TABLE OF CONTENTS I. Introduction a. Overview of the case b. Objective of the study c. Scope and Limitation of the study II.

III. Patients Profile Health History a. Family Health history b. Personal Health history c. History of Present Illness IV. V. Developmental Data Medical Management a. Medical Orders and Rationale b. Laboratory Results c. Drug Study VI. VII. VIII. Anatomy and Physiology Pathophysiology Nursing Management a.
b.

Ideal Nursing Management (NCP) Nursing Assessment (System Review & Nursing

Assessment II) Actual Nursing Management (SOAPIE) IX. X. XI. Discharge Plans and Prognosis Evaluation and Implications Bibliography

I. INTRODUCTION

A. Overview of the Case B. Objective of the Study This case study aims to improve the present condition of the patient and is conducted to gain thorough understanding concerning the case of the patient. And to apply our knowledge on nursing assessment, problem identification, nursing interventions and evaluation that is related to the disease condition. Furthermore, by gathering the subjective and objective data regarding the case, it will allow us to have a proper and appropriate nursing care towards the condition of an actual patient. This case study also aims to improve our skills in the clinical area, our interpersonal relationship with other health care givers and to gain more confidence in ourselves towards what is tasked to us. C. Scope and Limitation of the Study The study focuses on a Patient confined in Bethel Baptist Hospital, Bukidnon, Malabalay City, having the diagnosis of Breast CA Left. Nature, causes, signs and symptoms, pathophysiology, nursing

management, interventions and prognosis of the disease. Involves the ideal and actual nursing management appropriate for R.As condition, the drug study of the medications given, the health teachings and referrals for her. Assessment of R.As personal background, health history and history of present illness. Limited only to the history of the patient which is comprised of the patients profile, family and personal health history, chief complaints and history of present illness.

 Information obtained from the patients medical record, attending physician, from the staff, during patients assessment, from watcher and significant others and from the patient herself. The patient was only taken cared of for 3 days, starting December 11-13, 2008 and initial assessment on December 10, 2008. Other relevant information kept confidential same with her true identity to protect her privacy.

II. PATIENTS PROFILE Name: R.A. Age: 53 yrs. Old Date of Birth: September 24, 1955 Sex: Female Civil Status: Widow Religion: Roman Catholic Nationality: Filipino Occupation: Teacher Income: Php 12,000/month Address: Purok 2, Poblacion, Cabanglasan, Bukidnon Informants: the patient and her daughter Allergy: No Known Foods and Drugs Allergy Height: 51 Weight: 49.5 kgs Date of Admission: December 10, 2008 Time of Admission: 9:05 AM Chief complaints: breast mass on left for 3 months Admitting Diagnosis: Breast CA Left

Admitting Physician: Dr. Allan Melicor

III. HEALTH HISTORY A. Family Health History FAMILY A group of genes related in structure and in function that descend from an ancestral gene. It is the basic unit of the society. Family health history may be a huge factor in ones illness. Tracing back the health history of the family of R.A. on the paternal side, she remembered nothing about her grandfather since she was young then when her grandfather died. The father of R.A. is the eldest of the six siblings. Her father was non-DM and non-hypertensive. According to her, he was a drinker and a smoker. On the maternal side, her grandfather has arthritis and her grandmother has hypertension. She also claimed that one of her mothers sisters was diagnosed of breast cancer and underwent surgery (Mastectomy) 8 years ago. The mother of R.A. is a simple housewife. R.A. is the fourth of the five siblings. Most of her brothers were smokers and alcoholic drinkers. There are no known allergies on food and drugs among the siblings.

B. Personal Health History R.A. was born and delivered at home without any complications. She forgot already about her vaccinations during childhood. During her school age, she was participative in different activities in school. She had chicken pox and measles during her school age. She also experienced common illnesses such as fever, cough and common colds which were managed by taking over the counter

drugs (e.g. Paracetamol and Neozep). She is not a smoker and a non-alcoholic drinker. She sometimes skipped meals since she was busy with her work as a teacher. At the age of 25, she got married and was pregnant for her first baby and delivered it through normal spontaneous vaginal delivery at home at the year 1980. She was then again pregnant for the second and third baby who was unfortunately got aborted at the year 1981 and 1983 respectively. At January 1986, she was again pregnant for her fourth baby and delivered it through normal spontaneous vaginal delivery at home. Then on the year 1990, she got pregnant and delivered it through normal spontaneous vaginal delivery at Bukidnon Provincial Hospital. Unfortunately, her husband died due to vehicular accident last April 27, 2006 that really affect her emotionally. She was menopause and werent able to remember her last menstrual period. She had her self breast exam 3 months ago with unrecalled specific date. Last November 27, 2008, she had her check up at OPD and was advised for admission thus she was admitted. She underwent breast biopsy at the left breast on November 29, 2008. On November 30, 2008, she was discharged and was scheduled for surgery 2 weeks after. She was prescribed to take medications: (1) Oxycodone (Oxycontin) 10mg 1 tab BID for 6 days, (2) Flucloucacillin (Stafloxin) 500mg 1 cap TID for 5 days, (3) Tramadol 50mg 1 cap every 4 hours PRN and (4) Lactulose syrup 30cc at bedtime; with good compliance as verbalized by the patient.

C. History of Present Illness A case of R.A. 53 years old, Filipino, widow, from Purok 2 Poblacion, Cabanglasan, Bukidnon admitted for the second time at Bethel Baptist Hospital with chief complaints of breast mass left of 3 months. Three months prior to admission, the patient noted a mass on her left breast. There were no medications or consultation done. Two months PTA, the patient noted swelling and tenderness of the left breast. No consultation was done. 2 weeks PTA, when she was admitted (November 27, 2008), she

underwent core biopsy of the left breast. She was discharged and scheduled for mastectomy the following day.

