5 90 as the lowest, 10 as the highest) dahil sa wala na akong kanang suso pati na rin sa kondisyon ko ngayon (pertaining to her cancer and body image).

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The client said that sometimes, she is conscious about her appearance now that she has only one breast. She added, Minsan iniisip ko kung anong iniisip ng ibang tao pag nakikita nila ako. When the client talks about her removed breast, she is not looking at her breast and she also does not touch it. On the other hand, the client gets easily annoyed when someone is noisy. She said, Ayoko sa lahat yung maiingay at makukulit. Moreover, the client usually gets sad when her husband is away. She added, Minsan nalulungkot ako lalo na kapag hindi umuuwi yung mister ko. Interpretation: Client is experiencing disappointment over her loss especially the removal of her one breast and this affected her view to herself so she has negative self-concept. Analysis: Many factors affect a person's self-concept. There are four components of self-concept and under this is the Body image, how a person perceives the size, appearance and functioning of the body and its parts. Body image has both cognitive and affective aspects. The cognitive is the knowledge of the material body; the affective includes the sensations of the body, such as pain, pleasure, fatigue and physical movement. Body image is the sum of these attitudes, conscious and unconscious, that a person has toward his or her body. (Source: Kozier, Fundamentals of Nursing, page 1005-1006) 5. Emotional Patterns The client admits that she is an emotional person even though she does not get easily cry. She verbalized, Hindi ako mabilis mapaiyak. However, the client said that when she knew that she has cancer. She cant help it but to cry. She added, Nung malaman ko na may kanser ako, umiyak talaga ako. Mahirap kasi. She also said that it takes time to accept it and now already did. She does not cry anymore with regards to her condition. She said, medyo napapaiyak ako pero hindi na tumutulo kasi pinipigilan ko. The client has a strong personality because of her faith to God. The client verbalized, Kailangan kong maging malakas dahil alam ko nandiyan siya (pertaining to God). Interpretation: Feeling of sorrow was expressed by the client when she knew about the disease. However, the client tries to be strong and she tries not to show off her emotion and accept her disease because she believe that God is always there to help and guide her and this strong faith in God give her the courage to surpass day to day living. Analysis: It's important to remember that even people who have good emotional health can sometimes have emotional problems. People who are emotionally healthy have learned ways to cope with stress and problems. They know when they need to seek help from their doctor or a counsellor. Emotion focused coping includes thoughts and actions that relieve emotional stress. Emotion focused coping does not improve the

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situation, but the person often Fundamentals of Nursing, p. 1068)

feels

better.

(Source:

Kozier,

6. Sexuality The client said that her husband is the one special whom she considers significant in her life. However, the client is more comfortable and prefers going with those from the same sex. She added, Pag wala yung mister ko pati anak ko, lagi kong kasama sila Ate Belen. The client said that she had her first menarche when she was about 12 years old. She described her menstruation as regular. On the other hand, the client was got pregnant when she was about 23 years old. The client got pregnant only once thats why they have only one child. However, the client didnt breastfed her child. With regards to her breast, the client said that she wears bra all the time. However, the client does not know how to perform BSE (breast self-examination). She added, Laging nababanggit yun sakin pero hindi ko naman alam. The client said that she is willing to learn the self-examination. The client has only one breast since she undergone mastectomy on 2007 and her right breast was removed. Interpretation:

The client states that she her husband is a significant person in her life. Her husband may one of her source of strength in this problem aside from her children and friends. The
client has deficient knowledge pertaining to breast self-examination and she shows willingness to learn. Analysis: There are factors that may affect sexuality such as Physical health problems that may involve a persons sexual behavior. Breast Self Examination (BSE)- Monthly Breast Self-examination is an important part of self health care and should be included in health maintenance patient teaching. (Source: Kozier, Fundamentals of Nursing, p. 1023 & 1034) 7. Family Coping Patterns The client lives with her husband, son and two cousins. According to family structure, they belongs to the extended family since her two cousins is living with them. The client said that money is always a problem in her family. When the family is faced with problems, the client said that she and her husband talk it over. She added, Pag may problema kami sa pera, pinag-uusapan na namin yun ng mister ko pero hindi na namin sinasama si John Rae (her son). But most of the time according to her, she simply keep the problem to herself. She also verbalized, Kalimitan kapag kulang na sa pera, hindi ko na sinasabi sa mister ko, ako na ang gumagawa ng paraan. The client said that their problems are being solved that way. On the other hand, when asked about the recent problems they encountered as a family, the client said that her condition as having cancer and being hospitalized is the recent situational crisis experienced by the family. At first, her husband and son cannot

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believe to her condition but then afterwards they were able to accept it. The client added, Nung una, umiyak talaga sila pero ngayon okay na. Interpretation: When the clients family has problems, they solve it by talking to her husband not including their son and most of the time (if its about money) she keeps it to herself and their problems are usually being solved that way. However, the whole family was affected when they knew that she has cancer. Analysis: Family coping mechanisms are the behaviors families use to deal with stress or changes imposed from either within or without. Coping mechanisms can be viewed as an active method of problem solving developed to meet lifes challenges. The coping mechanisms families and individuals develop reflect their individual resourcefulness. (Source: Kozier, Fundamentals of Nursing, p. 435) B. SOCIO-CULTURAL PATTERNS 1. Cultural Patterns Since the client is a Filipino and a Roman Catholic, she follows some of their cultures. Her family celebrates Christmas and they always go to the church during that day and give gifts to each other. She verbalized, Tuwing Pasko, lagi kaming nagsisimba ng ank at mister ko. Nagbibigayan din kami ng regalo pati sa mga inaanak namin. However, the family do not celebrate their town fiesta. The client added, Hindi kami naghahanda tuwing pyesta, wala din naman kaming bisita at tsaka bihira lang din sa lugar namin yung naghahanda. However, the client and her family go to the church on fiesta day. The client said that most of the culture that they are practicing is in line with their religion. Interpretation: The clients culture is in line with her religion. Analysis: Culture may be defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. Culture defines roles and interactions with others as well as with families and communities. The attitudes and institutions are unique to particular group. Culture includes the beliefs, habits, likes and dislikes and customs and rituals learned from ones family. (Source: Fundamentals of Nursing, 5th Edition by: Carol Taylor, Carol Lillis, & Priscilla LeMone, pp. 40, 791) 2. Significant Relationships The client considers her family, neighbours and God as the most important persons in her life. The client verbalized, Yung mister ko at anak ko, pati yung mga kapitbahay naming at syempre si God. According to her, she has a good relationship with all of them. She added, Ayokong masira yung pamilya ko kaya usap lang agad pag may problema.

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On the other hand, the client smiled when she talks about her son, John Rae. She was so proud because her son will be graduating this May as a Computer Engineering student. She verbalized, Sa wakas, natapos na rin ang paghihirap namin sa kanya. However, when asked where her husband is during the interview, the client said that he is out for work. She verbalized, Wala siya ngayon nasa trabaho pero kahapon nandito siya. The client said that her significant others dont leave her and they are always there to support her especially now that she is hospitalized. Interpretation: The clients significant others are her husband, son and God and including her neighbours because whenever she has problems she can go to them and asks for help. Analysis: The family is a basic unit of society. It consists of those individuals, male or female, youth or adult, legally or not legally related, genetically or not genetically related, who are considered by the others to represent their significant persons. (Source: Kozier, Fundamentals of Nursing, p. 429) 3. Recreation Patterns During her free times, the client usually watches television. She approximated her watching as about 3 hours. The client said, Pagkatapos ng tanghalian, nanonood na ako ng TV. Basta pinapatay ko na lang yun pag katapos ng Temptation of Wife. After watching the television, she sometimes goes out in their house and goes to their neighbourhood and has a talk with them. The client also said, Pagkatapos ng Temptation of Wife, lumalabas na ako at pumupunta ako kina Ate Belen, Ate Marlyn o kina Rompel para makipagkuwentuhan. Minsan pumupunta din ako sa may kalsada. On the other hand, the client said that sometimes she use the computer however she said that she can only stand in front of it for only 5 minutes. She verbalized, Minsan din nagcocomputer ako pero mga limang minute lang kasi sumasakit ang mata ko. Interpretation: The client spends most of her time watching television and sometimes had a talk with her neighbours. However, the client is not fond of using the computer because she feels pain on her eyes. Analysis: Other aspects of recreation behaviour change with age. Also older adults are more likely to exercise alone. Close to of adults 45 years of age or over reported participating in physical activity alone. Personality, social influences, early life recreation experiences and leisure attitudes also shape recreation behaviour throughout lifetime. (Source: 3w.tpr.alberta, ca) 4. Environment The client is currently living in their one storey house with her husband, son and two cousins. She said that they are living in a subdivision and the client described it as like bahay ng kalapati.

