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Adamson University

College of Nursing

BREAST CANCER STAGE 4 WITH PLEURAL EFFUSION

An Undergraduate

CASE STUDY

Presented to the Faculty of the College of Nursing

ADAMSON UNIVERSITY

In Partial Fulfillment

Of the Requirements for the Subject of

Related Learning Experience

Submitted By:

Peetchee C. Malayao

November 23, 2018

Submitted to:

Mrs. Rufina Salvador., RN, MN

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Adamson University
College of Nursing

I. Objectives of the Case Study

 To be able to apply nursing process plan and implement care for the patient who experiences
late stage breast cancer with pleural effusion
 To be able to discuss the nursing intervention for the patient
 To know the proper treatment and management to be able to render excellent Nursing quality
care.

II. Introduction

a. Definition of Case

 Breast cancer is a malignant tumor that starts in the cells of the breast. A malignant tumor is a group of
cancer cells that can grow into (invade) surrounding tissues or spread (metastasize) to distant areas of
the body. Malignant pleural effusions occur commonly in patients with cancer. The malignancies
responsible for more than 75% of all of pleural effusions in order of frequency are lung, breast,
lymphoma, and ovarian cancer. The treatment receives to treat breast cancer is TAC chemotherapy
(T - docetaxel or Taxotere, doxorubicin AKA Adriamycin, Cyclophosphamide.). Pleural effusion,
drainage cannot be done if the lungs has no space in between which means it will be very hard to extract
fluid in the lungs. Based on study, chemotherapy achieved symptom relief.

 A Pleural Effusion is defined as an accumulation of fluid in the pleural space. Pleural fluid normally
seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed
by the visceral pleura, capillaries and lymphatic’s system. Any condition that interferes with either
secretion or drainage of this fluid leads to pleural effusion. Clinical manifestations depend of the amount
of fluid present and the severity of lung compression. If the effusion is small (ie 250 cc) its presence
may bed is covered only on a chest radiograph. For larger effusions, lung expansion may be restricted
and the client may experience dyspnea primarily on exertion, and a dry, non- productive cough caused
by bronchial irritation or mediastinal shift. (Black, Hawk. 2008.Vol. 2 p1631)Effusions also occur when
the rate of fluid formation exceeds the rate of fluid absorption. Pleural effusions are commonly classified
as being either exudative or transudative. An exudative pleural effusion implies that there is a disease

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College of Nursing

process that is affecting the pleura directly, causing the pleura to be damaged. A transudative pleural
effusion results when the pleura itself is healthy and implies that a disease process is affecting
hydrostatic and/or oncotic factors that either increase the formation of pleural fluid or decrease the
absorption of pleural fluid. Deciding if the pleura is injured or intact helps in formulating a concise
differential diagnosis for potential causes (Kollef et al.,2012, p.105).Factors that increase the chance of
developing pleural effusion include: pneumonia, tuberculosis or other lung diseases, heart attack, heart
failure, or infections such as pericarditis, recent cardiac surgery, pleurisy, tumors, cancers, such as lung,
breast, surgery, especially involving the heart, lungs, abdomen and organ transplantation. Tests to
diagnose pleural effusion include chest x-ray, ultrasound, CT scan, thoracentesis, pulmonary function
tests and biopsy.

b. Etiology
Age-adjusted incidence rates of breast cancer vary greatly worldwide with highest rates found in the
typically ‘westernized’ countries of North America and Europe. Much lower rates are observed in Asian and
African populations but an exception to this has been reported for the Manila Cancer Registry in the
Philippines. The reason for this high rate is unknown but may be associated with the change in lifestyle that
has occurred in urban Manila since the 1960s. In 1995, a randomized controlled trial was set up in Manila to
evaluate the feasibility of a screening intervention by clinical breast examination as an alternative to
mammography. There is still lack of knowledge of the direct etiology of breast cancer development, but, it is
estimated that 5-10% of breast cancer cases is due to inheritance in the close family (first degree relatives such
as mother, daughter, sister or grandmother).