IV. MEDICAL MANAGEMENT A. Medical Orders with Rationale

Date/Time 12/10/08 9:05 AM Doctors Order Please admit under the service of Dr.Melicor Rationale

For proper management. Dr. Melicor was the doctor incharge since patient is for surgery

Secure consent please

For legal purposes; consent is needed for any invasive procedures The surgical removal of one or both breast to treat breast cancer

For simple mastectomy left

Diagnostics:

Chest X-ray PA
To visualize the lung and

CBC

identify any abnormalities

Routine laboratory upon admission to determine any

U/A

hematologic problems Routine laboratory upon admission to determine any

FBS in AM Serum Creatinine

infection I the urine To determine blood sugar level in the blood

CRP in AM

To determine kidney function To monitor cardiac enzymes and determine any abnormalities To assess and record the electrical activity of the heart.

12 Lead ECG

Therapeutics:

Cefazolin 1mg IV

every 6 hours ANST starting at 6PM

Antibiotics: prophylaxis for infection since pt is for operation

IVF: PNSS 1L @ 30gtts/min x 3 cycles

Isotonic solution: this solution does not enter the cell because there is no osmotic force to shift the fluids; access for

DAT then NPO tonight for blood determination TPR every 4 hours

medications. To provide essential nutrients to the body; NPO to have an accurate result Provide baseline data for care. During this period of

8:30 PM Please inform OR of admission Dr.Melicor informed of admission

time, complications may possibly develop. In order to prepare the equipments and the area To inform the attending physician of admission

Please retrieve old chart

 To refer baseline data and

May have light breakfast after labs and then NPO

history of the patient To supplement nutrients; NP in preparation for the surgery

12/11/08

Rescheduled surgery at 7AM tomorrow

Surgery was moved because Dr. Melicor was not available.

NPO after midnight

In preparation for surgery to prevent aspiration. To inform the anesthesiologist ahead of time for preparation of the surgery. In this solution, the dextrose is quickly metabolized and only the isotonic solution remains; access for medications. Physical preparation for the surgery For reference purposes.

Inform OR and anesthesiologist TF IVF with D5LR 1L @ KVO rate then regulate @ 30gtts/min once on NPO Full body bath in AM Please attached old chart with biopsy result taken 2 11:25 AM 4 PM weeks ago

Transport to OR at 6:15 AM tomorrow.

PRE-OP EVALUATIO Please secure consent for anesthesia induction and affix patients/watchers signature in the space provided Consent is essential for operation for legal purposes Bring pt to OR where the operation will be performed

______________

 For OR use: Precetex #1 vial NSS 100ml #1 bag PCA power #1 unit PCA IV tubing #1 pc AA Energizer battery #2 pcs Therapeutics: Pantoprazole

Preparation for the materials and equipment needed for the surgery

Proton Pump Inhibitor: to prevent hyperacidity since pt is on NPO in preparation for surgery

40mg PO now then HS

Analgesics: treatment of pain

Etoricoxib 120mg 1

tab @ HS

Informing the nurse on duty about such activities for them to prepare the pt ahead of time. This will serve as the access for medications

Transport to OR 6 AM Induction Time: 6:30 AM Cutting Time: 7 AM

IVF insertion right upper extremity opposite to the site to be operated Refer accordingly
12/12/08 POST OP To patients room once stable at OR

For prompt intervention and management

For care and monitoring. RR

 V/S every 15 minutes until stable then every 4 hours DAT once fully awake

should be stable first to prevent complications For close monitoring; note any abnormalities thus prompt intervention For nutritional intake and

Regulate IVF @ 30gtts/min then follow up with:

supplement to restore bodys energy; to prevent aspiration. Solutions that are needed by the body; access for medications

D5NM 1L @ 20gtt/min D5LR 1L @ 20gtts/min

Therapeutics: Pantoprazole 40mg PO OD to continue x 5 days Etoricoxib 120mg 1 tab PO OD x 5 days Oxycontin 10mg 1 tab BID PO 12 hrs interval x 3 days only Oxycondone 5mg PO PRN if patient is still not comfortable with Oxycontin- may be given 1-2 hrs interval until patient is comfortable
O2 inhalation 2L/min until

Proton Pump Inhibitor: to prevent hyperacidity

Analgesics: treatment of pain

Opioid Analgesics: treatment of pain Opioid Analgesics: treatment of pain

fully awake
To provide supplemental oxygen on the patients lungs

and availability of oxygen to Please monitor patient for possible opioids adverse effects. body tissues since pt is post op

For proper monitoring and treatment

Refer should the following be noted:

Respirations: Hypotension: 80/60mmHg Bradycardia: vomiting

10 cpm

For proper monitoring of post patient especially that hey are under anesthesia

60 bpm

General pruritus, nausea, Heavy sedation

To prevent complications and early treatment

Please refer the opioids adverse effects treatment form if necessary Refer accordingly

For prompt intervention and

Continue Cefazolin as ordered

management Antibiotics: prophylaxis for infection. To allow patient to urinate on its own; to note kidney function To measure intake and output to determine fluid balance To promote wound healing and circulation

12/13/08

Remove FBC I&O every 6 hours Ambulate and start hand exercises IVF TF with D5NM 2L at

20 gtts/min

Solutions that are needed by the body; access for medications

Decrease Cafazolin every 8 hrs IVT x 3 doses then shift to Cefuruxime 500mg BID PO

Antibiotics: prophylaxis for infection.

Treatment purpose has been

D/C IVF after last dose of Cefazolin

achieved.

B. Laboratory Results December 10, 2008 Creatinine Determination Test Creatinine Result 1.3mg/dL Normal Values 0.8-1.7 mg/dL Clinical Significance Normal

December 10, 2008 Complete Blood Count Test Hemoglobin Hematocrit White Cell Count Results 11.8 gms % 39.1 vol % 11,900/mm3 Normal Values 11-16 gms % 37-47 vol % 5,000-10,000/mm3 Clinical Significance Normal Normal
Inflammatory response of the body since pt develop a breast mass Inflammatory response of the body

DIFFERENTIAL COUNT Lymphocytes 22 % 25-35%

since pt develop a breast mass

Segmenters Monocytes Eosinophils Basophils December 10, 2008

69% 7% 2% 0.5%

55-85% 2-4% 2-3% 0-0.5%

Normal
Inflammatory response of the body since pt develop a breast mass

Normal Normal

Clinical Chemistry Test Glucose (FBS) Cholesterol HDL-Cholesterol Results 90.1 mg/dL 154.9 27.8 Normal Values 80-120 mg/dL Increase >200mgs% Low risk: >65mgs % Risk: <45mgs% Suspect: >150mgs% Increase: >200mgs% Low risk: <35mgs % Risk: >190mgs% Low risk: >38% Risk: <13% Clinical Significance Normal Normal Normal

Triglyceride

115.0

Normal

LDL % HDL of Total Cholesterol

104.1 17.9

Normal Normal

December 10, 2008 Chest X-ray Findings: Trachea is at midline. The heart is not enlarged. Both hemidiagphragms and left costophrenic sulcus are intact. Cardiomediastinal silhouette appears normal.