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According to her, despite calling it as bahay ng kalapati, the ventilation in their house is adequate as well as the lighting since they have 3 electric fans and 3 windows. The client verbalized, Kahit parang bahay ng kalapati yung subdivision namin, malamig kasi may tatlo kaming electric fan pati bintana. But despite of it, the client said that there are mosquitoes, rats and cockroaches inside their house. She added, Madaming ipis, daga at lamok sa amin pero nilalason naman naming pati spray, nawawala naman pero bumabalik talaga. On the other hand, in terms of drainage, the client said that they have open drainage in front of their house as well as at the back of it. She verbalized, May kanal kami sa harap at likod pero yung nasa harap naming lagi naman siyang tuyo. Yung nasa likod naman laging may tubig pero umaagos naman. The client does not have any pet in their house. Interpretation: The clients environmental situation is not good as the way she described it however she is trying to do something for it like putting a lot electric fans or spraying the vectors. Analysis: The environment should meet the clients needs for physical and emotional, comfort and safety. Noise, temperature extremes, destructions, and lack of privacy or space may create confusion tension and discomfort. Environmental Destructions are common in Health Care settings and can interfere with messages sent between people, so nurses must try to control the environment as much as possible to create favorable conditions for effective communication. (Source: Fundamentals of Nursing, 5th Edition by: Patricia A. Potter & Anne Griffin Perry, page 449) 5. Economic The family of the client belongs to a middle family. Her husband is working as a police earning about 25,000 pesos per month but she verbalized, Sabi niya (pertaining to her husband) kapag wala daw loan 25,000 pesos per month and sweldo niya pero kapag meron, hindi ko na alam. The client also said that she have her own way of earning money. She is a Natasha dealer but she earn a little. She said, Sumasideline din naman ako. Nagpapaorder ako ng Natasha pero hindi naman regular ang kita ko. Minsan 100. Pinakamalaki na ang 500. However, the client said that they have problems in terms of the adequacy of their money. The client verbalized, Problema na naming ang pera nung nag-aaral pa lang si John Rae, pero ngayon mas lalo na (pertaining to her condition and hospitalization). Interpretation: The client and her family have problems with regard to financial issues and now that she is hospitalized it gives her family a burden in terms of money. Analysis: An individuals standard of living (reflecting occupation, income and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the propensity to seek health care advice

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and follow health regimes vary among high-income and groups. (Source: Kozier, Fundamentals of Nursing, p. 357)

low-income

C. Spiritual Patterns 1. Religious Beliefs and Practices The client is a Roman Catholic. According to her, God is very kind to her. She verbalized, Sobrang bait ni God halos lahat ng hiniling ko binigay niya kaya sana eto (pertaining to her condition) rin pagbigyan niya ako uli. The client said that she never forget to go to the church every week. She added, Linggu-linggo akong nagsisimba kasama ko mister ko at anak ko pero mas madalas yung kapitbahay namin. She said that the reason why her husband cant make it to the church every week is because of his work. On the other hand, the client admitted that she doesnt pray before and after eating as well as when going to sleep. However, she always prays in the morning after waking up. She verbalized, Hindi ako nagdarasal sa gabi bago matulog pero sa umaga, hindi ko nakakalimutang magpasalamat sa Kanya (pertaining to God). Interpretation: The client is a very religious person and it has also affected her beliefs and she has a strong faith to God. Analysis: In middle-aged, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death and tragedy. (Source: Kozier, Fundamentals of Nursing, p. 400) 2. Values and Valuing The client is a religious person. She always makes sure that she attends the mass every Sunday even though shes not with her family. She verbalized, Kahit wala yung mister ko pati anak ko, yung mga kapitbahay na lang namin yung kasama kong magsimba. The client believes that it is really important to go to the church every week and give thanks to the Lord. She said, Dapat na magthank you kay Lord kasi di naman niya ako pinapabayaan. She also said that she always tell it to her son as well as to her husband. She added, Sinasabi ko sa kanila na lagging magsimba at magdasal, lalo na ngayon sa kondisyon ko. Interpretation: The client is a religious person and it has impact on her values and she is teaching her family to do the right thing. Analysis: Values are enduring beliefs or attitudes about the worth of a person, object, idea, or action. Beliefs are interpretations or conclusions that people accept as true. Although people derive values from society and their individual subgroups, they internalize some or all of these values and perceive them as personal values. (Source: Fundamentals of Nursing by Kozier, 8th ed, vol. 1 page 80)

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IV. ACTIVITIES OF DAILY LIVING ADL 1. Nutrition Before Hospitalization The clients prefer eating vegetables and fish. She verbalized, Gulay at isda ang palagi naming kinakain, pinagbawalan na rin kasi ako sa karne. However, the client said that she still eats chicken. Before having diagnosed with Breast CA in 2007, she is fond of eating fatty foods. In terms of her water intake, she said that she is drinks about 6-7 glasses of water a day. During Hospitalization The client has a special order in terms of her diet. Her physician ordered her to have full diet with three egg whites per meal. On the other hand, she does not drink a lot of water. Her water intake is just about 2-3 glasses a day and she is hooked with D5NSS 1L. Interpretation and Analysis Interpretation: The client does not loss her appetite however she has special order for her food. The client drinks only a little amount. Analysis: Proper nutrition in hospitalized clients is necessary for wound healing, recovery, reduction in morbidity, and consequent reductions in length of stay and mortality. The most common nutritional deficiency in hospitalized clients is protein-energy malnutrition. This type of malnutrition depletes body cell mass and impairs tissue and organ function. (Source: Fundamentals of Nursing Standards and Practices Nsg. Education,p.1167) Interpretation: The clients intake has an influence on her elimination.

2. Elimination

The client urinates 5 to 8 times a day. She described her urine as yellow

During her hospitalization, the client seldom urinates. The client said that

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in color and in little amount. She added that she does not experience any difficulties or pain during urination. On the other hand, the client defecates twice a week. She described her stool as brownish black in color, foul in odor and is formed. However, the client said that she sometimes experience difficulty defecating especially when she does not go to the toilet immediately when there is an urge. She verbalized, Minsan mahirap ilabas kapag matagal kong pinigil yung tae pero umiinom naman ako ng Dulcolax. She added that the medication gives her some relief. The client does not have regular exercise but she considers her household works as a form of exercise. She verbalized, Exercise? Wala pero siguro yung mga pagwawalis ko

she only urinated twice on that day (during the interview). Her urine is brownish in color and is foul in odor. In terms of defecation, the client has not yet defecated for her entire stay in the hospital.

Analysis: Decrease urinary elimination can be attributed to derease fluid intake. (Source: Kozier and Erb, Fundamentals of Nursing Volume 2, page 1286)

3. Exercise

Because the client has an IV line and most of the time shes in bed, the client does not have regular exercise. She considers her walking inside the room as her form of exercise. She

Interpretation: The client is limited to do strenuous activities because of her condition. Analysis: Illness that causes pain may limit the

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at paglilinis siguro yun na ang exercise ko.

verbalized, Naglalakad lakad naman ako lalo na kapag iihi ako at pupunta sa CR.

4. Hygiene

The client usually takes a bath once a day in the morning. But when it is really hot, the client said that she takes a bath again in the afternoon. She verbalized, Minsan kapag mainit, dalawang beses akong naliligo.

Because of her IV line, the client has not yet taken a bath since her hospitalization. She said that she does not also receive any tepid spongebath. However, the client verbalized, Gumagamit naman ako ng Eskinol.

6. Sleep and Rest

The client usually sleeps at 10:00 or 11:00 in the evening and wakes up at around 05:00 to 06:00 in the morning. The client verbalized, Maaga ako gumising kasi hinahanda ko pa ang gamit ng mister ko. The client said that she feels refreshed every time she wakes up since she has

The client really finds it difficult to sleep during her hospitalization. The client verbalized, Wala pa akong tulog. Hindi ako makatulog dahil na din sa sakit ng tiyan ko.

dexterity and range of motion needed to perform certain measures. (Source: Potter & Perry, Fundamentals of Nursing 5th Edition, p.1060) Interpretation: The clients hygienic practices changed a lot when she was hospitalized since she cannot take a bath. Analysis: Disease or injury may reduce a persons ability to perform hygiene measures or motivation to follow usual hygiene habits. (Source: Taylor and Limone, Fundamentals of Nursing 5th Edition, p.1009) Interpretation: The client has difficulty in sleeping because of the pain she is experiencing. Analysis: The state in which an individual experiences or is at risk of experiencing a change in the quantity or quality of his or her rest pattern as related to the persons biolog-

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continuous sleep. The client also said that she sleeps besides her husband and she does not have any problems falling asleep but said that she cant sleep a lot if it is dark so she prefers that the light is on while sleeping.

ical and emotional needs. (Source: Fundamentals of Nursing Standards and Practices Nsg. Education,p.947)

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P H Y S I C A L

A S S E S S M E N T

Taking into consideration that we have only limited time and we cannot do a thorough head to toe physical assessment, we have decided to do a focused physical assessment, focusing on the body parts that the clients has complains. VITAL SIGNS AND ANTHROPOMETRIC DATA VITAL SIGNS: Body Temperature ACTUAL FINDINGS 36.4 Celsius, axilla NORMAL FINDINGS SOURCE: Author: Janet Weber & Jane Kelley Title: Health Assessment in Nursing, Third edition Page: 86 Copyright: Lippincott Williams & Wilkins 36.5 Celsius- 37.7 Celsius Respiratory Rate: 23 cpm SOURCE: Author: Kozier & Erbs Title: Fundamentals of Nursing, Eighth edition, Volume One Page: 538 Copyright: 2008 12- 20 cycles per minute Pulse Rate: 82 bpm 60-100 beats per minute Normal deviated from normal -patient has high respiratory rate due to environment and pain. REMARKS/ ANALYSIS Normal

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Blood Pressure:

110/ 70 mmHg

Systolic pressure <120mmHg, Diastolic pressure <180mmHg; varies with individual.