c. Incidence
About 1 in 8 U.S. women (about 12.4%) will develop invasive breast cancer over the course of her
lifetime.
In 2018, an estimated 266,120 new cases of invasive breast cancer are expected to be diagnosed
in women in the U.S., along with 63,960 new cases of non-invasive (in situ) breast cancer.
In 2016, the Philippines topped 197 countries with the most number of cases of breast cancer, data
released by Philippine Obstetrical and Gynecological Society have shown. (Manila Times, 2016)

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d. General signs and symptoms


1. skin changes like dimpling or ulceration (sometimes looking like an orange peel)
2. nipple discharge (other than breast milk)
3. Swelling of all or part of a breast (even if no distinct lump is felt)
4. large, hard palpable lymph nodes under your arm or in your neck
5. Breast or nipple pain
6. pain or discomfort
7. Nipple retraction (turning inward)
8. Redness, scaliness, or thickening of the nipple or breast skin

III. a. Patient’s Data

PATIENT’S PROFILE

NAME : Mrs. BreCa Pleura

AGE : 56 years old

GENDER : Female

ADDRESS : San Diego Manila

DATE OF BIRTH : August 13,1962

PLACE OF BIRTH : Manila

OCCUPATION : Military Nurse

NATIONALITY : Filipino

CIVIL STATUS : Married

RELIGION : Roman Catholic

Clinical Data

CHIEF COMPLAINT : Patient complains of painful firm breast lump

FINAL DIAGNOSIS : Stage IV Breast Cancer with Pleural Effusion

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DATE ADMITTED : October 28, 2018

TIME ADMITTED : 12:45 PM

ADMITTING INSTITUTION: Veterans Oncology ward

b. Nursing History

i. CHIEF COMPLAINT

The patient complains difficulty of breathing

ii. PRESENT HISTORY

2 months prior to admission, Mrs. BreCa Pleura experiences discomfort on her Right breast
sometimes radiating to the back. She said that she also sees discharges from her breast. She also
reported that her breast were swelling. She also complaining of dyspnea for couple of weeks and
cough, with production of whitish secretion she has been refusing to get admitted in the hospital
because of her work and other matters. She feel easy fatigability, she has pallor with chest pain but
no change in BMI. The persistent of these symptoms prompted her admission at Veterans Hospital
last October 28, 2018 at 12: 24 PM. After series of tests, she was diagnosed with having Stage IV
Breast Cancer with Pleural Effusion. As of now, she was having 6 cycle chemotherapy as her
treatment. After being diagnosed, we interviewed her and she was sad of having the diagnosis she
is very positive that it can be cured and she hope to go home as soon as she finish her therapy she
also have mentioned that only God knows what is going to happen to her and she is claiming that
she is a strong independent woman. She have mentioned that she is still currently working as Head
Nurse specialized in lung problem in the Hospital for Soldiers and she still want to go back to work
there when she come out the hospital.

PAST HISTORY

Mrs. BreCa Pleura was born via normal spontaneous vaginal delivery. She was delivered at term at
39 weeks age of gestation weighing 9 pounds at Public Hospital somewhere in Manila. She was a

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College of Nursing

fully immunized child receiving 3 doses of DPT, 3 doses of OPV, 3 doses of Hepatitis vaccine,
measles vaccine and PTT vaccines when she was pregnant. She stated that she already experienced
chicken pox and measles. There were no drugs were given to her as a relief. Mrs. BreaCa Pleura she
has been hospitalize when she delivered 3 of her children, All are delivered NSD and are in Normal
terms and their weight are all normal as well but aside from giving birth she hasn’t been admitted
to the hospital. She had Breast Cancer on the left side, Stage II and she had Mastectomy last 2012.
She also had Hypertension, Diabetes, Asthma, COPD and heart problem but patient doesn’t want to
admit that she had it. She always refuse taking Medications and since she is working in the hospital
as head nurse she doesn’t want to be admitted she keep on saying that she can take care of herself.
She also often experience common illness such as fever, colds and coughs once or twice in a year
and was treated at home. She consult the doctor before she take any medications. The only
medication she usually take Paracetamol for fever and Lagundi Herbal for cough and she does water
therapy when she had cold. She had no allergies on foods. She had her menarche when she was
12years old. And also had regular in menstruation cycle for 5 days) and consumes 3 pads per day.
Mrs. BreCa Pleura doesn’t have any vices, she drink alcohol very occasionally.