Both lung fields are clear. The rest of structures are unremarkable.

Impression: Radiographically negative chest findings C. Drug Study Generic Name of Ordered Drug: Ranitidine Brand Name: Zantac Date Ordered: 01/25/08 Classification: Anti-ulcerative (H2 Receptor Antagonist) Dose/ Frequency/ Route: 50 mg IVTT every 8 hrs Mechanism of Action: Competitively inhibits action of the H2 at receptor sites of parietal cells, decreasing gastric acid secretion. Specific Indication: To prevent ulcer and maintain the acidity of the stomach Contraindication: Contraindicated to patients with hypersensitivity to the drug or any of its components. Side Effects/ Toxic Effects: vertigo, malaise, blurred vision, jaundice, thrombocytopenia, anaphylaxis, angioedema Nursing Precaution: Drug may be taken with or without food If IVTT, administer slowly to minimize the discomfort on the IV site. Advise the patient to report if any adverse reaction will occur.

Generic Name of Ordered Drug: Tramadol Brand Name: Ultram Date Ordered: 01/25/08 Classification: Centrally acting analgesics Dose/ Frequency/ Route: 50mg every 8 hours Mechanism of Action: Binds to mu-opioids receptor and inhibits the neither reuptake of nor epinephrine and serotonin causes many side effects similar to opioids. Specific Indication: Relief of moderate pain Contraindication: Contraindicated to pregnancy; allergy; intoxication of alcohol; lactation Side Effects/ Toxic Effects: Sedation, headache, dizziness, hypotension, nausea, vomiting, sweating Nursing Precaution: Provide environmental control (temperature) if sweating occurs. Limit patient who has past history of addiction. Notify physician if adverse effects will occur.

VI. ANATOMY AND PHYSIOLOGY The breast is a mass of glandular, fatty, and fibrous tissues positioned over the pectoral muscles of the chest wall and attached to the chest wall by fibrous strands called Coopers ligaments. A layer of fatty tissue surrounds the breast glands and extends throughout the breast. The fatty tissue gives the breast a soft consistency.

The glandular tissues of the breast house the lobules (milk producing glands at the ends 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 to 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. The size and shape of womens 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 womans 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

A womans breasts are rarely balanced (symmetrical). Usually, one breast is slightly larger or smaller, higher or lower, or shaped differently than the other. The size and characteristics of the nipple also vary greater from one woman to another. In some women, the nipples are constantly erect. In others, they will only become erect when stimulated by cold or touch. Some women also have inverted (turned in) nipples. Inverted nipples are not a cause for concern unless the condition is a new change. Since there are hair follicles around the nipple, hair on the breast is not uncommon. The nipple can be flat, round, or cylindrical in 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 Montgomerys gland that may appear as tiny, raised bumps on the surface of the areola. The Montgomerys 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.

VI. PATHOPHYSIOLOGY Breast CA it is a malignancy that develops from the cells in the breast
PREDISPOSING FACTORS Gender: Female PRECIPITATING FACTOR Inherited abnormal genes (BRCA1 and BRCA2)

Age Family History Hormonal Changes

Genetic mutation of cellular DNA

Altered DNA repair mechanism

Permanent cellular mutation

Expression of abnormal/mutant genetic information

BRCA1 and BRCA2are tumor suppressor gene are mutated

Decrease apoptic signals thus decrease mutant cell death

Survival of mutant cell population

Increase malignant behavior of the cells

Formation of clones and begins to proliferate abnormally

S/sx: Mass on left breast

BREAST CANCER

Swelling Tenderness Nipple inversion

VII. NURSING MANAGEMENT A. Ideal Nursing Management Diagnosis: Risk for ineffective airway clearance related to depressed respiratory function secondary to anesthesia Independent 1. Monitor respiratory rate/depth; note ease of breathing. auscultate breath sound. Investigate restlessness, dyspnea, and development of cyanosis. Rationale Changes in

respirations,

used

of

accessory muscles and /or present of rhonchi/wheezes suggest retention of secretions. airway obstruction(even partial) can lead to ineffective breathing patterns and impaired gas exchange, resulting in complications, e.g., pneumonia, respiratory arrest. Facilitates drainage of secretions, work of breathing and lung expansion. Mobilizes secretions to clear airway, and helps prevent respiratory

2. Elevate head 30-45 degrees 3. Encourage effective coughing and deep breathing.

complications. 4. Assist patient to assume position of Elevation of the head of the bed comfort, e.g., elevate head of bed, facilitates respiratory function by use of have patient lean on over bed table or gravity sit on edge of bed. 5. Encourage/assist with abdominal or Provides patient with some means to pursed lip breathing exercise. cope with/control dyspnea and reduce

air trapping

Dependent 1. Provide supplemental humidification e.g., compress air/oxygen mist collar, increase fluid intake.

Normal passages)

physiological means humidity and of

(nose/nasal of decreases facilitates secretions

filtering/humidifying air are bypassed. Supplemental mucous crusting

coughing/suctioning 2. Monitor serial ABGs/pulse oximetry; chest x-ray.

through stoma. Pooling of secretions/ presence of atelectasis may lead to pneumonia, requiring more aggressive therapeutic measures.