Normal

Height

146.3 cm

Height within range for age, ethnic, and genetic heritage. Ref: Health Assessment in Nursing, page 621) Body weight may decrease with aging because of a loss of muscle tone or lean body tissue. Body weight is within 10% of ideal range. Ref: Health Assessment in Nursing, page 131)

Normal

Weight

46kg

Normal

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BODY PART EXAMINED Body built, height, and weight in relation to age, lifestyle and health Overall hygiene and grooming

NORMAL FINDINGS Proportion varies with lifestyle

GENERAL SURVEY ACTUAL FINDINGS Proportionate

INTERPRETATION/ANALYS IS Normal

Clean, Neat, Good grooming

Appears clean but appears weak

Client is weakened due to her disease condition thus making her ADL altered which includes grooming Normal

Body and breath odor Signs of distress Obvious signs of health/illnes s

No foul odor, no halitosis No distress noted Healthy appearance

No body and breath odor noted Appears distressed Appears restless and weak, guarding behavior noted, verbalizes pain upon palpation of abdomen and upon movement Cooperative Appropriate to situation, she looks sad Understandable, moderate pace, exhibits thought association Consistent and has sense of reality

She appears distress and restless due to her pain Due to pain brought by his condition

Attitude Mood and affect Quantity and Quality of speech

Cooperative Appropriate to situation Understandable , moderate pace, exhibits thought association Logical sequence, make sense, has sense of reality No abrasions or other

Normal She appears sad due to her pain Normal

Relevance and organization of thoughts

Normal

Skin lesions

No lesions/abrasion

Normal

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lesions(size, shape lesion) Skin moisture Moisture in the skin folds and the axillae(varies with environmental temperature and humidity, body temperature and activity) Uniform temperature, with normal range When pinched, skin springs back to previous state;slower in elders Highly vascular, pink in light skinned clients; dark skinned clients may have brown or black pigmentation in longitudinal steaks Prompt return of pink or usual color (generally less than four seconds) Soft, moist, smooth texture 32 adult teeth

s noted Skin appears dry Due to inadequate intake of fluids

Skin temperature

Uniform temperature, with normal range Skin springs back slower

Normal

Skin turgor

Due to inadequate intake of fluids

Fingernail and toenail bed color

Pink finger and toenail color

Normal

Blanch test Capillary refill

Returns to pink color

Normal

Lips Teeth

Appears dry

Due to inadequate intake of fluids

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(number, color, alignment)

Smooth, white, shiny tooth enamel Reference: Fundamentals of Nursing 8th edition vol.1 by kozier, 2008

Ear Auricle ( color, symmetry and position) Color same as facial skin, symmetrical, aligned with eyes Color same as facial skin, symmetrical, aligned with eyes Normal

Normal Voice Acuity Test Nose (shapes, size, color, and flaring or discharge from nares)

Normal voice tones audible

Normal voice tones audible

Normal

Symmetric and straight No discharge or flaring Uniform color

Symmetric and straight with no discharge or flaring and uniform in color

Normal

Presence of redness, swelling, growths and discharge.

Mucosa pink Clear, watery discharge no lesions

Mucosa is pink and clear, watery discharge and no lesions

Normal

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BREAST AND AXILLAE Inspect breast for size, symmetry, contour or shape while the client is in sitting position

ACTUAL FINDINGS -Unequal -Rounded shape of one breast -Absent of right breast -Scar on the right Breast (patient undergo mastectomy) -Scar is whitish, no redness or swelling, no lesions

NORMAL FINDINGS Rounded shape; slightly unequal in size ; generally symmetric REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 628 Skin uniform n color same in appearance as skin of abdomen or back Skin smooth and intact REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 628 Round or oval and bilaterally the same Color varies widely from light pink to

INTERPRETATION Patient undergone a breast surgery (mastectomy) on October 2007 wherein her right breast was removed

Inspect the skin of the breast for localized discoloration or hyper pigmentation, retraction, dimpling, localized hyper vascular arrears, swelling, or edema

Same color as the rest of the skin Skin smooth and intact

Normal

Inspect the areola for size, shape, position, color, discharge and lesion

Round Color varies from brown to dark brown Irregular placement of

Normal

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sebaceous glands on the surface of the areola

Inspect the nipples for size, shape, position, color, discharge and lesion

Round, soft and smooth; Inverted nipple No discharge

Palpate the axillary,

Slightly tenderness

dark brown Irregular placement of sebaceous glands on the surface of the areola REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 628 Round, everted and equal in size; similar in color; soft and smooth; both nipples point in the same directions No discharge, except from pregnant or breast-feeding females REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 628 No tenderness, masses or

A recently retracted nipple suggests malignancy REFERENCE: Health assessment in Nursing by Janet Weber & Jane Kelley, 3rd Edition Page 340

Normal

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subclavicular and supraclavicula r lymph nodes

upon palpation No masses or nodules

Palpate for breast for masses, tenderness

Non tender Mobile lump Irregular, firm, not defined masses Found at upper outer quadrant of the breast

nodules REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 629 No tenderness, masses, nodules or nipple discharge

This findings may represent characteristics of tumors or any breast abnormalities REFERENCE: Health assessment in Nursing by Janet Weber & Jane Kelley, 3rd Edition Page 340-342 Normal

*Palpate mastectomy

No lesions, lumps and tenderness noted in palpating the scar and remaining of the breast

No lesions, lumps and tenderness noted in palpating the scar and remaining of the breast REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008

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 Palpate nipples for tenderness and discharge.

No tenderness, masses, nodules or nipple discharge

Page 629 No tenderness, masses, nodules or nipple discharge REFERENCE: Kozier and Erbs Fundamentals of Nursing Concepts, Process and Practices 8th Edition Volume one Author: Berman, Snyder, Kozier and Erb Copyright 2008 Page 629-630

Normal

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ABDOMEN
Skin integrity

NORMAL FINDINGS
Uniform color, slightly lighter than the facial and extremity color Flat, rounded, No evidence of enlarge liver and spleen

ACTUAL FINDING
Uniform color, slightly lighter than facial skin color

ANALYSIS
Normal

Countour and symmetry

There is an evidence of enlarge liver as well as spleen

A hard firm liver may indicate cancer. Nodularity may occur with tumors, metastatic cancer, late cirrhosis or syphilis. A liver more than 1 to 3cm below coastal margin is considered enlarged. Enlargement may be due to hepatitis, liver tumors, cirrhosis and vascular engorgement. Reference: Health Assessmenr in Nursing,Janet weber et.al page 451 Early liver metastases may be asymptomatic. Nonspecific symptoms of cancer (eg, weight loss, anorexia, fever) often develop first. The liver may be enlarged, hard, or tender; massive hepatomegaly with easily palpable nodules signifies advanced disease. Source: http://www.merckmanua ls.com Normal

Abdominal movements

Symmetric movement caused by

Equal movement upon respiration

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Light Palpation

respiration No tenderness, relaxed abdomen with smooth consistency

Tenderness right upper quadrant of the abdomen

Deep Palpation

No tenderness

Tenderness of the right upper quadrant of the abdomen

Liver

not palpable and enlarge

Slightly Tender Enlarged Liver

The first symptoms of metastases are usually nonspecific (eg, weight loss, right upper quadrant pain); they are sometimes the first symptoms of the primary cancer. Source: http://www.merckmanua ls.com The first symptoms of metastases are usually nonspecific (eg, weight loss, right upper quadrant pain); they are sometimes the first symptoms of the primary cancer. Liver metastases are suspected in patients with weight loss and hepatomegaly or with primary tumors likely to spread to the liver. Diagnosis is usually supported by an imaging test, most often ultrasonography, spiral CT with contrast, or MRI with contrast. Treatment usually involves palliative chemotherapy. Source: http://www.merckmanua ls.com A hard firm liver may indicate cancer. Nodularity may occur with tumors, metastatic cancer, late cirrhosis or syphilis. A liver more than 1

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to 3cm below coastal margin is considered enlarged. Enlargement may be due to hepatitis, liver tumors, cirrhosis and vascular engorgement. Reference: Health Assessmenr in Nursing,Janet weber et.al page 451 Early liver metastases may be asymptomatic. Nonspecific symptoms of cancer (eg, weight loss, anorexia, fever) often develop first. The liver may be enlarged, hard, or tender; massive hepatomegaly with easily palpable nodules signifies advanced disease. Source: http://www.merckmanua ls.com Normal

bladder

No tenderness not palpable

Not palpable

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L A B O R A T O R Y A N D E X A M I N A T I O N

D I A G N O S T I C R E S U L T S

ECG RESULTS April 03, 2011 Rhythm: Sinus Rate Atrial: 125bpm Rate Ventral: 125 bpm QRS Axis: Normal PR: 0.12 seconds QRS: 0.06 seconds QT: 0.28 seconds

