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INTRODUCTION

Because we are exposed to different areas in the hospital, we were able

to meet people from all walks of life, being there beside them in their times of needs.

We are not merely fulfilling all our duties but we are treating them as a member of

our family as well. We feel fulfilled by providing our patient with utmost care,

comfort and encouragement to become well at the soonest possible time.

The group was exposed to various patients particularly in the recovery room

of the Chinese General Hospital in Manila. There were patients who are suffering

from mild to severe cases. There were also patients who are not cooperative and

are not willing to provide us the simple information we need, but we were all

optimistic that there are still other patients who are willing and able to provide us

information that we will be helpful to us for our case study. When one patient

arrived who just undergone Modified Radical Mastectomy on the left breast (MRM),

everybody became interested to have her as our case since we encountered her

case for the first time.

Since majority of the members were female, we also made us decide to

choose the Modified Radical Mastectomy because we will help not only our group

but we are also helping other people to become aware and fully understand the

importance of taking care of ones health. Our patient is very cooperative even

though she had her left breast removed, she was able to provide us necessary

information we need.

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Through this case study, our group will be able to expand our knowledge

and skills on how to handle patient who undergone MRM as well as to improve our

therapeutic communication techniques and proper care for all the patient we will

handle in future.

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OBJECTIVES

General Objectives:

This case study aims to identify and determine the general health problems

and the needs of the patient who just undergone Modified Radical Mastectomy of

the left breast and intends to help the patient promote health and better

understanding of her condition.

Specific Objectives:

Specifically the group aims:

1. To establish a good nurse-patient relationship and develop rapport.

2. To be able to determine the nature and factors that leads to the development of

the disease and how it affect our body.

3. To identify the pathophysiology of her condition.

4. To understand the effects of the medications prescribe to the process of

recovery.

5. To formulate nursing care plan for the continuous wellness of the patient.

6. To provide a discharge plan appropriate for continuous recovery

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HEALTH HISTORY
I. PATIENT’S DATA

Patient’s Name: Mrs. ET

Address: North Fairview, Quezon City

Date of Birth: July 19, 1965 Age: 45yo

Place of Birth: Tacloban City

Religion: Catholic

Civil Status: Married

Name of Spouse: Mr. RT

Hospital Case: 409956

Ward/Room No.: E1

Date Admitted: October 12, 2010

Time Admitted: 7:27 pm

Inclusive date of confinement: October 12 – 16, 2010

Attending Physician: Dr. T

Anesthesiologist: Dr. AG

Surgeon: Dr. CT

Procedure Done: Moderate Radical Mastectomy Left

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PHYSICAL ASSESSMENT

GENERAL SURVEY
The patient weighs 56 kilograms and in 5 feet 4 inches tall. She is awake, conscious,
coherent and oriented. She is a well developed mesomorph and looks according to age, She
is in a good nutritional state and in grooming. she looks weak and stated that she is restless
but she is very calm during physical assessment.

SKIN: The general skin color is brown to pallor, rough in texture, and in good turgor, Dry in
moisture and skin warm to touch. And with no signs of any lesions or breakage in the skin
integrity but with a non-pitting edema in the feet.

HEAD: Is in Normocephalic with no masses noted. The fontanels are closed with hair even
and dry and with a clean scalp.

EYES: Pale conjunctiva has been observed. She is nearsighted and states that can no
longer read or see people in a two-three meter away from her.

EARS: There is no negative observation, findings that has been noted.

NOSE: The client’s mucosa is pale with no other discharges has been noted.

MOUTH: The lips are dry and pallor.

NECK: The neck is in full range of motion and with no other abnormal findings has been
observed.

CHEST AND LUNGS: All are normal and client’s respiratory function is in good state upon
observation and auscultation

HEART: The heart sounds are distinct with regular beat, 89 bpm upon auscultation.

BREAST-AXILLAE: The client’s breast is asymmetrical, left breast tissues and nipple has
been removed

ABDOMEN: Her abdomen is in globular form, with normoactive sounds and tympany has
been observed in the assessment.
BACK AND EXTREMETIES: Peripheral pulses are present, symmetrical but strong to weak
in pulses.
ROM in upper extremeties are limited.
Muscle strength: weakness and immobility in left side.
Nails are pallor.
ANATOMY AND PHYSIOLOGY AND PATHOPHYSIOLOGY

THE HUMAN BREAST

It is essential for all the women to become familiar with the normal anatomy and

physiology of their breast. Through

proper information they can recognize

any early signs and most probably

possible abnormalities that might

development with their breast. This

section will outline basic information

regarding breast composition,

development and typical changes that

take place during puberty to pregnancy

up to menopause.

The breast or mammary tissues

are located between the second and

seventh ribs of the anterior chest wall

and are supported by the pectoral

muscles and superficial fascia. It has

abundant glandular structures hat have abundant shared nervous, vascular and lymphatic

supply. Contiguous nature of breast tissue is important in the health and illness. Both men
and women are born with rudimentary breast tissue with the ducts lines with epithelium.

Women usually released FSH, LH and prolactin and during puberty it stimulates the ovary to

produce and at the same time release estrogen. Estrogen stimulates the growth and

development of ductile system. With the onset of ovulatory cycle, progesterone releases and

stimulates the growth and development of ductile and alveolar secretory epithelium.

Breast Composition

The breast is a mass of glandular, fatty and fibrous tissues positioned and located

over the pectoral muscles of the chest wall and at the same time attached to the chest wall

by fibrous strands called Cooper’s ligaments. The layer of fatty tissues gives the breast a

soft consistency.
The glandular tissues of the breast house the lobules (milk producing glands at the

end of the lobes) and the ducts (milk passages). Toward the nipple, each duct widens to

form a sac (ampulla). During lactation, the bulbs on the ends of the lobules produce milk.