Diagnosis: Decrease cardiac output related to shock and hemorrhage. Independent Rationale 1. Maintain bed/chair rest in position of Decreases oxygen comfort during acute episodes. consumption/demand, reducing myocardial workload and risk of 2. Monitor vital signs (e.g., heart rate, BP) and cardiac rhythm. decompensation. Tachycardia may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. Changes may also occur in BP (hypertension or hypotension) because of cardiac response. 3. Auscultate breath sounds and heart S3, S4 or crakles can occur with sounds. Listen for murmurs. 4. Provide for adequate rest periods. cardiac decompensation or some medications (especially beta-blockers). Conserves energy, reduces cardiac

Assist with/perform self care activities,

workload. interventions can reduce

as indicated. 5. Encourage immediate reporting of Timely pain for prompt administration medications as indicted. 6. Note skin color and presence/quality of pulses.

of oxygen consumption and myocardial workload and may prevent/minimize cardiac complications. Peripheral circulation is reduced when cardiac output falls, giving the skin a pale or gray color (depending on level of hypoxia) and diminishing the strengths of peripheral pulses.

Dependent 1. Administer supplemental oxygen as needed. Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and

reduce lactic acid levels. 2. Monitor pulse oximetry or ABGs as Determines adequacy of respiratory indicated. function and/or O2 therapy.

Diagnosis: Acute pain related to surgical incision. Independent Rationale 1. Evaluate pain regularly (e.g., every 2 Provides information location, and intensity (0-10 scale). Emphasize patient's responsibilities for reporting pain/relief of pain completely. 2. Reposition as indicated e.g., semifowlers, lateral Sims. May relieve pain and fowlers enhance position

about

need

hours X 12) noting characteristics, for/effectiveness of interventions.

circulation.

Semi

relieves abdominal muscle tension, whereas lateral Sims relieves dorsal pressure.

3.

Provide

additional

comfort Improves circulation, reduces muscle pain. Enhances sense of well being.

measures, e.g., back rub heat/cold tension and anxiety associated with applications. 4. Encourage techniques exercises, use guided of relaxation breathing imagery,

e.g.,

deep

Relieves

muscle

and

emotional

tension; enhances sense of control and may improve coping abilities. Use for mild to moderate pain or adjuncts to opioid therapy when pain is moderate to severe. Allows for a lower dosage of narcotics, reducing potential for side effects.

visualization, music). Dependent 1. Administer Non Steroidal AntiInflamatory Drugs (NSAIDs) e.g., Tramadol, Mefenamic acid

Diagnosis: Risk for imbalanced body temperature related to surgical environment and anesthetic agents. Independent Rationale 1. Note for postoperative temperature Used as

baseline

for

monitoring

related to age and disease process. postoperative temperature. 2. Provide cooling measures for patient Cool irrigations and exposure of skin with postoperative temperature surfaces to air may be required to elevations decrease temperature. 3. Remove blankets and apply tepid To lower down body's high temperature sponge bath and recheck temperature through evaporation. after 30 minutes. 4. Monitor temperature every 30 To assess the temperature level. minutes. Dependent 1. Administer medications (e.g., Antipyretics drugs acts on the Paracetamol). hypothalamus, center to the lower thermoregulating down body

temperature.

Diagnosis: Impaired skin integrity related to surgical incision or drains. Independent 1. Reinforce initial dressing/change as indicated. Use strict aseptic techniques. Rationale Protects wound from mechanical injury and contamination. Prevents accumulation of fluids that may cause

excoriation. 2. Gently remove tape and dressing Reduces risk of skin trauma and when changing. disruption of wound. 3. Inspect wound regularly, noting Early recognition characteristics and integrity. 4. Assess amounts and characteristics of drainage. of delayed

healing/developing complications may prevent in more serious situations. Decreasing drainage suggests evolution of healing process, whereas continued drainage or presence of bloody/odoriferous exudates suggests complications. Prevents contamination of wound. Provides additional support for high risk incisions, e.g., obese patients. Removes infectious exudates to promote healing.

5. Caution patient not to touch wound. Dependent 1. Use of abdominal binder if indicated. 2. Irrigate wound;

Diagnosis: Activity intolerance related to generalized weakness secondary to surgery. Independent Rationale 1. Assess patient's ability to perform Influences choice of normal tasks/ADLs, noting reports of interventions/needed assistance.

weakness,

fatigue

and

difficulty May indicate neurological changes

accomplishing tasks. 2. Note changes in balance/gait associated with vitamin b12 deficiency, affecting patient safety/risk of injury. Enhances rest to lower body's oxygen requirements, and reduces strain on to the heart and lungs. prioritize Promotes adequate rest, maintains

disturbance, muscle weakness. 3. Recommend quiet atmosphere; bed rest if indicated. 4. Assist patient

ADLs/desired activities. Alternate rest energy level, and alleviates strain on periods with activity periods. Write out the cardiac and respiratory systems. schedule for patient to refer to. 5. Provide/recommend assistance with activities/ambulation as necessary, allowing patient to do as much as possible. Dependent 1. Monitor laboratory studies, e.g., Hgb/Hct and RBC count, ABGs.

Although help may be necessary, self esteem is enhanced when patient does something for self. Identifies and deficiencies in RBC to

components affecting oxygen transport treatment needs/response

therapy. 2. Provide supplemental oxygen as Maximizing oxygen transport to tissues indicated. improves ability to function.

Diagnosis: Risk for ineffective management of therapeutic regimen related to insufficient knowledge about wound care, dietary restrictions, activity recommendations, medications, follow up car or signs and symptoms of complications Independent 1. Review and have patient/SO demonstrated dressing/wound when indicated. 2. Identify specific activity limitations. Rationale Promotes competent self care and enhances independence. Prevents undue strain on operative

3. Recommend plan/progressive exercise.

site. Promotes return of normal function and enhances feelings of general well being Prevents fatigue and conserves energy for healing. Provides elements necessary for tissue regeneration/healing and support of tissue perfusion and organ function. Provides additional resources for reference after discharge. Promotes effective self care.