ECG Interpretation: Sinus Tachycardia Inferior Wall Ischemia Sinus tachycardia refers to impulses that originate from the sinus node with a rate that exceeds 100 beats per minute (bpm). Sinus tachycardia accelerates and decelerates gradually and is a classic example of a tachycardia that is nonparoxysmal. Sinus tachycardia usually has an identifiable cause, which could be physiologic, such as exercise, emotion, fear, or anxiety. The underlying condition may be pathologic, such as acute pulmonary embolism, acute pulmonary edema, thyrotoxicosis, infection, anemia, hypotension, shock, or haemorrhage. It may be due to the effect of pharmacologic agents such as atropine, hydralazine, epinephrine, norepinephrine and other catecholamines. (Source: Baltazar, Basic and Bedside Electrocardiography, page 180) Sinus tachycardia is a normal response to stress and exercise. If it is persistent, at rest may indicate a more severe underlying problem such as fever, dehydration, blood loss, anemia, anxiety, heart failure, hypermetabolic states or ingestion of a significant stimulant such as cocaine, or methampethamine. Sinus tachycardia increases the hearts need for oxygen, decreases ventricular diastolic time and decreases coronary artery perfusion. Reflexive sinus tachycardia is often seen in hypotensive patient, in an attempt to maintain adequate blood pressure. (Source: Martin, The Complete study guide to learning the electrocardiogram, page 29)

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RADIOLOGY REPORT April 03, 2011 Exam: Chest Clear Lung fields Heart is not enlarged Right hemidiaphragm is slightly elevated Left hemidiaphragm and sulci are intact Visualized osseous structures are unremarkable. Analysis: When listening to the lungs there are usually only breath sounds audible, i.e. the lung fields are usually clear. Fine crackles may be audible in the presence of heart failure. (Source: Hugo SpindolaFranco and Bernard G. Fish, Radiology of the heart: cardiac imaging in infants, children, and adults, page 78) The size of the heart related to the thoracic cage varies with age. Radiographically, the normal cardiothoracic ratio is 60% or less for newborns and 50 % or less in children and adult. In general, the normal human heart is roughly the size of the ones fist. In this regard, it is important to emphasize that a patients heart should be similar in size to the patients fist, not the examiners.(Source: Hugh D. Allen et.al., Heart disease in infants, children, and adolescents including the fetus and young adult 7th edition) The diaphragm is the major inspiratory muscle comprised of mascular origins along the costal margins and insertions into the membranous dome. The right hemidiaphragm overlies the liver, and the left hemidiaphragm overlies the stomach and spleen. On the frontal radiographs exposed in deep inspiration, the apex of the right hemidiaphagm typically lies at the level of the sixth anterior rib, approximately one half interspace above the apex of the left hemidiaphragm. A scalloped appearance to the hemidiaphragm is not common. Focal bulges in the diaphragmatic contour are usually a result of acquired diaphragmatic eventration (thinning). (Source: William E. Brant and Clyde A. Helms, Fundamentals of diagnostic radiology 3rd edition, page 354) The thoracic cage is symmetrical with no evidence of pathology in the ribs or other visualized osseous structures. This example may seem rather lengthy for a normal chest radiological report. (Source: Dennis M. Marchiori, Clinical imaging: with skeletal, chest, and abdomen pattern differentials, page 61)

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HEMATOLOGY April 03, 2011 Normal values Differential Count Segmenters Results Interpretation and Analysis An increase in segmentors is often seen in people who are physically active and athletes. A decrease in lymhocyte concentration is commonly a sign of infection, acute minor viral infection, aplastic anemia, or inherited immunoglubulin disorders. (Wallach, Jacques. Interpretation of Diagnostic Tests. 8th Edition) Decreased monocyte levels can indicate bone marrow injury or failure and some forms of leukemia. Within normal range Within normal range A decrease in haemoglobin may be indicative of hemorrhage,

50-65%

0.81

Lymphocytes

25-40%

0.14

Monocytes

0.02

3-9%

Eosinophil Platelet count Hemoglobin

0.03 150-400x109L 120-140gL

1-3% 400x109L 115

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Hematocrit

0.37-0.48

0.34

White Blood Cells

10.0

5-10x109L

anemia, hemodilution and fluid retention. (Rodak et al., Hematology, page20) A decrease in hematocrit may be indicative of hemorrhage, anemia and hemolysis of erythrocytes. (Wallach, Jacques. Interpretation of Diagnostic Tests. 8th Edition) Within normal range

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URINALYSIS April 03, 2011 Normal values Macroscopic Exam Color Transparency Straw-amber Clear Results yellow Slightly turbid Interpretation and Analysis Within normal range Turbid urine is usually a cause of urates/ uric acid, presence of leukocytes, red cells, mucin/ mucus thread, pus, clumps and tissue in the urine. (Henrys Clinical Diagnosis and Management by Laboratory Methods. 21st Edition) Within normal range Within normal range Within normal range Within normal range Red blood cells in the urine may have originated in any part of the urinary tract from the glomerulus to the urethral meatus, and in the female they may be the result of menstrual contamination. (Mundt and Shanahan, Graff`s Textbook

Reaction Specific Gravity Sugar Protein Microscopic Exam RBC

AcidicAlkaline 1.005-1.025 Negative Negative 0-1 hpf

Acidic 1.010 Negative Negative 0-2

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Pus cells Squamous Ephit Mucus Threads Amorphous urate

0-2 hpf Few Few Few

1-2 Few Few Few

of Routine of Urinalysis and Body fluids, page57) Within normal range Within normal range Within normal range Within normal range

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CT SCAN OF PLAIN WHOLE ABDOMEN April 13, 2011 HISTORY: Hepatic Masses Right Lobe FINDINGS: The liver is enlarged with multiple hypodense and isodense soft tissue masses. The liver is seen to the left hemiabdomen. The intrahepatic ducts are not dilated. The gallbladder is contracted. The common duct is not dilated. The pancreas shows no local enlargement. The pancreatic duct is not dilated. The spleen is enlarged without discrete focal glands are normal in size and configuration. mass. Both adrenal

Both kidneys show no opaque lithiasis or hyponephrosis. The ureters are normal in caliber. No discrete mass lesion seen. Enlarged lymph nodes are appreciated in the retroperitoneal region. Minimal ascites is seen. The abdominal aorta is normal in caliber. The uterus is appropriate for patient`s age. The urinary bladder is intact. The stomach is compressed. The small and large bowel segments are grossly normal. No sign for bone destruction. IMPRESSION: HEPATIC MASSES INDICATIVE OF NEWGROWTH An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis. (Source: Weber and Kelley, Health Assessment in Nursing, page 461) SPLENOMEGALY Splenomegaly is characterized by an area of dullness greater than 7cm wide. The enlargement may result from traumatic injury, portal hypertension, and mononucleosis. (Source: Weber and Kelley, Health Assessment in Nursing, page 447) ENLARGED RETROPERITONEAL LYMPH NODES Cervical, breast, prostatic, bladder, uterine, and renal and ovarian carcinoma frequently metastasize to retroperitoneal lymph nodes. Other primaries include lung and gastrointestinal tract carcinoma. (Source: Burgener, Differential Diagnosis in Magnetic Resonance Imaging, page 574) MINIMAL ASCITE Ascites is defined as the abnormal accumulation of fluid within the peritoneal cavity. In the clinical practice of oncology, most cases of ascites will occur as a result of

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progressive carcinoma within this cavity resulting in a diffuse involvement of all peritoneal surfaces by metastatic carcinoma. (Source: Furie et al, Clinical Hematology and Oncology Presentation, Diagnosis and Treatment, page 128-129)

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ULTRASOUND REPORT April 04, 2011 Examination request: ABDOMEN Follow-up examination top 14 Sept 2007 now shows: LIVER The liver measures 17 cm with course parenchyma. Nodular masses are seen on the right lobe with the largest measuring 2.0 x 1.9 x 1.6 cm. There is a solid mass noted on the upper abdominal area oblinerating the left lobe of the liver, pancreas and spleen. IMPRESION: LIVER PRENCHYMAL DISEASE AND HEPATOMEGALY Hepatomegaly, a liver span that exceeds normal limits (enlarged), is characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement. (Source: Weber and Kelley, Health Assessment in Nursing, page 446) HEPATIC MASSES, RIGHT LOBE An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis. (Source: Weber and Kelley, Health Assessment in Nursing, page 461) SOLID MASS, UPPER ABDOMINAL AREA A mass detected any quadrant may be due to tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions. (Source: Weber and Kelley, Health Assessment in Nursing, page 449) RECOMMEND WHOLE ABDOMINAL CT SCAN FOR FURTHER EVALUATION. GALLBLADDER: The gallbladder is contracted. KIDNEYS: The right kidney measures 8.1 x 3.4 cm. Cortical thickness 1.1 cm. The left kidney measures 8.5 x 3.4 cm. Cortical thickness 1.4 cm. Both kidneys are normal in size and echotexture. Mild caliectasia is noted bilaterally. IMPRESSION: MILD CALIECTASIA, BILATERAL Caliectasis is a kidney condition characterized by dilation of the calices, structures inside the kidney which form part of the renal pelvis which drains into the ureter. Once in the ureter, fluid can be moved into the bladder and periodically eliminated through the urethra once enough fluid builds up. In individuals with caliectasis, fluid backs up in the kidneys and the calices become distended. One reason for caliectasis to develop is a urinary tract obstruction. Stones, growths, and other obstructions can make it difficult for fluid to drain from the renal pelvis. As it builds up, it puts pressure on the calices and they start to expand. This causes