iii. FAMILY HISTORY

Mrs. BreaCa Pleura said that her mother has Hypertension and her Brother has
Esophageal Cancer.

iv. SOCIAL HISTORY

Mrs. BreCa Pleura is working as Head Nurse in Lung ward in a Govern Hospital
somewhere in Manila. Her father died when she was young from the plane crash. Her father was
an Airforce working in the Fort Bonifacio. She was greatly influence by her father that’s why she
join the Airforce group as well and serve her colleagues soldiers and for her country.
According to Mrs. BreCa Pleura they eat three times a day she said because she is very
busy she don’t have much time to cook so they do takeout food or delivery from fast food since
they live near the Market Market, they it is for their breakfast, lunch and dinner. Furthermore, she
has no and she doesn’t really drink alcohol unless there are special occasion. After working for

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College of Nursing

how many hours, she goes directly at home she don’t have much time sorting stuff at home to she
sometimes cannot sleep properly because of the paper works that she have to do. During the
weekend her and husband used to go church together with her children and grandchild.

v. DEVELOPMENTAL HISTORY

(According to Erikson, Piaget)

THEORIST AGE SEX PATIENT DESCRIPTION

Erickson Generativity vs FEMALE Adults who are in their 40s and 50s tend to find
Stagnation (40-65 meaning in their work. They feel like at this point
years old) in their lives, they should be able to contribute
something meaningful to the society and leave a
legacy. If they fail to achieve this, they feel like
they have been an unproductive member of the
society. Each adult must find some way to relate
to, lead, and support the next generation. This
period is inherently a period for leadership. The
biological imperative again is about effective
parenting, but Erikson claimed that every adult can
be generative as long as they are doing “the work
of the world.” Failure at this stage results in a
sense of stagnation and lagging purpose.

vi. FEEDING HISTORY

Mrs. BreCa Pleura very often prepare food for her family because of busy schedule. They
used to eat out or have the food to be delived ti their house. She usually eats instant foods and
preservative foods such as canned goods and instant pancit canton etc. She is though love eating
vegetables, fish and meat. She also love to eat barbecues and spicy foods.

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vii. IMMUNIZATION HISTORY

The patient has a complete immunization history.

viii. PHYSICAL EXAMINATION

General Survey

This physical assessment was conducted last November 19, 2018 @ 9:15 am to a 56 year old woman, at
the Oncology ward in room 104. Patient was sitting on a chair on a Orthopneic position, awake, conscious and
coherent; with respiratory difficulty breathing with an ongoing Oxygen therapy regulated at 2LMP. She was
wearing a comfortable dress. With an intravenous fluid of PNSS 1 liter to run at 27-28 gtts/min infusing well at
right metacarpal vein @ 60 cc level. She has an endomorphic body built. She is slightly irritable and
unapproachable at first but she become cooperative in at end of health assessment. Patient established good eye
contact when conversing with the student nurse assigned. Speech is clear and cultural appropriate. She gives
appropriate responses both verbally and non-verbally to our questions.

PHYSICAL ASSESSMENT

Date assessed: November


General assessment: conscious and coherent
Initial vital signs: T=36.8°C, RR=22 cpm, BP=110/70 mmHg, PR=98 bpm

Area Assessed Techniqu Normal Findings Actual Findings Evaluation


e
Skin

Color Inspection Tanned skin Light brown skin Normal


Soles and Inspection Lighter colored palms, Lighter colored palms, Normal
palms soles soles with rough skin
Moisture Inspection Skin normally dry Skin normally dry Normal
/
Palpation
Temperature Palpation Normally warm Normally warm Normal

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Texture Palpation Smooth and soft Smooth and soft Normal