4. Schedule adequate rest periods. 5. Review importance of nutritious diet and adequate fluid intake.

6. Provide written instructions/teaching materials.

VII. NURSING ASSESSMENT AND ACTUAL NURSING MANAGEMENT

Nursing System Review Chart Name: R.A Vital Signs: Temp: 36.5C Height: 51 Date: December 10, 2008 Pulse: 85 bpm BP: 120/80 mmHg Weight: 49.5 kgs Respiration: 20 cpm

Impaired vision Pain at the area with pain scale of 7

Anxious

Swelling of the breast Breast engorgement Tenderness Disproportioned breast IVF insertion: PNSS 1L @ 30gtts/min

Nursing Assessment II

SUBJECTIVE SKIN INTEGRITY: [ ] dry Comments: SUBJECTIVE [ ] itching Communication: [ ] other [ ] hearing loss Comments: [ ] denied [ ] visual changes [ ] denied ACTIVITY/ SAFETY: Oxygenation: [ ] convulsion Comments: [ ] dyspnea Comments: [ ] dizziness [ ] smoking history [ ]limited [ ] cough motion [ ]of joints denied Limitation in Circulation: Ability to [ ] chest pain [ ] ambulate [ ] leg pain [ ] bathe self [ ] numbness of [ ] extremities other [ ] denied ] denied [ Comments:

OBJECTIVE [ ] dry [ ] cold [ ] pale OBJECTIVE [ ] flushed [ ] warm ] moist [ ][ cyanotic [ ][ glasses ] languages *rashes, ulcers, decubitus (describe size, [ ] contact lens [ ] hearing aid location, drainage) R L Pupil Size: [ ] speech difficulties Reaction: [ ] LOC [and orientation:irregular Resp. ] regular [ ] Describe: R Gait: [ ] walker [ ] cane [ ] other : L: [ ] steady [ ] unsteady ______ [ ] sensory and motor losses in face or extremities Heart Rhythm [ ] regular [ ] irregular [ ] Edema : AnkleROM limitations: Pulse Car. Rad. DP R L Comments: ] facial grimace *If[applicable [ ] guarding ] other signs of pain: [ ][ dentures [ ] none Fem*

COMFORT/SLEEP/AWAKE: [ ] pain Comments: (location, frequency, Nutrition: remedies) Diet: [ nocturia [ ] ]N [ ] V Comments: [ ] sleep difficulties Character [ ] denied [ ] recent change in weight, appetite COPING: [ ] swallowing Occupation: difficulty Members [ ] denied of Household:

[ ] siderail Full release Partial form signed (60+ years) with Patient Upper [ ] [ ] [ ] Lower [ ] [ ] [ ] Observed non-verbal behavior:

The person and his phone number that can Most Supportive Person: be reached any time: Elimination: Usual bowel pattern [ ] urinary frequency Comments: Bowel Sounds: SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) Daily Weight [ ] urgency PT/OT Abdominal Distention . BP q Irradiation [ ] constipation Shift [ ] dysuria Present [ ] yes [ ] no Urine Test . remedy Neuro vs [ ] hematuria Urine* (color, CVP/SG Reading 24 hour Urine Collection [ ] incontinence consistency, odor) [ ] polyuria Date of Last BM [ ] foly in place [ ] denied *if they are in place [ ] diarrhea character MGT. OF HEALTH ILLNESS: [ ] alcohol [x] denied (amount, frequency) [ ] SBE Last Pap Smear LMP: Briefly describe the pt.s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).

Sakit kayo akong totoy. Naghubag man kini, as verbalized by the patient. Pain scale: 7 Swelling of the breast Breast engorgement Tenderness Disproportioned breast Pain related to the inflammatory reaction to the disease process (breast

mass)

At the end of 30 minutes, the patient will be able to verbalize lessen pain

1. Positioned patient in position of comfort. 2. Provided comfort measures such as back rubs. 3. Monitored vital signs every 4 hours. 4. Assisted in moving carefully the affected side. I 5. Demonstrated and encouraged use of relaxation technique such as deep breathing exercises.

At the end of 30 minutes, the patient was able to verbalize lessen pain with pain scale of 4.

[no subjective cues] Asking too many questions

Unfamiliarity of the condition Anxious Anxiety related to surgical procedure and unfamiliarity of the condition

At the end of 30 minutes, the patient will be able to lessen her anxiety.

1. Demonstrated and encouraged use of relaxation technique such as deep breathing exercises. 2. Encouraged verbalization of concerns and needs. 3. Provided pre-operative health teachings such as proper positioning on the OR, coughing exercises I 4. Explained the purpose of the surgery together with the nurse on duty.

At the end of 30 minutes, the patient was able to lessen her anxiety as E evidence by relaxed facial expression.

Nursing System Review Chart Name: R.A Vital Signs: Temp: 36.8C Height: 51 Date: December 11, 2008 Pulse: 80 bpm BP: 110/70 mmHg Weight: 49.5 kgs Respiration: 17 cpm

Impaired vision Pain at the area with pain scale of 7

Anxious

Swelling of the breast Breast engorgement Tenderness Disproportioned breast IVF insertion: PNSS 1L @ 30gtts/min

Nursing Assessment II

SUBJECTIVE SKIN INTEGRITY: [ ] dry Comments: SUBJECTIVE [ ] itching Communication: [ ] other [ ] hearing loss Comments: [ ] denied [ ] visual changes [ ] denied ACTIVITY/ SAFETY: Oxygenation: [ ] convulsion Comments: [ ] dyspnea Comments: [ ] dizziness [ ] smoking history [ ]limited [ ] cough motion [ ]of joints denied Limitation in Circulation: Ability to [ ] chest pain [ ] ambulate [ ] leg pain [ ] bathe self [ ] numbness of [ ] extremities other [ ] denied ] denied [ Comments:

OBJECTIVE [ ] dry [ ] cold [ ] pale OBJECTIVE [ ] flushed [ ] warm ] moist [ ][ cyanotic [ ][ glasses ] languages *rashes, ulcers, decubitus (describe size, [ ] contact lens [ ] hearing aid location, drainage) R L Pupil Size: [ ] speech difficulties Reaction: [ ] LOC [and orientation:irregular Resp. ] regular [ ] Describe: R Gait: [ ] walker [ ] cane [ ] other : L: [ ] steady [ ] unsteady ______ [ ] sensory and motor losses in face or extremities Heart Rhythm [ ] regular [ ] irregular [ ] Edema : AnkleROM limitations: Pulse Car. Rad. DP R L Comments: ] facial grimace *If[applicable [ ] guarding ] other signs of pain: [ ][ dentures [ ] none Fem*