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caliectasis. Likewise, infections in the urinary similar problems. (Source: http://www.wisegeek.com/)

tract

can

cause

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D R U G
Generic / Trade Name Pantoprazole Dosage / Frequency 40mg IV OD Classificati on Antisecretor y Drug Proton Pump Inhibitor

S T U D Y
Contraindica tion Contraind icated with hypersens itivity to any proton pump inhibitor or any drug component s Use cautiousl y with pregnancy , lactation . Side Effects Nursing Responsibili ty Administe r once or twice a day. Arrange to have regular medical follow up care while using this drug. Maintain all of the usual activitie s and restricti ons that apply to your condition . If this becomes difficult , consult your health

Indication

The shortterm treatment of erosive esophagit is associate d with GERD. Maintenan ce treatment of duodenal or gastric ulcers. Treatment of pathologi cal hypersecr etory condition s. Adjunct treatment with

CNS: headache, dizziness , asthenia, vertigo, insomnia, apathy, anxiety, paresthes ia, dream abnormali ties. Dermatolo gic: rash, inflammat ion, urticaria , pruritus, alopecia, dry skin. GI: diarrhea, abdominal pain, nausea, vomiting, constipat

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antibioti cs for Helicobac ter pylori. IV: short term (710 days) treatment of GERD in patients unable to continue oral therapy.

ion, dry mouth, tongue atrophy. Respirato ry: URI symptoms, cough, epistaxis Other: cancer in preclinic al studies, back pain, fever, vitamin b12 deficienc y.

care provider. Report severe headache, worsening of symptoms, fevers, chills, blurred vision, periorbit al pain.

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Generic / Trade Name Tramadol

Dosage / Frequency 50mg IV q8

Classificati on Analgesic (centrally acting) Opioid analgesic

Indication

Contraindica tion Contraind icated to patients who have previousl y demonstra ted hypersens itivity to tramadol, any other component of this product or opioids Use cautiousl y with pregnancy , lactation ; seixures; concomita nt use of CNS depressan ts, MAIOs,

Side Effects

Relief of moderate to moderatel y severe pain Relief of moderate to severe chronic pain in adults who need around the clock treatment for extended periods Unlabeled uses: premature ejaculati on; restless leg syndrome.

CNS: sedation, dizziness or vertigo, headache, confusion , dreaming, sweating, anxiety, seizures. CV: hypotensi on, tachycard ia, bradycard ia Dermatolo gic: sweating, pruritus, rash, pallor, urticaria GI: nausea, vomiting, dry mouth, constipat

Nursing Responsibili ty Control environme nt if sweating or CNS effect occurs. The client may experienc e these side effects: dizziness , sedation, drowsines s, impaired visual acuity; nausea, loss of appetite Report severe nausea, dizziness , severe constipat ion.

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SSRIs, TCAs, renal impairmen t; hepatic impairmen t.

ion, flatulenc e Other: potential for abuse, anaphylac toid reactions .

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Generic / Trade Name Clindamycin

Dosage / Frequency 300mg/cap 1 cap q6

Classificati on Lincosamide Antibiotic

Indication

Contraindica tion Contraind icated with allergy to clindamyc in lactation . Use cautiousl y in newborns and infants due to benzyl alcohol content and in patients with tartrazin e sensitivi ty or hepatic or renal impairmen t.

Side Effects

Is indicated in the treatment of serious infection s caused by susceptib le anaerobic bacteria. Is also indicated in the treatment of serious infection s due to susceptib le strains of streptoco cci, pneumococ ci, and staphyloc occi.

Gastroint estinal: Abdominal pain, pseudomem branous colitis, esophagit is, nausea, vomiting and diarrhea Hypersens itivity Reactions : General ized mild to moderate morbillif orm-like (maculopa pular) skin rashes are the most frequentl y reported adverse reactions .

Nursing Responsibili ty Take oral drug with a full glass of water or with food. Take food prescribe d course of oral drug. Do not stop taking without notifying your health care provider. The client may experienc e nausea, vomiting; superinfe ctions in the mouth ( use hygienic measures, request

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Skin and Mucous Membranes : Pruritu s, vaginitis , and rare instances of exfoliati ve dermatiti s have been reported. Liver: Ja undice and abnormali ties in liver function tests have been observed during clindamyc in therapy. Renal: Al though no direct relations hip of clindamyc in to

treatment if severe) Report sever or watery diarrhea, abdominal pain, inflamed mouth, skin rash or lesion

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renal damage has been establish ed, renal dysfuncti on as evidenced by azotemia, oliguria, and/or proteinur ia has been observed in rare instances . Hematopoi etic: Tra nsient neutropen ia (leukopen ia) and eosinophi lia agranuloc ytosis and thrombocy topenia

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Generic / Trade Name Zilongjin

Dosage / Frequency 1 tab TID

Classificati on Supportive Care Therapy

Indication Dietary supplemen t for relief of adverse clinical reactions associate d w/ chemother apy.

Contraindica tion Zilongjin should not be administe red to pregnant women

Side Effects No observabl e toxic effects.

Nursing Responsibili ty May be taken with or without food (Take before or after meals w/ lukewarm water.). Store in a cool and dry place.

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A N A T O M Y
T h e B r e a s t s

A N D

P H Y S I O L O G Y

In order to understand breast cancer, it helps to have some basic knowledge about the normal structure of the breasts. The female breast is made up mainly of lobules (milk-producing glands), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels).

Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues. T h e L y m p h a t i c s y s t e m

The lymph system is important to understand because it is one of the ways in which breast cancers can spread. This system has several parts. 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

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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).

Knowing if the cancer cells have spread to lymph nodes is important because if it has, 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 your treatment plan. Still, not all women with cancer cells in their lymph nodes develop metastases, and in some cases a woman can have negative lymph nodes and later develop metastases.

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F i b r o c y s t i c

c h a n g e s

Most lumps turn out to be fibrocystic changes. The term "fibrocystic" refers to fibrosis and cysts. Fibrosis is the formation of fibrous (scar-like) tissue, and cysts are fluidfilled sacs. Fibrocystic changes can cause breast This often happens just before a woman's about to begin. Her breasts may feel lumpy may notice a clear or slightly cloudy nipple B e n i g n B r e a s t L u m p s swelling and pain. menstrual period is and, sometimes, she discharge.

Benign breast tumors such as fibroadenomas or intraductal papillomas are abnormal growths, but they are not cancerous and do not spread outside of the breast to other organs.They are not life threatening. Still, some benign breast conditions are important because women with these conditions have a higher risk of developing breast cancer.

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P A T O P H Y S I O L O G Y
Predisposing Age Gender Family history Etiology Unknown Precipitating -Exposure to radiation and certain chemicals

Somatic mutations in the DNA

Activate oncogene / deactivate tumor suppressor gene

Neoplasm formation in the breast

Primary tumor begins in the breast

If treated: -Surgery -Chemotherapy -Radiotherapy

If not treated

Tumor becomes invasive

Cancer cell destroyed

Progressed beyond the breast to regional lymph node

Travel to other organ system

Compromise the functions of the major organs

DEATH Case Presentation Page 50

E C O L O G I C

M O D E L

A. Hypothesis The patients condition is caused by the variety of factors which have interrelationship to one another. The factors that contribute to the occurrence of having Breast cancer are the host, the agent and the environment. Among the three factors, the host factors or the demographic factors of the clietn as well as her lifestyle tremendously contribute in the occurrence and causation of the disease. B. Predsiposing Factors 1. Host a. Age: 45 years old Simply growing older is the second biggest risk factor for breast cancer. From age 30 to 39, the risk is 1 in 233, or .43%. That jumps to 1 in 27, or almost 4%, by the time you are in your 60s. b. Sex: Female Being a woman is the most significant risk factor for developing breast cancer. Although men can get breast cancer, too, womens breast cells are constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risk for breast cancer. c. Nationality: Filipino White women are slightly more likely to develop breast cancer than are African American women. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer. d. Heredity: Family history of breast cancer If you have a first-degree relative (mother, daughter, sister) who has had breast cancer, or you have multiple relatives affected by breast or ovarian cancer (especially before they turned age 50), you could be at higher risk of getting breast cancer. e. Personaly History of breast cancer If you have already been diagnosed with breast cancer, your risk of developing it again, either in the same breast or the other breast, is higher than if you never had the disease. f. Menstrual History: The client said that she had her first menarche when she was about 12 years old.