Turgor Palpation Skin snaps back Skin snaps back Normal
immediately immediately
Skin
appendages

a. Nails Inspection Transparent, smooth and Transparent, smooth and Normal


convex convex
Nail beds Inspection Pinkish Slightly Pale Due to decreased
blood flow
Nail base Inspection Firm Firm Normal
White color of nail bed Returns within 2-3 Normal
under pressure should seconds
Capillary refill Inspection return to pink within 2-3
/ Palpation seconds
b. Hair
Distribution Inspection Evenly distributed Not evenly distributed, Normal
Patient is having hair fall
everyday
Color Inspection Black Tri color: Black, brown Normal
and few gray color
Texture Inspection Smooth Smooth but thin hair Normal
/ Palpation
Eyes

Eyes Inspection Parallel to each other Parallel to each other Normal


Sclera Inspection Color is white Color is white Normal
Cornea Inspection Transparent, shiny Transparent, shiny Normal
Pupils Inspection Black, constrict briskly Black, constrict briskly Normal
Iris Inspection Clearly visible Clearly visible Normal
Ears
Ear canal Inspection Free of lesions, discharge Free of lesions, discharge Normal
opening of inflammation of inflammation

Canal walls pink Canal walls pink


Normal
Hearing Acuity Inspection Client normally hears Client normally hears
words when whispered words when whispered Normal
Nose

Shape, size and Inspection Smooth, symmetric with Smooth, symmetric with Normal
skin color same color as the face same color as the face

Nares Inspection

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Oval, symmetric and Oval, symmetric and Normal


without discharge without discharge

Mouth and
Pharynx
Lips Inspection Pink, moist symmetric Light pink, dry, Lack of fluid intake
symmetric
Teeth Inspection Firmly set, shiny Firmly set, shiny Normal
She had root canal on her
4 front bottom teeth
Hard and soft Inspection Hard palate- dome-shaped Hard palate- dome-
palate Soft Palate- light pink shaped Normal
Soft Palate- light pink
Neck

Symmetry of Inspection Neck is slightly hyper Neck is slightly hyper Normal


neck muscles, extended, without masses extended, without masses
alignment of or asymmetry or asymmetry
trachea
Neck ROM Inspection Neck moves freely, Neck moves freely, Normal
without discomfort without discomfort
Thyroid gland Palpation Rises freely with Rises freely with Normal
swallowing swallowing
Thorax and Auscultati Clear breath sounds Slight wheezing sound Maybe narrowing of
Lungs on on the right lungs bronchial tube due to
accumulation of fluid
Abdomen Inspection Skin same color with the Skin same color with the Normal
rest of the body rest of the body

Bowel sounds Auscultati Clicks or gurling sounds Clicks or gurling sounds Normal
on occur irregularly and occur irregularly and
range from 5-35 per range from 20 per minute
minute

Extremities Inspection Symmetrical Symmetrical Normal

Symmetry Inspection Same with the color of Same with the color of Normal
other parts of the body other parts of the body
Skin color
Evenly distributed Evenly distributed
Inspection Normal
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Function and Techniques Before During INTERPRETATION


Hospitalization Hospitalization
Warm to touch Warm to touch
Hair Palpation Normal
distribution
No lesions No lesions
Skin Inspection Normal
Temperature Moves freely without Able to move but with
Inspection discomfort assistance Due to body
Presence of weakness
lesion
ROM
Neurology
system

Level of Inspection Fully conscious, respond Fully conscious, respond Normal


consciousness to questions quickly, to questions quickly
perceptive of events perceptive of events

Behavior and Inspection Makes eye contact with Makes eye contact with
appearance examiner, hyperactive examiner, hyperactive
expresses feelings with expresses feelings with Normal
response to the situation response to the situation

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

Health Perception – She perceived her health She thinks that she is sick Due to her condition
Health Management in the state of good but she is sure that she can
Pattern condition. overcome it. She has
positive mindset.