COMFORT/SLEEP/AWAKE: [ ] pain Comments: (location, frequency, Nutrition: remedies) Diet: [ nocturia [ ] ]N [ ] V Comments: [ ] sleep difficulties Character [ ] denied [ ] recent change in weight, appetite COPING: [ ] swallowing Occupation: difficulty Members [ ] denied of Household:

[ ] siderail Full release Partial form signed (60+ years) with Patient Upper [ ] [ ] [ ] Lower [ ] [ ] [ ] Observed non-verbal behavior:

The person and his phone number that can Most Supportive Person: be reached any time: Elimination: Usual bowel pattern [ ] urinary frequency Comments: Bowel Sounds: SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) Daily Weight [ ] urgency PT/OT Abdominal Distention . BP q Irradiation [ ] constipation Shift [ ] dysuria Present [ ] yes [ ] no Urine Test . remedy Neuro vs [ ] hematuria Urine* (color, CVP/SG Reading 24 hour Urine Collection [ ] incontinence consistency, odor) [ ] polyuria Date of Last BM [ ] foly in place [ ] denied *if they are in place [ ] diarrhea character MGT. OF HEALTH ILLNESS: [ ] alcohol [x] denied (amount, frequency) [ ] SBE Last Pap Smear LMP: Briefly describe the pt.s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).

Sakit gihapon kaayo akong totoy. Wala man gud nadayon ang operasyon, as verbalized by the patient. Pain scale: 7 Swelling of the breast Breast engorgement Tenderness Disproportioned breast Pain related to the inflammatory reaction to the disease process (breast

mass)

At the end of 30 minutes, the patient will be able to verbalize lessen pain

1. Positioned patient in position of comfort. 2. Provided comfort measures such as back rubs. 3. Monitored vital signs every 4 hours. 4. Assisted in moving carefully the affected side. I 5. Facilitated the use of relaxation technique such as deep breathing exercises.

At the end of 30 minutes, the patient was able to verbalize lessen pain with pain scale of 4.

[no subjective cues] Asking too many questions

Unfamiliarity of the condition Anxious Anxiety related to surgical procedure and unfamiliarity of the condition

At the end of 30 minutes, the patient will be able to lessen her anxiety.

1. Facilitated the use of relaxation technique such as deep breathing exercises. 2. Encouraged verbalization of concerns and needs. 3. Provided pre-operative health teachings such as proper positioning on the OR, coughing exercises I 4. Explained the purpose of the surgery together with the nurse on duty.

At the end of 30 minutes, the patient was able to lessen her anxiety as E evidence by relaxed facial expression.

Nursing System Review Chart Name: R.A Vital Signs: Temp: 36.5C Height: 51 Date: December 12, 2008 Pulse: 76 bpm BP: 110/70 mmHg Weight: 49.5 kgs Respiration: 16 cpm

Impaired vision O2 inhalation 2L/min via face mask Pain at the area with pain scale of 7

Drowsy

Jackson Pratt draining with bloody fluid Post op wound

Unable to move extremity FBC to UB draining with greenish urine

IVF insertion: D5NM 1L @ 20gtts/min

Nursing Assessment II

SUBJECTIVE SKIN INTEGRITY: [ ] dry Comments: SUBJECTIVE [ ] itching Communication: [ ] other [ ] hearing loss Comments: [ ] denied [ ] visual changes [ ] denied ACTIVITY/ SAFETY: Oxygenation: [ ] convulsion Comments: [ ] dyspnea Comments: [ ] dizziness [ ] smoking history [ ]limited [ ] cough motion [ ]of joints denied Limitation in Circulation: Ability to [ ] chest pain [ ] ambulate [ ] leg pain [ ] bathe self [ ] numbness of [ ] extremities other [ ] denied ] denied [ Comments:

OBJECTIVE [ ] dry [ ] cold [ ] pale OBJECTIVE [ ] flushed [ ] warm ] moist [ ][ cyanotic [ ][ glasses ] languages *rashes, ulcers, decubitus (describe size, [ ] contact lens [ ] hearing aid location, drainage) R L Pupil Size: [ ] speech difficulties Reaction: [ ] LOC [and orientation:irregular Resp. ] regular [ ] Describe: R Gait: [ ] walker [ ] cane [ ] other : L: [ ] steady [ ] unsteady ______ [ ] sensory and motor losses in face or extremities Heart Rhythm [ ] regular [ ] irregular [ ] Edema : AnkleROM limitations: Pulse Car. Rad. DP R L Comments: ] facial grimace *If[applicable [ ] guarding ] other signs of pain: [ ][ dentures [ ] none Fem*

COMFORT/SLEEP/AWAKE: [ ] pain Comments: (location, frequency, Nutrition: remedies) Diet: [ nocturia [ ] ]N [ ] V Comments: [ ] sleep difficulties Character [ ] denied [ ] recent change in weight, appetite COPING: [ ] swallowing Occupation: difficulty Members [ ] denied of Household:

[ ] siderail Full release Partial form signed (60+ years) with Patient Upper [ ] [ ] [ ] Lower [ ] [ ] [ ] Observed non-verbal behavior:

The person and his phone number that can Most Supportive Person: be reached any time: Elimination: Usual bowel pattern [ ] urinary frequency Comments: Bowel Sounds: SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) Daily Weight [ ] urgency PT/OT Abdominal Distention . BP q Irradiation [ ] constipation Shift [ ] dysuria Present [ ] yes [ ] no Urine Test . remedy Neuro vs [ ] hematuria Urine* (color, CVP/SG Reading 24 hour Urine Collection [ ] incontinence consistency, odor) [ ] polyuria Date of Last BM [ ] foly in place [ ] denied *if they are in place [ ] diarrhea character MGT. OF HEALTH ILLNESS: [ ] alcohol [x] denied (amount, frequency) [ ] SBE Last Pap Smear LMP: Briefly describe the pt.s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).

Sakit ang gi-operahan na side, as verbalized by the patient. Pain scale: 7 Post op wound Facial grimace Guarding Pain related to the surgical procedure (mastectomy) as evidenced by facial

grimacing and guarding.