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Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer including starting menstruation (monthly periods) at a young age (before age 12) g. Pregnancy History: The client only got pregnant once and she didnt breastfed her child. Pregnancy and breastfeeding reduce the overall number of menstrual cycles in a womans lifetime, and this appears to reduce future breast cancer risk. h. Exercise: The client does not have regular exercise. Evidence is growing that exercise can reduce breast cancer risk. The American Cancer Society recommends engaging in 45-60 minutes of physical exercise 5 or more days a week. i. Diet: The client eats beef and chicken as well. Diet is a suspected risk factor for many types of cancer, including breast cancer, but studies have yet to show for sure which types of foods increase risk. Its a good idea to restrict sources of red meat and other animal fats (including dairy fat in cheese, milk, and ice cream), because they may contain hormones, other growth factors, antibiotics, and pesticides. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer, and studies show that eating a lot of red and/or processed meats is associated with a higher risk of breast cancer. 2. Agent a. Chemical: The client undergone a lot of x-ray examinations before. The client does noit smoke however she can be considered as second-hand smoker or a passive one. Mounting evidence suggests that X-ray and gamma-ray exposure may be a significant and causative factor, particularly if the exposure is during childhood or early adulthood. Breathing secondhand smoke increases breast cancer risk by 70% in younger, primarily premenopausal women. The California Environmental Protection Agency has concluded that passive smoking causes breast cancer and the US Surgeon General has concluded that the evidence is "suggestive," one step below causal. 3. Environment

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a. Physical: The client prefers sleeping while the light is on. In 1978 Cohen et al. proposed that reduced production of the hormone melatonin might increase the risk of breast cancer and citing "environmental lighting" as a possible causal factor. Researchers at the National Cancer Institute (NCI) and National Institute of Environmental Health Sciences conducted a study in 2005 that suggests that artificial light during the night can be a factor for breast cancer by disrupting melatonin levels. b. Socio-economic: the client said his family belongs to middle class family. Incidence and mortality vary with social status. Incidence rises with improving economic situation, while mortality is tied to low economic status. C. Ecologic Model The lever model is used to show the relationship between the host, agent and the environment and to determine if there is an imbalance between the three (3) predisposing factors that may lead to an occurrence of disease. The diagram below shows the possible imbalance of the ecologic model caused by lifestyle of the client leading to the presence of the disease.

AGENT

HOST

ENV

D. Analysis The agent-host-environment model is primarily use in predicting illness rather than promoting wellness, although identification of risk factors that result from the

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interactions of agent, host, and environment are helpful in promoting and maintaining health. Because each of the agenthost-environment factors constantly interacts with others, health is an ever changing state. Health is seen when all three elements are in balance while illness is seen when one, two, or all three elements are not in balance (Fundamentals of Nursing by Kozier 2004). There were particularly an imbalance between the host herself and the agent. It should be balanced for the client to be healthy. The most frequent anatomic site for a cancer diagnosis in females is the breast although lung cancer accounts for more deaths in the female population. The disease seldom occurs in males. There is no single, specific cause of breast cancer. A combination of genetic, hormonal and possibly environmental factors may increase the risk of its development. (Source: Smeltzer et al, Brunner and Suddarth`s textbook of medical surgical nursing, page 1482) Breat cancer may develop any time after puberty , but most cases are diagnosed in females between 60 and 79. Five-year survival rates show increasing improvement becasue of earlier diagnosis and better treatment. Mortality rates, however, havent changed in the past 50 years. (Source: Williams & Wilkins, Handbook of medical-surgical nursing, page 120) E. Conclusion and Recommendations We therefore conclude that our client is suffering from Breast cancer due to the demographic prfile and lifestyle of the patient before. Other risk factors may also involve such as familil history the way of living. Recommendations may include lifestyle modification and being aware ofother potential risk factor that will cause worsening the disease like undergoing radiation therapy or even smoking.

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P R O B L E M
Date 04-14-11

P R I O R I T I Z A T I O N
Cues SThe client verbalized, Sobrang sakit na ng tiyan ko nung December pa to. - She said, Hindi na nga ako makagawa nang ayos dahil dito (pertaining to the pain). - The client verbalized, Wala pa akong tulog. Hindi ako makatulog dahil na din sa sakit ng tiyan ko. - The clients chief complaint was her abdominal pain. - When asked to rate the pain she is feeling at that moment, she rated it as 9 out of 10 (0 as no Justification This problem is an actual problem because it is already present at the time of nursing assessment which needs immediate action. This problem is also the primary concern of the client. Resources such as manpower and medications are readily available. The problem arises because physiological needs were not met.

Nursing Problems Identified Acute pain related to disease process as manifested by verbal report of pain, observed evidence pain, guarding behaviour, sleep disturbance and restlessness

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04-15-11

pain and 10 as severe pain). O- During the interview, the clients hand is over her abdomen as if guarding it. - Restless Disturbed Body Image S- The client related to surgery said that (mastectomy) as sometimes, manifested by she is verbalization of conscious feelings that reflect about her an altered view of appearance ones body, negative now that she feelings , removed has only one breast and not breast. looking at and not - When asked touching her breast to rate self-esteem, she verbalized, Siguro mababa mga 5 90 as the lowest, 10 as the highest) dahil sa wala na akong kanang suso pati na rin sa kondisyon ko ngayon (pertaining to her cancer that metastasize) . - She added, Minsan iniisip ko

This problem is under Maslows self esteem needs. Resources for this problem are available but it takes time to accept those things.

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04-15-11

kung anong iniisip ng ibang tao pag nakikita nila ako. O- The client has only one breast remaining (left breast). - When the client talks about her removed breast, she is not looking at her breast and she also does not touch it. Situational low self- S- When asked esteem related to to rate selfdisturbed body image esteem, she as manifested by verbalized, verbally reports Siguro mababa current situational mga 5 90 as the challenge to selflowest, 10 as worth, evaluation of the highest) self as unable to dahil sa wala deal with situations na akong kanang and self-negating suso pati na verbalizations rin sa kondisyon ko ngayon (pertaining to her cancer and body image). - The client said that sometimes, she is conscious about her appearance now that she

This problem is in accordance with the other problem. Once that problem is solved, there will be no problem like this.This problem is under Maslows self esteem needs.

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04-15-11

has only one breast. - She added, Minsan iniisip ko kung anong iniisip ng ibang tao pag nakikita nila ako. O- The client seems negative with regards to her image and it affects her view to herself Deficient knowledge S- The client (performing breast said, Laging selfnababanggit yun examination)related sakin pero to unfamiliarity with hindi ko naman information resources alam. as manifested by - The client verbalization of the said that she problem and is willing to inaccurate learn the performance of the selftest. examination O- when asked, she was not able to perform it

This problem is considered significant for her condition since BSE is an examination for having breast cancer. Resources for this are readily available what it takes is a good and understandable teaching.

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N U R S I N G
NURSING PROBLEM/CUES Acute pain related to disease process as manifested by verbal report of pain, observed evidence pain, guarding behaviour, sleep disturbance and restlessness Subjective: - The client verbalized, Sobrang sakit na ng tiyan ko nung December pa to. - She said, Hindi na nga ako makagawa nang ayos dahil dito (pertaining to the pain). - The client verbalized, Wala pa akong tulog. Hindi ako makatulog dahil na din sa sakit ANALYSIS Acute pain is caused by activation of nociceptors, is usually of short duration (less than 6 months), and has an immediate onset, such as incisional pain after surgery. (Black and Hawks, MedicalSurgical Nursing Clinical Management for Positive Outcomes Eight Edition, page 352)

C A R E

O F

P L A N
RATIONALE EVALUATION EFFECTIVENESS: Was the client able to report pain as relieved and controlled as evidenced by decrease in the rate of pain scale after 3 days. ___ Yes ___ No, why? __________

GOAL/OBJECTIVES GOAL: After 8 hour shift, the client will report pain as relieved and controlled as evidenced by decrease in the rate of pain scale

NURSING INTERVENTION

OBJECTIVE: After 30 minutes of demonstration, the client will return demonstrate the use of relaxation skills and diversional activities.

INDEPENDENT: Explore behavioral pain-management strategies, including:

Behavioral strategies divert attention from the pain, promote a sense of selfcontrol, encourage muscle relaxation, and may stimulate endorphin release. (Doenges et al, Nurses Pocket Guide Edition 11, page 501) Distraction is especially helpful

Was the client able to return demonstrate the use of relaxation skills and diversional activities after 30 minutes of demonstration? ___ Yes ___ No, why? __________

a. Distraction techniques, such

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ng tiyan ko. - The clients chief complaint was her abdominal pain. - When asked to rate the pain she is feeling at that moment, she rated it as 9 out of 10 (0 as no pain and 10 as severe pain). Objective: - During the interview, the clients hand is over her abdomen as if guarding it. - Restless

as talking or listening to soothing music

for brief episodes of pain, but may increase pain perception and fatigue after the distracting pain is removed. (Doenges et al, Nurses Pocket Guide Edition 11, page 501) These techniques reduced muscle tension, enhance rest and promote a sense of well being by stimulating the relaxation response, which counteracts the physiological arousal of the stress response. (Doenges et al, Nurses Pocket Guide Edition 11, page 501)

b. Relaxation techniques, such as rhythmic breathing and progressive muscle relaxation

c. Use of guided The image of imagery during flying and painful procedure. looking down on

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a peaceful setting is especially helpful to detach the patient from the painful experience. (Doenges et al, Nurses Pocket Guide Edition 11, page 501) DEPENDENT: Collaborate with the physician and clinical pharmacist as needed to determine an effective analgesic regimen. Administer and document analgesics as ordered. Analgesics may include:

After every administration of medications (every 4 hours), the client will follow prescribed pharmacological regimen.