Nutrition  Eats 3x a day in the  Mostly eat Vegetable,  The Doctor


restaurants and take fruits without skin, ordered Low salt,
out fods fish and meat Low fat, Low
 She eat bread &  Eats 3x a day cholesterol, High
processed foods such Fiber and about
as hotdog, tocino, 1800 Kcal

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longanisa, noodle,
pickles and others.
 She eats vegetables
and more meat
Elimination She is able to urinate  She can urinate and  Her condition
& defecate normally defecate without does not affected
everyday by herself assistant her elimination
pattern.
She doesn’t have
any problem on her
elimination
 Defecates usually
early in the
morning before
going to school
Sleeping  Has a regular  No problem sleeping  She don’t have any
sleeping pattern she said because she complain about
 Normal sleep is 4- used to it when she sleeping
6hrs. per day but she work in the hospital
naps for 30 minutes
to 1 hour in the
afternoon
  

Cognitive-Perceptual  Has a normal  She is very  She is very


Pattern cognitive perception cooperative. She cooperative and
 Can comprehend knows most of the always compliant
well things that she have to
 She responds do to prevent
appropriately to complications.
verbal & physical
stimuli
Self- Perception-Self  Perceived herself as  This times she  She is very
concept a good friend, sister perceives herself as an friendly but she is
& daughter. approachable, friendly not able to see her
and very sociable friends because
she is hospitalize
though she have a
very positive
outlook that she
will be out the
hospital very soon.

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Role Relationship Pattern  She was able to do  This time her role as a  She remain strong
her responsibilities as mother partially met even though she is
a mother because even thought hospitalized. She
she is confined she is sweet and caring
still communicate and towards her family
guide her children and
her family never fail to
visit her even in the
hospital.
Sexuality-Reproductive  She thinks of having  Same  It is still not her
Pattern a positive priority in life but
relationship with her her family and
partner children.
Coping Stress & Tolerance  She doesn’t fully  She want everything  She said she can
Pattern identifies her to be organize and be a friend to
stressors. done appropriately she anyone but when it
don’t want please who comes to work she
doesn’t know what want everything to
they are doing. She is be perfect and
a little strict. correctly done
Activity-Exercise Pattern  Her daily routine is  She wasn’t able to do  Due to
going to work in the her routine due to hospitalization
hospital supervising being hospitalize.
the nurse on a public
hospital.
Value-Belief Pattern  She is a Catholic  They go to church  Due to their
every Sunday to pray culture preferences
and as well family & parent’s
influence
bonding

c. COURSE IN THE WARD

A 56 years old female was admitted at 12: 24 PM last October 28, 2018 accompanied by her husband, with
a chief complaint of difficulty of Breathing. She was admitted under the service of Dr. Malano and following
orders were given. Doctor request GS/CS test, ABG Chest UTZ on October 28, 2018. Then Doctor order Sputum
test Last October 30, 2018 and order for Chest Mapping, Chest X-ray on November 11, 2018. The physician
ordered a PNSS 1 liter with 40mg Kcl to run for 24 hours on November 12, 2018. ON November 15, 2018 there
is no presence of dyspnea and fever but had dry cough. November 18, 2018 Pleural effusion on the right lung.
November 19, 2018 with dry cough, dyspnea and no fever. Negative Sputum test.

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PROBLEMS IDENTIFIED.

PROBLEM CATEGORY

1. Risk for Activity Intolerance Physical

2. Ineffective breathing Pattern Physical

NURSING CARE PLAN #1

RISK FOR ACTIVITY INTOLERANCE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Activity After 2 hours of 1.) To develop 1.) Motivate the After 2 hours of
intolerance nursing alternative ways client to nursing
“I cannot go related to intervention, the to remain active adopt to intervention, the
back to work Difficulty of Patient will be within the limits lifestyle of Patient was able to
because I was breathing able to verbalize of disabling physical verbalize
confined here in understanding of condition. activity. understanding of
the hospital, temporary loss of 2.) Advice client to 2.) to prevent temporary loss of
hindi na rin ako ability to do her rest fatigue ability to do her job
makapagasikaso job as a nurse and 3.) Advice to 3.) to prevent as a nurse and her
sa mga anak her role as mother minimize getting tired role as mother to
madali rin kasi to her children physical activity her children
akong mapagod 4.) Advice to 4.) To divert the
at hingalin at”. practice attention of
As verbalized by diversional for the patient
the patient. the patient not to from
think about her worrying
responsibilities about her
Objectives: responsibilit
ies while she
- Dyspnea
is at the
- Fatigue
hospital
- Respiratory
Rate 22 cpm