At the end of 30 minute, the patient will be able to verbalize lessen pain

1. Assessed pain level. 2. Assisted patient to position in comfort. 3. Provided comfort measures such as back rubs. 4. Demonstrated relaxation technique such as deep breathing I exercises. 5. Encouraged early ambulation. 6. Administered pain medications(Etoricoxib) as ordered.

At the end of 30 minutes, the patient was able to verbalize lessen pain with pain scale of 4.

[no subjective cues] Post op wound Incision of about 10 cm Post op pain

Impaired skin integrity related to surgical incision and removal of tissue

At the end of 8 hours, the patient will be able to maintain dry and intact wound dressing.

1. Assessed dressing and wound for any abnormalities 2. Monitored patients temperature every 4 hours. 3. Assisted in wound dressing. 4. Avoided taking blood pressure on the affected arm. I 5. Placed in semi-fowlers position. 6. Provided wrinkle free bed. 7. Administered antibiotics (Cefazolin) as ordered.

At the end of 8 hours, the patient was able to maintain dry and intact wound dressing.

Dili kayo ko makalihok kay sakit akong operasyon, as verbalized by the patient.

Post op pain Reluctant to attempt movement Limited ROM

Activity intolerance related to pain and discomfort

At the end of 30 minutes, the patient will be able to demonstrate techniques that enable resumption of activities

1. Facilitated passive range of motion 2. Demonstrated and facilitated post mastectomy exercises 3. Assisted in ambulation 4. Recommended in proper deep breathing exercises I 5. Administered pain medications (Etoricoxib) as ordered.

At the end of 30 minutes, the patient was able to demonstrate techniques that enable resumption of activities such as hand movement and arm rising.

[no subjective cues] Post op wound dressing Presence of Jackson pratt Post op pain Risk for infection related to broken skin and presence of foreign material

secondary to surgical procedure

At the end of 8 hours, the patient will be able to maintain safe aseptic environment of the affected side

1. Assessed wound dressing 2. Maintained the patency of the drainage tube 3. Elevated the affected arm 4. Monitored the temperature every 4 hours. I 5. Facilitated post mastectomy exercises 6. Administered pain medications (Cefazolin) as ordered.

At the end of 8 hours, the patient was able to maintain safe aseptic environment of the affected side as evidence by temperature within normal range

Nursing System Review Chart

Name: R.A Vital Signs: Temp: 36.9C Height: 51

Date: December 13, 2008 Pulse: 84 bpm BP: 110/80 mmHg Weight: 49.5 kgs Respiration: 18 cpm

Impaired vision Pain at the area with pain scale of 6

Jackson Pratt draining with bloody fluid

Post op wound IVF insertion: D5NM 1L @ 20gtts/min

Nursing Assessment II

SUBJECTIVE SKIN INTEGRITY: [ ] dry Comments: SUBJECTIVE [ ] itching Communication: [ ] other [ ] hearing loss Comments: [ ] denied [ ] visual changes [ ] denied ACTIVITY/ SAFETY: Oxygenation: [ ] convulsion Comments: [ ] dyspnea Comments: [ ] dizziness [ ] smoking history [ ]limited [ ] cough motion [ ]of joints denied Limitation in Circulation: Ability to [ ] chest pain [ ] ambulate [ ] leg pain [ ] bathe self [ ] numbness of [ ] extremities other [ ] denied ] denied [ Comments:

OBJECTIVE [ ] dry [ ] cold [ ] pale OBJECTIVE [ ] flushed [ ] warm ] moist [ ][ cyanotic [ ][ glasses ] languages *rashes, ulcers, decubitus (describe size, [ ] contact lens [ ] hearing aid location, drainage) R L Pupil Size: [ ] speech difficulties Reaction: [ ] LOC [and orientation:irregular Resp. ] regular [ ] Describe: R Gait: [ ] walker [ ] cane [ ] other : L: [ ] steady [ ] unsteady ______ [ ] sensory and motor losses in face or extremities Heart Rhythm [ ] regular [ ] irregular [ ] Edema : AnkleROM limitations: Pulse Car. Rad. DP R L Comments: ] facial grimace *If[applicable [ ] guarding ] other signs of pain: [ ][ dentures [ ] none Fem*

COMFORT/SLEEP/AWAKE: [ ] pain Comments: (location, frequency, Nutrition: remedies) Diet: [ ] nocturia [ ]N []V Comments: [ ] sleep difficulties Character [ ] denied [ ] recent change in weight, appetite COPING: [ ] swallowing Occupation: difficulty Members [ ] denied of Household:

[ ] siderail Full release Partial form signed (60+ years) with Patient Upper [ ] [ ] [ ] Lower [ ] [ ] [ ] Observed non-verbal behavior:

The person and his phone number that can Most Supportive Person: be reached any time: Elimination: Usual bowel pattern [ ] urinary frequency Comments: Bowel Sounds: SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) Daily Weight [ ] urgency PT/OT Abdominal Distention . BP q Irradiation [ ] constipation Shift [ ] dysuria Present [ ] yes [ ] no Urine Test . remedy Neuro vs [ ] hematuria Urine* (color, CVP/SG Reading 24 hour Urine Collection [ ] incontinence consistency, odor) [ ] polyuria Date of Last BM [ ] foly in place [ ] denied *if they are in place [ ] diarrhea character MGT. OF HEALTH ILLNESS: [ ] alcohol [ ] denied (amount, frequency) [ ] SBE Last Pap Smear LMP: Briefly describe the pt.s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).

Medyo sakit gihapon ang gi-operahan na side, as verbalized by the patient. Pain scale: 6 Post op wound Facial grimace Guarding Pain related to the surgical procedure (mastectomy) as evidenced by facial

grimacing and guarding.

At the end of 30 minute, the patient will be able to verbalize lessen pain

1. Assessed pain level. 2. Assisted patient to position in comfort. 3. Provided comfort measures such as back rubs. 4. Demonstrated relaxation technique such as deep breathing I exercises. 5. Demonstrated and facilitated post mastectomy exercises 6. Administered pain medications (Etoricoxib) as ordered.

At the end of 30 minutes, the patient was able to verbalize lessen pain with pain scale of 4.