Personalizing the analgesic regimen recognizes individual differences in pain perception and provides the most effective control for particular patient. (Doenges et al, Nurses Pocket Guide Edition 11, page 502) Nonnarcotic analgesics work peripherally, inhibiting formation of prostaglandins

Was the client able to follow prescribed pharmacological regime after every administration of medications (every 4 hours)? . ___ Yes ___ No, why? __________ EFFICIENCY: Were the time, materials, and the resources used economically? ___ Yes ___ No, why? __________ ADEQUACY: Were the numbers of intervention sufficient?

a. nonnarcotic analgesics or nonsteroidal antiinflammatory drugs

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(NSAIDs), such as aspirin, acetaminophen, ibuprofen, ketorolac

and bradykinins (inflammatory mediators that increase pain). These drugs are used alone for mild pain and in combination with opioids for moderate to severe pain. NSAIDs should be used as the basis for managing all types of pain. (Doenges et al, Nurses Pocket Guide Edition 11, page 502) Opioids work by occupying central receptor sites, decreasing the perception of pain. Theyre used for moderate or severe pain, and they may cause sedation, respiratory depression,

___ Yes ___ No, why? __________ ACCEPTABILITY: Were the interventions suitable to clients situation? ___ Yes ___ No, why? __________ APPROPRIATENESS: Were the intervention setting and time table realistic to clients situation? ___ Yes ___ No, why? __________

b. opioids (narcotics), such as codeine, morphine, and meperidine (Demerol).Note: Monitor for oversedation, hypotension, or respiratory depression. If they occur, limit

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the amount or interval before administering the next opioid dose. Obtain an order to discontinue meperidine within 24 hours. Evaluate and document clients response to analgesia, and assist in transitioning or altering drug regimen, if needed.

nausea, vomiting, or constipation. (Doenges et al, Nurses Pocket Guide Edition 11, page 502)

Stepped program (switching from injection or parenteral to oral route, increased time span as pain lessens) helps in self-management of pain (Doenges et al, Nurses Pocket Guide Edition 11, page 502)

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A P P E N D I C E S
S t a g e s
Stage Stage 0 Stage I

o f

B r e a s t

C a n c e r

Stage IIA

Stage IIB

Stage IIIA

Stage IIIB

Definition Cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue. Cancer is 2 centimeters or less and is confined to the breast (lymph nodes are clear). No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm) OR the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes OR the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes. The tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes OR the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes. No tumor is found in the breast. Cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone OR the tumor is any size. Cancer has spread to the axillary lymph nodes, which are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone. The tumor may be any size and has spread to the chest wall and/or skin of the breast AND may have spread to axillary lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone. Inflammatory breast cancer is considered at least stage IIIB. There may either be no sign of cancer in the breast or a tumor may be any size and may have spread to the chest wall and/or the skin of the breast AND the cancer has spread to lymph nodes either above or below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone. The cancer has spread or metastasized to other parts of the body.

Stage IIIC

Stage IV

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B r e a s t

C a n c e r

R i s k

F a c t o r s

A risk factor is anything that increases your risk of developing breast cancer. Many of the most important risk factors for breast cancer are beyond your control, such as age, family history, and medical history. However, there are some risk factors you can control, such as weight, physical activity, and alcohol consumption. Be sure to talk with your doctor about all of your possible risk factors for breast cancer. There may be steps you can take to lower your risk of breast cancer, and your doctor can help you come up with a plan. Your doctor also needs to be aware of any other risk factors beyond your control, so that he or she has an accurate understanding of your level of breast cancer risk. This can influence recommendations about breast cancer screening what tests to have and when to start having them.

I.

Risk

factors

you

can

control

Weight. Being overweight is associated with increased risk of breast cancer, especially for women after menopause. Fat tissue is the bodys main source of estrogen after menopause, when the ovaries stop producing the hormone. Having more fat tissue means having higher estrogen levels, which can increase breast cancer risk. Diet. Diet is a suspected risk factor for many types of cancer, including breast cancer, but studies have yet to show for sure which types of foods increase risk. Its a good idea to restrict sources of red meat and other animal fats (including dairy fat in cheese, milk, and ice cream), because they may contain hormones, other growth factors, antibiotics, and pesticides. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer, and studies show that eating a lot of red and/or processed meats is associated with a higher risk of breast cancer. A low-fat diet rich in fruits and vegetables is generally recommended. For more information, visit our page on healthy eating to reduce cancer risk in the Nutrition section. Exercise. Evidence is growing that exercise can reduce breast cancer risk. The American Cancer Society recommends engaging in 45-60 minutes of physical exercise 5 or more days a week. Alcohol consumption. Studies have shown that breast cancer risk increases with the amount of alcohol a woman drinks. Alcohol can limit your livers ability to control blood levels of the hormone estrogen, which in turn can increase risk. Smoking. Smoking is associated with a small increase in breast cancer risk.

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Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are under your control, such as:

taking combined hormone replacement therapy (estrogen and progesterone; HRT) for several years or more, or taking estrogen alone for more than 10 years being overweight regularly drinking alcohol

Recent oral contraceptive use. Using oral contraceptives (birth control pills) appears to slightly increase a womans risk for breast cancer, but only for a limited period of time. Women who stopped using oral contraceptives more than 10 years ago do not appear to have any increased breast cancer risk. Stress and anxiety. There is no clear proof that stress and anxiety can increase breast cancer risk. However, anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction can have a major effect on your quality of life. So-called mindful measures (such as meditation, yoga, visualization exercises, and prayer) may be valuable additions to your daily or weekly routine. Some research suggests that these practices can strengthen the immune system.

I I . R i s k f a c t o r s c o n t r o l

y o u

c a n t

Gender. Being a woman is the most significant risk factor for developing breast cancer. Although men can get breast cancer, too, womens breast cells are constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risk for breast cancer. Age. Simply growing older is the second biggest risk factor for breast cancer. From age 30 to 39, the risk is 1 in 233, or .43%. That jumps to 1 in 27, or almost 4%, by the time you are in your 60s. Family history of breast cancer. If you have a first-degree relative (mother, daughter, sister) who has had breast cancer, or you have multiple relatives affected by breast or ovarian cancer (especially before they turned age 50), you could be at higher risk of getting breast cancer. Personal history of breast cancer. If you have already been diagnosed with breast cancer, your risk of developing it again, either in the same breast or the other breast, is higher than if you never had the disease.

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Race. White women are slightly more likely to develop breast cancer than are African American women. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer. Radiation therapy to the chest. Having radiation therapy to the chest area as a child or young adult as treatment for another cancer significantly increases breast cancer risk. The increase in risk seems to be highest if the radiation was given while the breasts were still developing (during the teen years). Breast cellular changes. Unusual changes in breast cells found during a breast biopsy (removal of suspicious tissue for examination under a microscope) can be a risk factor for developing breast cancer. These changes include overgrowth of cells (called hyperplasia) or abnormal (atypical) appearance. Exposure to estrogen. Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of these risk factors are not under your control, such as:

starting menstruation (monthly periods) at a young age (before age 12) going through menopause (end of monthly cycles) at a late age (after 55) exposure to estrogens in the environment (such as hormones in meat or pesticides such as DDT, which produce estrogen-like substances when broken down by the body)

Pregnancy and breastfeeding. Pregnancy and breastfeeding reduce the overall number of menstrual cycles in a womans lifetime, and this appears to reduce future breast cancer risk. Women who have never had a full-term pregnancy, or had their first full-term pregnancy after age 30, have an increased risk of breast cancer. For women who do have children, breastfeeding may slightly lower their breast cancer risk, especially if they continue breastfeeding for 1 1/2 to 2 years. For many women, however, breastfeeding for this long is neither possible nor practical. DES exposure. Women who took a medication called diethylstilbestrol (DES), used to prevent miscarriage from the 1940s through the 1960s, have a slightly increased risk of breast cancer. Women whose mothers took DES during pregnancy may have a higher risk of breast cancer as well.

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S y m p t o m s

&

D i a g n o s i s

Breast cancer symptoms vary widely from lumps to swelling to skin changes and many breast cancers have no obvious symptoms at all. Symptoms that are similar to those of breast cancer may be the result of non-cancerous conditions like infection or a cyst. Breast self-exam should be part of your monthly health care routine, and you should visit your doctor if you experience breast changes.

Mammogram. If you're over 40 or at a high risk for the disease, you should also have an annual mammogram. Physical Exam by a doctor. The earlier breast cancer is found and diagnosed, the better your chances of beating it. The actual process of diagnosis can take weeks and involve many different kinds of tests. Waiting for results can feel like a lifetime. The uncertainty stinks. But once you understand your own unique big picture, you can make better decisions. You and your doctors can formulate a treatment plan tailored just for you.

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R i s k

o f

D e v e l o p i n g C a n c e r

B r e a s t

The term risk is used to refer to a number or percentage that describes how likely a certain event is to occur. When we talk about factors that can increase or decrease the risk of developing breast cancer, either for the first time or as a recurrence, we often talk about two different types of risk: absolute risk and relative risk. I . A b s o l u t e r i s k

Absolute risk is used to describe an individuals likelihood of developing breast cancer. It is based on the number of people who will develop breast cancer within a certain time period. Absolute risk also can be stated as a percentage. The absolute risk of developing breast cancer during a particular decade of life is lower than 1 in 8. The younger you are, the lower the risk. For example:

From age 30 to 39, absolute risk is 1 in 233, or 0.43%. This means that 1 in 233 women in this age group can expect to develop breast cancer. Put another way, your odds of developing breast cancer if you are in this age range are 1 in 233. From age 40 to 49, absolute risk is 1 in 69, or 1.4%. From age 50 to 59, absolute risk is 1 in 38, or 2.6%. From age 60 to 69, absolute risk is 1 in 27, or 3.7%. R e l a t i v e r i s k

I I .