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5.) Advice the 5.) Family


Patients family support is
to be with her at the best we
all times for can give to
support the patient
experiencin
g this type of
condition

NURSING CARE PLAN #2

INEFFECTIVE BREATHING PATTER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective After 4 hours of 1.) Monitor Vital 1.) To check for After 4 hours of
“Nahirapan Breathing nursing Signs baseline data nursing
akong huminga, Pattern related to intervention the intervention the
hindi ko kayang Fatigue due patient will patient was able to
wala akong respiratory establish a 2.) Auscultate 2.) To check establish a normal,
Oxygen”. As muscle fatigue normal, effective Lungs sounds breath sound effective
verbalized by due to respiratory as and identify respiratory as
the patient. Immunosuppress evidence by the evidence by
ion from improved respiratory improved Oxygen
Objectives: Chemotherapy respiration rate problem Saturation from 92
- Nasal flaring from 22 cpm to 20 to 95 up to 100. His
- Dyspnea cmp and Oxygen 3.) Maintain 3.) To make Respiration is still
- Pale Saturation from Adequate air sure that the 22 cpm
- Purse lip 92 to 95 upto 100 patency oxygen
breathing therapy is
- Respiratory working
Rate 22 cpm
- O2 4.) Regulate 4.) To provide
Saturation 92 Oxygen adequate
Therapy up to 2 oxygen to
LPM the body

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5.) This will


5.) Assist patient expand the
the patient to lung surface
position herself of the
on a Orthopneic patient
position
6.) To provide
6.) Encourage relief
position of
comfort

PATHOPHYSIOLOGY:

Altered permeability of the


pleural membranes due to
malignancy

Increased capillary
permeability or vascular
disruption

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IX. Discharge Planning

Medications:

 Instruct client to follow and take medications prescribed by the physician.


 Explain to the client the nature of the drugs so as the prescription.

Exercise:

 Advise client to take adequate rest and sleep.

Treatment:

 Explain to the client and family the need for treatment and that it is a long process depending on
the compliance of the client to the therapeutic regimen.
 Encourage family member to provide patient emotional support

Hygiene

 Advise to do proper hygiene everyday.

Diet:

 Educate client about the importance of taking proper diet


 Instruct client to take variety of nutritious foods such as fruits and vegetables

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 Nursing Research

Nurses use research to provide evidence-based care that promotes quality health outcomes

for individuals, families, communities and health care systems. Nurses also use research to shape health

policy in direct care, within an organization, and at the local, state and federal levels. Nurses conduct

research, use research in practice, and teach about research. Through research, we can know about the

things that we can use in our practice to have quality health care. We should always bear in mind that we

are dealing with real lives, with real hearts and real feelings and real emotions.

 Nursing Education

This study deals with the importance of the concept in giving spiritual care. It is being

emphasized the basic knowledge of Late Stage Breast Cance and the relation of it from pelural effusion

in which they usually goes hand and hand because of its nature which is cancer cell being metasis and the

important details about it. This study further encourage the health team to teach their clients and enrich

them with health education for the betterment of the community.

 Nursing Practice

This study focuses on the skill that is necessary to provide optimum care. Knowledge should

be supported with skills and positive attitudes. Skills are designed to be polished with constant practice

and an open mind for corrections that would open doors for improvements. That is Important in dealing

with a fast-changing and updating world like ours.

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XI. BIBLIOGRAPHY

Online Resources

REFERRENCE:

file:///C:/Users/Acer-pc/Downloads/10.5923.j.rog.20150301.02.pdf

https://www.ucsfhealth.org/education/follow-up_care_for_breast_cancer_patients/

https://www.oncologynurseadvisor.com/breast-cancer/monitoring-metastasis-and-cachexia-in-a-patient-with-
breast-cancer-a-case-study/article/527447/

http://www.breastcancer.org/symptoms/understand_bc/statistics

https://www.ucsfhealth.org/education/follow-up_care_for_breast_cancer_patients/

https://www.scribd.com/doc/52630343/NCP-ineffective-breathing-pattern

https://emedicine.medscape.com/article/299959-overview

https://www.mayoclinicproceedings.org/article/S0025-6196(12)60872-6/pdf

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