[no subjective cues] Post op wound Incision of about 10 cm Post op pain

Impaired skin integrity related to surgical incision and removal of tissue

At the end of 8 hours, the patient will be able to maintain dry and intact wound dressing.

1. Assessed dressing and wound for any abnormalities 2. Monitored patients temperature every 4 hours. 3. Assisted in wound dressing. 4. Avoided taking blood pressure on the affected arm. I 5. Placed in semi-fowlers position. 6. Provided wrinkle free bed. 7. Administered antibiotics (Cefazolin) as ordered.

At the end of 8 hours, the patient was able to maintain dry and intact wound dressing.

Dili kayo ko makalihok kay sakit akong operasyon, as verbalized by the patient.

Post op pain Reluctant to attempt movement Limited ROM

Activity intolerance related to pain and discomfort

At the end of 30 minutes, the patient will be able to demonstrate techniques that enable resumption of activities

1. Facilitated passive range of motion 2. Demonstrated and facilitated post mastectomy exercises 3. Assisted in ambulation 4. Recommended in proper deep breathing exercises I 5. Administered pain medications (Etoricoxib) as ordered.

At the end of 30 minutes, the patient was able to demonstrate techniques that enable resumption of activities such as hand movement, arm rising and ambulation within room premises.

[no subjective cues] Post op wound dressing Presence of Jackson pratt Post op pain Risk for infection related to broken skin and presence of foreign material

secondary to surgical procedure

At the end of 8 hours, the patient will be able to maintain safe aseptic environment of the affected side

1. Assessed wound dressing 2. Maintained the patency of the drainage tube 3. Elevated the affected arm 4. Monitored the temperature every 4 hours. I 5. Facilitated post mastectomy exercises 6. Administered pain medications (Cefazolin) as ordered.

At the end of 8 hours, the patient was able to maintain safe aseptic environment of the affected side as evidence by temperature within normal range

IX. DISCHARGE PLANS Medications Encouraged strict adherence to the medication regimen to attain therapeutic effects Instructed patient to strictly follow orders for take home medications upon discharge as prescribed by the physician such as: Cefuruxime 500mg BID PO Pantoprazole 40mg PO OD to continue x 5 days Etoricoxib 120mg 1 tab PO OD x 5 days Oxycontin 10mg 1 tab BID PO 12 hrs interval x 3 days only Oxycondone 5mg PO PRN if patient is still not comfortable with Oxycontin- may be given 1-2 hrs interval until patient is comfortable Advised to continue taking the medications as indicated.

Activity/Exercise Encouraged to ambulate every morning to hasten her recovery since it will promote circulation and promote wound healing. Encouraged the patient to do deep breathing exercises to promote lung expansion. Encouraged the patient to perform post mastectomy exercises for 8 counts or as tolerated. Encouraged patient to perform some exercise like walking exercises for at least 10-15 minutes every morning

Diet

 Encouraged to eat foods high in protein since it will help in tissue healing. Foods rich in beta carotene like sweet potato to boost immune system and a good source of vitamin A. Green leafy vegetables like malungay and camote tops Foods rich in Vitamin E like papaya and tomato to prevent stress Encourage to increase water intake to 12 glasses or 2-3 liters per day

Out-Patient/Follow Up Encouraged a responsible member of the family to serve as a treatment partner of the patient who will constantly remind about the medication regimen especially on the timing of administration Reminded patient to return to the hospital for follow up check up on December 20, 2008 at OPD. Provided education regarding the nature of the patients disease condition.

Prognosis Three months prior to admission, R.A. manifested the onset of illness like noting a breast mass, swelling and tenderness on the breast. Patient failed to consult directly after noting such symptoms. Patient was supported by the family most especially her daughter from the day she knew about her condition until she was discharged from Bethel Baptist Hospital. According to the patient, she felt relieved after the surgery (Mastectomy) and because of that she had a lesser chance to develop into malignancy. Patients recovery will depend on the strict compliance of home medications prescribed by the physician, patients nutrition and regular check up.

X. EVALUATION AND IMPLICATION After 3 days of duty at Bethel Baptist Hospital, nursing care had been implemented to our client through a day to day assessment. Since she was a post operative patient, the main objective was to prevent complications. Thus, interventions such as early ambulation, passive range of motion exercises and deep breathing exercises were primarily implemented. Health teachings regarding adequate nutrition, infection control and proper hygiene were also emphasized. In a sense that we are future health care providers, it is crucial in our part that we see to it and identified the health problem of our patient, which is significant in our nursing field and study, somehow we were able to identify nursing diagnosis and implemented possible effective nursing care, which gave sense of accomplishment in our part as student nurses. Eventually, we should be cautious at all times in giving care to our patient and should always bear in mind that we are dealing with life. And must always be compassionate and provide holistic approach. This study will serve as a reference material in rendering competent care to our client especially those with similar situation. Through this, we will be able to develop our knowledge as well as our skills and attitudes in applying the prescribed procedure to improve the health status of the patient. The case study paved way for student nurses to identify and determine issues related to mastectomy and post operative interventions to prevent possible complications.

X. BIBLIOGRAPHY Doenges, M. et al. Nurses Pocket Guide: Diagnosis, Interventions and Rationales. 8th edition. Davis Company: Bangkok Thailand, 2002. Doenges, M. et al. Nursing Care Plans. 6th Bangkok Thailand, 2002. edition. Davis Company:

Gilliam, S. Nurses Drug Guide 2006. 7th ed. Lippincot Williams and Wilkins Kozier,B. et al. Fundamentals of Nursing Concepts, Process and Practices. 5th edition. Upper Saddle, New Jersey, 2004. Smeltzer,S. et al. Medical-Surgical Nursing. Vol.1. 10th edition. Lippincot Williams amd Wilkins.2004. Microsoft Encarta 2006. 1993-2005 Microsoft Corporation. All rights reserved.

http://www.imaginis.com/breasthealth/breast_anatomy2.asp www.breastcancer.org www.feminist.org/other/bc www.cancerbackup.org.uk/Cancertype/Breast www.nlm.nih.gov/medlineplus/breastcancer.html www.cancer.gov/cancerinfo/wyntk/breast