Relative risk is a number or percentage that compares one groups risk of developing breast cancer to anothers. This is the type of risk frequently reported by research studies, which often compare groups of women with different characteristics or behaviors to determine whether one group has a higher or lower risk of breast cancer than the other (either as a first-time diagnosis or recurrence). E n d - o f - L i f e I s s u e s

Palliative care, which provides physical, emotional, and spiritual relief, must be provided with attempts for curative therapy and becomes the exclusive goal when cure cannot be expected. At all stages of breast cancer, treatment needs to be modified for life expectancy. For patients with metastatic disease for which cure is not attainable, the physician should clarify the goals of care through frequent, clear discussions with the patient and, when appropriate, the family. All should recognize that cognitive impairment alone does

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not exclude the patient from participating in decision making, because some patients with impaired cognition are able to understand, explain the consequences of, and voice an opinion about certain treatment options. Pain from bony metastases should be treated as described above with nonsteroidal anti-inflammatory drugs, pamidronate, local radiation, and strontium 89 rather than with opioids if possible. Palliative chemotherapy may be useful when the tumor invades vital organs.

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Chemotherapy
Chemotherapy is treatment with cancer-killing drugs that may be given intravenously (injected into a vein) or by mouth. The drugs travel through the bloodstream to reach cancer cells in most parts of the body. The chemotherapy is given in cycles, with each period of treatment followed by a recovery period. Treatment usually lasts for several months. When is chemotherapy used? There are several situations in which chemotherapy may be recommended. Adjuvant chemotherapy: Systemic therapy given to patients after surgery who have no evidence of cancer spread is called adjuvant therapy. When used as adjuvant therapy after breast-conserving surgery or mastectomy, chemotherapy reduces the risk of breast cancer coming back. Even in the early stages of the disease, cancer cells may break away from the primary breast tumor and spread through the bloodstream. These cells don't cause symptoms, they don't show up on imaging tests, and they can't be felt during a physical exam. But if they are allowed to grow, they can establish new tumors in other places in the body. The goal of adjuvant chemotherapy is to kill undetected cells that have traveled from the breast. Neoadjuvant chemotherapy: Chemotherapy given before surgery is called neoadjuvant therapy. The major benefit of neoadjuvant chemotherapy is that it can shrink large cancers so that they are small enough to be removed by lumpectomy instead of mastectomy. Another possible advantage of neoadjuvant chemotherapy is that doctors can see how the cancer responds to chemotherapy. If the tumor does not shrink, your doctor may try different chemotherapy drugs. So far, it's not clear that neoadjuvant chemotherapy improves survival, but it seems to be at least as effective as adjuvant therapy after surgery. Chemotherapy for advanced breast cancer: Chemotherapy can also be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is diagnosed, or if it spreads after initial treatments. The length of treatment depends on whether the cancer shrinks, how much it shrinks, and how a woman tolerates length of treatment. Some of the most common possible side effects include: hair loss mouth sores loss of appetite nausea and vomiting increased chance of infections (due to low white blood cell counts) easy bruising or bleeding (due to low blood platelet counts) fatigue (due to low red blood cell counts and other reasons)

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D E F I N I T I O N

O F

T E R M S

Breast cancer general terms It is important to understand some of the key words used to describe breast cancer. Carcinoma This is a term used to describe a cancer that begins in the lining layer (epithelial cells) of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas). Adenocarcinoma Is a type of carcinoma that starts in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk), so cancers starting in these areas are sometimes called adenocarcinomas. Carcinoma in situ This term is used for the early stage of cancer, when it is confined to the layer of cells where it began. In breast cancer, in situ means that the cancer cells remain confined to ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). They have not invaded into deeper tissues in the breast or spread to other organs in the body, and are sometimes referred to as non-invasive breast cancers. Invasive (infiltrating) carcinoma An invasive cancer is one that has already grown beyond the layer of cells where it started(as opposed to carcinoma in situ). Most breast cancers are invasive carcinomas either invasive ductal carcinoma or invasive lobular carcinoma. Sarcoma Sarcomas are cancers that start from connective tissues such as muscle tissue, fat tissue, or blood vessels. Sarcomas of the breast are rare. Triple-negative breast cancer This term is used to describe breast cancers (usually invasive ductal carcinomas) whose cells lack estrogen receptors and progesterone receptors. Breast cancers with these characteristics tend to occur more often in younger women and in African-American women, and they tend to grow and spread more quickly than most other types of breast cancer. Because the tumor cells lack these receptors, neither hormone therapy nor drugs that target HER2 are effective against these cancers (although chemotherapy may be useful if needed). Mixed tumors Mixed tumors are those that contain a variety of cell types, such as invasive ductal cancer combined with invasive lobular breast

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cancer. In this situation, the tumor is treated as if it were an invasive ductal cancer. Medullary carcinoma This special type of infiltrating breast cancer has a rather well defined boundary between tumor tissue and normal tissue. It also has some other special features, including the large size of the cancer cells and the presence of immune system cells at the edges of the tumor. Medullary carcinoma accounts for about 3% to 5% of breast cancers. The outlook (prognosis) for this kind of breast cancer is generally better than for the more common types of invasive breast cancer. Most cancer specialists think that true medullary cancer is very rare, and that cancers that are called medullary cancer should be treated as the usual invasive ductal breast cancer. Metaplastic carcinoma Is a very rare type of invasive ductal cancer. These tumors include cells that are normally not found in the breast, such as cells that look like skin cells (squamous cells) or cells that make bone. These tumors are treated like invasive ductal cancer. Mucinous carcinoma Also known as colloid carcinoma, this rare type of invasive breast cancer is formed by mucus-producing cancer cells. The prognosis for mucinous carcinoma is usually better than for the more common types of invasive breast cancer. Paget disease of the nipple This type of breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola, the dark circle around the nipple. It is rare, accounting for only about 1% of all cases of breast cancer. The skin of the nipple and areola often appears crusted, scaly, and red, with areas of bleeding or oozing. The woman may notice burning or itching. Paget disease is almost always associated with either ductal carcinoma in situ (DCIS) or, more often, with infiltrating ductal carcinoma. If no lump can be felt in the breast tissue and the biopsy shows DCIS but no invasive cancer, the prognosis is excellent. Tubular carcinoma Tubular carcinomas are another special type of invasive ductal breast carcinoma. They are called tubular because of the way the cells are arranged when seen under the microscope. Tubular carcinomas account for about 2% of all breast cancers and tend to have a better prognosis than most other infiltrating ductal or lobular carcinomas. Papillary carcinoma The cells of these cancers tend to be arranged in small, fingerlike projections when viewed under the microscope. These cancers are most often considered to be a subtype of ductal carcinoma in situ (DCIS), and are treated as such. In rare cases they are invasive, in

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which case they are treated like invasive ductal carcinoma, although the outlook is likely to be better. These cancers tend to be diagnosed in older women, and they make up no more than 1% or 2% of all breast cancers. Adenoid cystic carcinoma (adenocystic carcinoma) These cancers have both glandular (adenoid) and cylinder-like (cystic) features when seen under the microscope. They make up less than 1% of breast cancers. They rarely spread to the lymph nodes or distant areas, and they tend to have a very good prognosis. Phyllodes tumor This very rare breast tumor develops in the stroma (connective tissue) of the breast, in contrast to carcinomas, which develop in the ducts or lobules. Other names for these tumors include phylloides tumor and cystosarcoma phyllodes. These tumors are usually benign but on rare occasions may be malignant. Benign phyllodes tumors are treated by removing the mass along with a margin of normal breast tissue. A malignant phyllodes tumor is treated by removing it along with a wider margin of normal tissue, or by mastectomy. While surgery is often all that is needed, these cancers may not respond as well to the other treatments used for invasive ductal or lobular breast cancer. Angiosarcoma This is a form of cancer that starts from cells that line blood vessels or lymph vessels. It rarely occurs in the breasts. When it does, it is usually seen as a complication of radiation to the breast. It tends to develop about 5 to 10 years after radiation treatment. However, this is an extremely rare complication of breast radiation therapy. Angiosarcoma can also occur in the arm of women who develop lymphedema as a result of lymph node surgery or radiation therapy to treat breast cancer. These cancers tend to grow and spread quickly. Treatment is generally the same as for other sarcomas.

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B I B L I O G R A P H Y

Huether, S.E., McCance K.L., (2004). Understanding Pathophysiology 3rd edition. USA: Mosby Doenges, M E., Moorehouse, M.F., (2002). Nursing Care Plans: Guidelines for individualizing patient cares 6th edition. Philadelphia USA: Davis company Lee, E.C., Banasik, J., (2005). Philippines: Elsevier Saunders Pathophysiology 3rd edition. Critical

Lemone, P., Burke, K., (2004). Medical-surgical Thinking in Client Care 3rd edition. USA: Pearson

Nursing:

Schilling, J.A., Kelly, W.J., et al (2007). Nursing Drug Handbook 27th edition. Philippines: Lippincott William and Wilkins. Smeltzer, S.C., Bare, B.G., Hinkle, J.L., and Cheever, K.H. (2008). Brunner and Suddarths Textbook of Medical-Surgical Nursing 11th edition. Philippines: Lippincott Williams and Wilkins. Kozier and Erb, Fundamentals of Nursing Weber and Kelly, Health Assessment in Nursing 3rd Edition Smeltzer et al, Brunner and Suddarth`s textbook of medical surgical nursing

Case Presentation

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