Once milk is produced, it is transferred through the ducts of the nipple.

The breast is composed of:

• milk glands (lobules) that produce milk

• ducts that transport milk from the milk glands


(lobules) to the nipple
• nipple
• areola (pink or brown pigmented region
surrounding the nipple)
• connective (fibrous) tissue that surrounds the
lobules and ducts
• fat

Arteries carry oxygen rich blood from the heart to the chest wall and the breasts and

veins take de-oxygenated blood back to the heart. The axillary artery extends from the armpit

and supplies the outer half of the breast with blood; the internal mammary artery extends

down from neck and supplies the inner portion of the breast.

Initial Breast Development

Human breast tissue begins to develop in the sixth week of fetal life. Breast tissue

initially develops along the lines of the armpits and extends to the groin (this is called the milk

ridge). By the ninth week of fetal life, it regresses (goes back) to the chest area, leaving two

breast buds on the upper half of the chest. In females, columns of cells grow inward from

each breast bud, becoming separate sweat glands with ducts leading to the nipple. Both
male and female infants have very small breasts and actually experience some nipple

discharge during the first few days after birth.

Female breasts do not begin growing until puberty—the period in life when the body

undergoes a variety of changes to prepare for reproduction. Puberty usually begins for

women around age 10 or 11. After pubic hair begins to grow, the breasts will begin

responding to hormonal changes in the body. Specifically, the production of two hormones,

estrogen and progesterone, signal the development of the glandular breast tissue. This initial

growth of the breast may be somewhat painful for some girls. During this time, fat and fibrous

breast tissue becomes more elastic. The breast ducts begin to grow and this growth

continues until menstruation begins (typically one to two years after breast development has

begun). Menstruation prepares the breasts and ovaries for potential pregnancy.

Before puberty Early puberty Late puberty

the breast is flat except the areola becomes a glandular tissue and fat
for the nipple that sticks prominent bud; breasts increase in the breast, and
out from the chest begin to fill out areola becomes flat
Breast Size, Appearance, and Changes Over Time

The size and shape of women’s breasts varies considerably. Some women have a

large amount of breast tissue, and therefore, have large breasts. Other women have a

smaller amount of tissue with little breast fat.

Factors that may influence a woman’s breast size include:

• Volume of breast tissue

• Family history

• Age

• Weight loss or gain

• History of pregnancies and lactation

• Thickness and elasticity of the breast skin

• Degree of hormonal influences on the breast (particularly estrogen and progesterone)

• Menopause

The nipple can be flat, round, or cylindrical in


17 y/o w/ full & normal breast
development 20 y/o w/ asymmetrical breast development
shape. The color of the nipple is determined by the

thinness and pigmentation of its skin. The nipple and areola (pigmented region surrounding

the nipple) contain specialized muscle fibers that respond to stimulation to make the nipple
erect. The areola also houses the Montgomery’s gland that may appear as tiny, raised

bumps on the surface of the areola. The Montgomery’s gland helps lubricate the areola.

When the nipple is stimulated, the muscle fibers will contract, the areola will pucker, and the

nipples become hard.

Breast shape and appearance undergo a number of changes as a woman ages. In

young women, the breast skin stretches and expands as the breasts grow, creating a

rounded appearance. Young women tend to have denser breasts (more glandular tissue)

than older women.

Breast Changes After Menopause

When a woman reaches menopause (typically in her late 40s or early 50s), her

body stops producing estrogen and progesterone. The loss of these hormones causes a

variety of symptoms in many women including hot flashes, night sweats, mood changes,

vaginal dryness and difficulty sleeping. During this time, the breasts also undergo

change. For some women, the breasts become more tender and lumpy, sometimes

forming cysts (accumulated packets of fluid).

The breasts’ glandular tissue, which has been kept firm so that the glands could

produce milk, shrinks after menopause and is replaced with fatty tissue. The breasts also

tend to increase in size and sag because the fibrous (connective) tissue loses its

strength. Because the breasts become less dense after menopause, it is often easier for

radiologists to detect breast cancer on an older woman’s mammogram films, since


abnormalities are not hidden by breast density. Since a woman’s risk of breast cancer

increases with age, all women should begin receiving screening mammograms at age

40, and continue monthly breast self-exams and physician-performed clinical breast

exams every year.

BREAST CANCER
P R E D IS P O S IN G F A C T O R S P R E C IP IT A T IN G F A C T
• A g e 4 y/o
5 • H is to ry o f a b no rm a l b
• F e m a le • P re g n an c y 2 c h ild re n
• E a ting fa tty fo o d s • J o b : ho u s e m a id
• E a rly o n s e t o f m e ns tru ay/o
tio n 1 0 • U s e o f O ra l C o n tra ce
• F a m ily H is to ry • E xp o s u re to a lc o h ol a

N e o p la s m for m a tio n in th e b r e a s t

P r im a r y tu m o r b e g in n in g in th e L e ft b re a s t

T u m o r b e c am e in va s iv e

M e t as t a s ize to o th e r o r g a n s ys te m
p ro g re s s in g b e yo n d b re a s t t o r

P r im a r y c a nc er s p re

IF T R EA T E D : S U R G E R Y IF N O T T R
• L e f t– M o d if ie d R a d ic a l • B r e as t m
GOOD
M as te c to m y POOR m a jo r o r g a
PROGNOSIS PROGNOSIS

R e m o va l o f b r e a s t C om p
tis s u e f u n c t io n s